Thomas Corbridge

Cortisol levels and mortality in severe sepsis

objective  Serum cortisol levels rise in response to the stress of critical illness but the optimal range of serum cortisol in such settings is not clearly defined. The objectives of this study were to determine the range of serum cortisol levels in a group of medical intensive care unit patients with severe sepsis/septic shock using uniform criteria, and to correlate serum cortisol levels to mortality.

Autologous non-myeloablative hematopoietic stem cell transplantation in patients with systemic sclerosis

Autologous hematopoietic stem cell transplantation (HSCT) utilizing a myeloablative regimen containing total body irradiation has been performed in patients with systemic sclerosis (SSc), but with substantial toxicity. We, therefore, conducted a phase I non-myeloablative autologous HSCT study in 10 patients with SSc and poor prognostic features. PBSC were mobilized with CY and G-CSF. The PBSC graft was cryopreserved without manipulation and re-infused after the patient was treated with a non-myeloablative conditioning regimen of 200 mg/kg CY and 7.5 mg/kg rabbit antithymocyte globulin. There was a statistically significant improvement of modified Rodnan skin score whereas cardiac (ejection fraction, pulmonary arterial pressure), pulmonary function (DLCO) and renal function (creatinine) remained stable without significant change. One patient with advanced disease died 2 years after the transplant from progressive disease. After median follow-up of 25.5 months, the overall and progression-free survival rates are 90 and 70% respectively. Autologous HSCT utilizing a non-myeloablative conditioning regimen appears to result in improved skin flexibility similar to a myeloablative TBI containing regimen, but without the toxicity and risks associated with TBI.

Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial.

PURPOSE The purpose of this study is to determine the effect of simulation-based education on the knowledge and skills of internal medicine residents in the medical intensive care unit (MICU). METHODS AND MATERIALS From January 2009 to January 2010, 60 first-year residents at a tertiary care teaching hospital were randomized by month of rotation to an intervention group (simulator-trained, n = 26) and a control group (traditionally trained, n = 34). Simulator-trained residents completed 4 hours of simulation-based education before their medical intensive care unit (MICU) rotation. Topics included circulatory shock, respiratory failure, and mechanical ventilation. After their rotation, residents completed a standardized bedside skills assessment using a 14-item checklist regarding respiratory mechanics, ventilator settings, and circulatory parameters. Performance of simulator-trained and traditionally trained residents was compared using a 2-tailed independent-samples t test. RESULTS Simulator-trained residents scored significantly higher on the bedside skills assessment compared with traditionally trained residents (82.5% ± 10.6% vs 74.8% ± 14.1%, P = .027). Simulator-trained residents were highly satisfied with the simulation curriculum. CONCLUSIONS Simulation-based education significantly improved resident knowledge and skill in the MICU. Knowledge acquired in the simulated environment was transferred to improved bedside skills caring for MICU patients. Simulation-based education is a valuable adjunct to standard clinical training for residents in the MICU.

Independent lung ventilation

Situations in which independent lung ventilation may be of use include massive hemoptysis, pulmonary alveolar proteinosis, risk of interbronchial aspiration, unilateral lung injury, single lung transplant, and BPF. Any decision to attempt independent lung ventilation should take into consideration the many technical difficulties associated with the procedure. They include difficulties in the placement of DLTs and monitoring tube position, the risk of tube displacement, and the risk of airway trauma. The clinician also must consider the costs in terms of available manpower and resources. Maintaining a patient on independent lung ventilation requires highly skilled nursing care, specialized monitoring devices, and readily available FOB. Even with these limitations, independent lung ventilation may be of use in certain clinical situations when standard methods have failed.

Variability in interventions with pulmonary artery catheter data

ObjectivesTo determine if intensivists given PAC data from critically ill patients make uniform management choices.DesignCross-sectional survey of board-certified intensivists.SettingMedical intensive care unit.ParticipantsBoard-certified intensivists who are members of the American College of Chest Physicians and Society of Critical Care Medicine.InterventionsA survey questionnaire containing three medical intensive care clinical vignettes was mailed to critical care physicians. Each vignette contained PAC data and one-half of the surveys contained echocardiographic (Echo) information. Every respondent was asked to select one of six interventions for each vignette.MeasurementsThere were 126 evaluable surveys returned. In vignette 1 an intervention (none of the above) was selected by more than 50% of respondents. In vignettes 2 and 3, the most frequent selection was chosen only 44 and 37% of the times, respectively. There was a significant difference in the distribution of management choices between the Echo and the non-Echo subgroups.ConclusionsThere is significant heterogeneity in selecting an intervention based on PAC data among intensivists. The presence of Echo information may change the intervention selected but does not reduce heterogeneity. Any randomized trial evaluating efficacy of PACs will have to have strict treatment protocols.

First-year residents outperform third-year residents after simulation-based education in critical care medicine.

Introduction Previous research shows that gaps exist in internal medicine residents’ critical care knowledge and skills. The purpose of this study was to compare the bedside critical care competency of first-year residents who received a simulation-based educational intervention plus clinical training with third-year residents who received clinical training alone. Methods During their first 3 months of residency, a group of first-year residents completed a simulation-based educational intervention. A group of traditionally trained third-year residents who did not receive simulation-based training served as a comparison group. Both groups were evaluated using a 20-item clinical skills assessment at the bedside of a patient receiving mechanical ventilation at the end of their medical intensive care unit rotation. Scores on the skills assessment were compared between groups. Results Simulator-trained first-year residents (n = 40) scored significantly higher compared with traditionally trained third-year residents (n = 27) on the bedside assessment (91.3% [95% confidence interval, 88.2%–94.3%] vs. 80.9% [95% confidence interval, 76.8%–85.0%]; P < 0.001). Conclusions First-year residents who completed a simulation-based educational intervention demonstrated higher clinical competency compared with third-year residents who did not undergo simulation training. Critical care competency cannot be assumed after clinical intensive care unit rotations; simulation-based curricula can help ensure residents are proficient to care for critically ill patients.

Basic Invasive Mechanical Ventilation

Invasive mechanical ventilation is a lifesaving intervention for patients with respiratory failure. The most commonly used modes of mechanical ventilation are assist-control, synchronized intermittent mandatory ventilation, and pressure support ventilation. When employed as a diagnostic tool, the ventilator provides data on the static compliance of the respiratory system and airway resistance. The clinical scenario and the data obtained from the ventilator allow the clinician to provide effective and safe invasive mechanical ventilation through manipulation of the ventilator settings. While life-sustaining in many circumstances, mechanical ventilation may also be toxic and should be withdrawn when clinically appropriate.

Utility of [18F]2-Fluoro-2-Deoxyglucose-PET in Sporadic and Tuberous Sclerosis-Associated Lymphangioleiomyomatosis

Mutations in tuberous sclerosis complex (TSC) genes are associated with dysregulated mammalian target of rapamycin (mTOR)/Akt signaling and unusual neoplasms called perivascular epithelioid cell tumors (PEComas), including angiomyolipomas (AMLs) and lymphangioleiomyomatosis (LAM). Tools that quantify metabolic activity and total body burden of AML and LAM cells would be valuable for the assessment of disease progression and the response to therapy in patients with TSC and LAM. Our hypothesis was that constitutive activation of mTOR in LAM and AML cells would result in increased glucose uptake of [(18)F]2-fluoro-2-deoxyglucose (FDG) on PET scanning, as has been suggested by a single prior case report. After institutional review board approval, FDG-PET scanning was performed in six LAM patients. Six additional LAM patients underwent FDG-PET scanning for clinical evaluation of suspected malignancy. Pleural uptake related to prior therapy was identified in four individuals with a remote history of talc pleurodesis. Focal increased uptake was observed in a supraclavicular lymph node in a patient with Hodgkin lymphoma and in a lung nodule in a patient with a biopsy-documented primary lung adenocarcinoma. In one TSC-LAM patient with a biopsy-documented malignant uterine PEComa, robust uptake was noted in metastatic nodules in the lung but not in the LAM-involved lung parenchyma or the patients massive abdominal lymphangioleiomyomas. No abnormal uptake was identified in the AMLs or LAM lesions in any patients. This pilot study suggests that FDG-PET scans are negative in patients with benign PEComas and therefore are not likely to be useful for estimating the burden of disease in patients with TSC or LAM, but that FDG-PET scans can be used to identify or exclude other neoplasms in these patients.

Retention of critical care skills after simulation-based mastery learning.

BACKGROUND Whether cognitive and patient care skills attained during simulation-based mastery learning (SBML) are retained is largely unknown. OBJECTIVE We studied retention of intensive care unit (ICU) clinical skills after an SBML boot camp experience. METHODS Forty-seven postgraduate year (PGY)-1 residents completed SBML intervention designed to increase procedural, communication, and patient care skills. The intervention included ICU skills such as ventilator and hemodynamic parameter management. Residents were required to meet or exceed a minimum passing score (MPS) on a clinical skills examination before starting actual patient care. Skill retention was assessed in 42 residents who rotated in the medical ICU. Residents received a standardized 15-minute booster teaching session reviewing key concepts during the first week of the rotation. During the fourth week of their rotation, PGY-1 residents completed a clinical skills examination at the bedside of an actual ICU patient. Group mean examination scores and the proportion of subjects who met or exceeded the MPS at each testing occasion were compared. RESULTS Residents scored a mean 90% (SD  =  6.5%) on the simulated skills examination immediately after training. Residents retained skills obtained through SBML as the mean score at bedside follow-up testing was 89% (SD  =  8.9%, P  =  .36). Thirty-seven of 42 (88%) PGY-1 residents met or exceeded the MPS at follow-up. CONCLUSION SBML leads to substantial retention of critical care knowledge, and patient care skills PGY-1 boot camp is a highly efficient and effective model that can be administered at the beginning of the academic year.

Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure

There are approximately 2 million emergency department visits for acute asthma per year with 12 million people reporting having had asthma “attacks” in the past year (1). Approximately 2% to 20% of admissions to intensive care units (ICUs) are attributed to severe asthma, with intubation and mechanical ventilation deemed necessary in up to one third in the ICU (2) and mortality rates in patients receiving intubation from 10% to 20% in this patient population (3). The onset of acute asthma symptoms ranges from hours to weeks. Type I acute asthma, also known as slow-onset asthma, often presents as a gradual deterioration of the clinical scenario, which is superimposed on a background of chronic and poorly controlled asthma. Type II acute asthma, or rapid-onset asthma, tends to be more dangerous and frequently presents with sudden narrowing of the airways (4). This article reviews the recent evidence-based data regarding the indications, techniques, and complications of intubation and mechanical ventilation in the treatment of acute asthma in the emergency department (ED). It also discusses possible strategies for preventing the need for intubation in patients with severe exacerbations who are not responding to conventional therapy. Finally, this article provides practical management recommendations in this clinical setting.