Pablo Moreno Franco

β2 Agonist for the Treatment of Acute Lung Injury: A Systematic Review and Meta-analysis

BACKGROUND: The use of β2 agonist as an intervention for acute lung injury (ALI) and ARDS patients is controversial, so we performed a systematic review and meta-analysis of the published randomized controlled trials of using β2 agonists to improve outcomes (mortality and ventilator free days) among patients with ALI/ARDS. METHODS: A comprehensive search of 7 major databases (Ovid MEDLINE In-Process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Cochrane Database of Systematic Reviews, Web of Science, and Scopus) for randomized controlled trials using β2 agonists for ALI from their origin to March 2013 was conducted. The effect size was measured by relative risk for dichotomous outcomes, and mean difference for continuous outcomes, with 95% CI. The statistical heterogeneity between the studies was assessed with the Cochran Q test and I2 statistic. The heterogeneity of > 50% was considered significant for the analysis. The Cochrane risk of bias tool was used to ascertain the quality of the included studies. RESULTS: Out of 219 studies screened, 3 randomized controlled trials reported mortality and ventilator-free days, in 646 ALI/ARDS subjects. Of the 646 subjects, 334 (51.7%) received β2 agonist and 312 (48.3%) received placebo. There was no significant decrease in 28-day mortality or hospital mortality in the β2-agonist group: relative risk 1.04, 95% CI 0.50–2.16, and relative risk 1.22, 95% CI 0.95–1.56, respectively. The ventilator-free days and organ-failure-free days were significantly lower for the ALI subjects who received β2 agonists: mean difference −2.19 days (95% CI −3.68 to −1.99 d) and mean difference −2.04 days (95% CI −3.74 to −0.35 d), respectively. CONCLUSIONS: In subjects with ALI/ARDS, β2 agonists were not only nonbeneficial in improving the survival, but were harmful and increased morbidity (reduced organ-failure-free days and ventilator-free days). The current evidence discourages the use of β2 agonist in ALI/ARDS patients. (International Prospective Register of Systematic Reviews, http://www.crd.york.ac.uk/prospero, 2012:CRD42012002616.)

Severe Anion Gap Metabolic Acidosis From Acetaminophen Use Secondary to 5-Oxoproline (Pyroglutamic Acid) Accumulation

Abstract:Anion gap metabolic acidosis (AGMA) is commonly encountered in medical practice. Acetaminophen-induced AGMA is, however, not widely recognized. We report 2 cases of high anion gap metabolic acidosis secondary to 5-oxoproline accumulation resulting from acetaminophen consumption: the first case caused by acute one-time ingestion of large quantities of acetaminophen and the second case caused by chronic repeated ingestion in a patient with chronic liver disease. Recognition of this entity facilitated timely diagnosis and effective treatment. Given acetaminophen is commonly used over the counter medication, increased recognition of this adverse effect is of important clinical significance.

User perception and experience of the introduction of a novel critical care patient viewer in the ICU setting.

OBJECTIVE Failure to rapidly identify high-value information due to inappropriate output may alter user acceptance and satisfaction. The information needs for different intensive care unit (ICU) providers are not the same. This can obstruct successful implementation of electronic medical record (EMR) systems. We evaluated the implementation experience and satisfaction of providers using a novel EMR interface-based on the information needs of ICU providers-in the context of an existing EMR system. METHODS This before-after study was performed in the ICU setting at two tertiary care hospitals from October 2013 through November 2014. Surveys were delivered to ICU providers before and after implementation of the novel EMR interface. Overall satisfaction and acceptance was reported for both interfaces. RESULTS A total of 246 before (existing EMR) and 115 after (existing EMR+novel EMR interface) surveys were analyzed. 14% of respondents were prescribers and 86% were non-prescribers. Non-prescribers were more satisfied with the existing EMR, whereas prescribers were more satisfied with the novel EMR interface. Both groups reported easier data gathering, routine tasks & rounding, and fostering of team work with the novel EMR interface. This interface was the primary tool for 18% of respondents after implementation and 73% of respondents intended to use it further. Non-prescribers reported an intention to use this novel interface as their primary tool for information gathering. CONCLUSION Compliance and acceptance of new system is not related to previous duration of work in ICU, but ameliorates with the length of EMR interface usage. Task-specific and role-specific considerations are necessary for design and successful implementation of a EMR interface. The difference in user workflows causes disparity of the way of EMR data usage.

Prospective validation of a near real-time EHR-integrated automated SOFA score calculator

OBJECTIVES We created an algorithm for automated Sequential Organ Failure Assessment (SOFA) score calculation within the Electronic Health Record (EHR) to facilitate detection of sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock (SEPSIS-3) clinical definition. We evaluated the accuracy of near real-time and daily automated SOFA score calculation compared with manual score calculation. METHODS Automated SOFA scoring computer programs were developed using available EHR data sources and integrated into a critical care focused patient care dashboard at Mayo Clinic in Rochester, Minnesota. We prospectively compared the accuracy of automated versus manual calculation for a sample of patients admitted to the medical intensive care unit at Mayo Clinic Hospitals in Rochester, Minnesota and Jacksonville, Florida. Agreement was calculated with Cohens kappa statistic. Reason for discrepancy was tabulated during manual review. RESULTS Random spot check comparisons were performed 134 times on 27 unique patients, and daily SOFA score comparisons were performed for 215 patients over a total of 1206 patient days. Agreement between automatically scored and manually scored SOFA components for both random spot checks (696 pairs, κ=0.89) and daily calculation (5972 pairs, κ=0.89) was high. The most common discrepancies were in the respiratory component (inaccurate fraction of inspired oxygen retrieval; 200/1206) and creatinine (normal creatinine in patients with no urine output on dialysis; 128/1094). 147 patients were at risk of developing sepsis after intensive care unit admission, 10 later developed sepsis confirmed by chart review. All were identified before onset of sepsis with the ΔSOFA≥2 point criterion and 46 patients were false-positives. CONCLUSIONS Near real-time automated SOFA scoring was found to have strong agreement with manual score calculation and may be useful for the detection of sepsis utilizing the new SEPSIS-3 definition.

A Comparative Effectiveness Study of Rescue Strategies in 1,000 Subjects With Severe Hypoxemic Respiratory Failure

BACKGROUND: Subjects with severe hypoxemic respiratory failure have shown a high mortality in previous studies. METHODS: All adult ICU patients requiring mechanical ventilation from 2005 to 2010 at Mayo Clinic were screened for severe hypoxemia (Murray lung injury score of ≥ 3). Extracorporeal membrane oxygenation, prone positioning, high-frequency oscillatory ventilation (HFOV), and inhaled vasodilators were considered as rescue strategies. A propensity-based scoring was created for the indication or predilection to use each strategy. A model was created to evaluate the association of each rescue strategy with hospital mortality. RESULTS: Among 1,032 subjects with severe hypoxemia, 239 subjects received some form of rescue strategy (59 received a combination of therapies, and 180 received individual therapies). Inhaled vasodilators were the most common, followed by HFOV. Rescue strategies were used in younger subjects with severe oxygenation deficits. Subjects receiving rescue strategies had higher mortality and longer ICU stays. None of the strategies individually or in combination showed a significant association with hospital mortality after adjusting covariates by propensity scoring. Adjusted Odds ratios and respective 95% CI were as follows: HFOV 0.67 (0.35–1.27), extracorporeal membrane oxygenation 0.63 (0.18–1.92), prone position 1.07 (0.49–2.28), and inhaled vasodilators 1.17 (0.78–1.77). CONCLUSIONS: In this retrospective comparative effectiveness study, there was no association of rescue strategies with hospital mortality in subjects with severe hypoxemia.

Early prediction of extracorporeal membrane oxygenation eligibility for severe acute respiratory distress syndrome in adults.

PURPOSE Appropriately identifying and triaging patients with newly diagnosed acute respiratory distress syndrome (ARDS) who may progress to severe ARDS is a common clinical challenge without any existing tools for assistance. MATERIALS AND METHODS Using a retrospective cohort, a simple prediction score was developed to improve early identification of ARDS patients who were likely to progress to severe ARDS within 7 days. A broad array of comorbidities and physiologic variables were collected for the 12-hour period starting from intubation for ARDS. Extracorporeal membrane oxygenation (ECMO) eligibility was determined based on published criteria from recent ECMO guidelines and clinical trials. Separate data-driven and expert opinion approaches to prediction score creation were completed. RESULTS The study included 767 patients with moderate or severe ARDS who were admitted to the intensive care unit between January 1, 2005, and December 31, 2010. In the data-driven approach, incorporating the ARDS index (a novel variable incorporating oxygenation index and estimated dead space), aspiration, and change of Pao2/fraction of inspired oxygen ratio into a simple prediction model yielded a c-statistic (area under the receiver operating characteristic curve) of 0.71 in the validation cohort. The expert opinion-based prediction score (including oxygenation index, change of Pao2/fraction of inspired oxygen ratio, obesity, aspiration, and immunocompromised state) yielded a c-statistic of 0.61 in the validation cohort. CONCLUSIONS The data-driven early prediction ECMO eligibility for severe ARDS score uses commonly measured variables of ARDS patients within 12 hours of intubation and could be used to identify those patients who may merit early transfer to an ECMO-capable medical center.

Sepsis and Shock Response Team: Impact of a Multidisciplinary Approach to Implementing Surviving Sepsis Campaign Guidelines and Surviving the Process

The Surviving Sepsis Campaign guidelines are designed to decrease mortality through consistent application of a 7-element bundle. This study evaluated the impact of improvement in bundle adherence using a time-series analysis of compliance with the bundle elements before and after interventions intended to improve the process, while also looking at hospital mortality. This article describes interventions used to improve bundle compliance and hospital mortality in patients admitted through the emergency department with sepsis, severe sepsis, or septic shock. Quality improvement methodology was used to develop high-impact interventions that led to dramatically improved adherence to the Surviving Sepsis Campaign guidelines bundle. Improved performance was associated with a significant decrease in the in-hospital mortality of severe sepsis patients presenting to the emergency department.

Black Esophagus: An Unexpected Complication in an Orthotopic Liver Transplant Patient with Hemorrhagic Shock

A 50-year-old Caucasian woman postorthotopic liver transplantation developed severe hemorrhagic shock (BP 53/35 mmHg) from a right inferior phrenic artery hemorrhage on postoperative day (POD) 10 requiring emergent surgery. On POD 42, she underwent EGD for dysphagia and evaluation for placement of a percutaneous gastrostomy tube. Upon entering the esophagus, the entire mucosa had a dark gray and black discoloration (Figs. 1, 2). Biopsies demonstrated necrotic debris with scattered inflammatory cells and entrapped bacteria and yeast forms, consistent with acute esophageal necrosis. She was treated with intravenous proton pump inhibitor, antibiotics and kept nothing by mouth. EGD 10 weeks later, performed for dysphagia, revealed deep ulcerations throughout the entire esophagus (Fig. 3) and a severe stricture in the distal esophagus (3 mm) that could not be safely traversed. Esophagram confirmed severe tapering of the esophagus below the level of the carina (Fig. 4). The patient required serial esophageal dilatations. However, due to the long length of the stricture and dense fibrosis, the stricture was not amenable to standard dilation and required placement of temporary partially covered esophageal self-expandable metal stents (SEMS). Five weeks later, she was admitted to the hospital with respiratory distress. A bronchoscopy was performed and revealed a tracheoesophageal fistula with erosion of the posterior wall of the trachea by the esophageal stent 2 cm above the carina (Fig. 5). The patient subsequently underwent a right thoracotomy with esophagectomy, repair of the tracheoesophageal fistula and creation of a subclavicular esophagostomy. She was eventually liberated from mechanical ventilation and continued to recover in the hospital. Plans have been made from a cardiothoracic surgery perspective to re-evaluate for re-establishment of continuity by either stomach pull-up and colonic interposition, but issues regarding her ongoing poor nutritional status and need for immunosuppressive therapy after liver transplantation are needing to be addressed. She continues with jejunal feeds and has a spit fistula in place. Acute esophageal necrosis, also known as ‘‘black esophagus,’’ is a rare endoscopic entity that occurs in critically ill patients with multiple medical co-morbidities. The etiology is multifactorial, arising from low-flow state conditions resulting in tissue hypoperfusion and ischemic injury to the esophagus, impaired mucosal barrier systems and reflux injury from chemical contents of gastric secretions [1, 2]. Compared with the dense vascular network of arteries found in the proximal and middle regions of the esophagus, the distal esophagus, mainly receiving blood from the branches off the left gastric artery or left inferior phrenic artery (although variations do exist and include small branches off the celiac, splenic, short gastric or left hepatic arteries), is more prone to ischemic injury [3, 4]. In V. Gómez (&) D. L. Francis Division of Gastroenterology and Hepatology, Mayo Clinic, Davis Building 6, 4500 San Pablo Road, Jacksonville, FL 32224, USA e-mail: Gomez.victoria@mayo.edu