Mithil Gajera

Transfusion of packed red blood cells is not associated with improved central venous oxygen saturation or organ function in patients with septic shock.

BACKGROUND The exact role of packed red blood cell (PRBC) transfusion in the setting of early resuscitation in septic shock is unknown. STUDY OBJECTIVE To evaluate whether PRBC transfusion is associated with improved central venous oxygen saturation (ScvO(2)) or organ function in patients with severe sepsis and septic shock receiving early goal-directed therapy (EGDT). METHODS Retrospective cohort study (n=93) of patients presenting with severe sepsis or septic shock treated with EGDT. RESULTS Thirty-four of 93 patients received at least one PRBC transfusion. The ScvO(2) goal>70% was achieved in 71.9% of the PRBC group and 66.1% of the no-PRBC group (p=0.30). There was no difference in the change in Sequential Organ Failure Assessment (SOFA) score within the first 24 h in the PRBC group vs. the no-PRBC group (8.6-8.3 vs. 5.8-5.6, p=0.85), time to achievement of central venous pressure>8 mm Hg (732 min vs. 465 min, p=0.14), or the use of norepinephrine to maintain mean arterial pressure>65 mm Hg (81.3% vs. 83.8%, p=0.77). CONCLUSIONS In this study, the transfusion of PRBC was not associated with improved cellular oxygenation, as demonstrated by a lack of improved achievement of ScvO(2)>70%. Also, the transfusion of PRBC was not associated with improved organ function or improved achievement of the other goals of EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock.

The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy.

Background: The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown. Aims: To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT). Settings and Design: Retrospective cohort study of 93 patients who presented with septic shock, to a single center academic intensive care unit and received EGDT. Materials and Methods: Data were collected on patients identified via the Surviving Sepsis Campaign Chart Review database and linked to Project IMPACT database. The PRBC group and no PRBC group were compared by the Pearson chi-square and Fisher’s exact test to analyze statistical significance. Results: The PRBC group had a mortality of 41.2% vs. 33.9% in the no PRBC transfusion group (P = NS). The PRBC group also had more mechanical ventilation days (11.2 days vs. 5.0 days, (P ≤ 0.05), longer hospital length of stay (25.9 days vs. 12.5 days, (P ≤ 0.05), and longer intensive care unit length of stay (11.4 days vs. 3.8 days, (P ≤ 0.05). Conclusions: In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with PRBC transfusion.

Excessive dynamic airway collapse for the internist: new nomenclature or different entity?

Excessive dynamic airway collapse (EDAC) refers to abnormal and exaggerated bulging of the posterior wall within the airway lumen during exhalation. This condition is pathological if the reduced airway lumen is <50% of the normal. It is a relatively new disease entity that is recognised more easily now with the increased use of multi-detector row CT. EDAC is often asymptomatic and diagnosed incidentally. Although the term excessive dynamic airway collapse is often used interchangeably with tracheobronchomalacia, both entities represent morphologically and physiologically distinct processes. Considering the confusion between the two entities, the prevalence of stand-alone EDAC remains unclear. The prevalence of tracheobronchomalacia and EDAC depends upon the patient population, associated comorbidities and underlying aetiologies, diagnostic tools used and criteria used to define the airway collapse. This review defines EDAC and describes its pathophysiology, precipitating factors, associated symptoms and potential treatments.

Primary malignant melanoma presenting as superior mediastinal mass

Malignant melanoma accounts for 1.5% of all cancers, and arises from a preexisting nevus in 40% of cases. Skin is the most common site for primary malignant melanoma. We present an extremely rare case of primary malignant melanoma presenting as a superior mediastinal mass.

The Association of Prior Statin Use in Septic Shock Treated With Early Goal Directed Therapy

Background Previous literature suggests statins may have a therapeutic role in sepsis. No data have examined if statin use may have a positive impact beyond that afforded by early goal directed therapy (EGDT). Objective To test the hypothesis that previous statin use is associated with improved clinically relevant outcomes in patients with severe sepsis and septic shock receiving EGDT. Methods Retrospective cohort study of 91 patients who presented in an academic center in severe sepsis or septic shock and received EGDT. Primary outcome was mortality and secondary outcomes included mechanical ventilation days, ICU length of stay, and hospital length of stay. Results Patients (87 of 91) presented to the Emergency Department before ICU admission. Patients (18 of 91) were receiving statin therapy before presentation. The statin group had a mortality rate of 22.2 vs. 39.7% in the nonstatin group (P=0.273). The statin group had fewer mechanical ventilation days (8.49 vs. 7.29 days, P=0.026), and a trend in improved hospital length of stay (17.9 vs. 14.4 days, P=0.065), and ICU length of stay (7.15 vs. 4.89 days, P=0.077). Conclusion Prior statin use is associated with fewer mechanical ventilation days and a trend toward improvement in other clinically relevant outcomes. This trial is limited by its retrospective nature and small sample size. These results should serve as hypothesis generating for future prospective trials, as the lack of novel drug therapy and the mortality rate of septic shock both remain unacceptable.

741: A PROTOCOL FOR THE MANAGEMENT OF ALCOHOL WITHDRAWAL IN THE INTENSIVE CARE UNIT

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Alcohol withdrawal syndrome is a common diagnosis in critical care, yet there is a paucity of literature regarding the optimal treatment strategy for this population. We hypothesized that creating a Richmond Agitation-Sedation Scale (RASS) based protocol focused on limiting benzodiazepine dose, early use of adjunctive agents, and aggressive taper would lead to improved patient outcomes. Methods: This is a retrospective pre-post study utilizing data from the University HealthSystem Consortium database for 552 patients admitted to the medical ICU with a primary or secondary diagnosis of alcohol withdrawal based on ICD 9,10 codes. The pre-intervention (PRE) cohort (N = 359) was from 01/201408/2015 and the post-intervention (POST) cohort (N = 193) was from 10/2015-01/2017. The PRE cohort was treated based on the Clinical Institute Withdrawal Assessment (CIWA-Ar) scale and according to provider preference. The POST cohort was treated using a protocol which included a maximum benzodiazepine loading dose, timing and dosing of adjunctive agents, and an aggressive benzodiazepine taper. The RASS scale was used rather than CIWA-Ar. Primary outcome measures were ICU length of stay (LOS) and total ICU cost. Results: The PRE and POST cohort were well matched with no significant difference in age, illness severity score, and risk of mortality score (p> 0.05). There was a one day decrease in ICU LOS post-intervention. Although the mean difference was not statistically significant (5.05+/-5.28 vs. 4.28+/-4.84; p = 0.10), the median difference was (3 [1–7] vs. 2 [1–5]; p = 0.008). There was a reduction in cost in the POST intervention group. The mean difference of approximately

Triad of Interstitial Pneumonia, Eosinophilia, and Eosinophilic Pleural Effusion: A Rare Paraneoplastic Manifestation of Lung Adenocarcinoma

3,000 did not reach statistical significance (38,362+/-39,152 vs. 35,084+/38,686; p = 0.60), however the median difference of approximately

Cardiac Tamponade as Manifestation of Rickettsial Infection

5,000 did (27,372 [13,748–46,755] vs. 22,165 [13,103-40,535]; p = 0.026). Conclusions: Our study suggests that utilization of a protocol for treatment of ICU patients with alcohol withdrawal leads to decreased ICU length of stay and reduced ICU cost.