David Berlin

Pancreatic Necrosectomy Using Covered Esophageal Stents A Novel Approach

Background: Endoscopic necrosectomy for necrotizing pancreatitis has been increasingly used as an alternative to surgical or percutaneous interventions. The use of fully covered esophageal self-expandable metallic stents may provide a safer and more efficient route for internal drainage. The aim of this study was to evaluate the safety and efficacy of endoscopic treatment of pancreatic necrosis with these stents. Methods: A retrospective study at 2 US academic hospitals included patients with infected pancreatic necrosis from July 2009 to November 2012. These patients underwent transgastric placement of fully covered esophageal metallic stents draining the necrosis. After necrosectomy, patients underwent regular sessions of endoscopic irrigation and debridement of cystic contents. The efficacy endpoint was successful resolution of infected pancreatic necrosis without the need for surgical or percutaneous interventions. Results: Seventeen patients were included with the mean age of 41±12 years. A mean of 5.3±3.4 sessions were required for complete drainage and the follow-up period was 237.6±165 days. Etiology included gallstone pancreatitis (6), alcohol abuse (6), s/p distal pancreatectomy (2), postendoscopic retrograde cholangiopancreatography pancreatitis (1), medication-induced pancreatitis (1), and hyperlipidemia (1). Mean size of the necrosis was 14.8 cm (SD 5.6 cm), ranging from 8 to 19 cm. Two patients failed endoscopic intervention and required surgery. The only complication was a perforation during tract dilation, which was managed conservatively. Fifteen patients (88%) achieved complete resolution. Conclusions: Endoscopic necrosectomy with covered esophageal metal stents is a safe and successful treatment option for infected pancreatic necrosis.

Starling curves and central venous pressure

Recent studies challenge the utility of central venous pressure monitoring as a surrogate for cardiac preload. Starting with Starling’s original studies on the regulation of cardiac output, this review traces the history of the experiments that elucidated the role of central venous pressure in circulatory physiology. Central venous pressure is an important physiologic parameter, but it is not an independent variable that determines cardiac output.

Understanding venous return

Received: 4 June 2014 Accepted: 17 June 2014 Published online: 26 June 2014 Springer-Verlag Berlin Heidelberg and ESICM 2014 D. A. Berlin ()) Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, 1300 York Avenue, 10021 New York, NY, USA e-mail: berlind@med.cornell.edu Tel.: 646-962-2333 J. Bakker Department of Intensive Care Adults, Erasmus MC University, Room H 325, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

Bronchoscopic Intubation During Continuous Nasal Positive Pressure Ventilation in the Treatment of Hypoxemic Respiratory Failure

Endotracheal intubation is difficult in patients with hypoxemic respiratory failure who deteriorate despite treatment with noninvasive positive pressure ventilation (NIPPV). Maintaining NIPPV during intubation may prevent alveolar derecruitment and deterioration in gas exchange. We report a case series of 10 nonconsecutive patients with NIPPV failure who were intubated via a flexible bronchoscope during nasal mask positive pressure ventilation. All 10 patients were intubated in the first attempt. Hypotension was the most frequent complication (33%). Mean decrease in oxyhemoglobin saturation during the procedure was 4.7 ± 3.1. This method of intubation may extend the benefits of preoxygenation throughout the whole process of endotracheal intubation. It requires an experienced operator and partially cooperative patients. A prospective trial is necessary to determine the best intubation method for NIPPV failure.

Pathophysiology of Pulmonary Hypertension in Chronic Parenchymal Lung Disease

Pulmonary hypertension commonly complicates chronic obstructive pulmonary disease and interstitial lung disease. The association of chronic lung disease and pulmonary hypertension portends a worse prognosis. The pathophysiology of pulmonary hypertension differs in the presence or absence of lung disease. We describe the physiological determinants of the normal pulmonary circulation to better understand the pathophysiological factors implicated in chronic parenchymal lung disease-associated pulmonary hypertension. This review will focus on the pathophysiology of 3 forms of chronic lung disease-associated pulmonary hypertension: idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, and sarcoidosis.

Hemodynamic consequences of auto-PEEP.

Auto–positive end-expiratory pressure (PEEP) is a common but frequently unrecognized problem in critically ill patients. It has important physiologic consequences and can cause shock and cardiac arrest. Treatment consists of relieving expiratory airflow obstruction and reducing minute ventilation delivered by positive pressure ventilation. Sedation and fluid management are important adjunctive therapies. This analytic review discusses the prevalence, pathophysiology, and hemodynamic consequences of auto-PEEP and an approach to its treatment.

Bronchoscopic intubation is an effective airway strategy in critically ill patients.

Purpose: American Society of Anesthesiologists guidelines recommend the use of bronchoscopic intubation as a rescue technique in critically ill patients. We sought to assess the safety and efficacy of bronchoscopic intubation as an initial approach in critically ill patients. Methods: We performed a retrospective cohort study of patients who underwent endotracheal intubation in the medical intensive care unit of a tertiary urban referral center over 1 academic year. The primary outcome was first‐pass success rate. Measurements and main results: We identified 219 patients who underwent either bronchoscopic (n = 52) or laryngoscopic guided (n = 167) intubation as the initial attempt. There was a higher first‐pass success rate in the bronchoscopic intubation group than in the laryngoscopic group (96% vs 78%; P = .003). The bronchoscopic intubation group had a higher body mass index (28.4 vs 25.9; P = .027) and higher preintubation fraction of inspired oxygen requirement (0.73 ± 0.27 vs 0.63 ± 0.30; P = .044) than the laryngoscopic group. There were no cases of right mainstem intubation, esophageal intubation, or pneumothorax with bronchoscopic intubation. Rates of postintubation hypotension and hypoxemia were similar in both groups. The association with first‐pass success remained with multivariate and propensity matched analysis. Conclusions: Bronchoscopic intubation as an initial strategy in critically ill patients is associated with a higher first‐pass success rate than laryngoscopic intubation, and is not associated with an increase in complications.

A Technique for Bronchoscopic Intubation During High-Flow Nasal Cannula Oxygen Therapy.

Despite preoxygenation, critical hypoxemia can occur during intubation. We describe a technique of high-flow nasal cannula oxygen support during bronchoscopic intubation

A Technique of Awake Bronchoscopic Endotracheal Intubation for Respiratory Failure in Patients With Right Heart Failure and Pulmonary Hypertension

Objective: Patients with pulmonary hypertension and right heart failure have a high risk of clinical deterioration and death during or soon after endotracheal intubation. The effects of sedation, hypoxia, hypoventilation, and changes in intrathoracic pressure can lead to severe hemodynamic instability. In search for safer approach to endotracheal intubation in this cohort of patients, we evaluate the safety and feasibility of an alternative intubation technique. Data Sources: Retrospective data analysis. Study Selection: Two medical ICUs in large university hospitals in the United States. Data Extraction: We report a case series of nine nonconsecutive patients with compromised right heart function, pulmonary hypertension, and severe acute hypoxemic respiratory failure who underwent endotracheal intubation with a novel technique combining awake bronchoscopic intubation supported with nasally delivered noninvasive positive pressure ventilation or high-flow nasal cannula. Data Synthesis: All patients were intubated in the first attempt without major complications and eight patients (88%) were alive 24 hours after intubation. Systemic hypotension was the most frequent complication following the procedure. Conclusions: Awake bronchoscopic intubation supported with a noninvasive positive pressure delivery systems may be feasible alternative to standard direct laryngoscopy approach. Further studies are needed to better assess its safety and applicability.

Beyond Pain: Nurses' Assessment of Patient Suffering, Dignity, and Dying in the Intensive Care Unit

Context Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients’ experiences at the end of life in the ICU. Objectives The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity. Methods From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients’ experiences. Medical chart abstraction was used to document baseline patient characteristics and care. Results The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12). Conclusion Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU.