Jason Poston

Temporal Disorganization of Circadian Rhythmicity and Sleep-Wake Regulation in Mechanically Ventilated Patients Receiving Continuous Intravenous Sedation

OBJECTIVES Sleep is regulated by circadian and homeostatic processes and is highly organized temporally. Our study was designed to determine whether this organization is preserved in patients receiving mechanical ventilation (MV) and intravenous sedation. DESIGN Observational study. SETTING Academic medical intensive care unit. PATIENTS Critically ill patients receiving MV and intravenous sedation. METHODS Continuous polysomnography (PSG) was initiated an average of 2.0 (1.0, 3.0) days after ICU admission and continued ≥ 36 h or until the patient was extubated. Sleep staging and power spectral analysis were performed using standard approaches. We also calculated the electroencephalography spectral edge frequency 95% SEF₉₅, a parameter that is normally higher during wakefulness than during sleep. Circadian rhythmicity was assessed in 16 subjects through the measurement of aMT6s in urine samples collected hourly for 24-48 hours. Light intensity at the head of the bed was measured continuously. MEASUREMENTS AND RESULTS We analyzed 819.7 h of PSG recordings from 21 subjects. REM sleep was identified in only 2/21 subjects. Slow wave activity lacked the normal diurnal and ultradian periodicity and homeostatic decline found in healthy adults. In nearly all patients, SEF₉₅ was consistently low without evidence of diurnal rhythmicity (median 6.3 [5.3, 7.8] Hz, n = 18). A circadian rhythm of aMT6s excretion was present in most (13/16, 81.3%) patients, but only 4 subjects had normal timing. Comparison of the SEF₉₅ during the melatonin-based biological night and day revealed no difference between the 2 periods (P = 0.64). CONCLUSIONS The circadian rhythms and PSG of patients receiving mechanical ventilation and intravenous sedation exhibit pronounced temporal disorganization. The finding that most subjects exhibited preserved, but phase delayed, excretion of aMT6s suggests that the circadian pacemaker of such patients may be free-running.

Impact of Ventilator Adjustment and Sedation–analgesia Practices on Severe Asynchrony in Patients Ventilated in Assist-control Mode*

Objectives:Breath-stacking asynchrony during assist-control-mode ventilation may be associated with increased tidal volume and alveolar pressure that could contribute to ventilator-induced lung injury. Methods to reduce breath stacking have not been well studied. The objective of this investigation was to evaluate 1) which interventions were used by managing clinicians to address severe breath stacking; and 2) how effective these measures were. Setting:Sixteen-bed medical ICU. Patients and Interventions:Physiological study in consecutively admitted patients without severe brain injury, who had severe breath stacking defined as an asynchrony index greater than or equal to 10% of total breaths. During 30 minutes before (baseline) and after any intervention employed by the managing clinician, the ventilator flow, airway pressure, and volume/time waveforms were continuously recorded and analyzed to detect normal and stacked breaths. The initial approach taken was assigned to one of three categories: no intervention, increase of sedation–analgesia, or change of ventilator setting. Nonparametric Wilcoxon-Mann-Whitney tests and multiple regression were used for statistical analysis. Quantitative data are presented as median [25–75]. Main Results:Sixty-six of 254 (26%) mechanically ventilated patients exhibited severe breath-stacking asynchrony. A total of 100 30–minute sequences were recorded and analyzed in 30 patients before and after 50 clinical decisions for ongoing management (no intervention, n = 8; increasing sedation/analgesia, n = 16; ventilator adjustment, n = 26). Breath-stacking asynchrony index was 44 [27–87]% at baseline. Compared with baseline, the decrease of asynchrony index was greater after changing the ventilator setting (−99 [−92, −100]%) than after increasing the sedation–analgesia (−41 [−66, 7]%, p < 0.001) or deciding to tolerate the asynchrony (4 [−4, 12]%, p < 0.001). Pressure-support ventilation and increased inspiratory time were independently associated with the reduction of asynchrony index. Conclusions:Compared with increasing sedation–analgesia, adapting the ventilator to patient breathing effort reduces breath-stacking asynchrony significantly and often dramatically. These results support an algorithm beginning with ventilator adjustment to rationalize the management of severe breath-stacking asynchrony in ICU patients.

Pharmacist Contributions as Members of the Multidisciplinary ICU Team

Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists. Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.

Patient safety room of horrors: a novel method to assess medical students and entering residents' ability to identify hazards of hospitalisation

Background Patient safety curricula in undergraduate medical education (UME) are often didactic format with little focus on skills training. Despite recent focus on safety, practical training in residency education is also lacking. Assessments of safety skills in UME and graduate medical education (GME) are generally knowledge, and not application-focused. We aimed to develop and pilot a safety-focused simulation with medical students and interns to assess knowledge regarding hazards of hospitalisation. Methods A simulation demonstrating common hospital-based safety threats was designed. A case scenario was created including salient patient information and simulated safety threats such as the use of upper-extremity restraints and medication errors. After entering the room and reviewing the mock chart, learners were timed and asked to identify and document as many safety hazards as possible. Learner satisfaction was assessed using constructed-response evaluation. Descriptive statistics, including per cent correct and mean correct hazards, were performed. Results All 86 third-year medical students completed the encounter. Some hazards were identified by a majority of students (fall risk, 83% of students) while others were rarely identified (absence of deep venous thrombosis prophylaxis, 13% of students). Only 5% of students correctly identified pressure ulcer risk. 128 of 131 interns representing 49 medical schools participated in the GME implementation. Incoming interns were able to identify a mean of 5.1 hazards out of the 9 displayed (SD 1.4) with 40% identifying restraints as a hazard, and 20% identifying the inappropriate urinary catheter as a hazard. Conclusions A simulation showcasing safety hazards was a feasible and effective way to introduce trainees to safety-focused content. Both students and interns had difficulty identifying common hazards of hospitalisation. Despite poor performance, learners appreciated the interactive experience and its clinical utility.

Improving medical and pharmacy student confidence in medication management and attitudes about interprofessional collaboration by utilizing an interprofessional module

ABSTRACT Adverse drug events are common and often preventable. Educating the interprofessional workforce to appropriately manage medications as part of a team is a priority. An interprofessional medication management module for graduating medical and pharmacy students was developed. The module was case-based and co-led by physicians and pharmacists. Students completed pre- and post-module surveys regarding their attitudes about interprofessional collaboration, confidence in managing medications, and self-reported ability to perform the tasks laid out in the minimum geriatrics competencies as a result of the module. Eighteen medical and 13 pharmacy students participated over a two-year period. There was statistically significant improvement in students’ attitudes about interprofessional collaboration with regards to understanding their role and the role of others on the interprofessional team, and about teamwork between medical and pharmacy students. There was also statistically significant improvement in confidence with regards to the 3 medication management competencies after completion of the module. The vast majority of students agreed that the module improved their self-reported ability to manage medications. An interprofessional medication management module is an effective way to improve medical and pharmacy students’ attitudes about interprofessional collaboration and confidence in medication management.

ATS Core Curriculum 2017: Part II. Pediatric pulmonary medicine series editor: Jason T. Poston Part II Editors: Paul E. Moore and Jessica Pittman

Paul E. Moore, Jason T. Poston, Debra Boyer, Emily Barsky, Jonathan Gaffin, Kathleen B. Boyne, Kristie R. Ross, Laura Beth Mann Dosier, Timothy J. Vece, Alicia M. Casey, Sebastian K. Welsh, J. Wells Logan, Edward G. Shepherd, Pelton A. Phinzy, Howard B. Panitch, Christina M. Papantonakis, Eric D. Austin, Amir B. Orandi, Maleewan Kitcharoensakkul, Mark K. Abe, Amjad Horani, Jordan S. Rettig, and Jessica Pittman Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Section of Pulmonary and Critical Care Medicine, Department of Medicine, and Section of Critical Care, Department of Pediatrics, University of Chicago, Chicago, Illinois; Division of Respiratory Diseases and Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Division of Pediatric Pulmonology, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina; Division of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio; Division of Pulmonary Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri

ATS Core Curriculum 2017: Part IV. Adult Pulmonary Medicine

Gaëtane C. Michaud, Colleen L. Channick, Caralee Caplan-Shaw, Jonathan M. Iaccarino, Christopher G. Slatore, Brett Bade, Nichole Tanner, Catherine Robitaille, Anne V. Gonzalez, Eric Goudie, Moishe Liberman, Deepankar Sharma, Samira Shojaee, Christopher M. Merrick, Fabien Maldonado, Quyen L. Nguyen, Belinda Rivera-Lebron, and Jason T. Poston Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts; Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon; Division of Pulmonary, Critical Care, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Respirology, McGill University, Montreal, Quebec, Canada; Department of Surgery, Division of Thoracic Surgery, University of Montreal, Montreal, Quebec, Canada; Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, Virginia; Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois

ATS core curriculum 2014: Part II. Adult critical care medicine

Jakob I. McSparron, Margaret M. Hayes, Jason T. Poston, Carey C. Thomson, Henry E. Fessler, Renee D. Stapleton, W. Graham Carlos, Laura Hinkle, Kathleen Liu, Stephanie Shieh, Alyan Ali, Angela Rogers, Nirav G. Shah, Donald Slack, Bhakti Patel, Krysta Wolfe, William D. Schweickert, Rita N. Bakhru, Stephanie Shin, Rebecca E. Sell, and Andrew M. Luks Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; Division of Pulmonary and Critical Care, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts; Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland; Division of Pulmonary Disease and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont; Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Division of Nephrology, Department of Medicine, and Division of Critical Care Medicine, Department of Anesthesia, University of California San Francisco, San Francisco, California; Division of Nephrology, Department of Medicine, Saint Louis University, Saint Louis, Missouri; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California; Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Section of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, San Diego, California; and Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington

Hemoglobin-unchained and causing harm in sepsis?

Critical Care Medicine www.ccmjournal.org 917 on early cytokine/chemokine profiles. Anesthesiology 2006; 104:73–79 5. El-Solh AA, Vora H, Knight PR 3rd, et al: Diagnostic use of serum procalcitonin levels in pulmonary aspiration syndromes. Crit Care Med 2011; 39:1251–1256 6. El Solh AA, Akinnusi ME, Peter M, et al: Triggering receptors expressed on myeloid cells in pulmonary aspiration syndromes. Intensive Care Med 2008; 34:1012–1019 7. Weiss CH, Moazed F, DiBardino D, et al: Bron choalveolar Lavage Amylase Is Associated With Risk Factors For Aspiration and Predicts Bacterial Pneumonia. Crit Care Med 2013; 41:765–773 8. Clarke PD, Bain BC, Davies A, et al: Aspiration in seriously ill patients: A study of amylase in bronchial secretions. J Clin Pathol 1981; 34: 803–805 9. Nandapalan V, McIlwain JC, Hamilton J: A study of alpha-amylase activity in tracheobronchial secretions of seriously ill patients with tracheostomies. J Laryngol Otol 1995; 109:640–643