Ilya Kagan

Inhaled Aerosolized Insulin: A “Topical” Anti-inflammatory Treatment for Acute Lung Injury and Respiratory Distress Syndrome?

Acute lung injury (ALI) and the more severe acute respiratory distress syndrome (ARDS) are forms of pulmonary edema that result from robust local and systemic inflammatory states, such as sepsis. The morbidity and mortality associated with ALI and ARDS are significant and the treatment of these conditions presents a formidable challenge. Controlling hyperglycemia with insulin is a core component of patient management in the critically ill. Insulin treatment also exerts beneficial metabolic effects beyond glucose control, as well as non-metabolic effects, in insulin-resistant states. For instance, insulin inhibits NF-κB—dependent synthesis of pro-inflammatory factors and attenuates production of ROS. Indeed, intravenous administration of insulin ameliorates pulmonary injury and dysfunction in the LPS model of ALI. Most recently, an inhalable insulin formulation was shown to effectively reduce glucose concentrations with minimal impact on long-term pulmonary function. We propose that administering inhalable insulin to hyperglycemic ALI/ARDS patients could directly reduce alveolar inflammation while reducing circulating glucose levels.

Better late than never: a re-examination of ethical dilemmas in coping with severe acute respiratory syndrome

Summary At the end of 2002 severe acute respiratory syndrome (SARS) emerged and spread worldwide. The pathogen was unknown, as was its mechanism of transfer, and there was no effective therapy for the disease. There was a large element of hysteria and anxiety in societys reaction to SARS. The initial steps taken to cope with SARS were clear-cut and even dramatic. Decision-making in a time of emergency is associated with a high potential for ethical dilemmas and conflicts. In the course of efforts to cope with a threatening disease, it is important to appraise our activities from an ethical point of view. A retrospective look at this period of time shows that we did not do this. This article examines the ethical aspects of the process undertaken to cope with SARS in our medical centre.

Computerized Lung Acoustic Monitoring Can Help to Differentiate between Various Chest Radiographic Densities in Critically Ill Patients

Background: Complementary bedside lung monitoring modalities are often sought in order to assist in the differentiation between several lung opacities in the intensive care unit (ICU). Objectives: To evaluate the use of computerized lung acoustic monitoring as a complementary approach in the differentiation between various chest radiographic densities in critically ill patients. Methods: Lung vibration intensity was assessed in 82 intensive care patients using vibration response imaging. Patients were classified according to their primary findings on chest radiography (CXR): consolidation (n = 35), congestion (n = 10), pleural effusion (n = 15), atelectasis/hypoinflation (n = 10) and normal findings (n = 12). Sixty patients were mechanically ventilated and 22 patients were spontaneously breathing. Results: Significantly elevated vibration intensity was detected in patients with consolidation, as opposed to pleural effusion, atelectasis and normal CXR (p < 0.01, Mann-Whitney U test). Vibration intensity was also increased for congestion, but this increase was not significant. The positive predictive value of CXR lung opacity in combination with increased vibration intensity to detect consolidations and/or congestions was 95% (20/21). Furthermore, vibration intensity was significantly higher in mechanically ventilated patients compared to spontaneously breathing patients (p = 0.001, Mann-Whitney U test). Differences related to gender, age and body position were not significant. Conclusions: Computerized lung acoustic monitoring at the bedside was found to be a useful, readily available, noninvasive, adjunctive tool in the differentiation between various CXR densities in critically ill patients.

Changes in regional distribution of lung sounds as a function of positive end-expiratory pressure

IntroductionAutomated mapping of lung sound distribution is a novel area of interest currently investigated in mechanically ventilated, critically ill patients. The objective of the present study was to assess changes in thoracic sound distribution resulting from changes in positive end-expiratory pressure (PEEP). Repeatability of automated lung sound measurements was also evaluated.MethodsRegional lung sound distribution was assessed in 35 mechanically ventilated patients in the intensive care unit (ICU). A total of 201 vibration response imaging (VRI) measurements were collected at different levels of PEEP between 0 and 15 cmH2O. Findings were correlated with tidal volume, oxygen saturation, airway resistance, and dynamic compliance. Eighty-two duplicated readings were performed to evaluate the repeatability of the measurement.ResultsA significant shift in sound distribution from the apical to the diaphragmatic lung areas was recorded when increasing PEEP (paired t-tests, P < 0.05). In patients with unilateral lung pathology, this shift was significant in the diseased lung, but not as pronounced in the other lung. No significant difference in lung sound distribution was encountered based on level of ventilator support needed. Decreased lung sound distribution in the base was correlated with lower dynamic compliance. No significant difference was encountered between repeated measurements.ConclusionsLung sounds shift towards the diaphragmatic lung areas when PEEP increases. Lung sound measurements are highly repeatable in mechanically ventilated patients with various lung pathologies. Further studies are needed in order to fully appreciate the contribution of PEEP increase to diaphragmatic sound redistribution.

Assessment of orthostatic hypotension in the emergency room

The study sought to determine the duration of standing needed to detect most cases of orthostatic hypotension (OH) in the emergency room (ER) and to correlate OH with symptoms, hospitalization and survival. Patients attending a tertiary‐center ER within a 2‐month period underwent orthostatic tests after 1, 3 and 5 min of standing. OH was defined as a drop of ⩾20 mmHg in systolic pressure or ⩾10 mmHg in diastolic pressure on assuming an upright posture. Of the 814 patients tested (402 men, mean age 56.6±19.9 years), 206 (25.3%) had OH, detected in most cases (83.5%) after 3 min of standing. OH was associated with significantly higher supine systolic (p = 0.013) and diastolic (p = 0.004) blood pressure, symptoms of syncope (r = 0.11, p<0.001) or dizziness (r = 0.14, p<0.0001) and risk of hospitalization (50.9% vs 22.9%, p<0.0001). Crude mortality was similar between patients with and without OH (13.8% vs 8.7%, p = 0.06). However, on age‐adjusted analysis, patients older than 75 years with OH had significantly increased mortality (p = 0.04). In conclusion, 3 min of standing is apparently sufficient for the diagnosis of most cases of OH. Considering the high rate of OH and its predictive value for hospitalization, it should be routinely assessed in all ER patients.

Red blood cell transfusions—are we narrowing the evidence-practice gap? An observational study in 5 Israeli intensive care units

PURPOSE The aim of the study was to document transfusion practices in a cross section of general intensive care units (ICUs) in Israel and to determine whether current guidelines are being applied. MATERIALS AND METHODS This prospective study was performed in 5 general ICUs in Israel over a 3-month period. Red cell transfusion data collected on consecutive patients included the trigger, units transfused per transfusion event, and indications, categorized either to treat a specified condition for which transfusions may be beneficial (acute hemorrhage, acute myocardial ischemia, or severe sepsis) or to treat a low hemoglobin concentration. RESULTS Of the 238 patients studied, 50% received at least one red blood cell transfusion. The main indication for transfusion (43.7%, or 162/368 U transfused) was to treat a low hemoglobin concentration, in the absence of one of the specified conditions. Total red cell use was 3.0 ± 2.9 U per admission, and patients received a mean of 1.2 ± 0.4 U per transfusion event. The transfusion trigger for the whole group was 7.9 ± 1.1 g/dL. This did not differ significantly between the indications apart from a significantly higher trigger for patients with acute myocardial ischemia (8.8 ± 0.9 g/dL). In addition, patients with a history of heart disease had a higher trigger irrespective of the primary indication for transfusion and received significantly more units per transfusion event. Patients receiving a transfusion had significantly longer ICU stay and hospital mortality. CONCLUSIONS Our study showed that evidence-practice gaps continue to exist, and it appears that physician behavior is mainly driven by the absolute level of hemoglobin. Educational interventions focused on these factors are required to limit the widespread and often unnecessary use of this scarce and potentially harmful resource.

Comparison between two metabolic monitors in the measurement of resting energy expenditure and oxygen consumption in diabetic and non-diabetic ambulatory and hospitalized patients

OBJECTIVE The aim of this study was to assess the validity and reliability of the Fitmate metabolic system in measuring the oxygen consumption and resting metabolic rate (RMR) in ambulatory and hospitalized patients. METHODS We conducted a prospective simultaneous clinical comparison. We enrolled 37 patients (19 women and 18 men) for the four groups of the study. Group 1 (n = 12) included patients receiving home parenteral nutrition. Group 2 (n = 5) included diabetic overweight outpatients with body mass index >30 kg/m(2) and hemoglobin A1c > 8 g/dL. Group 3 (n = 10) included hospitalized patients receiving artificial nutrition. Group 4 (n = 10) included patients with congenital heart disease, pulmonary hypertension of any etiology, and other heart disease who have had hemodynamic evaluation during catheterization by the adult congenital team. The patients were tested successively during the same session using the Fitmate metabolic system for 15 min and the Deltatrac II metabolic monitor for 20 min, measuring resting energy expenditure and oxygen consumption. The test was conducted in random order. RESULTS No significant differences were found between Fit Mate and Deltatrac II for oxygen consumption (238 ± 18 and 240 ± 18 mL/min, respectively, P = 0.72, r = 0.86, mean ± SD absolute difference 22.32 ± 16.99 mL/min) or RMR (1659 ± 122.34 and 1625 ± 118.4 kcal/d, P = 0.28, r = 0.87, mean ± SD absolute difference 152.9 ± 111.95 kcal/d). A degree of limit of agreement (403 kcal) was observed using the Bland-Altman test. When compared with Harris-Benedict predictive equations, Fitmate was found to be superior in accuracy. CONCLUSIONS These data indicate that the Fitmate using a mask provided a fair evaluation of REE despite a large limit of agreement. It remains a reliable and valid system for measuring oxygen consumption and RMR in nonventilated patients.

Patient Rights and Law: tobacco smoking in psychiatric wards and the Israeli Prevention of Smoking Act

In August 2001, the Israeli Ministry of Health issued its Limitation of Smoking in Public Places Order, categorically forbidding smoking in hospitals. This forced the mental health system to cope with the issue of smoking inside psychiatric hospitals. The main problem was smoking by compulsorily hospitalized psychiatric patients in closed wards. An attempt by a psychiatric hospital to implement the tobacco smoking restraint instruction by banning the sale of cigarettes inside the hospital led to the development of a black market and cases of patient exploitation in return for cigarettes. This article surveys the literature dealing with smoking among psychiatric patients, the role of smoking in patients and the moral dilemmas of taking steps to prevent smoking in psychiatric hospitals. It addresses the need for public discussion on professional caregivers’ dilemmas between their commitment to uphold the law and their duty to act as advocates for their patients’ rights and welfare.

Caloric Requirements of Patients With Brain Impairment and Cerebral Palsy Who Are Dependent on Chronic Ventilation

Background and Objective: Israeli law mandates chronic ventilator support for children and adolescents who are severely brain impaired and show minimal responses. Feeding protocols in these cases have been based on the caloric requirements of healthy children, deducting calories for lack of activity as well as an individual adjustment according to the cerebral palsy growth curves. However, patients are still inclined to gain excessive weight. Our objective was to determine the caloric requirements of these patients. Design and Method: Sixteen patients hospitalized in a dedicated unit who were ventilated through tracheostomies and fed via gastrostomies were included. Patients were aged 3–24 years; duration of ventilation was 1–7.5 years; and diagnoses included congenital genetic or brain malformations (n = 9), hypoxic accidents (n = 4), and postbacterial or postviral encephalitis (n = 3). Resting energy expenditure (REE) was determined by indirect calorimetry. REE values were compared with the caloric requirements of age-comparable healthy children and the calories actually delivered. Data were analyzed with paired t tests, Pearson correlations, and linear regression. Results: The REE of our patients was 46% lower than the estimated caloric requirements of healthy children. In practice, patients received 32% more calories than that measured by REE. These findings were not affected by age, weight, diagnosis, or length of hospitalization. Conclusions: The caloric expenditure of these patients is very low. A diet guided by indirect calorimetry is proposed to aid in providing optimal nutrition support for this unique population to avoid overfeeding and obesity.

Nutritional Imbalances during Extracorporeal Life Support

Extracorporeal life support has become an integral part of the technologies used in the intensive care. Renal replacement therapy is used daily and extracorporeal membrane oxygenation (ECMO) has become more popular in the recent years with the increasing prevalence of influenza-induced severe respiratory failure. Many years ago, critically ill infants requiring ECMO were found to have the highest rates of whole body protein breakdown ever recorded. However, most of the physicians are not aware of the nutritional consequences of the use of new technologies. The aim of this chapter is to describe the changes induced by artificial membranes and the required therapies to optimize nutritional support.