Soophia Naydenov

Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality.

Purpose: To determine whether progressively increasing fluid balance after initial fluid resuscitation for septic shock is associated with increased mortality. Methods: A retrospective review of the use of intravenous fluids in patients with septic shock in a large university affiliated hospital with 56 medical–surgical intensive care unit beds. We analyzed the data of 350 patients with septic shock who were managed according to the Surviving Sepsis Campaign guidelines. Based on net fluid balance at 24 hours, we examined the results of increase in positive fluid balance on the risk of in-hospital mortality. Patients were divided into 4 groups based on the amount of fluid balance by 24 hours, based on 6-L aliquots. Results: At 24 hours, the average fluid balance was +6.5 L. After correcting for age and sequential organ failure assessment score, a more positive fluid balance at 24 hours significantly increased the risk of in-hospital mortality. Using Cox proportional hazard analysis, excess 12-, 18-, and 24-L positive fluid balance had higher risk of mortality than those patients with a neutral to positive 6-L fluid balance (reference group). Adjusted hazard ratios, 1.519 (95% confidence interval [CI], 1.353-1.685), 1.740 (95% CI, 1.467-2.013), and 1.620 (95% CI, 1.197-2.043), respectively, P < .05. Conclusion: In patients with septic shock resuscitated according to current guidelines, a more positive fluid balance at 24 hours is associated with an increase in the risk of mortality. Optimal survival occurred at neutral fluid balance and up to 6-L positive fluid balance at 24 hours after the development of septic shock.

Theophylline for Bradycardia Secondary to Cervical Spinal Cord Injury

BackgroundSpinal cord injury (SCI) is a devastating disease process that can occur as a consequence of motor vehicle collisions, falls, or other traumatic injuries. Persistent bradycardia was found to be universally present in all high cervical SCI patients. Limited data exists to suggest the most effective therapy for the bradycardia associated with high cervical SCI. Treatment includes atropine, epinephrine, dopamine, and even implantable cardiac pacemakers, all of which have their risks and side effects. There are no prospective studies to evaluate methylxanthines for the treatment of bradycardia secondary to cervical SCI.MethodsWe report on four patients in whom Theophylline was successfully used enterally as a second line agent to treat bradycardia secondary to cervical SCI. We also reported on two patients in whom Theophylline was successfully used as a first line agent. Bradycardia resolved in all patientsResultsTheophylline levels were below toxic levels in all of the patients and no side effects from theophylline were observed.ConclusionsTheophylline’s use via enteral route can successfully and safely treat SCI-related bradycardia, and may help avoid the long term use of inotropic and chronotropic infusions and pacemakers and their associated risks and complications. We strongly recommend further studies to establish the role of this agent as a first line therapy in this specific patient population. Optimal dosing and duration of therapy will also need to be established.

Nuts and bolts of running a pulmonary embolism response team: results from an organizational survey of the National PERT™ Consortium members

ABSTRACT Objectives: Pulmonary embolism response teams (PERT) are developing rapidly to operationalize multi-disciplinary care for acute pulmonary embolism patients. Our objective is to describe the core components of PERT necessary for newly developing programs. Methods: An online organizational survey of active National PERT™ Consortium members was performed between April and June 2016. Analysis, including descriptive statistics and Kruskal-Wallis tests, was performed on centers self-reporting a fully operational PERT program. Results: The survey response rate was 80%. Of the 31 institutions that responded (71% academic), 19 had fully functioning PERT programs. These programs were run by steering committees (17/19, 89%) more often than individual physicians (2/19, 11%). Most PERT programs involved 3–5 different specialties (14/19, 74%), which did not vary based on hospital size or academic affiliation. Of programs using multidisciplinary discussions, these occurred via phone or conference call (12/18, 67%), with a minority of these utilizing ‘virtual meeting’ software (2/12, 17%). Guidelines for appropriate activations were provided at 16/19 (84%) hospitals. Most PERT programs offered around-the-clock catheter-based or surgical care (17/19, 89%). Outpatient follow up usually occurred in personal physician clinics (15/19, 79%) or dedicated PERT clinics (9/19, 47%), which were only available at academic institutions. Conclusions: PERT programs can be implemented, with similar structures, at small and large, community and academic medical centers. While all PERT programs incorporate team-based multi-disciplinary care into their core structure, several different models exist with varying personnel and resource utilization. Understanding how different PERT programs impact clinical care remains to be investigated.