Sudhir Krishnan

Lung Transplantation after 125 Days on ECMO for Severe Refractory Hypoxemia with No Prior Lung Disease

Venovenous extracorporeal membrane oxygenation (ECMO) has become a viable and increasingly utilized option for the treatment of refractory hypoxemia in severe acute respiratory distress syndrome (ARDS). However, options are limited for ARDS patients who fail to wean from ECMO. The high rates of infection, presence of extrapulmonary end organ damage, intensive care unit-acquired weakness, and high short-term mortality associated with ARDS are all significant hurdles that make lung transplantation a difficult prospect to consider. However, ECMO support has been used as a bridge to transplant in patients with other underlying chronic lung diseases. Our case illustrates the successful use of lung transplantation for a patient with no previous lung disease who developed refractory ARDS requiring protracted ECMO support. The use of ambulatory ECMO with early institution of physical therapy is an essential component in preparing such patients for successful transplantation.Veno-venous extracorporeal membrane oxygenation (ECMO) has become a viable and increasingly utilized option for the treatment of refractory hypoxemia in severe acute respiratory distress syndrome (ARDS). However, options are limited for ARDS patients who fail to wean from ECMO. The high rates of infection, presence of extrapulmonary end organ damage, ICU-acquired weakness, and high short-term mortality associated with ARDS are all significant hurdles that make lung transplantation a difficult prospect to consider. However, ECMO support has been used as a bridge to transplant in patients with other underlying chronic lung diseases. Our case illustrates the successful use of lung transplantation for a patient with no previous lung disease who developed refractory ARDS requiring protracted ECMO support. The use of ambulatory ECMO with early institution of physical therapy is an essential component in preparing such patients for successful transplantation.

Acute ischemic optic neuropathy with extended prone position ventilation in a lung transplant recipient.

Prone position ventilation (PPV) improves mortality in severe acute respiratory distress syndrome (ARDS), but outcomes following its use in lung transplant recipients are not known. We report the case of a 42-year-old Caucasian man who presented with severe ARDS from Bordetella pertussis, 5 years after bilateral sequential lung transplant for cystic fibrosis. He was managed with PPV for 22 days and had a prolonged ICU stay complicated by hypoxic ischemic optic neuropathy leading to blindness. Since his discharge from the ICU 6 months ago, his FEV1has recovered to 47% predicted compared to his pre-ICU peak FEV1of 85% predicted, suggesting recovery of lung function. This is the first report of optic nerve damage and vision loss in patients undergoing PPV. Our report also suggests that, in appropriately selected lung transplant recipients, severe hypoxemia could potentially be managed with prone ventilation.

Radiation Exposure in the Medical ICU: Predictors and Characteristics

Background Patients admitted to the medical ICU (MICU) are often subjected to multiple radiologic studies. We hypothesized that some endure radiation dose exposure (cumulative effective dose [CED]) in excess of annual US federal occupational health standard limits (CED ≥ 50 mSv) and 5‐year cumulative limit (CED ≥ 100 mSv). We also evaluated the correlation of CED with Acute Physiology and Chronic Health Evaluation (APACHE) III score and other clinical variables. Methods Retrospective observational study conducted in an academic medical center involving all adult admissions (N = 4,155) to the MICU between January 2013 and December 2013. Radiation doses from ionizing radiologic studies were calculated from reference values to determine the CED. Results Three percent of admissions (n = 131) accrued CED ≥ 50 mSv (1% [n = 47] accrued CED ≥ 100 mSv). The median CED was 0.72 mSv (interquartile range, 0.02‐5.23 mSv), with a range of 0.00 to 323 mSv. Higher APACHE III scores (P = .003), longer length of MICU stay (P < .0001), sepsis (P = .03), and gastrointestinal disorders and bleeding (P < .0001) predicted higher CED in a multivariable linear regression model. Patients with gastrointestinal bleeding and disorders had an odds ratio of 21.05 (95% CI, 13.54‐32.72; P < .0001) and 6.94 (95% CI, 3.88‐12.38; P < .0001), respectively, of accruing CED ≥ 50 mSv in a multivariable logistic regression model. CT scan and interventional radiology accounted for 49% and 38% of the total CED, respectively. Conclusions Patients in the MICU are exposed to radiation doses that can be substantial, exceeding federal annual occupational limits, and in a select subset, are > 100 mSv. Efforts to justify, restrict, and optimize the use of radiologic resources when feasible are warranted.

A Woman in Her 80s With Weakness, Hypoxia, and Bone Marrow Granulomas

A white woman in her 80s presented to the ED with nonproductive cough, fever, and 2 weeks of progressive generalized weakness. Previously ambulatory, she now was so weak she required assistance out of bed.

Acute respiratory distress syndrome: Implications of recent studies

Acute respiratory distress syndrome (ARDS) remains challenging to diagnose and manage. This article reviews the new definition of ARDS and the key findings of landmark studies over the last 5 years of prone-position ventilation, high-frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and neuromuscular blockade in patients with ARDS. A review of the new definition of this disease and new important studies of ventilatory and nonventilatory therapies.