Mark M. Wilson

Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation

ObjectiveTo examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes. DesignProspective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation. Patients and SettingPatients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital. InterventionsAfter the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy. Main ResultsThe number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p = .006) and to 26.2 in year 2 (p < .0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p = .608), hospital length of stay decreased from 37.5 to 31.6 days (p = .058), ICU length of stay decreased from 30.5 to 25.9 days (p = .133), and total cost per case decreased from

A prospective evaluation of the 1-hour decision point for admission versus discharge in acute asthma

92,933 to

Gas Embolism: Part I. Venous Gas Emboli

78,624 (p = .061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p = .004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from

Gas Embolism: Part II. Arterial Gas Embolism and Decompression Sickness

92,933 to

Bronchopulmonary Segmental Lavage with Surfaxin (KL4-Surfactant) for Acute Respiratory Distress Syndrome

63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p < .0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p = .039), a total cost savings of

Chronic cough due to gastroesophageal reflux disease: failure to resolve despite total/near-total elimination of esophageal acid.

3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p = .062). ConclusionsA multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.

The Association of Asthma and Obesity: Is It Real or a Matter of Definition, Presbyterian Ministers' Salaries, and Earlobe Creases?

Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV 1 alone as an outcome predictor yielded suboptimal performance. FEV 1 at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better ( P = .0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV 1 reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.

Thoracentesis in Medical ICU Patients: When is “Safe” Really “Safe Enough”?

Gas emboli syndromes occur in many different settings, and their medical significance ranges from being life-threatening emergencies to being totally innocuous. We discuss venous gas embolization in Part I of this review, and it can result from a variety of traumatic, diagnostic, therapeutic, and surgical interventions. The pathophysiological consequences depend on where the gas bubbles impact and obstruct the circulation—by creating an “air lock” in the right ventricle, by obstruction of pulmonary arterioles, and sometimes with passage into the arterial circulation (so called paradoxical emboli). Various monitoring techniques are available and are known to be useful in high-risk patients. Nevertheless, the diagnosis can be difficult to establish. Myriad and generally nonspecific clinical manifestations may be present; the patient may often exhibit signs and symptoms suggestive of other acute cardiopulmonary or central nervous system events. The classically described “mill-wheel murmur” is actually a rare finding, and it is transient at best. There are no specific diagnostic tests available, and clinicians, must depend on a high level of suspicion in the appropriate settings. Rapid identification of the problem, with prevention of further gas entry into the venous circulation, should be a routine measure. The left lateral decubitus position, administration of 100% oxygen, and hyperbaric oxygenation should all be considered, and they have been shown to be effective treatment modalities.

EVALUATION OF SUGAMMADEX VS NEOSTIGMINE IN THE REVERSAL OF NEUROMUSCULAR BLOCKADE

Gas emboli syndromes are known to occur in many different settings, and they may result in life-threatening emergencies. Venous gas embolization was discussed previously in Part I of this review. Gas emboli that gain access to the arterial circulation or that result from exposures to decreased ambient pressures in the environment are discussed in Part II. The prevalence of arterial gas emboli and decompression sickness are likely not as high as for venous gas emboli. Most cases are preventable, and prompt treatment is frequently effective. Once present, gas bubbles generally distribute themselves throughout the body based on the relative blood flow at the time, thus making the nervous system, heart, lung, and skin the primary organ systems involved. Both mechanical and biophysical effects lead to intravascular and extracellular alterations that result in tissue injury. The clinical manifestations of these disorders are varied, and a high index of suspicion in the appropriate settings will aid health care providers in prompt recognition of these problems and allow timely intervention with specific therapy. Management of arterial gas emboli and decompression sickness is similar, with a focus on hyberbaric chamber therapy and intermittent hyperoxygenation. Recompression schedules in current use have withstood the test of time. Research continues to refine our understanding of these diseases and to optimize the treatment regimens available.