Jordan S. Rettig

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

OBJECTIVE The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting. METHODS The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure. RESULTS Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help. CONCLUSIONS Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.

Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU

ObjectiveTo examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients.Design and settingProspective randomized, double-blind controlled trial in a surgical ICU.Patients44 patients who developed AWS after admission to the ICU.InterventionsPatients were randomized to either (a) a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b) the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group).Measurements and resultsThe administration of “as-needed” medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%).ConclusionsWe conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.

Mechanical ventilation guided by electrical impedance tomography in experimental acute lung injury.

Objective:To utilize real-time electrical impedance tomography to guide lung protective ventilation in an animal model of acute respiratory distress syndrome. Design:Prospective animal study. Setting:Animal research center. Subjects:Twelve Yorkshire swine (15 kg). Interventions:Lung injury was induced with saline lavage and augmented using large tidal volumes. The control group (n = 6) was ventilated using ARDSnet guidelines, and the electrical impedance tomography–guided group (n = 6) was ventilated using guidance with real-time electrical impedance tomography lung imaging. Regional electrical impedance tomography–derived compliance was used to maximize the recruitment of dependent lung and minimize overdistension of nondependent lung areas. Tidal volume was 6 mL/kg in both groups. Computed tomography was performed in a subset of animals to define the anatomic correlates of electrical impedance tomography imaging (n = 5). Interleukin-8 was quantified in serum and bronchoalveolar lavage samples. Sections of dependent and nondependent regions of the lung were fixed in formalin for histopathologic analysis. Measurements and Main Results:Positive end-expiratory pressure levels were higher in the electrical impedance tomography–guided group (14.3 cm H2O vs. 8.6 cm H2O; p < 0.0001), whereas plateau pressures did not differ. Global respiratory system compliance was improved in the electrical impedance tomography–guided group (6.9 mL/cm H2O vs. 4.7 mL/cm H2O; p = 0.013). Regional electrical impedance tomography–derived compliance of the most dependent lung region was increased in the electrical impedance tomography group (1.78 mL/cm H2O vs. 0.99 mL/cm H2O; p = 0.001). Pao2/FIO2 ratio was higher and oxygenation index was lower in the electrical impedance tomography–guided group (Pao2/FIO2: 388 mm Hg vs. 113 mm Hg, p < 0.0001; oxygentation index, 6.4 vs. 15.7; p = 0.02) (all averages over the 6-hr time course). The presence of hyaline membranes (HM) and airway fibrin (AF) was significantly reduced in the electrical impedance tomography–guided group (HMEIT 42% samples vs. HMCONTROL 67% samples, p < 0.01; AFEIT 75% samples vs. AFCONTROL 100% samples, p < 0.01). Interleukin-8 level (bronchoalveolar lavage) did not differ between the groups. The upper and lower 95% limits of agreement between electrical impedance tomography and computed tomography were ± 16%. Conclusions:Electrical impedance tomography–guided ventilation resulted in improved respiratory mechanics, improved gas exchange, and reduced histologic evidence of ventilator-induced lung injury in an animal model. This is the first prospective use of electrical impedance tomography–derived variables to improve outcomes in the setting of acute lung injury.

High-Frequency Oscillatory Ventilation in Pediatric Acute Lung Injury : A Multicenter International Experience

Objective:We aim to describe current clinical practice, the past decade of experience and factors related to improved outcomes for pediatric patients receiving high-frequency oscillatory ventilation. We have also modeled predictive factors that could help stratify mortality risk and guide future high-frequency oscillatory ventilation practice. Design:Multicenter retrospective, observational questionnaire study. Setting:Seven PICUs. Patients:Demographic, disease factor, and ventilatory and outcome data were collected, and 328 patients from 2009 to 2010 were included in this analysis. Interventions:None. Measurement and Main Results:Patients were classified into six cohorts based on underlying diagnosis. We used univariate analysis to identify factors associated with mortality risk and multivariate logistic regression to identify independent predictors of mortality risk. An oxygenation index greater than 35 and immunocompromise exhibited the greatest predictive power (p < 0.0001) for increased mortality risk, and respiratory syncytial virus was associated with lowest mortality risk (p = 0.003). Differences in mortality risk as a function of oxygenation index were highly dependent on primary underlying condition. A trend toward an increase in oscillator amplitude and frequency was observed when compared with historical data. Conclusions:Given the number of centers and subjects included in the database, these findings provide a robust description of current practice regarding the use of high-frequency oscillatory ventilation for pediatric hypoxic respiratory failure. Patients with severe hypoxic respiratory failure and immunocompromise had the highest mortality risk, and those with respiratory syncytial virus had the lowest. A means of identifying the risk of 30-day mortality for subjects can be obtained by identifying the underlying disease and oxygenation index on conventional ventilation preceding the initiation of high-frequency oscillatory ventilation.

Comparison of 2 Lung Recruitment Strategies in Children With Acute Lung Injury

BACKGROUND: Lung recruitment maneuvers are frequently used in the treatment of children with lung injury. Here we describe a pilot study to compare the acute effects of 2 commonly used lung recruitment maneuvers on lung volume, gas exchange, and hemodynamic profiles in children with acute lung injury. METHODS: In a prospective, non-randomized, crossover pilot study, 10 intubated pediatric subjects with lung injury sequentially underwent: a period of observation; a sustained inflation (SI) maneuver of 40 cm H2O for 40 seconds and open-lung ventilation; a staircase recruitment strategy (SRS) (which utilized 5 cm H2O increments in airway pressure, from a starting plateau pressure of 30 cm H2O and PEEP of 15 cm H2O); a downwards PEEP titration; and a 1 hour period of observation with PEEP set 2 cm H2O above closing PEEP. RESULTS: Arterial blood gases, lung mechanics, hemodynamics, and functional residual capacity were recorded following each step of the study and following each increment of the SRS. Both SI and SRS were effective in raising PaO2 and functional residual capacity. During the SRS maneuver we noted significant increases in dead-space ventilation, a decrease in carbon dioxide elimination, an increase in PaCO2, and a decrease in compliance of the respiratory system. Lung recruitment was not sustained following the decremental PEEP titration. CONCLUSIONS: SRS is effective in opening the lung in children with early acute lung injury, and is hemodynamically well tolerated. However, attention must be paid to PaCO2 during the SRS. Even minutes following lung recruitment, lungs may derecruit when PEEP is lowered beyond the closing pressure.

Decreased Proopiomelanocortin mRNA in Lymphocytes of Chronic Alcoholics After Intravenous Human Corticotropin Releasing Factor Injection

BACKGROUND Alcohol abuse may involve an altered neuroendocrine response that mediates lymphocyte-derived proopiomelanocortin (POMC) production and inflammation. We investigated POMC messenger RNA (mRNA) expression in human lymphocytes ex vivo and their relation to plasma ACTH and immunoreactive beta-endorphin (IR-beta-EP) after intravenous injection of human corticotropin releasing factor (hCRF) in chronic alcoholics (n = 12) and nonalcoholics (n = 12) before surgery. Lipopolysaccharide-stimulated interleukin (IL)-1 receptor antagonist (IL-1 Ra) as a marker for chronic inflammation was determined. METHODS Chronic alcohol abuse was diagnosed according to DSM-IV criteria and alcohol consumption >60 g/day. A reverse transcription-polymerase chain reaction method with total RNA and subsequent solid phase minisequencing was used to quantify lymphocytic POMC mRNA after intravenous hCRF injection. Plasma ACTH, cortisol, and lipopolysaccharide-stimulated IL-1 Ra of monocytes were measured by enzyme-linked immunosorbent assay, and plasma IR-beta-EP was measured by using radioimmunoassay. RESULTS Baseline values of POMC mRNA content in lymphocytes and IL-1 Ra of chronic alcoholics were significantly increased compared with nonalcoholics (p < 0.01). Thirty minutes after intravenous hCRF injection, a significant increase of lymphocytic POMC mRNA was measured (p < 0.05) in nonalcoholics, whereas in chronic alcoholics a significant decrease was observed (p < 0.05). CONCLUSIONS Chronic alcoholic patients had an altered neuroendocrine immune axis before intravenous hCRF administration and were not able to adjust to intravenous CRF injection by increasing lymphocytic POMC mRNA expression.

Categorization in Mechanically Ventilated Pediatric Subjects: A Proposed Method to Improve Quality

BACKGROUND: Thousands of children require mechanical ventilation each year. Although mechanical ventilation is lifesaving, it is also associated with adverse events if not properly managed. The systematic implementation of evidence-based practice through the use of guidelines and protocols has been shown to mitigate risk, yet variation in care remains prevalent. Advances in health-care technology provided the ability to stream data about mechanical ventilation and therapeutic response. Through these advances, a computer system was developed to enable the coupling of physiologic and ventilation data for real-time interpretation. Our aim was to assess the feasibility and utility of a newly developed patient categorization and scoring system to objectively measure compliance with standards of care. METHODS: We retrospectively categorized the ventilation and oxygenation statuses of subjects within our pediatric ICU utilizing 15 rules-based algorithms. Targets were predetermined based on generally accepted practices. All patient categories were calculated and presented as a percent score (0–100%) of acceptable ventilation, acceptable oxygenation, barotrauma-free, and volutrauma-free states. RESULTS: Two hundred twenty-two subjects were identified and analyzed encompassing 1,578 d of mechanical ventilation. Median age was 3 y, median ideal body weight was 14.7 kg, and 63% were male. The median acceptable ventilation score was 84.6%, and the median acceptable oxygenation score was 70.1% (100% being maximally acceptable). Potential for ventilator-induced lung injury was broken into 2 components: barotrauma and volutrauma. There was very little potential for barotrauma, with a median barotrauma-free state of 100%. Median potential for a volutrauma-free state was 56.1%. CONCLUSIONS: We demonstrate the first patient categorization system utilizing a coordinated data-banking system and analytics to determine patient status and a surveillance of mechanical ventilation quality. Further research is needed to determine whether interventions such as visual display of variance from goal and patient categorization summaries can improve outcomes. (ClinicalTrials.gov registration NCT02184208.)

Daily Goals Formulation and Enhanced Visualization of Mechanical Ventilation Variance Improves Mechanical Ventilation Score

BACKGROUND: The systematic implementation of evidence-based practice through the use of guidelines, checklists, and protocols mitigates the risks associated with mechanical ventilation, yet variation in practice remains prevalent. Recent advances in software and hardware have allowed for the development and deployment of an enhanced visualization tool that identifies mechanical ventilation goal variance. Our aim was to assess the utility of daily goal establishment and a computer-aided visualization of variance. METHODS: This study was composed of 3 phases: a retrospective observational phase (baseline) followed by 2 prospective sequential interventions. Phase I intervention comprised daily goal establishment of mechanical ventilation. Phase II intervention was the setting and monitoring of daily goals of mechanical ventilation with a web-based data visualization system (T3). A single score of mechanical ventilation was developed to evaluate the outcome. RESULTS: The baseline phase evaluated 130 subjects, phase I enrolled 31 subjects, and phase II enrolled 36 subjects. There were no differences in demographic characteristics between cohorts. A total of 171 verbalizations of goals of mechanical ventilation were completed in phase I. The use of T3 increased by 87% from phase I. Mechanical ventilation score improved by 8.4% in phase I and 11.3% in phase II from baseline (P = .032). The largest effect was in the low risk VT category, with a 40.3% improvement from baseline in phase I, which was maintained at 39% improvement from baseline in phase II (P = .01). mechanical ventilation score was 9% higher on average in those who survived. CONCLUSIONS: Daily goal formation and computer-enhanced visualization of mechanical ventilation variance were associated with an improvement in goal attainment by evidence of an improved mechanical ventilation score. Further research is needed to determine whether improvements in mechanical ventilation score through a targeted, process-oriented intervention will lead to improved patient outcomes. (ClinicalTrials.gov registration NCT02184208.)

Pediatric chronic home invasive ventilation

Pediatric Chronic Home Invasive Ventilation Paul E. Moore, Debra Boyer, Michael G. O’Connor, Christopher D. Baker, Jordan S. Rettig, Laura Sterni, Ann Halbower, Kevin C. Wilson, and Carey C. Thomson Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Pulmonary Medicine, and Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; Breathing Institute and Pulmonary Section, Children’s Hospital Colorado and University of Colorado School of Medicine, Denver, Colorado; Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary and Critical Care, Boston University, Boston, Massachusetts; and Division of Pulmonary and Critical Care, Mount Auburn Hospital, and Harvard Medical School, Boston, Massachusetts

Implementation of an Inhaled Nitric Oxide Protocol: A Paradox or the Perfect Pair?

Nitric oxide was first described over 200 years ago, initially for its toxic effects.[1][1] More recently, nitric oxide was named Molecule of the Year in 1992 by the journal Science . In 1998, the Nobel Prize in Physiology and Medicine was awarded to 3 scientists for further elucidating nitric oxide