Peter Clardy

Clinical Characteristics and Outcomes of Sepsis-Related vs Non-Sepsis-Related ARDS

BACKGROUND ARDS may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS, but little is known about the differences between sepsis-related and non-sepsis-related ARDS. METHODS A total of 2,786 patients with ARDS-predisposing conditions were enrolled consecutively into a prospective cohort, of which 736 patients developed ARDS. We defined sepsis-related ARDS as ARDS developing in patients with sepsis and non-sepsis-related ARDS as ARDS developing after nonseptic injuries, such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. RESULTS Compared with patients with non-sepsis-related ARDS (n = 62), patients with sepsis-related ARDS (n = 524) were more likely to be women and to have diabetes, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (median, 78 vs 65, P < .0001). There were no differences in lung injury score, blood pH, Pao(2)/Fio(2) ratio, and Paco(2) on ARDS diagnosis. However, patients with sepsis-related ARDS had significantly lower Pao(2)/Fio(2) ratios than patients with non-sepsis-related ARDS patients on ARDS day 3 (P = .018), day 7 (P = .004), and day 14 (P = .004) (repeated-measures analysis, P = .011). Compared with patients with non-sepsis-related ARDS, those with sepsis-related had a higher 60-day mortality (38.2% vs 22.6%; P = .016), a lower successful extubation rate (53.6% vs 72.6%; P = .005), and fewer ICU-free days (P = .0001) and ventilator-free days (P = .003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality (hazard ratio, 1.26; 95% CI, 0.71-2.22). CONCLUSION Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ARDS. Worse clinical outcomes in sepsis-related ARDS appear to be driven by disease severity and comorbidities.

Procedural Competence in Internal Medicine Residents: Validity of a Central Venous Catheter Insertion Assessment Instrument

Purpose Despite mandates from accreditation bodies for programs to ensure procedural competence, standardized measures do not exist to assess residents’ skills in performing central venous catheter (CVC) insertion. The objective of the present study was to develop an instrument to assess residents in subclavian (SC) CVC insertion, to set performance standards, and to validate the tool using performance data. Method In 2007, the authors convened experts to create an assessment tool for CVC insertion using a modified Delphi method. They applied the Angoff method to a second set of experts to determine minimum passing scores (MPSs) for both the borderline trainee and the competent trainee. Two faculty evaluators then used the checklist to assess residents performing CVCs on simulators. Results The authors created and experts confirmed a 24-item checklist. Using the Angoff method, the MPS required completion of 10 major and 2 minor criteria for a trainee to show borderline proficiency with CVC insertion under supervision. This MPS was correlated with a global rating of 2 on a 5-point scale. The MPS for competence was 17 major and 5 minor criteria. None of the residents deemed competent on a global rating scale achieved the MPS for competence. Conclusions The authors were able to create and validate a consensus-driven procedural assessment tool with data-driven standards for basic proficiency and competence that faculty can use to assess residents as they perform CVC insertion.

Simulation training and its effect on long-term resident performance in central venous catheterization

Introduction: Simulation is a safe alternative to practicing procedural skills on patients. However, few published studies have examined the long-term effect of simulation technology on bedside procedures such as central venous catheter (CVC) insertion. Methods: To determine whether simulation-based teaching improves procedural comfort, performance, and clinical events in CVC insertion, over traditional methods of procedural teaching, and to assess the long-term effect of this training, we conducted a prospective, randomized controlled trial with 53 postgraduate year-1 and postgraduate year-2 medical residents at a tertiary-care teaching hospital. At the start of the study, we assessed all residents’ procedural comfort and previous training and experience with CVCs. We then measured their baseline performance in placing CVCs on simulators, using a validated assessment tool (pretest). For the intervention group, we reassessed performance immediately after simulation training (posttest). All subjects then placed actual CVCs as clinically indicated while on their medical intensive care unit rotations, under the supervision of critical care faculty. We measured clinical events associated with these CVCs. After their medical intensive care unit rotations, we reassessed CVC insertion skills on simulators and procedural comfort of all subjects (delayed posttest). Results: Intervention subjects demonstrated a significant improvement in skills immediately after simulation training. At delayed posttesting, performance diminished somewhat in the intervention subjects and was not significantly different from control subjects; however, a significant increase over pretest scores persisted in both groups. Conclusions: A CVC insertion simulation course improves procedural skills. These skills decline over time, and simulation conferred no long-term additional benefit over traditional methods of procedural teaching.

When policy gets it right: variability in u.s. Hospitals' diagnosis of ventilator-associated pneumonia*.

Objective:The Centers for Disease Control has recently proposed a major change in how ventilator-associated pneumonia is defined. This has profound implications for public reporting, reimbursement, and accountability measures for ICUs. We sought to provide evidence for or against this change by quantifying limitations of the national definition of ventilator-associated pneumonia that was in place until January 2013, particularly with regard to comparisons between, and ranking of, hospitals and ICUs. Design:A prospective survey of a nationally representative group of 43 hospitals, randomly selected from the American Hospital Association Guide (2009). Subjects classified six standardized vignettes of possible cases of ventilator-associated pneumonia as pneumonia or no pneumonia. Subjects:Individuals responsible for ventilator-associated pneumonia surveillance at 43 U.S. hospitals. Interventions:None. Measurements and Main Results:We measured the proportion of standardized cases classified as ventilator-associated pneumonia. Of 138 hospitals consented, 61 partially completed the survey and 43 fully completed the survey (response rate 44% and 31%, respectively). Agreement among hospitals about classification of cases as ventilator-associated pneumonia/not ventilator-associated pneumonia was nearly random (Fleiss &kgr; 0.13). Some hospitals rated 0% of cases as having pneumonia; others classified 100% as having pneumonia (median, 50%; interquartile range, 33–66%). Although region of the country did not predict case assignment, respondents who described their region as “rural” were more likely to judge a case to be pneumonia than respondents elsewhere (relative risk, 1.25, Kruskal-Wallis chi-square, p = 0.03). Conclusions:In this nationally representative study of hospitals, assignment of ventilator-associated pneumonia is extremely variable, enough to render comparisons between hospitals worthless, even when standardized cases eliminate variability in clinical data abstraction. The magnitude of this variability highlights the limitations of using poorly performing surveillance definitions as methods of hospital evaluation and comparison, and our study provides very strong support for moving to a more objective definition of ventilator-associated complications.

Statin therapy is associated with decreased mortality in patients with infection.

OBJECTIVES The objective was to investigate the association between statin therapy and mortality in emergency department (ED) patients with suspected infection. METHODS A secondary analysis of a prospective, observational cohort study was conducted at an urban, academic ED with approximately 50,000 annual visits. Data were collected between December 2003 and September 2004. Inclusion criteria consisted of age > or = 18 years, clinical suspicion of infection, and hospital admission. Patients were divided by those receiving statin therapy and those not receiving statins while hospitalized. Medication data were collected from an inpatient pharmacy database. Comparisons were conducted with Fishers exact test or Wilcoxon rank sum test. To adjust for baseline differences, multivariable logistic regression analysis controlling for gender, severity of illness (Mortality in Emergency Department Sepsis [MEDS] score), Charlson Comorbidity Index, and duration of statin therapy was performed. RESULTS Of 2,132 patients with suspected infection, 2,036 (95%) had interpretable pharmacy data and were analyzed. The cohort had a median age of 61 years (interquartile range [IQR] = 46-78 years) and a mortality of 3.9% (95% confidence interval [CI] = 3.1% to 4.8%). Patients who received statins (n = 474) had a lower unadjusted crude mortality (1.9%; 95% CI = 0.6% to 3.3%) compared to those who did not (4.5%; 95% CI = 3.4% to 5.4%; p </= 0.01). When adjusting for gender, MEDS score, Charlson Comorbidity Index, and duration of statin therapy, the odds of death for statin patients was 0.27 (95% CI = 0.1 to 0.72; p < or = 0.01). CONCLUSIONS Patients who were admitted to the hospital with infection and received statin therapy while hospitalized had a significantly lower in-hospital mortality compared to patients who did not receive a statin.

Klebsiella Pneumoniae Liver Abscess: An Emerging Problem in North America

BACKGROUND Before the 1980s, Escherichia coli was the most common cause of pyogenic liver abscess, but more recently, Klebsiella pneumoniae has emerged as the most common organism in the United States and Taiwan. OBJECTIVE Our goal is to present a case of K. pneumoniae liver abscess (KLA) and review the risk factors, presenting symptoms, complications, and treatment of this disease that is emerging in North America. CASE REPORT We present a patient who was found to have KLA complicated by bacteremia and sepsis. CONCLUSIONS Initially described in the Asian literature, KLA is an emerging problem in North America. We present this case to increase awareness among emergency physicians of the diagnosis, risk factors, potential complications-including bacteremia and disseminated infection-and treatment.

Distinct and replicable genetic risk factors for acute respiratory distress syndrome of pulmonary or extrapulmonary origin

Background The role of genetics in the development of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) from direct or indirect lung injury has not been specifically investigated. The aim of this study was to identify genetic variants contributing to ALI/ARDS from pulmonary or extrapulmonary causes. Methods We conducted a multistage genetic association study. We first performed a large-scale genotyping (50K ITMAT-Broad_CARe Chip) in 1717 critically ill Caucasian patients with either pulmonary or extrapulmonary injury, to identify single nucleotide polymorphisms (SNPs) associated with the development of ARDS from direct or indirect insults to the lung. Identified SNPs (p≤0.0005) were validated in two separated populations (Stage II), with trauma (Population I; n=765) and pneumonia/pulmonary sepsis (Population II; n=838), as causes for ALI/ARDS. Genetic variants replicating their association with trauma related-ALI in Stage II were validated in a second trauma-associated ALI population (n=224, Stage III). Results In Stage I, non-overlapping SNPs were significantly associated with ARDS from direct/indirect lung injury, respectively. The association between rs1190286 (POPDC3) and reduced risk of ARDS from pulmonary injury was validated in Stage II (p<0.003). SNP rs324420 (FAAH) was consistently associated with increased risk of ARDS from extrapulmonary causes in two independent ALI-trauma populations (p<0.006, Stage II; p<0.05, Stage III). Meta-analysis confirmed these associations. Conclusions Different genetic variants may influence ARDS susceptibility depending on direct versus indirect insults. Functional SNPs in POPDC3 and FAAH genes may be driving the association with direct and indirect ALI/ARDS, respectively.

Noninvasive ventilation for acute respiratory failure: a review of the literature and current guidelines

Noninvasive ventilation, both continuous positive airway pressure and noninvasive positive pressure ventilation, has been used increasingly for acute respiratory failure over the past several years. Noninvasive ventilation has been proven to be beneficial for some causes of acute respiratory failure, most clearly for acute exacerbations of chronic obstructive pulmonary disease, while its use in other forms of acute respiratory failure remains more controversial. In this article, the evidence for the use of noninvasive ventilation in various kinds of acute respiratory failure will be examined. Particular attention will be paid to the clinical situations commonly encountered by emergency medicine and general internal medicine clinicians. The potential dangers of noninvasive ventilation as well as some guidelines for clinical decision making when treating patients with this mode of ventilator support will also be discussed.

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU

Objectives: We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs. Design: Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008. Intervention: None. Patients: Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code). Measurements and Main Results: The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively). Conclusion: Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.

Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates

Effective communication between providers and patients and their surrogates in the intensive care unit (ICU) is crucial for delivery of high-quality care. Despite the identification of communication as a key education focus by the American Board of Internal Medicine, little emphasis is placed on teaching trainees how to effectively communicate in the ICU. Data are conflicting on the best way to teach residents, and institutions vary on their emphasis of communication as a key skill. There needs to be a cultural shift surrounding the education of medical residents in the ICU: communication must be treated with the same emphasis, precision, and importance as placing a central venous catheter in the ICU. We propose that high-stakes communications between physicians and patients or their surrogates must be viewed as a medical procedure that can be taught, assessed, and quality controlled. Medical residents require training, observation, and feedback in specific communication skill sets with the goal of achieving mastery. It is only through supervised training, practice in real time, observation, and feedback that medical residents can become skillful practitioners of communication in the ICU.