Brice Taylor

Health care-associated pneumonia in haemodialysis patients: Clinical outcomes in patients treated with narrow versus broad spectrum antibiotic therapy

Background and objective:  Although the 2005 American Thoracic Society/Infectious Disease Society of America antibiotic guidelines classify pneumonia occurring in patients receiving chronic haemodialysis as health care‐associated pneumonia (HCAP), and thus recommend treatment with broad‐spectrum antibiotics for these patients, little data support this classification. We compared clinical outcomes in haemodialysis patients hospitalized with pneumonia, who were treated with broad‐spectrum antibiotics versus narrow‐spectrum antibiotics.

A Case of Chyloperitoneum Secondary to Follicular Lymphoma and a Review of Prognostic Implications

Chyloperitoneum, or chylous ascites, is a rare condition characterized by milky-appearing fluid with elevated triglyceride content and the presence of chylomicrons. Malignancy, specifically lymphoma, is reported to be the predominant cause in Western countries. Previously, the prognosis for patients with chyloperitoneum due to lymphoma has been reported as poor. We present a case of chyloperitoneum and chylothorax due to follicular lymphoma with excellent response to bendamustine and Rituxan. A review of the literature indicates that patients with chyloperitoneum associated with lymphoma generally have a favorable response to contemporary treatment regimens.

Early versus delayed right heart catheterization in evaluation of pulmonary arterial hypertension

When pulmonary arterial hypertension (PAH) is suspected by clinical signs and symptoms, screening echocardiography is recommended for initial evaluation of the disease. Because of the inherent inaccuracy of echocardiographic estimates of pulmonary pressures, right heart catheterization (RHC) is the standard of care for assessing pulmonary vascular hemodynamics and confirming PAH. However, current diagnostic algorithms for PAH do not stress the importance of confirmation of PAH with RHC. Guidelines recommend that a work-up for underlying causes be performed prior to confirmation of PAH by RHC. We conducted a retrospective review of patients referred for RHC based on echocardiographic findings to illustrate the importance of confirming PAH by RHC early in the diagnostic process. We retrospectively reviewed 190 patients with pulmonary artery systolic pressure (PaSP) 440 mm Hg on transthoracic echocardiogram who also underwent RHC at Tampa General Hospital between January 2007 and October 2009. The average mean pulmonary artery pressure (mPAP) at RHC was compared with the average PaSP by echocardiogram using Pearson’s correlation. World Health Organization (WHO) Group 1 PAH was diagnosed if mean pulmonary artery pressure (mPAP) was 425 mm Hg with a pulmonary artery wedge pressure (PaWP) of r15 mm Hg, and WHO Group 2 PAH was diagnosed if mPAP was 425 mm Hg and PaWP was 415 mm Hg. The positive predictive value of echocardiography to predict a diagnosis of PAH at RHC was calculated. Institutional review board approval (No. 108617) for this study was obtained from the University of South Florida. Table 1 shows the characteristics of the study population. There was a modest correlation between PaSP obtained by echocardiography and PaSP obtained at RHC (r 1⁄4 0.68, p o 0.001). The distribution of RHC results is shown in Fig. 1 Only 67 of 190 patients (35%) with elevated PaSP on echocardiogram met the criteria for the diagnosis of WHO Group 1 PAH. Seventy of 190 patients (37%) with elevated PaSP on echocardiogram had mPAP r25 mm Hg at RHC. Interestingly, 53 of 190 patients (28%) with elevated PASP on echocardiogram and mPAP 425 mm Hg on RHC were reclassified as WHO Group 2 PAH (pulmonary venous hypertension). In this study, only about one third of patients referred for RHC based on elevated PaSP on echocardiography actually had WHO Group 1 PAH. One third of patients were reclassified as WHO Group 2 PAH based on elevated PaWP, and one third had normal mPAP measured directly on RHC. Although there was a modest correlation between

Palla’s Sign and Hampton’s Hump in Pulmonary Embolism

A 37-year-old female with lupus anticoagulant developed severe hypoxia during dilation and curettage for spontaneous abortion. A chest radiograph (panel A) showed a wedge-shaped peripheral opacity (Hampton’s hump [1] , long arrow) as well as a prominent right descending pulmonary artery with a sharp cutoff (Palla’s sign [2] , short arrow). Subsequently, a CT angiogram (panel B) demonstrated massive pulmonary embolism in the right main pulmonary artery extending to the upper, middle, and lower lobe branches with features suggesting subacute or chronic thrombus. Bilateral pulmonary arteries were enlarged, indicative of pulmonary hypertension. A peripheral opacity was seen in the right middle lobe consistent with pulmonary infarct. A recent analysis of CT angiography in patients with massive pulmonary embolism found that 76% had pulmonary artery dilation, and 36% had wedge-shaped pleural-based consolidation [3] . Despite the common occurrence of these findings on CT, the concurrence of both Palla’s sign and Hampton’s hump on chest radiograph has not yet been reported to our knowledge.

1493: INITIAL FLUID BY ADJUSTED BODY WEIGHT LINKED TO LOWER MORTALITY IN OBESE PATIENTS WITH SEPTIC SHOCK

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Sepsis Associated Macrophage Activation Syndrome (S-MAS) occurs in children, but little is known about S-MAS in adults. We conducted a systematic review to investigate rates, mortality, pattern of organ compromise and treatment strategies for adult S-MAS. Methods: We reviewed EMBASE, Cochrane and MEDLINE 20012017, using medical subject heading terms and text words with Boolean logic. We included observational and interventional studies in adult (> 18 y) patients with sepsis/infection and MAS, or hemophagocytic lymphohystiocytosis (S-HLH). We excluded studies enrolling patients with rheumatological disorders, family history of HLH or malignancy. Results: We found 3,692 articles and excluded 3,663 for duplications, not reporting outcomes, and including patients with rheumatologic conditions, malignancies or < 18 years. We selected 29 articles, including 1,272 patients -10 case reports, 1 case series, 17 cohort studies, and 1 post-hoc analysis of a randomized trial (ph-RCT) on IL-1R antagonist (IL-1Ra) for treatment of sepsis. Only the ph-RCT reported on the rate of S-MAS (6.1%). Mortality was reported in 12 studies, ranging from 50% in case reports to 60% in the ph-RCT. Six studies reported on organ dysfunction, most often citing hepatobiliary and renal compromise. All 29 studies reported treatment. Eight studies of S-MAS reported treatment with pulse methylprednisolone+etoposide, IL-1Ra, cyclosporine, intravenous immunoglobulin (IVIG)+fresh frozen plasma, IVIG+prednisolone. A case series described 3 patients treated with IL-1Ra and IVIG +/steroids, with 50% survival. The ph-RCT reported mortality reduction from 60 to 29.7% with Anti-IL-1Ra. Nineteen studies on S-HLH reported as most common treatments steroids +/etoposide, etoposide, cyclosporine, IVIG, plasmapheresis, stem cell transplant and Alemtuzumab. Conclusions: There is very little evidence on the frequency, outcome, and potential therapeutic interventions in adult S-MAS. Although the incidence is low, mortality is very high. Treatment strategies varied, however, the best evidence suggested a promising therapeutic role for IL-1Ra.

1477: DELAYS FROM FIRST TO SECOND ANTIBIOTIC ADMINISTRATION IN EMERGENCY DEPARTMENT PATIENTS WITH SEPSIS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Robust evidence links timely administration of antibiotics to good outcomes in patients with sepsis. Current guidelines recommend an ambitious goal of antibiotic administration within 1 hour from “time zero”. Little is known about the timing of key processes from Emergency Department (ED) arrival to antibiotic administration for patients with sepsis. Methods: We studied patients presenting to the ED with sepsis (defined as suspected infection and organ dysfunction) at two hospitals with mature sepsis treatment pathways including order sets with preselected antibiotic regimens. We conceptualized the total time from ED arrival to antibiotic administration into 3 intervals. Interval 1: time from arrival to the time a physician opens the patient’s medical record (door to doctor time), Interval 2: time from chart open to entering the antibiotic order (doctor to decision time) and Interval 3: time from order entry to administration of the antibiotic (decision to drug time). We retrospectively abstracted these times from medical records. Because we were specifically interested in how antibiotic allergies might affect delays, we recorded whether patients had allergy to any of the preselected antibiotics. Results: Of 155 patients presenting to the ED with sepsis, 18.7% (28) died during hospitalization. Overall, a mean time of 119.08 minutes (SD 88.8) elapsed between ED arrival and antibiotic administration. The mean time between ED arrival and chart opening by a physician was 16.9 minutes (SD 29.8), the mean time required for physicians to enter an antibiotic order was 68.2 minutes (SD 60.5), followed by another mean time of 40.2 minutes (SD 38.2) to begin drug infusion. Patients with allergy to the preselected antibiotics experienced a longer delay from antibiotic order to administration (36.3 vs 50.1 min, p = 0.09) and longer total delay from chart open to administration (101.6 vs 125.2 min, p = 0.16), but similar time from chart open to placement of antibiotic order (65.3 vs 75.7 min, p = 0.43). Conclusions: In order to reduce ED delays in antibiotic administration for patients with sepsis, we examined the critical phases between arrival and treatment. We report average times for 3 intervals, showing that the time from physician chart open to antibiotic order (doctor to decision time) represents the longest interval of delay. Although not statistically significant, allergy to order set antibiotics was associated with longer time from order to administration (decision to drug time).

1476: INTERVALS OF DELAY IN ANTIBIOTIC ADMINISTRATION FOR EMERGENCY DEPARTMENT PATIENTS WITH SEPSIS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Robust evidence links timely administration of antibiotics to good outcomes in patients with sepsis. Current guidelines recommend an ambitious goal of antibiotic administration within 1 hour from “time zero”. Little is known about the timing of key processes from Emergency Department (ED) arrival to antibiotic administration for patients with sepsis. Methods: We studied patients presenting to the ED with sepsis (defined as suspected infection and organ dysfunction) at two hospitals with mature sepsis treatment pathways including order sets with preselected antibiotic regimens. We conceptualized the total time from ED arrival to antibiotic administration into 3 intervals. Interval 1: time from arrival to the time a physician opens the patient’s medical record (door to doctor time), Interval 2: time from chart open to entering the antibiotic order (doctor to decision time) and Interval 3: time from order entry to administration of the antibiotic (decision to drug time). We retrospectively abstracted these times from medical records. Because we were specifically interested in how antibiotic allergies might affect delays, we recorded whether patients had allergy to any of the preselected antibiotics. Results: Of 155 patients presenting to the ED with sepsis, 18.7% (28) died during hospitalization. Overall, a mean time of 119.08 minutes (SD 88.8) elapsed between ED arrival and antibiotic administration. The mean time between ED arrival and chart opening by a physician was 16.9 minutes (SD 29.8), the mean time required for physicians to enter an antibiotic order was 68.2 minutes (SD 60.5), followed by another mean time of 40.2 minutes (SD 38.2) to begin drug infusion. Patients with allergy to the preselected antibiotics experienced a longer delay from antibiotic order to administration (36.3 vs 50.1 min, p = 0.09) and longer total delay from chart open to administration (101.6 vs 125.2 min, p = 0.16), but similar time from chart open to placement of antibiotic order (65.3 vs 75.7 min, p = 0.43). Conclusions: In order to reduce ED delays in antibiotic administration for patients with sepsis, we examined the critical phases between arrival and treatment. We report average times for 3 intervals, showing that the time from physician chart open to antibiotic order (doctor to decision time) represents the longest interval of delay. Although not statistically significant, allergy to order set antibiotics was associated with longer time from order to administration (decision to drug time).

1506: RACIAL DIFFERENCES IN PREDICTORS OF TIMELY ANTIBIOTICS AND MORTALITY IN SUSPECTED SEPTIC SHOCK

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Most research demonstrates that black patients suffer nearly double the incidence of severe sepsis than do white patients, although this is not a universal finding. The disparity in sepsis outcomes persists even after controlling for source of infection and underlying chronic illnesses. The mechanism for this racial disparity is unclear. We previously showed that black patients are less likely to receive timely antibiotics compared to white patients. We examined predictors associated with timely antibiotics and mortality in separate models of black and white patients Methods: We analyzed patients from 9 regional hospitals within Carolinas Healthcare System who presented to the Emergency Department with suspected septic shock based on activation of “code sepsis” treatment pathway. We created separate logistic regression models for black and white patients to identify predictors of antibiotic compliance and mortality. Results: Of the 2,928 patients, 2221 (75.8%) were white and 707 (24.1%) were black. White patients were older than black patients but had a lower burden of comorbid conditions. Health insurance payor mix was significantly different between white and black patients, with higher rates of Medicaid in the black subject group and higher rates of Medicare in white patients. On ED presentation, black patients had higher serum lactate but no statistical difference in shock index compared to white patients. In the adjusted analysis for receipt of antibiotics within 1 hour of triage, higher shock index was associated with greater rate of antibiotic timeliness in black patients whereas higher temperature was the physiologic parameter associated with increased antibiotic timeliness in white patients. In the adjusted model for mortality male sex was significantly associated with mortality for black but not white patients. Conclusions: There may be race-specific factors associated with both antibiotic compliance and mortality in suspected septic shock. Clinicians may be responsive to different signals suggesting infection in black versus white patients.

1437: THE EFFECT OF LACTATE CLEARANCE ON MORTALITY IN PATIENTS WITH ACUTE KIDNEY INJURY

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) study of critically ill pediatric patients (0–16 years) transported by an intensive care team to one of the three pediatric intensive care units (PICU) in England. All patients were classified as per pediatric sepsis definitions based on clinical data at first contact with the intensive care team. At the end of the PICU admission, patients were categorized according to their infection status (DB: definite bacterial; DV: definite viral; P: probable; I: inconclusive; and NI: not infection). The sensitivity and specificity of the pediatric sepsis definition in predicting SBI and PICU mortality was assessed. Results: A total of 409 patients were included in the analysis. Infection status was DB: 38 (9%); DV: 85 (21%); P: 59 (15%); I: 99 (24%) and NI: 128 (31%). Of the 38 children with definite bacterial infection, only 24 fulfilled the sepsis definition (sensitivity: 63%; specificity: 64%; positive likelihood ratio: 1.8). Conversely, of the 128 children with no evidence of infection, 16 fulfilled the sepsis definition (sensitivity: 88%; specificity: 51%). Of the 409 patients analysed, 12 (3%) died in the PICU. The predictive value of the sepsis definition to predict PICU mortality was poor (sensitivity: 42%; specificity: 61%). Conclusions: The 2005 pediatric consensus guidelines for the definition of sepsis have poor sensitivity and specificity to predict SBI and patient outcome. Newer definitions that include a measure of organ dysfunction in the definition of sepsis might have better predictive ability as demonstrated in adults.

Reflux of Contrast into the Inferior Vena Cava: A Sign of Right Ventricular Failure Due To Multiple Conditions

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