J. Steven Hata

Economic trends from 2003 to 2010 for perioperative myocardial infarction: a retrospective, cohort study.

Background:Perioperative myocardial infarction (PMI) is a major surgical complication that is costly and causes much morbidity and mortality. Diagnosis and treatment of PMIs have evolved over time. Many treatments are expensive but may reduce ancillary expenses including the duration of hospital stay. The time-dependent economic impact of novel treatments for PMI remains unexplored. The authors thus evaluated absolute and incremental costs of PMI over time and discharge patterns. Methods:Approximately 31 million inpatient discharges were analyzed between 2003 and 2010 from the California State Inpatient Database. PMI was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Propensity matching generated 21,637 pairs of comparable patients. Quantile regression modeled incremental charges as the response variable and year of discharge as the main predictor. Time trends of incremental charges adjusted to 2012 dollars, mortality, and discharge destination was evaluated. Results:Median incremental charges decreased annually by

Reduced mortality with noninvasive hemodynamic monitoring of shock

1,940 (95% CI,

RETRACTED: A New Rule for Femoral Nerve Blocks

620 to

Implementing a hybrid web-based curriculum for an elective medical student clerkship in a busy surgical intensive care unit (ICU): effect on test and satisfaction scores.

3,250); P < 0.001. Compared with non-PMI patients, the median length of stay of patients who experienced PMI decreased significantly over time: yearly decrease was 0.16 (0.10 to 0.23) days; P < 0.001. No mortality differences were seen; but over time, PMI patients were increasingly likely to be transferred to another facility. Conclusions:Reduced incremental cost and unchanged mortality may reflect improving efficiency in the standard management of PMI. An increasing fraction of discharges to skilled nursing facilities seems likely a result from hospitals striving to reduce readmissions. It remains unclear whether this trend represents a transfer of cost and risk or improves patient care.

The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: a systematic review.

PURPOSEnThis study compared clinical outcomes associated with exposure to pulmonary artery catheters (PACs), central venous catheters (CVCs), arterial pressure waveform analysis for cardiac output (APCO), or no central monitoring (NCM) in patients with shock.nnnMATERIALS AND METHODSnWe assessed 6929 consecutive patients from 2003 to 2006 within a surgical intensive care unit of a university hospital, identifying 237 mechanically ventilated patients with shock.nnnRESULTSnAdjusted for severity of illness, use of APCO monitoring, compared with other options, was associated with reduced intensive care unit mortality (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.18-0.77) and 28-day mortality (OR, 0.43; 95% CI, 0.22-0.85). Other monitors were not associated with changes of 28-day mortality (CVC: OR, 0.63; 95% CI, 0.34-1.17; PAC: OR, 0.78; 95% CI, 0.36-1.69) or were associated with increased risk (NCM: OR, 2.29; 95% CI, 1.14-4.61). There were significant differences in the fluid and vasoactive drug prescriptions among the groups.nnnCONCLUSIONSnThis study supports an association between the use of APCO monitoring and reduction in mortality in shock compared with traditional methods of monitoring. Although it is impossible to exclude the role of unrecognized/unrecorded differences among the groups, these findings may result from differences in supportive care, directed by monitor technology.

The acute effectiveness and safety of the constant-flow, pressure-volume curve to improve hypoxemia in acute lung injury.

Background and Objectives: Acupuncture points are described by use of a proportional system that is based on the width of the thumb at the level of the distal interphalangeal joint, defined as 1 CUN. Our study tested first the correlation between the CUN and weight and height in 500 Americans and second the hypothesis that the CUN system is superior to the conventional landmarks to localize the femoral nerve 1 or 2 cm lateral to the artery in a prospective, double-blinded, randomized study. Methods: Sixty-two patients were randomized to receive a femoral nerve block by a needle entry point either 1 CUN lateral, 1 cm lateral, or 2 cm lateral to the femoral artery at the level of the inguinal crease. The time from needle entry to injection of local anesthetic was measured by an investigator blind to the technique, who also counted the frequency of needle repositioning, graded the ease of the block and its success, and registered complications. Results: Good correlation occurred between weight and CUN (r = 0.79) and height and CUN (r = 0.83), which indicates that the CUN of a normal person (predefined as 175 cm tall and 70 kg weight) is 18.7 ± 1 mm. In the CUN group, the femoral block was achieved significantly faster (P < .01) with fewer attempts (P < .003). The success rate was the same and complications did not differ significantly between the groups. Conclusion: A needle insertion point 1 CUN lateral to the midpoint of the palpated femoral artery at the level of the inguinal crease makes femoral nerve blocks faster and easier compared with conventional landmark 1 cm to 2 cm lateral to the artery.

Correlation between PaO2/FiO2 and airway and vascular parameters in the assessment of cellular ex vivo lung perfusion system

OBJECTIVEnTo determine whether a hybrid traditional and web-based curriculum improves test scores and enrollment among senior medical students in an elective critical care rotation.nnnDESIGN AND SETTINGnRetrospective study in a surgical ICU at a major academic center.nnnSUBJECTSnOne hundred twenty-one fourth year medical students completing an elective ICU clerkship between 2007 and 2010.nnnINTERVENTIONSnPre-test and post-test during a 4-week rotation.nnnMETHODSnWe implemented a hybrid curriculum that involved both traditional teaching methods and a new online core curriculum that incorporating audio, video, and text using screen capture technology. The curriculum was hosted on a secure online portal called ICON (Desire2Learn Inc., Ontario, Canada). The core curriculum covered topics that were considered essential to meet the didactic objectives of the rotation. MEASUREMENTS AND EVALUATIONS: A pre-test was administered online on day 1 of the rotation. A post-test was administered on the second to last day of the rotation. Both tests were composed of 20 questions randomly chosen from a question bank of 100 questions. The tests are managed (administering, grading, and reporting) exclusively online.nnnRESULTSnOne hundred twenty-one medical students have successfully completed the clerkship since implementing the new curriculum. Each group of students showed an improvement in the mean post-test score by at least 17%+ to 10%. The satisfaction scores of the clerkship improved consistently from 2007 and is currently rated at 4.31 ± 0.85 (on a 5-point scale). The rotation is in the top 25(th) percentile of all clinical clerkships offered at the University of Iowa.nnnCONCLUSIONnA systematically implemented hybrid web-based critical care curriculum can improve knowledge based test scores and overall clerkship satisfaction scores in a busy surgical ICU.

Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases:

Purpose Methods to optimize positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) remain controversial despite decades of research. The pressure–volume curve (PVC), a graphical ventilator relationship, has been proposed for prescription of PEEP in ARDS. Whether the use of PVC’s improves survival remains unclear. Methods In this systematic review, we assessed randomized controlled trials (RCTs) comparing PVC-guided treatment with conventional PEEP management on survival in ARDS based on the search of the National Library of Medicine from January 1, 1960, to January 1, 2010, and the Cochrane Central Register of Controlled Trials. Three RCTs were identified with a total of 185 patients, 97 with PVC-guided treatment and 88 with conventional PEEP management. Results The PVC-guided PEEP was associated with an increased probability of 28-day or hospital survival (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.5, 4.9) using a random-effects model without significant heterogeneity (I 2 test: P = .75). The PVC-guided ventilator support was associated with reduced cumulative risk of mortality (−0.24 (95% CI −0.38, −0.11). The PVC-managed patients received greater PEEP (standardized mean difference [SMD] 5.7 cm H2O, 95% CI 2.4, 9.0) and lower plateau pressures (SMD −1.2 cm H2O, 95% CI −2.2, −0.2), albeit with greater hypercapnia with increased arterial pCO2 (SMD 8 mm Hg, 95% CI 2, 14). Weight-adjusted tidal volumes were significantly lower in PVC-guided than conventional ventilator management (SMD 2.6 mL/kg, 95% CI −3.3, −2.0). Conclusion This analysis supports an association that ventilator management guided by the PVC for PEEP management may augment survival in ARDS. Nonetheless, only 3 randomized trials have addressed the question, and the total number of patients remains low. Further outcomes studies appear required for the validation of this methodology.

Mechanically Ventilated, Cardiothoracic Surgical Patients Have Significantly Different Energy Requirements Comparing Indirect Calorimetry and the Penn State Equations

Objective: To investigate the effectiveness of the constant-flow, pressure-volume curve (PVC) to prescribe positive end-expiratory pressure (PEEP) in acute lung injury (ALI) and risk of cardiopulmonary deterioration during the PVC process. Design: A retrospective, cohort study. Setting: A surgical intensive care unit (ICU) of a tertiary, university hospital. Patients: Fifty consecutive ventilated patients diagnosed with ALI undergoing the PVC maneuver from 1999 to 2003. Interventions: Titration of PEEP based on the lower inflection point of the constant-flow, pressure-volume curve. Measurements and Main Results: Patients were divided into 2 groups based on PVC-guided PEEP changes of <3 cm H2O (PVC-NC or “no change”) or ≥3 cm H2O (PVC-CHG or “change”) from the initial empiric prescription. There was a greater increase in partial pressure of arterial oxygen (PaO2)/fractional concentration of inspired oxygen (FiO2) in the PVC-CHG group, with a mean change of 80 ± 50 (95% confidence interval [CI] 61, 98) versus 42 ± 54 (95% CI 17, 67) in the PVC-NC group. Eighty-two percent of patients (41/50) showed an increase in ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) by 20% within 6 to 24 hours after the PVC test—greater in the PVC-CHG group (OR 1.44, 95% CI 1.02, 2.01). Thirteen percent (4/30) within the PVC-CHG group and none within the PVC-NC group (0/20) required a 25% increase in vasoactive infusion rates (P = .089) in relation to the procedure. Univariate logistic regression showed that PVC-CHG was significantly associated with a 20% change in PaO2/FiO2 (OR 7.54, 95% CI 1.37, 41.41). Multivariate logistic modeling showed that PVC-guided PEEP changes of ≥3 cm H2O, age ≤65 years, and pre-PVC FiO2 ≥.85 were significantly associated with a 20% increase in PaO2/FiO2 (receiver operator area under the curve = .86). Conclusions: In the setting of acute lung injury, use of the constant-flow, pressure-volume curve to prescribe PEEP appears associated with improvement in oxygenation with limited risk of acute, process-related, cardiopulmonary deterioration.

A Prospective, Observational Clinical Trial of Fever Reduction to Reduce Systemic Oxygen Consumption in the Setting of Acute Brain Injury

BACKGROUNDnEx vivo lung perfusion (EVLP) may be an essential process for the pre-transplant evaluation of the donor lungs. Currently, the partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2, or PF) ratio is the standard in the assessment of lung function in cellular EVLP, whereas other parameters, including airway and vascular parameters, have only been partially utilized. The primary purpose of this study is to assess the potential utility of other parameters as a surrogate of lung function in EVLP.nnnMETHODSnYorkshire swine lungs (n = 12) and rejected human donor lungs (n = 12) were perfused in cellular-based EVLP for 2 hours. PF ratio, airway parameters (peak airway pressure, plateau pressure, dynamic compliance and static compliance) and vascular parameters (pulmonary vascular resistance and pulmonary artery pressure) were measured. The correlations between PF ratio and one of these parameters were analyzed.nnnRESULTSnCorrelations were identified in the following combinations: PF ratio and airway parameters (p < 0.05, each); PF ratio and vascular parameters (p < 0.05, each); static compliance and pulmonary vascular resistance in swine lungs (p = 0.0001); and PF ratio and airway parameters in rejected human lungs (p < 0.05, each). There were significant differences in all parameters between suitable cases and non-suitable cases in swine lungs (p < 0.02, each).nnnCONCLUSIONSnOur results show that airway parameters are complementary quantitative indicators of lung function in cellular EVLP, based on the correlations with PF ratio in both swine lungs and human lungs.