Imran Khalid

Early Enteral Nutrition and Outcomes of Critically Ill Patients Treated With Vasopressors and Mechanical Ventilation

OBJECTIVE To determine the effect of early enteral feeding on the outcome of critically ill medical patients whose hemodynamic condition is unstable. METHODS Prospectively collected data in a multi-institutional medical intensive care unit database were analyzed retrospectively. A total of 1174 patients were identified who required mechanical ventilation for more than 2 days and were treated with vasopressor agents to support blood pressure. The patients were divided into 2 groups: those who received enteral nutrition (n = 707) within 48 hours of the start of mechanical ventilation, termed the early enteral nutrition group, and those who did not (n = 467), termed the late enteral nutrition group. The primary end points were overall intensive care unit and hospital mortality. Subgroup analyses were used to evaluate potential confounding variables. The data were also analyzed after adjustments for confounding by matching for propensity score. RESULTS Intensive care unit and hospital mortality were lower in the early enteral nutrition group than in the late enteral group: 22.5% vs 28.3%; P = 03; and 34.0% vs 44.0%; P < .001, respectively. The beneficial effect of early feeding was more evident in the sickest patients, that is, those treated with multiple vasopressors (odds ratio, 0.36; 95% confidence interval, 0.15-0.85) and those without early improvement (odds ratio, 0.59; 95% confidence interval, 0.39-0.90). When adjustments were made for confounding by matching for propensity score, early feeding was associated with decreased hospital mortality. CONCLUSION Early enteral nutrition may be associated with reduced intensive care unit and hospital mortality in patients whose hemodynamic condition is unstable.

Acute Management and Long-Term Survival Among Subjects With Severe Middle East Respiratory Syndrome Coronavirus Pneumonia and ARDS

BACKGROUND: Data on the management, clinical course, and outcome of critical patients with Middle East Respiratory Syndrome coronavirus are scarce. We report here our experience and long-term outcome of such patients. METHODS: Subjects intubated for management of ARDS from Middle East Respiratory Syndrome coronavirus pneumonia and ARDS during the April-May 2014 outbreak were included. Their characteristics, ICU course, management, and outcome were evaluated. RESULTS: Fourteen subjects, including 3 health-care workers, met study criteria. Besides 2 health-care workers, all subjects had comorbidities. Predominant symptoms were fever, cough, and dyspnea. The worst median PaO2/FIO2 ratio of 118 post-intubation was seen on the third day, and median APACHE II score was 27. All subjects received lung-protective ventilation and 1 mg/kg/d methylprednisolone infusion for ARDS. Eleven subjects received ribavirin and peginterferon α-2a. Subjects had a critical ICU course and required neuromuscular blockade (n = 11; 79%), required rescue therapy for respiratory failure (n = 8; 57%), developed shock (n = 10; 71%), and required renal replacement therapy (n = 8; 57%). Declining C-reactive protein levels correlated with clinical improvement despite continued positive real-time polymerase chain reaction results. Nine subjects died in ICU. Five subjects, including 3 health-care workers, were discharged from hospital and were alive after 1 y. CONCLUSIONS: Middle East Respiratory Syndrome coronavirus pneumonia with ARDS has high mortality in subjects with comorbidities. The mainstay of treatment is meticulous ARDS management. Those who survived the acute infection and its complications remained well after 1 y in our study. The role of ribavirin and interferon warrants urgent further evaluation.

End-of-Life Care in Muslim Brain Dead Patients: A 10-Year Experience

Background: In Muslim countries, end-of-life practices in Muslim brain-dead patients are unknown. We conducted this study to evaluate this issue. Results: We identified 42 brain-dead patients between 2001 and 2011. The expectant terminal extubation occurred only in 5. Largely due to family opposition, 2 patients remained “full code,” and rests were “do not attempt resuscitation” with varying usage of “life-sustaining” therapies. Only 2 out of 24 eligible patients donated organs. There was minimal involvement of social worker, palliative team, or Muslim chaplain in the end-of-life discussions. Conclusion: In Muslim patients, the concept of terminal withdrawal and organ donation after brain death is still not well accepted. Future multicenter studies, involving palliative teams, should focus on improving these issues.

Outcomes of Patients Treated With Noninvasive Ventilation by a Medical Emergency Team on the Wards

BACKGROUND: Initiation of noninvasive ventilation (NIV) on the wards is not universally accepted. Medical emergency teams (METs) provide acute care and monitoring to deteriorating patients on the general wards. Whether it is safe for an MET to start NIV in ward patients with respiratory distress remains unclear. METHODS: We evaluated 1,123 MET calls in 30,217 ward patients between January 2009 and June 2011 from the prospectively maintained MET database in our tertiary care hospital. We identified ward patients with acute desaturation (< 90%) and tachypnea (breathing frequency > 28 breaths/min), for whom an MET was called. Subjects transferred to the ICU at the end of an MET call were excluded. The remaining ward subjects were divided into 2 groups: patients who were not started on NIV by the MET; versus patients who were started on NIV by the MET. The primary outcome was endotracheal intubation or ICU transfer within 48 hours of MET activation. Secondary outcome measures were 28-day mortality and ICU mortality. RESULTS: Two hundred thirty-eight MET subjects met the study criteria, and 109 immediate ICU transfers were excluded. Of the remaining 129 ward subjects, 54 were in the NIV group, and 75 in the no-NIV group. The NIV group subjects were sicker (mean Acute Physiology and Chronic Health Evaluation II score 17.6 ± 5.1 versus 14.4 ± 5, P < .001). Subjects with pulmonary edema, COPD exacerbation, or asthma exacerbation were more likely, while those with pneumonia were less likely to be placed on NIV. The primary outcome was reached in 2/54 (3.7%) of the NIV subjects and 12/75 (16%) of the no-NIV subjects (P = .03). There was no significant difference (P > .30) between the groups in 28-day mortality (7.4% vs 13.3%) or ICU mortality (3.7% vs 8%). CONCLUSIONS: In selected ward patients, especially those with COPD or pulmonary edema, NIV can be safely initiated by an MET.

Healthcare Workers Emotions, Perceived Stressors and Coping Strategies During a MERS-CoV Outbreak

Objective Healthcare workers (HCWs) are at high risk of contracting Middle East respiratory syndrome coronavirus (MERS-CoV) during an epidemic. We explored the emotions, perceived stressors, and coping strategies of healthcare workers who worked during a MERS-CoV outbreak in our hospital. Design A cross-sectional descriptive survey design. Setting A tertiary care hospital. Participants HCWs (150) who worked in high risk areas during the April–May 2014 MERS-CoV outbreak that occurred in Jeddah, Saudi Arabia. Methods We developed and administered a “MERS-CoV staff questionnaire” to study participants. The questionnaire consisted of 5 sections with 72 questions. The sections evaluated hospital staffs emotions, perceived stressors, factors that reduced their stress, coping strategies, and motivators to work during future outbreaks. Responses were scored on a scale from 0–3. The varying levels of stress or effectiveness of measures were reported as mean and standard deviation, as appropriate. Results Completed questionnaires were returned by 117 (78%) of the participants. The results had many unique elements. HCWs ethical obligation to their profession pushed them to continue with their jobs. The main sentiments centered upon fear of personal safety and well-being of colleagues and family. Positive attitudes in the workplace, clinical improvement of infected colleagues, and stoppage of disease transmission among HCWs after adopting strict protective measures alleviated their fear and drove them through the epidemic. They appreciated recognition of their efforts by hospital management and expected similar acknowledgment, infection control guidance, and equipment would entice them to work during future epidemics. Conclusion The MERS-CoV outbreak was a distressing time for our staff. Hospitals can enhance HCWs experiences during any future MERS-CoV outbreak by focusing on the above mentioned aspects.

A welder with pneumosiderosis: a case report

Pneumosiderosis or Welders lung is an occupational lung disease which is usually seen after chronic exposure to iron dust. We present a case of a 64-year-old welder in whom the diagnosis of pneumosiderosis was made by lung biopsies. We also briefly review the literature regarding the disease, its prognosis and association with development of lung cancer. Avoidance of iron dust exposure and implementing prevention strategies in people at risk are the mainstay of therapy.

Pericardial Tamponade after Superior Vena Cava Stent: Are Nitinol Stents Safe?

Placement of a single new-generation nitinol stent resulted in acute pericardial tamponade in a 70-year-old man with superior vena cava syndrome.

A Unique Case of Pulmonary Hyalinizing Granuloma Associated With FDG-avid PET Scan and Deep Venous Thrombosis.

An 83-year-old obese woman with a 60-pack-year smoking history was referred for evaluation of an abnormal chest radiograph [chest x-ray (CXR)]. Her past medical history was significant for recurrent deep venous thrombosis without any predisposing factors. CXR showed a large mass in the right mid lung and another nodule at the right apex, highly suspicious for a neoplastic process. These were not present on a CXR from 2 years earlier. An 18fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scan revealed that all lesions were strongly FDG-avid. Six CT-guided core-needle lung biopsy specimens were obtained from the lung mass and all contained dense, lamellar, or “ropy” keloid-like collagen bundles arranged in a haphazard pattern. The biopsy specimens lacked significant necrosis and granulomas. Congo red stain with polarization was also negative for amyloid. The diagnosis of pulmonary hyalinizing granuloma (PHG) was made. A complete hypercoagulable workup was performed but no underlying abnormalities were found, including a negative lupus anticoagulant and malignancy workup. The patient was maintained on warfarin and followed with serial CT scans for 1 year, with spontaneous regression in the lung mass. The case is unique as it is the first case that reports an association of PHG with recurrent deep venous thrombosis in the absence of autoimmune or procoagulant factors and emphasizes the need for life-long anticoagulation in such scenarios. Also, we report the FDG-avid PET scan findings here that are novel for this disease in adults and add PHG to the list of diseases causing false-positive PET scans when malignancy is suspected.

Introducing the Comprehensive Unit-based Safety Program for mechanically ventilated patients in Saudi Arabian Intensive Care Units

Over the past decade, there have been major improvements to the care of mechanically ventilated patients (MVPs). Earlier initiatives used the concept of ventilator care bundles (sets of interventions), with a primary focus on reducing ventilator-associated pneumonia. However, recent evidence has led to a more comprehensive approach: The ABCDE bundle (Awakening and Breathing trial Coordination, Delirium management and Early mobilization). The approach of the Comprehensive Unit-based Safety Program (CUSP) was developed by patient safety researchers at the Johns Hopkins Hospital and is supported by the Agency for Healthcare Research and Quality to improve local safety cultures and to learn from defects by utilizing a validated structured framework. In August 2015, 17 Intensive Care Units (ICUs) (a total of 271 beds) in eight hospitals in the Kingdom of Saudi Arabia joined the CUSP for MVPs (CUSP 4 MVP) that was conducted in 235 ICUs in 169 US hospitals and led by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. The CUSP 4 MVP project will set the stage for cooperation between multiple hospitals and thus strives to create a countrywide plan for the management of all MVPs in Saudi Arabia.

Outcome of patients treated with noninvasive ventilation by a medical emergency team on the wards: scarce and probably secure and resourceful monitoring in select subjects--reply.

In Reply: We reviewed the comments by Killen H Briones Claudett. Of 238 subjects, we excluded the ones who were immediately transferred to the ICU. These subjects were deemed to be ICU candidates during the initial medical emergency team (MET) evaluation and were not the focus of our study.