Bruno DiGiovine

The Association Between Depressive Symptoms and Acute Exacerbations of COPD

BackgroundDepression is an important comorbidity for patients with chronic obstructive pulmonary disease (COPD). The association between depression and acute exacerbations of COPD is unknown. This study was designed to determine the frequency of COPD exacerbations in outpatients with and without depressive symptoms.MethodsIn this retrospective cohort study, patients with a primary diagnosis of COPD were followed for 1xa0year after discharge from a pulmonary rehabilitation program and the frequency of exacerbations was recorded. Upon completion of the program, all patients were administered the Short-Form 36 Health Survey (SF-36), which contains a mental health domain. Patients were classified as having depressive symptoms based on their domain score, which was separately validated in a second population of patients. ResultsOf the 194 patients with COPD who completed the pulmonary rehabilitation program, 32 (16.5%) had depressive symptoms. There were no differences in terms of age, race, pack-years, forced expiratory volume in 1 second (FEV1), 6-minute walk distance, body mass index, use of supplemental oxygen, use of inhaled steroids, or the Charlson Comorbidity Index between patients with and without depressive symptoms. Patients with depressive symptoms had more exacerbations in the following year (1.91 vs. 1.36; pxa0=xa00.02), were 2.8 times more likely to have ever had an exacerbation (95% confidence interval (CI), 1.1–7.3; pxa0=xa00.03), and suffered a first exacerbation earlier (148xa0days compared with 266xa0days; pxa0=xa00.04) than nondepressed patients. ConclusionsCOPD patients with depressive symptoms have a significantly higher risk for exacerbations. Early screening for depression in patients with COPD may help identify those patients at higher risk for subsequent exacerbations.

Long-acting β-agonists: Anti-inflammatory properties and synergy with corticosteroids in asthma

Purpose of review Contemporary asthma management calls for combination inhaled corticosteroid (ICS) and long-acting β-agonist (LABA) for patients with moderate to severe persistent asthma. This combination has consistently shown superior clinical efficacy compared with monotherapy with higher doses of ICS. It is unclear whether ICS and LABA act additively because of their complementary mechanisms of action, or whether they act synergistically based on possible favorable interactions between them. The purpose of this review is to summarize research findings on the anti-inflammatory activity of LABA published since October 2002 and to speculate on how these findings will affect future asthma management recommendations. Recent findings Combination ICS plus LABA consistently demonstrates superiority over ICS monotherapy in clinical outcomes such as pulmonary function, symptoms, and exacerbation rates, and is consistent with definitive data published before the review period. However, investigations into possible effects of LABA on inflammatory mediators are preliminary. Positive effects of LABA on some serum and bronchial inflammatory measures have been observed, but the clinical importance of these findings has not been established. Summary Current asthma treatment recommendations are based on clinical trials demonstrating improved clinical outcomes of combination ICS plus LABA over ICS alone. Whether LABA possesses clinically important benefits beyond bronchodilation remains to be established. Distinguishing anti-inflammatory activity of LABA will help define optimal long-term treatment regimens for asthma that not only improve pulmonary function, symptoms, and exacerbation rates but also protect against airway remodeling.

Resuscitation Bundle Compliance in Severe Sepsis and Septic Shock: Improves Survival, Is Better Late than Never

While clinicians management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign’s (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg, and central venous oxygen saturation (ScvO2) ≥70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% (P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01.Conclusions: Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.

Reducing hospital standardized mortality rate with early interventions.

ABSTRACT Henry Ford Hospital is undertaking multiple initiatives to reduce patient mortality. One such project is the deployment of a rapid response team (RRT). Rapid response teams contribute to reducing in-patient mortality rates by identifying and treating patients at risk for physiological deterioration outside the intensive care unit (ICU) setting. Rapid response teams differ from code teams because they proactively look for at-risk patients, whereas code teams are activated after a patients arrest. Team members include ICU nurses, medical doctors, house managers, and respiratory therapists, with the ICU nurses acting as primary responders. The RRT at Henry Ford Hospital is available 24 hours a day, 7 days a week. Criteria for the members of the RRT were developed by a committee of physician and nursing leadership. Nurses on the RRT need a minimum of 2 to 3 years of intensive care background. Weekly meetings with planning committee members were held to discuss issues regarding the implementation of the RRT pilot. The RRT committee consists of 3 nurse administrators, a house manager, a clinical nurse specialist, 2 nurse managers, clinical coordinators, a quality assurance nurse, a statistician, and the medical director of medical critical care. The population analyzed was a sample of 1,335 RRT consults and 207 medical ICU discharge follow-ups. The processes that were measured were percentage of blue alerts outside the ICU, the number of calls to the RRT, and the location, reason, time, and outcome of an RRT call. Outcome measures consisted of unadjusted hospital mortality rate, blue alerts per 1,000 discharges, percentage of patients with blue alerts discharged alive, and number of days between blue alerts on the pilot unit. Initial results are positive, with evidence that the number of blue alerts on general practice units is being reduced. Statistical data collected from the consult forms indicate that the greatest number of occurrences were respiratory triggers. From a sample size of 1,335 consults, 30% of the sample group had low pulse oximetry, 30% presented with respiratory distress, and 20% had respiratory rate issues. Future implications for the RRT will be along the lines of early sepsis recognition, retention and recruitment tool, education and practice links, and using families as initiators of a RRT consult.

Protocol-Based Resuscitation Bundle to Improve Outcomes in Septic Shock Patients: Evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative.

Objectives:To evaluate the impact of a multi-ICU quality improvement collaborative implementing a protocol-based resuscitation bundle to treat septic shock patients. Design:A difference-in-differences analysis compared patient outcomes in hospitals participating in the Michigan Health & Hospital Association Keystone Sepsis collaborative (n = 37) with noncollaborative hospitals (n = 50) pre- (2010–2011) and postimplementation (2012–2013). Collaborative hospitals were also stratified as high (n = 19) and low (n = 18) adherence based on their overall bundle adherence. Setting:Eighty-seven Michigan hospitals with ICUs. Patients:We compared 22,319 septic shock patients in collaborative hospitals compared to 26,055 patients in noncollaborative hospitals using the Michigan Inpatient Database. Interventions:Multidisciplinary ICU teams received informational toolkits, standardized screening tools, and continuous quality improvement, aided by cultural improvement. Measurements and Main Results:In-hospital mortality and hospital length of stay significantly improved between pre- and postimplementation periods for both collaborative and noncollaborative hospitals. Comparing collaborative and noncollaborative hospitals, we found no additional reductions in mortality (odds ratio, 0.94; 95% CI, 0.87–1.01; p = 0.106) or length of stay (–0.3 d; 95% CI, –0.7 to 0.1 d; p = 0.174). Compared to noncollaborative hospitals, high adherence hospitals had significant reductions in mortality (odds ratio, 0.84; 95% CI, 0.79–0.93; p < 0.001) and length of stay (–0.7 d; 95% CI, –1.1 to –0.2; p < 0.001), whereas low adherence hospitals did not (odds ratio, 1.07; 95% CI, 0.97–1.19; p = 0.197; 0.2 d; 95% CI, –0.3 to 0.8; p = 0.367). Conclusions:Participation in the Keystone Sepsis collaborative was unable to improve patient outcomes beyond concurrent trends. High bundle adherence hospitals had significantly greater improvements in outcomes, but further work is needed to understand these findings.

Outcome of hypotensive ward patients who re-deteriorate after initial stabilization by the Medical Emergency Team

PURPOSEnWe evaluated the outcome of hypotensive ward patients who re-deteriorated after initial stabilization by the Medical Emergency Team (MET) in our hospital, due to limited data in this regard.nnnMETHODSnOne thousand one hundred seventy-nine MET calls in 32184 ward patients from January 2009 to August 2011 were evaluated. Four hundred ten hypotensive patients met study criteria and were divided into: (1)Immediate Transfers (IT), n = 136:admitted by MET to intensive care unit (ICU) immediately; (2)Re-deteriorated Transfers (RDT) n = 72:initially stabilized and signed off by MET, but later re-deteriorated within 48-hours and admitted to ICU; (3)Ward Patients (WP) n = 202: remained stable on ward after treatment.nnnRESULTSnThe RDT and IT had similar APACHE II scores (20.2 ± 5.1 vs. 19.8 ± 4.8; P=.57], but RDT showed hemodynamic stabilization with initial MET resuscitation. Patients who re-deteriorated were younger, took longer for eventual ICU transfer, had higher initial lactic acid and delayed normalization as compared to IT (P < .04). The re-deterioration predominantly occurred within 8-hours of MET evaluation. RDT had higher 28-day mortality than IT and WP; 42% vs. 27% vs. 7% respectively (P < .03). RDT also had a higher rate of endotracheal intubation and worse ICU mortality (P < .01).nnnCONCLUSIONnHypotensive ward patients who re-deteriorate after initial stabilization have higher mortality. METs should consider implementing at least an 8-hour follow-up in patients who are deemed stable to remain on the wards after hypotensive episodes.

A patient with an uncommon complication from insertion of a central venous catheter: A case report

BackgroundA 72 year old male was admitted to the medical intensive care unit with septic shock.Case presentationA left subclavian central venous catheter was inserted on the day of admission whose tip was pushing against the wall of the vessel lumen. The patients condition improved with treatment, but three days later had a new episode of acute hypotension. CT scan of the chest showed that the catheter had eroded through the superior vena cava wall.ConclusionThe catheter was pulled out and patient recovered from the complication with supportive therapy. Care should be taken that the tip of the catheter is in the center of the vessel lumen to avoid this rare, but potentially life threatening, complication.

Anaerobic antibiotic usage for pneumonia in the medical intensive care unit

Pneumonia is a common admitting diagnosis in the intensive care unit (ICU). When aspiration is suspected, antibiotics to cover anaerobes are frequently used, but in the absence of clear risk factors, current guidelines have questioned their role. It is unknown how frequently these guidelines are followed.