Young Im Lee

Diaphragm muscle thinning in patients who are mechanically ventilated.

BACKGROUND Approximately 40% of patients in medical ICUs require mechanical ventilation (MV). Approximately 20% to 25% of these patients will encounter difficulties in discontinuing MV. Multiple studies have suggested that MV has an unloading effect on the respiratory muscles that leads to diaphragmatic atrophy and dysfunction, a process called ventilator-induced diaphragmatic dysfunction (VIDD). VIDD may be an important factor affecting when and if MV can be discontinued. A sensitive and specific diagnostic test for VIDD could provide the physician with valuable information that might influence decisions regarding extubation or tracheostomy. The purpose of this study was to quantify, using daily sonographic assessments, the rate and degree of diaphragm thinning during MV. METHODS Seven intubated patients receiving MV during acute care were included. Using sonography, diaphragm muscle thickness was measured daily from the day of intubation until the patient underwent extubation or tracheostomy or died. We analyzed our data using standard descriptive statistics, linear regression, and mixed-model effects. RESULTS The overall rate of decrease in the diaphragm thickness of all seven patients over time averaged 6% per day of MV, which differed significantly from zero. Similarly, the diaphragm thickness decreased for each patient over time. CONCLUSION Sonographic assessment of the diaphragm provides noninvasive measurement of diaphragmatic thickness and the degree of diaphragm thinning in patients receiving MV. Our data show that diaphragm muscle thinning starts within 48 h after initiation of MV. However, it is unclear if diaphragmatic thinning correlates with diaphragmatic atrophy or pulmonary function. The relationship between diaphragm thinning and diaphragm strength remains to be elucidated.

The Medical Emergency Team Call: A Sentinel Event That Triggers Goals of Care Discussion*

Objective:Several studies have questioned the effectiveness of rapid-response systems when measured by outcomes such as decreased overall hospital mortality or cardiac arrest rates. We studied an alternative outcome of rapid-response system implementation, namely, its effect on goals of care and designation of do not resuscitate. Design:Retrospective chart review. Setting:Veterans Administration Hospital in New York City. Subjects:All patients requiring a medical emergency team call. Interventions:None Measurements and Main Results:Monthly hospital census and discharge data, death occurrences, and do-not-resuscitate order placements were collected over an 8-year pre-medical emergency team and 5-year post-medical emergency team period. All medical emergency team calls and subsequent transfers to a critical care unit were reviewed and correlated to the placement and timing of do-not-resuscitate orders. Interrupted time-series analysis was used to evaluate the impact of the medical emergency team implementation on the change in trend of do-not-resuscitate orders and the hospital mortality. A total of 390 medical emergency team calls were associated with 109 do-not-resuscitate orders (28%). Of the 209 medical emergency team calls (54%) resulting in transfer to a critical care unit, 66 were associated with do-not-resuscitate orders, 73% of which were obtained after transfer. The odds of becoming do not resuscitate for a patient going to the ICU after the medical emergency team call were 2.9 (95% CI, 1.6–5.5; p = 0.001) times greater than for patients staying on the floors after the medical emergency team call. The medical emergency team implementation significantly changed the trend of do-not-resuscitate orders (p < 0.001) but had no impact on hospital mortality rate (p = 0.638). Conclusion:Implementation of a rapid-response system was associated with an increase in do-not-resuscitate order placement. As a sentinel event, medical emergency team activation and transfer to a critical care unit foster consideration of goals of care and frequently results in a transition to a palliative care strategy.

Amiodarone versus digoxin for rate control in critically ill patients with rapid atrial fibrillation or flutter

Background: In critically ill patients with atrial fibrillation (AF) with rapid ventricular rate (RVR), first-line agents may be due to hemodynamically unfavorable. Amiodarone and digoxin are alternatives, however, there is a paucity of literature comparing their effectiveness. This study compared the effectiveness of these agents in critically ill patients in AF with RVR. Methods: This retrospective chart review included critically ill adults between June 2014 and December 2016 who experienced AF with RVR (HR ≥110 bpm) and were initiated on digoxin or amiodarone. The primary endpoint was time until ventricular rate control (HR <110 bpm) within 24 hours. Secondary endpoints included maintenance of target heart rate, time to sinus rhythm conversion, need for rescue therapy, ICU length of stay, 30-day in-hospital mortality, and safety. Results: Thirty-two patients were included in the amiodarone group and 54 patients in the digoxin group. There was no statistically significant difference in time to ventricular rate control between amiodarone and digoxin [4 (IQR, 2–4) vs. 5.5 h (IQR, 2–11), P=0.46], and both agents were similarly efficacious in maintaining rate control (74% vs. 78%, P=0.18). Digoxin was less effective in patients requiring catecholamines in lowering heart rate at 24 hours (107±12 vs. 95±16 bpm, P=0.02). Conclusions: Both groups were similar in time to rate control and rate control at 24 hours. Digoxin was less effective at lowering HR in patients requiring catecholamines.

PICC’ing Your Way into the Pericardium: A Potential Catastrophic Complication of a PICC Line

This is a rare case of a peripherally inserted central catheter (PICC) that was found to be in the pericardiacophrenic vein on a post-procedure chest X-ray. An 82-year-old man was admitted to the medical ICU for severe sepsis with shock and a PICC was placed for vasopressor support. Malpositioning of a central venous catheter can lead to catastrophic results including, perforation, pericardial effusion and tamponade.

Fluid resuscitation-associated increased mortality and inflammatory cytokine expression in murine polymicrobial sepsis

1 Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA 2 Pulmonary and Critical Care Sections of Veterans Administration, New York Harbor Healthcare System, New York, NY, USA 3 Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA

CorrespondenceThe Unsung Hero: Role of Thiamine in the ‘Vitamin C Cocktail’

To the Editor: The study by Marik and colleagues, published in the June issue of CHEST, is thought-provoking and exciting. Combining intravenous vitamin C with corticosteroids and thiamine reduced mortality by 31.9% in a beforeand-after cohort. This research has sparked much interest and debate regarding the efficacy of this “cocktail,” with the majority of focus placed on the vitamin C component. The effects of corticosteroids in sepsis have long been discussed and debated, and the potential synergism between corticosteroids and vitamin C is interesting. However, we believe that the contribution of thiamine in this “cocktail” may have been underappreciated.

Enigmatic Fever and Delirium in a Critically Ill Patient.

A 43-year-old man with a history of chronic neuropathic pain was admitted for respiratory failure and septic shock due to bacterial pneumonia. Mechanical ventilation, intravenous fluids, a vasopressor, and antibiotics were begun for the treatment of respiratory failure and septic shock. His clinical status improved until hospital day 3, when he manifested fever, hypertension, diaphoresis, severe agitation, and delirium. Antibiotics, antipyretics, antipsychotics, fentanyl, and sedatives including benzodiazepines, propofol, and dexmedetomidine, were ineffective at improving his condition.