Krishna Kakkera

Prospective Open-label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

Delays in achieving target mean arterial pressure (MAP) are associated with increased morbidity and mortality in patients with septic shock. This trial was conducted to test the hypothesis that early concomitant treatment with vasopressin and norepinephrine reduces the time to achieve and maintain target MAP compared with initial norepinephrine monotherapy.

National Trends (2007-2013) of Clostridium difficile Infection in Patients with Septic Shock: Impact on Outcome

BACKGROUND: Clostridium difficile is the most common infectious cause of healthcare‐associated diarrhea and is associated with worse outcomes and higher cost. Patients with septic shock (SS) are at increased risk of acquiring C. difficile infections (CDIs) during hospitalization, but little data are available on CDI complicating SS. OBJECTIVE: Prevalence of CDI in SS between 2007‐2013 and impact of CDI on outcomes in SS. DESIGN: We used the National Inpatient Sample to identify hospitalizations (2007‐2013) of adults with SS and CDI and the Nationwide Readmissions Database 2013 to calculate 30‐day readmissions. MAIN MEASUREMENTS: Outcomes were prevalence of CDI in SS, effect on mortality, length of stay (LOS), and 30‐day readmission. RESULTS: There were 2,031,739 hospitalizations with SS (2007‐2013). CDI was present in 8.2% of SS. The in‐hospital mortality of SS with and without CDI were comparable (37.1% vs 37.0%; P = 0.48). Median LOS was longer for SS with CDI (13 days vs 9 days; P < 0.001). LOS >75th percentile (>17 days) was 36.9% in SS with CDI vs 22.7% without CDI (P < 0.001). Similarly, LOS > 90th percentile (> 29 days) was 17.5% vs 9.1%, P < 0.001. Odds of LOS >75% and >90% in SS were greater with CDI (odds ratio [OR] 2.11; 95% confidence interval [CI], 2.06‐2.15; P < 0.001 and OR 2.25; 95% CI, 2.22‐2.28; P < 0.001, respectively). Hospital readmission of SS with CDI was increased, adjusted OR 1.26 (95% CI, 1.22‐1.31; P < 0.001). CONCLUSIONS: CDI complicating SS is common and is associated with increased hospital LOS and 30‐day hospital readmission. This represents a population in which a focus on prevention and treatment may improve clinical outcomes.

1926: LEPIDIC PREDOMINANT ADENOCARCINOMA: A RARE CAUSE OF RESPIRATORY FAILURE WITH DIFFUSE LUNG DISEASE.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) arrival, she underwent hyperbaric oxygen (HBO) treatment at 4.8 absolute atmosphere (ATA). Chest X-ray performed after HBO treatment showed pneumomediastinum, a finding that was not present in two chest X-rays performed prior to HBO treatment. Pneumomediastinum was further confirmed on CT-chest. Esophagogram was performed to rule out esophageal perforations, and the pneumomediastinum resolved without any further intervention on hospital day three. Results: Our patient had vomiting during intubation, which made esophageal perforation (Boerhaave syndrome) a possible differential diagnosis. Limited data on pneumomediastinum following HBO made us deeply concerned about the catastrophic consequences of delayed diagnosis of Boerhaave syndrome. However, CT chest and barium esophagogram conclusively ruled out esophageal perforation. The temporal relation of the development of pneumomediastinum after HBO treatment, lack of esophageal injury on esophagogram, and self-resolution of the pneumomediastinum indicate that it was secondary to alveolar injury from HBO treatment. To date, HBO-related pneumomediastinum has been described only once in a 5-year-old patient. Our case is the first description of HBO-related pneumomediastinum in an adult patient.

Contemporary national trends of cystic fibrosis hospitalizations and co-morbidities in the United States.

INTRODUCTION Cystic fibrosis (CF) is a life-limiting multisystemic genetic disease. Patients with CF have a high rate of hospitalization. We attempt to ascertain national trends of inpatient stays, prevalence of various co-morbidities during hospitalizations, outcomes and discharge disposition among CF patients. MATERIAL AND METHODS Data from the National Inpatient Sample (NIS) was used to identify all hospitalizations of patients with CF and their demographic characteristics from 2003 to 2013. Prevalence and effects of various co-morbidities like acute kidney injury (AKI) were determined. Detailed sub-group analysis was performed for individuals with lung transplant. RESULTS The annual rate of hospitalization per 1,000 CF patients in the U.S. increased from 994 in 2003 to 1,072 in 2013. The overall in-hospital mortality was 1.5%; median age at death was 27 years. In-hospital mortality trended down from 1.9% to 1.2% from 2003 to 2013 (p-value for trend: 0.002). The median length of stay was 7 days. The prevalence of chronic liver disease and AKI was 3.7% and 3.8% respectively. Multivariate adjusted odds of mortality for AKI was 1.74 (95% CI 1.57-1.93, p < 0.001). Patients with prior lung transplantation accounted for 6.5% of hospitalizations. These patients had a significantly higher prevalence of AKI. CONCLUSIONS The annual hospitalization rates of CF patients is increasing over the years. Females with CF constitute a higher proportion of hospitalized patients despite a higher male preponderance of males with CF in the community. AKI is associated with a significantly higher in-hospital mortality. Lung transplant recipients have a higher prevalence of AKI and mortality.

Central Venous Line Insertion Revealing Partial Anomalous Pulmonary Venous Return: Diagnosis and Management

Central venous line malposition is a well-known complication of line insertion. Rarely, it can be mal-positioned in an anomalous pulmonary vein. We present an unusual case of a 56-year-old woman that was found to have partial anomalous pulmonary venous return on central venous line insertion. In this report, we describe a systematic approach to diagnosis and management of this unusual situation.

553: NATIONAL TRENDS (2009-2013) FOR PALLIATIVE CARE UTILIZATION IN MECHANICALLY VENTILATED PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) Specifically, to measure FMs’ symptoms of anxiety, depression, posttraumatic stress (PTSD), prolonged grief, and satisfaction with ICU care as compared to ICU FMs who did not receive bereavement follow-up. Methods: This cross-sectional, prospective pilot study assessed 40 FMs in two tertiary care ICUs. FMs of patients who died in the Medical-Surgical ICU (MS ICU) received bereavement follow up, and FMs of patients who died in the Cardiac ICU (CICU) did not receive bereavement follow up. FMs completed surveys 13 months after the ICU experience including: the HADS (anxiety and depression), IES-R (posttraumatic stress), PG-13 (prolonged grief ), and the FS-ICU (family satisfaction with ICU care). Aims were analyzed using student’s t-test, ANCOVA, and Chi-square. Results: There were 30 FMs in the bereavement group and 10 FMs in the non-bereavement group. Most were female (n = 29, 72.5%), spouses (n = 29, 72.5%), white (n = 31, 77.5%), with a mean age (SD) of 60.1 (13.3). Non-bereavement FMs group had statistically significant more prolonged grief than bereavement group FMs (p = 0.012). There were no significant differences between the two groups in PTSD, anxiety, depression, or ICU satisfaction. However, the overall scores for PTSD and anxiety were trending higher for the non-bereavement group than the bereavement group (mean of PTSD 1.5, vs 1.2; mean of anxiety 7.4 vs 5.9), where a mean score of 1.5 on the IES-R indicates a significant risk of PTSD. Conclusions: Study findings suggest that bereavement follow-up after an ICU death may help reduce family members’ prolonged grief. This type of support may also reduce FMs’ levels of PTSD and anxiety, although it did not have a measurable effect on depression or satisfaction with ICU care.

Successful Management of Neobladder Variceal Bleeding

Hematuria from a neobladder can occur due to a variety of pathologies including tumors, stones, and fistulas. Variceal bleeding in a neobladder is a very rare condition with only one case reported in literature. We present a case of a patient with cirrhosis and portal hypertension and an ileocolic orthotopic neobladder presenting with hematuria. Computed tomographic angiography showed dilated varices around the neobladder which were successfully embolized. To the best of our knowledge, this is the first report case of variceal bleeding in a neobladder successfully managed with the combination of TIPS (transjugular intrahepatic portosystemic shunt) procedure and embolization.

ACCURACY OF TRADITIONAL AND NOVEL RISK FACTORS FOR PREDICTING THE EXTENT AND SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is associated with a higher risk for coronary artery disease (CAD). Traditional risk factors are limited in their predictive accuracy for CAD. Our objective was to study the association between RA specific factors and CAD in patients with RA. 84 patients with chronic