Excipient-Induced Pulmonary Vascular Disease: An Underrecognized and Deadly Complication of Opioid Addiction.

Despite widespread public health concern regarding opioid misuse and overuse, there is a paucity of literature on the acute and chronic pulmonary vascular and cardiac implications of excipient lung disease. This case series describes the clinical presentation of five adult patients who experienced profound pulmonary hypertension and right heart failure in the setting of confirmed or suspected crushed opioid injection at a single academic center between 2012 and 2019. The clinical characteristics and right heart catheterization data presented in these cases demonstrate the acute intravascular effects of the intravenous injection of crushed opioids and potential for hemodynamic collapse. Moreover, these cases suggest that survivors of acute excipient lung disease may develop chronic pulmonary vascular disease. Further studies are needed to explore the epidemiology and outcomes of oral opioid-induced intravascular excipient lung disease to increase awareness of this life-threatening complication among health care professionals and guide treatment and prevention measures.

Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998-2008.

RATIONALE: The patterns and outcomes of noninvasive, positive-pressure ventilation (NIPPV) use in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) nationwide are unknown. OBJECTIVES: To determine the prevalence and trends of noninvasive ventilation for acute COPD. METHODS: We used data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample to assess the pattern and outcomes of NIPPV use for acute exacerbations of COPD from 1998 to 2008. MEASUREMENTS AND MAIN RESULTS: An estimated 7,511,267 admissions for acute exacerbations occurred from 1998 to 2008. There was a 462% increase in NIPPV use (from 1.0 to 4.5% of all admissions) and a 42% decline in invasive mechanical ventilation (IMV) use (from 6.0 to 3.5% of all admissions) during these years. This was accompanied by an increase in the size of a small cohort of patients requiring transition from NIPPV to IMV. In-hospital mortality in this group appeared to be worsening over time. By 2008, these patients had a high mortality rate (29.3%), which represented 61% higher odds of death compared with patients directly placed on IMV (95% confidence interval, 24-109%) and 677% greater odds of death compared with patients treated with NIPPV alone (95% confidence interval, 475-948%). With the exception of patients transitioned from NIPPV to IMV, in-hospital outcomes were favorable and improved steadily year by year. CONCLUSIONS: The use of NIPPV has increased significantly over time among patients hospitalized for acute exacerbations of COPD, whereas the need for intubation and in-hospital mortality has declined. However, the rising mortality rate in a small but expanding group of patients requiring invasive mechanical ventilation after treatment with noninvasive ventilation needs further investigation.

Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care During a Pandemic.

Introduction: Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19 infection. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of labs that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infection. Methods: An anonymous 10-question survey was distributed to 125 physicians (Infectious Disease, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results: Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3 - 10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusions: Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

Hospital Collaboration in Response to the COVID-19 Pandemic in Kansas City Metropolitan Region.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, aka COVID-19) virus has evolved into a World Health Organization-declared pandemic which has strained our regional critical care and hospital resources. METHODS: A Critical Care Task Force was established between Kansas City area intensive care units to allow for preparedness for potential surges by sharing of bed capacity both in the ICU and hospital, and ventilator capacity as well as weekly web-based meetings to share resource concerns and best practice. This Task Force also collected patient information to understand the dynamics of community impact and resource needs better. This effort allowed for compilation and dissemination of information regarding data that describe characteristics of patients with COVID-19 compared to a random sample of medical ICU patients with conditions other than COVID-19.Demographic and therapeutic factors affecting patients admitted to medical intensive care units in the Kansas City metro area are reported from May 5, 2020 until June 2, 2020 using a retrospective case-control study examining gender, race, and therapeutic options including modes of ventilation, vasopressor requirements, renal-replacement therapy, and disposition. RESULTS: During data collection, patients being treated for COVID-19 in intensive care units in the Kansas City metropolitan area were more likely to be older, less likely to be white, and less likely to be immunosuppressed as compared to those being treated for non-COVID illnesses. They were more likely to require non-invasive ventilation and undergo prone positioning but were equally likely to require invasive ventilation and other organ supportive therapy. CONCLUSIONS: Hospitalized patients being treated for COVID-19 in the Kansas City metropolitan area have similar demographics to those being reported in the U.S. including age and race. Additionally, establishing a Critical Care Task Force in response to the pandemic allowed for preparation for a potential surge, establishing capacity, and disseminating timely information to policy makers and critical care workers on the front line.

An Open Label Trial to Assess Safety of Losartan for Treating Worsening Respiratory Illness in COVID-19.

Rationale: Coronavirus disease 2019 (COVID-19) can cause disruption of the renin-angiotensin system in the lungs, possibly contributing to pulmonary capillary leakage. Thus, angiotensin receptor blockers (ARBs) may improve respiratory failure. Objective: Assess safety of losartan for use in respiratory failure related to COVID-19 (NCT04335123). Methods: Single arm, open label trial of losartan in those hospitalized with respiratory failure related to COVID-19. Oral losartan (25 mg daily for 3 days, then 50 mg) was administered from enrollment until day 14 or hospital discharge. A post-hoc external control group with patients who met all inclusion criteria was matched 1:1 to the treatment group using propensity scores for comparison. Measures: Primary outcome was cumulative incidence of any adverse events. Secondary, explorative endpoints included measures of respiratory failure, length of stay and vital status. Results: Of the 34 participants enrolled in the trial, 30 completed the study with a mean age SD of 53.8 ± 17.7 years and 17 males (57%). On losartan, 24/30 (80%) experienced an adverse event as opposed to 29/30 (97%) of controls, with a lower average number of adverse events on losartan relative to control (2.2 vs. 3.3). Using Poisson regression and controlling for age, sex, race, date of enrollment, disease severity at enrollment, and history of high-risk comorbidities, the incidence rate ratio of adverse events on losartan relative to control was 0.69 (95% CI: 0.49-0.97) Conclusions: Losartan appeared safe for COVID-19-related acute respiratory compromise. To assess true efficacy, randomized trials are needed.

Novel findings from the second wave of adult pH1N1 in the United States.

OBJECTIVE: To describe the impact of novel pH1N1 virus in Atlanta, GA, for inpatient and intensive care services, including lung lavage data and determinants of disease outcome, from the earliest group of infected US population after initial cases. DESIGN: An observational review of all patients with laboratory-confirmed pH1N1 disease hospitalized in four Atlanta hospitals from August 1 through October 31, 2009. Data reviewed included demographics, anthropometrics, clinical laboratory, and respiratory physiology. SETTING: Four hospitals in urban Atlanta, Georgia. PATIENTS: Consecutively admitted patients between August 1 and October 31, 2009 with laboratory confirmed pH1N1 infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 109 patients were admitted during the surveillance period and intensive care unit care was required in 23 patients (21%) among which there were six deaths (26%). Only eight of the 109 (7%) patients were without medical comorbidity; 34% of the 65 female patients were pregnant and none died or required intensive care unit care. Patients with respiratory failure undergoing bronchoalveolar lavage exhibited neutrophilic predominance (average 64%) and negative bacterial cultures. Body mass index was > 30 kg/m in 35 of 81 (43%) of patients with anthropometric data and 16 of 23 (70%) patients requiring intensive care unit care (p = .03). The 16 patients who required mechanical ventilation (70% of intensive care unit patients) were characterized by severe hypoxemia (requiring high levels of inspired oxygen and positive end-expiratory pressures), reduced lung compliance, and high lung injury scores. CONCLUSIONS: This first report of the second wave of US pH1N1 disease from Atlanta, GA, shares epidemiologic characteristics of earlier cohorts but differs by having an even greater prevalence of obesity and fewer patients who were free from chronic medical conditions. Importantly, lung lavage fluid in severe pH1N1 disease is predominantly neutrophilic and culture-negative. Further reports are needed to validate these new findings regarding pH1N1 disease in the United States.

Serum lactate poorly predicts central venous oxygen saturation in critically ill patients: a retrospective cohort study.

BACKGROUND: Serum lactate and central venous oxygen saturation (ScvO2) are commonly used and commonly recommended as markers of tissue oxygenation in shock states. Medical literature has both explicitly stated and implied that the two biomarkers are interchangeable in the management of patients with shock. However, there have been relatively few direct comparisons of these tests in clinical circumstances, and the relationship between them is uncertain. The objective of our study was to evaluate whether simultaneous or near-simultaneous measurements of lactate and ScvO2 reveal a consistent relationship between these two biomarkers. METHODS: A retrospective cohort study was conducted in an urban, academic US hospital. All adults in ICUs between March 2007 and March 2017 who had a lactate measurement and ScvO2 or mixed venous oxygen saturation (SvO2) measurement made +/- 1 h from the lactate were included. Linear and non-linear correlations of ScvO2 and lactate were assessed in a variety of shock states. RESULTS: Two thousand sixty-two patients were included. Lactate and ScvO2 correlated poorly (r 2 = 0.0041, p = 0.0019). This was true for patients with ScvO2 ≤ 65% (r 2 = 0.0431, p < 0.001), patients with normal kidney and liver function (r 2 = 0.0517, p < 0.001), and septic shock patients (r 2 = 0.0037, p = 0.17). For patients with an O2 extraction ratio ≥ 50%, lactate and ScvO2 were strongly correlated (r 2 = 0.93, p = 0.0019), but these patients represented only 2.8% of patients in whom the ratio could be calculated. CONCLUSIONS: Lactate can predict ScvO2 when patients are at or below the critical oxygen delivery threshold, but relatively few shock patients meet this criterion. In the overall population of critically ill patients, serum lactate predicts ScvO2 poorly, even after controlling for factors that may affect lactate production. Lactate and ScvO2 should not be assumed to be interchangeable markers of tissue oxygenation/perfusion.

A Retrospective, Pilot Study of De Novo Antidepressant Medication Initiation in Intensive Care Unit Patients and Post-ICU Depression.

Post-ICU Syndromes (PICS) remain a devastating problem for intensive care unit (ICU) survivors. It is currently unknown if de novo initiation of an antidepressant medication during ICU stay decreases the prevalence of post-ICU depression. We performed a retrospective, pilot study evaluating patients who had not previously been on an antidepressant medication and who were started on an antidepressant while in the trauma surgical, cardiothoracic, or medical intensive care unit (ICU). The PHQ-2 depression scale was used to ascertain the presence of depression after ICU discharge and compared this to historical controls. Of 2,988 patients admitted to the ICU, 69 patients had de novo initiation of an antidepressant medication and 27 patients were alive and available for study inclusion. We found the prevalence of depression in these patients to be 26%, which is not statistically different than the prevalence of post-ICU depression in historical controls [95% CI (27.6%, 51.6%)]. De novo initiation of an antidepressant medication did not substantially decrease the prevalence of post-ICU depression in this retrospective, pilot study.

Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes.

To determine whether stroke volume (SV) guided fluid resuscitation in patients with severe sepsis and septic shock alters Intensive Care Unit (ICU) fluid balance and secondary outcomes, this retrospective cohort study evaluated consecutive patients admitted to an ICU with the primary diagnosis of severe sepsis or septic shock. Cohorts were based on fluid resuscitation guided by changes in SV or by usual care (UC). The SV group comprised 100 patients, with 91 patients in the UC group. Net fluid balance for the ICU stay was lower in the SV group (1.77L) than in the UC group (5.36L) (p=0.022). ICU length of stay was 2.89days shorter (p=0.03) and duration of vasopressors was 32.8h less (p=0.001) in the SV group. SV group required less mechanical ventilation (RR, 0.51; p=0.0001). The SV group was less likely to require acute hemodialysis (6.25%) compared with the UC group (19.5%) (RR, 0.32; p=0.01). In multivariable analysis, SV was an independent predictor of lower fluid balance, LOS, time on vasopressors, and not needing mechanical ventilation. This study demonstrated that SV guided fluid resuscitation in patients with severe sepsis and septic shock was associated with reduced fluid balance and improved secondary outcomes.

Successfully treated mitral valve Proteus mirabilis endocarditis.

Infective endocarditis caused by Proteus mirabilis is rare and is fatal in most cases. A case of a 64-year-old man presenting with fever, dysuria, and murmur is reported. P mirabilis endocarditis was diagnosed based on clinical presentation, blood culture findings, and the presence of a large mitral valve vegetation seen on echocardiogram. The patient survived after long-term antibiotics and surgical replacement of the mitral valve. The clinical characteristics and complications from reported cases of P mirabilis endocarditis are reviewed.

Central intranodal vessels to predict cytology during endobronchial ultrasound transbronchial needle aspiration.

BACKGROUND: : There has been recent interest in identifying the endoscopic ultrasonographic characteristics of lymph nodes (LNs) that predict the presence or absence of malignant involvement. Normal LN anatomy includes the presence of a central intranodal blood vessel (CIV) that can be obliterated with invasion of malignant cells. We sought to determine whether examining LNs for the presence or absence of a CIV during endobronchial ultrasound (EBUS) could predict benign or malignant cytology of the samples obtained. METHODS: : We prospectively evaluated patients undergoing EBUS-transbronchial needle aspiration (TBNA) for mediastinal or hilar adenopathy in a tertiary care referral center. All LNs were prospectively characterized as having or not having a CIV and subsequently classified as benign or malignant by cytologic analysis. RESULTS: : A total of 56 patients undergoing EBUS-TBNA were evaluated. One hundred three LNs were available for analysis. Fifty-six of 103 LNs were positive for malignancy (54.3%). Ultrasonographic identification of a CIV was associated with benign LN cytology with a sensitivity of 83.0% and a specificity of 91.1% and an OR of 49.7 (95% confidence interval, 15.1-163.9). Finding a CIV had a positive predictive value for benign LN cytology of 88.6%. The absence of finding a CIV had a positive predictive value for malignant cytology of 86.4%. The presence or absence of a CIV had an overall diagnostic accuracy of 87.4% (correctly categorizing 90 of 103 LNs). CONCLUSIONS: : There are morphologic characteristics of LNs that can be visualized at the time of EBUS to help predict whether the nodes being evaluated have malignant involvement. The presence of a CIV suggests that the node is benign, whereas the absence of a central intranodal vessel increases the likelihood of malignancy. The presence or absence of a CIV has a good overall accuracy in predicting malignancy (87.4%).

Safety and efficacy of continuous insulin infusion in noncritical care settings.

BACKGROUND: Continuous insulin infusion (CII) to manage hyperglycemia is the accepted standard of care in the intensive care unit (ICU); however, the safety and efficacy of CII in the non-ICU setting has not been determined. RESEARCH DESIGN AND METHODS: This is a retrospective analysis of 200 consecutive patients receiving CII while admitted to general medical-surgical units at Emory University Hospital. We evaluated clinical outcomes and rates of hyperglycemia (blood glucose [BG] >200 mg/dL) and hypoglycemia (BG <60 mg/dL) events during CII. RESULTS: A total of 200 patients (age 52 +/- 16 years; male/female [M/F] 108/92) were admitted to general medicine (45%) or surgery (55%) services, 88.5% with history of diabetes and 41% treated with corticosteroids. The mean BG prior to and during the CII was 323 mg/dL and 170 mg/dL, respectively. Blood glucose of