Dereddi Raja Reddy

Reducing Deep Sedation and Delirium in Acute Lung Injury Patients: A Quality Improvement Project*

Objective:Deep sedation and delirium are common in the ICU. Mechanically ventilated patients with acute lung injury are at especially high risk for deep sedation, delirium, and associated long-term physical and neuropsychiatric impairments. We undertook an ICU-wide structured quality improvement project to decrease sedation and delirium. Design:Prospective quality improvement project in comparison with a retrospective acute lung injury control group. Setting:Sixteen-bed medical ICU in an academic teaching hospital with pre-existing use of goal-directed sedation with daily interruption of sedative infusions. Patients:Consecutive acute lung injury patients. Intervention:A “4Es” framework (engage, educate, execute, evaluate) was used as part of the quality improvement process. A new sedation protocol was created and implemented, which recommends a target Richmond Agitation Sedation Scale score of 0 (alert and calm) and requires failure of intermittent sedative dosing prior to starting continuous infusions. In addition, twice-daily delirium screening using the Confusion Assessment Method for the ICU was introduced into routine practice. Measurements and Main Results:Sedative use and delirium status in acute lung injury patients after implementation of the quality improvement project (n = 82) were compared with a historical control group (n = 120). During the quality improvement vs. control periods, use of narcotic and benzodiazepine infusions were substantially lower (median proportion of medical ICU days per patient: 33% vs. 74%, and 22% vs. 70%, respectively, both p < 0.001). Further, wakefulness increased (median Richmond Agitation Sedation Scale score per patient: −1.5 vs. −4.0, p < 0.001), and days awake and not delirious increased (median proportion of medical ICU days per patient: 19% vs. 0%, p < 0.001). Conclusion:Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury.

Physical Rehabilitation of Patients in the Intensive Care Unit Requiring Extracorporeal Membrane Oxygenation: A Small Case Series

Background and Purpose Neuromuscular weakness and impaired physical function are common and long-lasting complications experienced by intensive care unit (ICU) survivors. There is growing evidence that implementing rehabilitation therapy shortly after ICU admission improves physical function and reduces health care utilization. Recently, there is increasing interest and utilization of extracorporeal membrane oxygenation (ECMO) to support patients with severe respiratory failure. Patients receiving ECMO are at great risk for significant physical impairments and pose unique challenges for delivering rehabilitation therapy. Consequently, there is a need for innovative examples of safely and feasibly delivering active rehabilitation to these patients. Case Description This case report describes 3 patients with respiratory failure requiring ECMO who received physical rehabilitation to illustrate and discuss relevant feasibility and safety issues. Outcomes In case 1, sedation and femoral cannulation limited rehabilitation therapy while on ECMO. In the 2 subsequent cases, minimizing sedation and utilizing a single bicaval dual lumen ECMO cannula placed in the internal jugular vein allowed patients to be alert and participate in active physical therapy while on ECMO, illustrating feasible rehabilitation techniques for these patients. Discussion Although greater experience is needed to more fully evaluate the safety of rehabilitation on ECMO, these initial cases are encouraging. We recommend systematically and prospectively tracking safety events and patient outcomes during rehabilitation on ECMO to provide greater evidence in this area.

A Quality Improvement Project Sustainably Decreased Time to Onset of Active Physical Therapy Intervention in Patients with Acute Lung Injury

RATIONALE Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI). METHODS This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU. MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]). CONCLUSIONS In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.

Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

Case series Patient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61 Final Diagnosis: — Symptoms: Hypotension • respiratory failure Medication: Ketamine • Propofol • Etomidate Clinical Procedure: Endotracheal intubation Specialty: Critical Care Medicine Objective: Educational Purpose (only if useful for a systematic review or synthesis) Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. Case Series: We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. Conclusions: This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

Transfusion-Related Acute Lung Injury After IVIG for Myasthenic Crisis

BackgroundA 26-year-old female with myasthenic crisis developed transfusion-related acute lung injury (TRALI) after she was treated with intravenous immunoglobulin.MethodsCase report.ResultsRespiratory status markedly worsened with each intravenous immunoglobulin (IVIG) administration and progressing from a need to use bilevel positive airway pressure (BiPAP) to intubation. Pulmonary function tests improved during this episode.ConclusionsIVIG may cause TRALI and due to subtle clinical findings can be mistaken for neuromuscular respiratory failure.

Identification of acute brain failure using electronic medical records.

PURPOSE Up to 80% of critically ill patients have acute neurologic dysfunction syndromes. We evaluated interrater reliability between the examination by the investigator and the charted assessment by the nurse because the accuracy and reliability of detailed data sets extracted from the electronic medical records represents a keystone for creating EMR-based definitions. MATERIALS AND METHODS We conducted a prospective observational study of intensive care unit (ICU) patients to assess the reliability of charted Confusion Assessment Method for the ICU, Glasgow Coma Scale (GSC), Full Outline of Unresponsiveness, and Richmond Agitation Sedation Scale (RASS) scores, and a composite measure of ABF defined as new-onset coma or delirium. Trained investigator blinded to nursing assessments performed the neurologic evaluations that were compared with nursing documentation. RESULTS A total of 202 observations were performed in 55 ICU patients. Excellent correlation was noted for GCS and Full Outline of Unresponsiveness scores on Bland-Altman plots (Pearson correlation 0.87 and 0.92, respectively). Correlation for Confusion Assessment Method for the ICU was also high (κ= 0.86; 95% confidence interval [CI], 0.70-1.01). Richmond Agitation Sedation Scale had good agreement when scores were dichotomized as oversedated (less than -2) vs not oversedated, with κ= 0.76 (95% CI, 0.54-0.98). Investigator assessment and nurse charting were highly concordant (κ= 0.84; 95% CI, 0.71-0.99). CONCLUSION Neurologic assessments documented on the EMR are reliable.

Risk factors and outcomes of critically ill patients with acute brain failure: A novel end point

Objective: To determine the incidence, risk factors and outcomes of acute brain failure (ABF) in a mixed medical and surgical cohort of critically ill patients and its effect on ICU & hospital mortality. Design: Observational electronic medical record (EMR) based retrospective cohort study of critically ill patients admitted to the ICU between 2006 and 2013. Setting: Tertiary academic medical center. Patients: Consecutive adult (>18 years) critically ill patients admitted to medical and surgical ICUs. Patients admitted to the Neuroscience, Pediatric and Neonatal ICUs were excluded. Interventions: None. Measurements and main results: ABF was defined by the presence of delirium (positive CAM‐ICU) or depressed level of consciousness (by abnormal GCS and FOUR scores) in the absence of deep sedation (RASS < −3). Severity of ABF was categorized as grade I if there was delirium with GCS consistently >8 and grade II if the GCS was ≤8 with or without delirium during the ICU hospitalization. ABF duration was not used for this study. Univariate and multivariable analyses were used to access the factors associated with the development of ABF and its effect on short and long term mortality. Of 67,333 ICU patients included in the analysis, ABF was present in 30,610 (44.6%). Patients with ABF had an isolated delirium in 1985 (6.5%) patients, isolated depressed consciousness in 18,323 (59.9%), and both delirium and depressed consciousness in 10,302 (33.6%) patients. When adjusted for comorbidities and severity of illness ABF was associated with increased hospital (OR 3.47; 95% CI 3.19–3.79), and at one year (OR 2.36; 95% CI 2.24–2.50) mortality. Both hospital and one year mortality correlated with the increased severity of ABF. The factors most strongly associated with ABF were pre‐admission dementia (OR 7.86; 95% CI 6.15–10.19) and invasive ventilation (OR 2.32; 95% CI 2.24–2.40) but older age, female sex, presence of liver disease, renal failure, diabetes mellitus, malignancy and COPD were also associated with increased risk of ABF. Conclusions: ABF is a common complication of critical illness and is associated with increased short and long term mortality. The risk of ABF was particularly high in older patients with baseline dementia, COPD, diabetes, liver and renal disease and those treated with invasive mechanical ventilation. Highlights:ABF has a high incidence among critically ill patients.ABF is associated with poor clinical outcome including hospital and 1 year mortality.Clinical outcomes worsen with increasing severity of ABF.Pre‐existing dementia and invasive ventilation are strongly associated with ABF.

Judgment of futile care in the ICU.

To the Editor: In a recent issue of Critical Care Medicine, Huynh et al (1) reported about the cost of futile treatment in the ICU. They make a valiant attempt to assess the impact of futile care provided in the ICU on patients awaiting ICU admission and costs to the healthcare system at large. With healthcare costs peaking toward the end of life and the aging demographic of ICU patients, the authors’ focus of research is certainly the need of the hour. We applaud their efforts in quantifying this difficult topic of futility and its related cost. However, we have several concerns about how such findings might be applicable to clinical practice. In particular, the authors highlight that futility was determined only from the point of view of the clinician and did not include the thoughts and opinions of patients and their families (1, 2). Schneiderman et al (3) describe a futile action as “one that cannot achieve the goals of the action, no matter how often repeated.” We contend that futility is often quantified in terms of probability, but this term should only be applied to those clinical situations where the probability of the desired outcome is close to zero. For many patients and their families, particularly during critical illness, a probability of even 5–10% is better than zero, and beginning a discussion describing the relative risks and benefits in terms of odds of success or likelihood of failure may mislead or confuse further, particularly as many activities done in the context of critical illness serve quite well initial physiological goals (maintenance of blood pressure, oxygen saturation, heart rate, etc.) but may not individually affect likelihood of survival. As a further example, we note that of the 123 patients deemed to be receiving futile care in this study, 20 patients (16%) survived up to 6 months following hospital discharge (though details of their medical conditions were not reported) (2). The remaining 84% of patients either died prior to discharge (84/123) or had terminal conditions and/or severe cognitive impairment (19/123). In clinical practice, it would not be considered appropriate to unilaterally make an assessment of futility based on these findings if 16% of patients with such a determination would be expected to survive up to 6 months. Whether that survival is meaningful, even if quality of life is debased, is a judgment reserved for patients and their families and may be unlikely considered futile in their minds (16% chance of survival is better than 0%). Indeed, futility judgments are often understood relative to specific clinical but value-laden goals (4). The same intervention may be considered futile with respect to one goal, for example, returning to premorbid quality of life, but may be effective in relation to another, for example, surviving critical illness. Therefore, any meaningful definition of futility must be context dependent. As one might imagine, input from patients would be of utmost importance in understanding their goals and expectations from medical care. As a result, patient-centered and physician-centered perceptions of futility may be vastly different (5, 6). The authors allude to this in their study by discussing indeed why care that is considered futile is still even provided when clinicians have a right not to provide such care. This highlights the fact that opinions of patients and families often differ from those of clinicians. Further studies are needed to assess aspects of futility beyond clinician perception and to examine the conflicts that can occur when clinician and family opinions differ. We believe that critical care providers should be extremely cautious when using the term “futile” especially because our ability to predict futility is currently limited. Future research in this field should focus on better models of medical prediction and methods of conflict resolution in order to have candid and open discussions with patients and families. To conserve precious healthcare resources, employ palliative care at the appropriate time, and provide a timely referral to hospice care as needed are important and lofty goals, but likely only possible when the goals and expectations of patients and their families are engaged and duly respected. This work was performed at the Mayo Clinic, Rochester, MN. The authors have disclosed that they do not have any potential conflicts of interest.

Diffuse cholangiocarcinoma presenting with hepatic failure and extensive portal and mesenteric vein thrombosis

A 64-year-old previously healthy man presented with a 4-week history of vague right upper quadrant abdominal pain. Imaging studies revealed extensive portal, splenic, superior and inferior mesenteric vein thrombosis with mosaic perfusion and wedge-shaped areas of liver perfusion abnormalities. An extensive thrombophilia workup including tests for factor V Leiden, prothrombin G20210A, lupus anticoagulant, paroxysmal nocturnal haemoglobinuria, protein C and S, homocysteine and antinuclear antibody titres were all negative. Other laboratory testing revealed an elevated alkaline phosphatase (340 IU/L). Surgical exploration and catheter-directed thrombolysis were not felt to be feasible given the extensive clot burden. He was started on anticoagulation therapy. Over the next 10 days, he required intensive care unit admission due to progressive hepatic encephalopathy and fulminant liver failure. He continued to decline and eventually died of multiorgan failure. Autopsy revealed extensive, diffuse intrahepatic cholangiocarcinoma that had almost entirely replaced his normal liver parenchyma.

1129: SILICONE PNEUMONITIS AFTER BREAST AUGMENTATION SURGERY

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: The use of silicone for breast augmentation and other cosmetic procedures is common in the United States. In rare cases silicone can cause pulmonary toxicity related to injections and silicone gel prostheses. We describe a case of silicone pneumonitis in the postoperative setting. Methods: A 33 year old woman with no significant past medical history presented with acute shortness of breath, chest pain and hemoptysis after undergoing breast augmentation surgery the previous day. At initial evaluation, the patient presented with a Temp of 97.6 F, P 113, O2 Sat 84% on room air, RR 26, and BP 149/82. On exam she appeared in distress, tachycardic, and had rales bilaterally. She was placed on a non-re-breather and was transferred to the ICU. She had a CT Chest with contrast that was negative for pulmonary embolus, but showed diffuse patchy ground glass opacities identified in both lungs most prominent along the dependent segments of the upper lobes and along the basal regions of the lower lobes. She was started on IV Solumedrol with improvement in symptoms within in one day. She was slowly weaned of steroids and discharged 3 days after admission. Results: The first case of silicone pneumonitis was described in the 1970s. Some respiratory complications related to silicone include acute pneumonitis, acute respiratory distress syndrome (ARDS) and pulmonary embolism. Our patient presented with acute dyspnea, hemoptysis, chest pain and bilateral ground glass opacities consistent with pneumonitis. Other diseases such as fat embolism, ARDS and organizing pneumonias may have similar symptoms and image findings. However, the timing of surgery and immediate improvement of symptoms within days with steroids and without antibiotics make the diagnosis of silicone pneumonitis more likely. The definitive diagnosis of silicone pneumonitis is made with transbronchial or open lung biopsy and shows macrophages and lipoid vacuoles. However, given the quick improvement in symptoms in our patient we did not feel a biopsy was required. The treatment for silicone pneumonitis is respiratory support and steroids though whether the clinical use of steroids is required is unclear. In conclusion, silicone pneumonitis is a rare severe complication that should be considered in patients who present with acute inflammatory pulmonary processes following cosmetic procedures with silicone.