Auxora for the Treatment of Patients With Acute Pancreatitis and Accompanying Systemic Inflammatory Response Syndrome: Clinical Development of a Calcium Release-Activated Calcium Channel Inhibitor.

OBJECTIVES: To assess the safety of Auxora in patients with acute pancreatitis (AP), systemic inflammatory response syndrome (SIRS), and hypoxemia, and identify efficacy endpoints to prospectively test in future studies. METHODS: This phase 2, open-label, dose-response study randomized patients with AP, accompanying SIRS, and hypoxemia (n = 21) to receive low-dose or high-dose Auxora plus standard of care (SOC) or SOC alone. All patients received pancreatic contrast-enhanced computed tomography scans at screenings, day 5/discharge, and as clinically required 90 days postrandomization; scans were blinded and centrally read to determine AP severity using computed tomography severity index. Solid food tolerance was assessed at every meal and SIRS every 12 hours. RESULTS: The number of patients experiencing serious adverse events was not increased with Auxora versus SOC alone. Three (36.5%) patients with moderate AP receiving low-dose Auxora improved to mild AP; no computed tomography severity index improvements were observed with SOC. By study end, patients receiving Auxora better tolerated solid foods, had less persistent SIRS, and had reduced hospitalization versus SOC. CONCLUSIONS: The favorable safety profile and patient outcomes suggest Auxora may be an appropriate early treatment for patients with AP and SIRS. Clinical development will continue in a randomized, controlled, blinded, dose-ranging study.

Angiotensin II for the Treatment of Vasodilatory Shock.

BACKGROUND: Vasodilatory shock that does not respond to high-dose vasopressors is associated with high mortality. We investigated the effectiveness of angiotensin II for the treatment of patients with this condition. METHODS: We randomly assigned patients with vasodilatory shock who were receiving more than 0.2 µg of norepinephrine per kilogram of body weight per minute or the equivalent dose of another vasopressor to receive infusions of either angiotensin II or placebo. The primary end point was a response with respect to mean arterial pressure at hour 3 after the start of infusion, with response defined as an increase from baseline of at least 10 mm Hg or an increase to at least 75 mm Hg, without an increase in the dose of background vasopressors. RESULTS: A total of 344 patients were assigned to one of the two regimens; 321 received a study intervention (163 received angiotensin II, and 158 received placebo) and were included in the analysis. The primary end point was reached by more patients in the angiotensin II group (114 of 163 patients, 69.9%) than in the placebo group (37 of 158 patients, 23.4%) (odds ratio, 7.95; 95% confidence interval [CI], 4.76 to 13.3; P<0.001). At 48 hours, the mean improvement in the cardiovascular Sequential Organ Failure Assessment (SOFA) score (scores range from 0 to 4, with higher scores indicating more severe dysfunction) was greater in the angiotensin II group than in the placebo group (-1.75 vs. -1.28, P=0.01). Serious adverse events were reported in 60.7% of the patients in the angiotensin II group and in 67.1% in the placebo group. Death by day 28 occurred in 75 of 163 patients (46%) in the angiotensin II group and in 85 of 158 patients (54%) in the placebo group (hazard ratio, 0.78; 95% CI, 0.57 to 1.07; P=0.12). CONCLUSIONS: Angiotensin II effectively increased blood pressure in patients with vasodilatory shock that did not respond to high doses of conventional vasopressors. (Funded by La Jolla Pharmaceutical Company; ATHOS-3 ClinicalTrials.gov number, NCT02338843 .).

Does Robotic Telerounding Enhance Nurse-Physician Collaboration Satisfaction About Care Decisions?

BACKGROUND: Delivering healthcare using remote robotic telepresence is an evolving practice in medical and surgical intensive critical care units and will likely have varied implications for work practices and working relationships in intensive care units. Our study assessed the nurse-physician collaboration satisfaction about care decisions from surgical intensive critical care nurses during remote robotic telepresence night rounds in comparison with conventional telephone night rounds. MATERIALS AND METHODS: This study used a randomized trial to test whether robotic telerounding enhances the nurse-physician collaboration satisfaction about care decisions. A physician randomly used either the conventional telephone or the RP-7 robot (InTouch(®) Health, Santa Barbara, CA) to perform nighttime rounding in a surgical intensive care unit. The Collaboration and Satisfaction About Care Decisions (CSACD) survey instrument was used to measure the nurse-physician collaboration. The CSACD scores were compared using the signed-rank test with a significant p value of ≤0.05. RESULTS: From December 1, 2011 to December 13, 2012, 20 off-shift nurses submitted 106 surveys during telephone rounds and 108 surveys during robot rounds. The median score of surveys during robot rounds was slightly but not significantly higher than telephone rounds (51.3 versus 50.5; p=0.3). However, the CSACD score was significantly increased from baseline with robot rounds (51.3 versus 43.0; p=0.01), in comparison with telephone rounds (50.5 versus 43.0; p=0.09). The mediators, including age, working experience, and robot acceptance, were not significantly (p>0.1) correlated with the CSACD score difference (robot versus telephone). CONCLUSIONS: Robot rounding in the intensive care unit was comparable but not superior to the telephone in regard to the nurse-physician collaboration and satisfaction about care decision. The working experience and technology acceptance of intensive care nurses did not contribute to the preference of night shift rounding method from the aspect of collaboration with the physician about care decision-making.

Left-sided superior vena cava and venous hyperoxia masquerading as inadvertent carotid artery catheterization.

BACKGROUND: A persistent left-sided superior vena cava (PLSVC) is a rare, often asymptomatic, venous anomaly that may be first diagnosed during central venous catheterization. During chest radiograph interpretation, a PLSVC can be confused with inadvertent arterial catheterization. CASE REPORT: We describe the presentation of a 45-year-old man with end-stage liver disease who required central venous catheterization for treatment of septic shock. An aberrantly placed catheter noted on chest radiograph and an elevated central venous oxygen saturation gave the appearance of inadvertent carotid artery catheterization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A persistent left-sided superior vena cava can masquerade as an inadvertent cannulation of the carotid artery during central line placement. It is important for emergency physicians to be aware of this possibility when evaluating a chest radiograph with an aberrantly placed catheter. Venous hyperoxia may further complicate attempts to differentiate between arterial and venous catheterization in patients with septic shock. After confirmatory tests, the emergency physician should consider removal of the catheter due to potential complications.

Resource utilization and end-of-life care in a US hospital following medical emergency team-implemented do not resuscitate orders.

BACKGROUND: Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE: To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN: Retrospective review. SETTING: Single, tertiary care center. PATIENTS: Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS: Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS: None. RESULTS: We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS: Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.