Long-term impact of add-on sequential triple combination therapy in pulmonary arterial hypertension: real world experience.

BACKGROUND: Sequential triple combination therapy is recommended for pulmonary arterial hypertension (PAH) patients who are not at therapeutic goal on dual therapy, but long-term data on efficacy and safety is scarce. OBJECTIVE: To assess the long-term impact of sequential triple combination therapy in patients with PAH who are not at goal on dual combination therapy. STUDY DESIGN AND METHODS: We performed a retrospective observational study in a racially/ethnically diverse cohort of consecutive PAH patients on a stable dual therapy regimen who remained in intermediate- or high-risk category and were subsequently initiated on sequential triple combination therapy. We studied interval change in functional, echocardiographic, and hemodynamic parameters, REVEAL 2.0 risk category and ERS/ESC 2022 simplified four-strata risk category. Multivariate logistic regression analysis was performed to identify independent predictors of successful risk reduction (achievement or maintenance of REVEAL 2.0 low-risk category). Kaplan-Meier survival curves were created to assess the effect of risk reduction on survival. RESULTS: Out of 414 PAH patients seen in our program, 55 patients received add-on sequential triple combination regimen and had follow-up hemodynamic data. The mean age was 57 years, with 85% women. The most common etiology of PAH was idiopathic/heritable (41.8%). Most patients were WHO functional class III (76.4%), and 34.5% of patients were in high-risk category (REVEAL 2.0). On a median follow-up of 68 weeks, there was a significant improvement in WHO Functional Class (p < 0.001), six-minute walk distance (35 m) with 61.8% of patients achieving low-risk status by REVEAL 2.0, and a 28% of patients' improvement in pulmonary vascular resistance. Female gender was identified as a strong predictor of successful risk reduction, whereas Hispanic ethnicity estimated right atrial pressure on echocardiogram and pericardial effusion predicted lower probability of risk reduction. Patients who achieved or maintained low-risk status had significantly improved survival. CONCLUSION: Add-on sequential triple combination therapy significantly increased functional, echocardiographic, and hemodynamic parameters with improvement in risk category and survival.

Impact of Deliberate Practice on Point-of-Care Ultrasound Interpretation of Right Ventricle Pathology.

Background: Point-of-care (POC) ultrasound (POCUS) has become an essential tool in caring for critically ill patients in several specialties. Mastery in POCUS requires competency in image acquisition, image interpretation, and integration into clinical care. Deliberate practice is an effective method for performance improvement in many areas of medical education; however, it is not well described in the literature for POCUS training. Objective: To analyze differences in the effect of deliberate practice in POCUS image interpretation on performance improvement in groups with varying skill levels. Methods: We recruited attending physicians and trainees with varying degrees of expertise in POCUS to complete a 50-item educational instrument on the interpretation of right ventricle size and function. The instrument incorporated deliberate practice for the task of correctly identifying right ventricle size and function as either normal or abnormal. Pulmonary critical care trainees obtained and interpreted POCUS images of patients with diagnosed acute pulmonary embolism, which were compared with gold-standard, two-dimensional echocardiographic scans obtained by an expert technician and interpreted by a cardiologist board-certified in echocardiography. We mapped learners' cumulative accuracy on a learning curve to assess their performance. In addition, we compared groups on the basis of prior experience with using POC echocardiography. Results: Seventy-nine of 81 participants completed the survey and examination and were included in the analysis. Of the participants, 69 (87.3%) were trainees. The overall cumulative accuracy for the group was 72.9%. All groups demonstrated improvement in accuracy with repetitive practice. Conclusion: Deliberate practice in POC echocardiograph interpretation is effective for improving performance in a wide range of learners. Further study is needed to define accuracy cutoffs for competency to help guide learning plans and program requirements and for application into a model for global POC echocardiography competence.

Safety of a Novel Obstructive Sleep Apnea Triage Tool for Postoperative Orthopedic Surgery Patients.

PURPOSE: The purpose of this quality improvement project is to provide a tool for effective and safe triage of postoperative patients in the postanesthesia care unit with known or suspected obstructive sleep apnea (OSA) at an academic orthopedic hospital in New York City. DESIGN: The structure of this project was observational after implementation of a novel OSA triage tool. METHODS: Results were reported from a single center experience in a hospital where there was no existing standard assessment tool consistently used to triage patients with either known or suspected OSA in the postoperative period. Adult patients who underwent orthopedic surgery between October 2018 and February 2020 and who had a known or suspected history of OSA were included. After admission to the postanesthesia care unit (PACU) and upon meeting their modified Aldrete criteria or after 2 hours had elapsed, the PACU primary provider used the OSA triage tool to assess whether the patient had a high or low risk of respiratory deterioration after discharge from the PACU related to OSA. Patients without high-risk criteria were discharged from the PACU to a medical/surgical unit. For patients with high-risk criteria, the PACU provider requested critical care consultation to determine each patient's appropriate hospital disposition upon PACU discharge. FINDINGS: Over the course of the study period, 216 patients were evaluated using the OSA triage tool: 53.2% of the cohort was male, median BMI was 36.3 kg/m2, and 80.1% had a prior diagnosis of obstructive sleep apnea. Patients underwent a variety of orthopedic surgeries with 23.6% having undergone hip surgery, 51.4% knee surgery, 13.4% spine surgery, 9.7% shoulder surgery, and 1.9% foot or ankle surgery. Notably, with the use of this tool, only 12.5% of patients met criteria for critical care consult and 91.7% were admitted to the floor from the PACU. Rapid response for respiratory complications were not observed in any of the patients. There were only three patients who required critical care evaluation after PACU discharge. An anonymous survey completed by PACU nurse practitioners and anesthesiologists revealed a 96.8% self-reported satisfaction with OSA triage tool. CONCLUSION: We demonstrated that use of a OSA triage tool in the single-center orthopedic PACU at NYULH is potentially a safe and effective method of triaging patients with known or suspected OSA to acute care beds versus higher levels of care.

Influence of head-of-bed elevation on the measurement of inferior vena cava diameter and collapsibility.

PURPOSE: Inferior vena cava (IVC) diameter and variation are commonly measured in the supine position to estimate intravascular volume status of critically ill patients. Many scientific societies describe the measurement of IVC diameter in the supine position. However, critically ill patients are rarely placed supine due to concerns for aspiration risk, worsened respiratory mechanics, increases in intracranial pressure, and the time it takes to change patient position. We assessed the influence of head-of-bed (HOB) elevation on IVC measurements. METHODS: We conducted a prospective observational study of critically ill patients undergoing critical care ultrasound. With HOB at 0°, IVC maximum (IVCmax0°) and minimum (IVCmin0°) diameters were measured. Measurements were then repeated with HOB elevated to 30° and 45°. Collapsibility index (CI), defined as (IVCmax - IVCmin)/IVCmax, was calculated for each HOB elevation. Mean differences were then compared. RESULTS: A convenience sample of 95 patients was studied, of whom 45% were on vasopressors and 44% were spontaneously breathing. The CI did not significantly differ between the three positions. We found a significant difference (P ≤ .0001) between IVCmax at 45° (2.09 cm) and 0° (1.96 cm), IVCmin at 45° (1.75 cm) and 0° (1.59 cm), IVCmax at 45° (2.09 cm) and 30° (1.97 cm), and IVCmin at 45° (1.75 cm) and 30° (1.61 cm). CONCLUSIONS: In a population of critically ill patients undergoing goal-directed ultrasound examinations, elevating HOB to 30° did not significantly alter IVC measurements or CI. At 45°, however, IVCmax and IVCmin diameters increased significantly, albeit with no significant change in CI. Performing ultrasound measurements of the IVC with HOB elevated to 30° is unlikely to produce clinically meaningful changes.

Reducing length of stay with the direct oral anti-coagulants in low and intermediate risk pulmonary embolism: a single center experience.

Direct oral anti-coagulants (DOACs) reduce hospital length-of-stay (LOS) in patients with acute pulmonary embolism (PE) in clinical trials. There is a paucity of literature describing real world utility of DOACs, particularly in intermediate-risk patients. To evaluate if the utilization of DOACs vs. non-DOACs in acute PE patients, reduces LOS without a difference in safety in patients defined as low and intermediate-risk of mortality by the European Society of Cardiology. This was a retrospective cohort study of prospectively collected data from a single center registry of consecutive adult outpatients diagnosed with acute PE who survived to hospital discharge. Primary outcome was median hospital LOS. Secondary outcomes were 30-day readmission, survival, and incidence of major and minor bleeding. There were 307 outpatients admitted with acute PE 88 (28.7%) low-risk, 213 (69.4%) intermediate-risk, and 6 (2.0%) high-risk. Two hundred and twenty-six (73.6%) received a DOAC. There was a statistically significant shorter median LOS in all patients treated with a DOAC (2.9 days, IQR 1.8-4.7) vs non-DOAC (4.9 days, IQR 3-8.9) (Generalized Linear Model p < 0.001). There was a shorter median LOS between intermediate-risk patients treated with a DOAC (3.6 days, IQR 2-5.8) vs non-DOAC (5, IQR 3-9). There was no difference in 30-day readmission, survival, or bleeding complications in both cohorts. There was a reduction in LOS in low and intermediate risk patients treated with a DOAC without a difference in 30-day safety and efficacy. Treating acute PE patients with DOACs including intermediate-risk patients, compared to conventional anticoagulation, may facilitate early discharge, and potentially reduce hospital costs.

Extended Versus Short-Course Corticosteroid Taper Regimens in the Management of Chronic Obstructive Pulmonary Disease Exacerbations in Critically Ill Patients.

BACKGROUND: Previous literature has suggested that a short course of corticosteroids is similarly effective as an extended course for managing an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, there are limited data regarding the optimal corticosteroid regimen in critically ill patients and the dosing strategies remain highly variable in this population. METHODS: This retrospective cohort study evaluated patients with AECOPD admitted to the intensive care unit within a 2-year period. Patients were divided into short-course (≤5 days) or extended-course (>5 days) corticosteroid taper groups. The primary end point was treatment failure, defined as the need for intubation, reintubation, or noninvasive mechanical ventilation. Secondary end points included the duration of mechanical ventilation, hospital and intensive care unit length of stay, and adverse events. RESULTS: Of the 151 patients who met the inclusion criteria, 94 received an extended taper and 57 received a short taper. Treatment failure occurred in 3 patients, who were all in the extended taper group (P = .17). In a propensity score-matched cohort, the hospital length of stay was 7 days in the short taper group compared to 11 days in the extended taper group (P < .0001). No differences in adverse events were observed. CONCLUSION: A short-course corticosteroid taper in critically ill patients with AECOPD is associated with reduced hospital length of stay and decreased corticosteroid exposure without increased risk of treatment failure. A prospective randomized trial is warranted.

A narrative review of red blood cell distribution width as a marker for pulmonary embolism.

Red blood cell distribution width (RDW) is a marker of variability in red blood cell size, and is routinely reported as part of a patient's complete blood count. RDW has been shown to be associated with the prediction, severity and prognosis of pulmonary embolism (PE) in recent studies. The underlying biomolecular mechanism of the relationship of RDW to PE is largely unknown, but is thought to be due to the relationship of RDW with acute inflammatory markers and variations in blood viscosity. This review substantiates that a high RDW level, defined using either an arbitrary number or according to receiver operator curve statistics, is associated with a higher risk of acute PE, increased severity (massive vs. submassive) of PE and increased mortality in patients with PE. Nevertheless, the comparison of current studies is limited due to the definition of high RDW (each study uses a different RDW cutoff level), the broad range of exclusion criteria and the inclusion of differing modalities used to diagnose a PE (computed tomography angiogram, ventilation-perfusion study, or clinical diagnosis). Despite the above limitations, these studies provide a promising future clinical use for RDW as a marker of PE.

Oxacillin-Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS).

BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic life-threatening reaction comprised of fevers, rash, and leukocytosis with eosinophilia. Though characteristically associated with leukocytosis, there are rare case reports of DRESS-induced agranulocytosis. DRESS is most frequently caused by antiepileptic medications; however, it has very rarely been reported in relation to oxacillin. We describe a case of oxacillin-induced DRESS associated with agranulocytosis. CASE REPORT A 52-year-old male was admitted for an epidural abscess secondary to oxacillin-sensitive Staphylococcus aureus, for which an extended course of oxacillin and rifampin was initiated. On day 22 of therapy, the patient developed a fever of 38.7°C (101.6°F) with rigors. His complete blood cell count revealed new leukopenia (1.8×10³/uL) with 16% eosinophils and 3% atypical lymphocytes. Antibiotics were transitioned from oxacillin and rifampin to vancomycin, cefepime, and rifampin for presumed sepsis of unclear etiology. On day 23, he was noted to have a pruritic erythematous blanching papular rash on his chest, trunk, neck, and left upper extremity. Infectious workup was unrevealing, and his fever curve up-trended to 39.3°C (102.7°F) with no clinical improvement on broad-spectrum antimicrobials, suggestive of a non-infectious etiology of his rash and fevers. His rash evolved into confluent red patches, and eosinophilia rose to 21%, which was concerning for a drug reaction. His RegiSCAR score was calculated to be 6, consistent with definite DRESS. Leukopenia resolved (6.3×10³/uL) 4 days after discontinuing oxacillin. His epidural abscess was ultimately treated with daptomycin, and DRESS was managed supportively with antihistamines and triamcinolone cream. CONCLUSIONS We highlight this case because of the rarity of DRESS with agranulocytosis related to oxacillin. Beta-lactam antibiotics are widely used, and while DRESS is an uncommon condition, clinicians should consider this diagnosis when managing patients with fevers, leukopenia, and rash.

Pulmonary infarction secondary to pulmonary embolism: An evolving paradigm.

BACKGROUND AND OBJECTIVE: Pulmonary infarction (PI) from pulmonary embolism (PE) remains an entity of unclear aetiology. PI has been thought to occur in elderly patients with cardiopulmonary disease. We hypothesize younger patients without cardiopulmonary comorbidities are at highest risk. Our study aims to characterize PI clinically and radiographically, determine associated risk factors and determine their clinical significance. METHODS: We conducted a single-centre retrospective review of 367 consecutive patients with PE. Clinical and radiographic data were compared between patients with and without PI using chi-square and F-tests. Univariate and multivariate analyses were performed to evaluate risk factors for PI. RESULTS: PI occurred in 62 of 367 patients with acute PE (16.9%). Patients with PI were significantly younger (48 ± 20.3 vs 59.6 ± 17.2 years, P < 0.01), with lower pulmonary embolism severity index (PESI) scores (73.7 ± 38.1 vs 91.9 ± 37.5 years, P < 0.01) and endorsed chest pain with significantly higher frequency (65% vs 39%, P < 0.01). There was no significant difference in other clinical symptoms, hospital length of stay or mortality between groups. Presence of radiographic cardiopulmonary disease was significantly lower in patients with PI (emphysema: 5% vs 22%, P = <0.01; aortic atherosclerosis: 23% vs 43%, P = <0.01). In multivariate analysis, age ≤33 (OR 3.5 CI: 1.37-8.95, P < 0.01), chest pain (OR 2.15 CI: 1.15-4.00, P = 0.02) and pleural effusion (OR 2.18 CI: 1.08-4.41, P = 0.03) increased PI risk and presence of emphysema decreased risk (OR 0.21 CI: 0.06-0.70, P = 0.01). CONCLUSION: Younger patients without cardiopulmonary comorbidities are at highest risk of PI. Chest pain and pleural effusion significantly increased risk of PI while presence of radiographic emphysema reduced risk.

Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism.

OBJECTIVES: Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism. DESIGN: Prospective observational study and retrospective chart review. SETTING: Four hundred fifty bed urban teaching hospital. PATIENTS: Adult in/outpatients diagnosed with acute pulmonary embolism. INTERVENTIONS: Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date. MEASUREMENTS AND MAIN RESULTS: Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes. CONCLUSIONS: This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.

Ibuprofen vs acetaminophen vs their combination in the relief of musculoskeletal pain in the ED: a randomized, controlled trial.

Non-opioid analgesics are often administered to emergency department (ED) patients with musculoskeletal pain but if inadequate, opioids are given with associated potential adverse events. We tested the hypothesis that the reduction in pain scores with the combination of ibuprofen and acetaminophen would be at least 15 mm greater than with either of the agents alone. We conducted a double-blind, randomized, controlled trial of adult ED patients with acute musculoskeletal pain. Patients were randomized to oral ibuprofen 800 mg, acetaminophen 1 g, or their combination. Pain scores across the groups were compared with repeated measures analysis of variance at 20, 40, and 60 minutes. A sample of 30 patients in each group had 80% power to detect a 15 mm difference in pain scores across the groups (α = .05). Thirty patients were randomized to each study group. Mean (SD) age was 36 (15), 54% were male, 73% were white, and 13% were Hispanic. Groups were well balanced in baseline characteristics including initial pain scores (59, 61, and 62 for ibuprofen, acetaminophen, and their combination). Pain decreased over the one hour study period for all groups (P < .001) with mean (SD) scores about 20 mm lower on the Visual Analogue Scale than the mean initial score. However, there was no significant difference among treatments (P = .59). The need for rescue analgesics was similar across groups. We conclude that the combination of ibuprofen and acetaminophen did not reduce pain scores or the need for rescue analgesics compared with either agent alone in ED patients with pain secondary to acute musculoskeletal injuries.