Implementation of a Goal-Directed Mechanical Ventilation Order Set Driven by Respiratory Therapists Improves Compliance With Best Practices for Mechanical Ventilation.

PURPOSE: Data regarding best practices for ventilator management strategies that improve outcomes in acute respiratory distress syndrome (ARDS) are readily available. However, little is known regarding processes to ensure compliance with these strategies. We developed a goal-directed mechanical ventilation order set that included physician-specified lung-protective ventilation and oxygenation goals to be implemented by respiratory therapists (RTs). We sought as a primary outcome to determine whether an RT-driven order set with predefined oxygenation and ventilation goals could be implemented and associated with improved adherence with best practice. METHODS: We evaluated 1302 patients undergoing invasive mechanical ventilation (1693 separate episodes of invasive mechanical ventilation) prior to and after institution of a standardized, goal-directed mechanical ventilation order set using a controlled before-and-after study design. Patient-specific goals for oxygenation partial pressure of oxygen in arterial blood (Pao 2), ARDS Network [Net] positive end-expiratory pressure [PEEP]/fraction of inspired oxygen [Fio 2] table use) and ventilation (pH, partial pressure of carbon dioxide) were selected by prescribers and implemented by RTs. RESULTS: Compliance with the new mechanical ventilation order set was high: 88.2% compliance versus 3.8% before implementation of the order set ( P < .001). Adherence to the PEEP/Fio 2 table after implementation of the order set was significantly greater (86.0% after vs 82.9% before, P = .02). There was no difference in duration of mechanical ventilation, intensive care unit (ICU) length of stay, and in-hospital or ICU mortality. CONCLUSIONS: A standardized best practice mechanical ventilation order set can be implemented by a multidisciplinary team and is associated with improved compliance to written orders and adherence to the ARDSNet PEEP/Fio 2 table.

Regulation of iron-sulphur cluster homeostasis through transcriptional control of the Isc pathway by [2Fe-2S]-IscR in Escherichia coli.

Fe-S clusters are essential across the biological world, yet how cells regulate expression of Fe-S cluster biogenesis pathways to cope with changes in Fe-S cluster demand is not well understood. Here, we describe the mechanism by which IscR, a [2Fe-2S] cluster-containing regulator of Escherichia coli, adjusts the synthesis of the Isc Fe-S biogenesis pathway to maintain Fe-S homeostasis. Our data indicate that a negative feedback loop operates to repress transcription of the iscRSUA-hscBA-fdx operon, encoding IscR and the Isc machinery, through binding of [2Fe-2S]-IscR to two upstream binding sites. IscR was shown to require primarily the Isc pathway for synthesis of its Fe-S cluster, providing a link between IscR activity and demands for Fe-S clusters through the levels of the Isc system. Surprisingly, the isc operon was more repressed under anaerobic conditions, indicating increased Fe-S cluster occupancy of IscR and decreased Fe-S cluster biogenesis demand relative to aerobic conditions. Consistent with this notion, overexpression of a Fe-S protein under aerobic conditions, but not under anaerobic conditions, led to derepression of P(iscR). Together, these data show how transcriptional control of iscRSUA-hscBA-fdx by [2Fe-2S]-IscR allows E. coli to respond efficiently to varying Fe-S demands.

Association of Perioperative Variables and the Acute Respiratory Distress Syndrome in Liver Transplant Recipients.

BACKGROUND: The assessment of perioperative risk factors for the development of acute respiratory distress syndrome (ARDS) has been described in various surgical populations. However, there are only limited data among patients undergoing liver transplantation (LT), particularly regarding the influence of intraoperative ventilation parameters. We sought to identify the perioperative risk factors associated with the development of ARDS in LT recipients. METHODS: This is a single-center, retrospective cohort study of adult patients who underwent LT at a tertiary academic medical center between January 1, 2006, and January 31, 2016. Postoperative ARDS was identified using the Berlin definition. Multivariable logistic regression analysis was used to identify perioperative risk factors for ARDS. RESULTS: Of 817 eligible patients who underwent an LT during the study period, 20 (2.45%) developed postoperative ARDS. In the preoperative model, ongoing dialysis (odds ratio, 6.41; P < 0.01) was identified as an independent risk factor of ARDS post-LT. A higher mean peak inspiratory pressure per increase of 1 cm H2O (odds ratio, 1.31; P < 0.01) was the only independent risk factor in the intraoperative model. Patients who developed ARDS postoperatively had significantly greater intensive care unit and hospital stay compared to non-ARDS patients (P < 0.001). There were no significant differences in the 30-day (P = 0.16) and 1-year (P = 0.51) mortality between the groups. CONCLUSIONS: Dialysis at the time of transplant and elevated intraoperative mean peak inspiratory pressure were associated with the development of ARDS. ARDS post LT was associated with increased intensive care unit and hospital length of stay, but not increased mortality.

The burden of suicide in Wisconsin's older adult population.

INTRODUCTION: Suicide rates in the older adult population are disproportionately high, yet most studies focus on youth suicide. This study characterized risk factors for elder suicide in Wisconsin. METHODS: Wisconsin residents aged > or =65 who committed suicide from 2001-2006 were identified using the Violent Injury Reporting System (VIRS; 2001-2003) and the Wisconsin Violent Death Reporting System (WVDRS; 2004-2006). Multivariate regression was used to determine the risk of suicide and to adjust crude rates. Suicide circumstances and methods were also examined. RESULTS: From 2001-2006, the rate of suicide of those > or =65 was 12.4 per 100,000 per year, lower than the national average of 14.7 per 100,000. Multivariate analysis in Caucasians found that compared to married individuals, those widowed, divorced, or never married had a 2.5- to nearly 5-fold increase in risk of suicide death. Males aged 65-74 had almost a 7-fold increased risk compared to females of that age, and the risk increased for males as they aged, compared to females 65-74 years old. Almost 40% of the cases had a medical examiner or coroner report that the victim had a diagnosed mental illness. Forty-two percent of victims had documented alcohol toxicology screening; of these, 16% were positive for alcohol at the time of death. The most common method of suicide was firearm use (66.9%). DISCUSSION: Being single, male, and a male advancing in age are risk factors of suicide in the elderly. Health care workers, community advocates, and public health workers should be cognizant of these risk factors to facilitate early recognition and intervention.

Intra-Operative Inspired Fraction of Oxygen and the Risk of Surgical Site Infections in Patients with Type 1 Surgical Incisions.

BACKGROUND: Whether the fraction of inspired oxygen (FIO2) influences the risk of surgical site infection (SSI) is controversial. The World Health Organization and the World Federation of Societies of Anesthesiologists offer conflicting recommendations. In this study, we evaluate simultaneously three different definitions of FIO2 exposure and the risk of SSI in a large surgical population. PATIENTS AND METHODS: Patients with clean (type 1) surgical incisions who developed superficial and deep organ/space SSI within 30 days after surgery from January 2003 through December 2012 in five surgical specialties were matched to specialty-specific controls. Fraction of inspired oxygen exposure was defined as (1) nadir FIO2, (2) percentage of operative time with FIO2 greater than 50%, and (3) cumulative hyperoxia exposure, calculated as the area under the curve (AUC) of FIO2 by time for the duration in which FIO2 greater than 50%. Stratified univariable and multivariable logistic regression models tested associations between FIO2 and SSI. RESULTS: One thousand two hundred fifty cases of SSI were matched to 3,248 controls. Increased oxygen exposure, by any of the three measures, was not associated with the outcome of any SSI in a multivariable logistic regression model. Elevated body mass index (BMI; 35+ vs. <25, odds ratio [OR] 1.78, 95% confidence interval [CI] 1.43-2.24), surgical duration (250+ min vs. <100 min, OR 1.93, 95% CI 1.48-2.52), diabetes mellitus (OR 1.37, 95% CI 1.13-1.65), peripheral vascular disease (OR 1.52, 95% CI 1.10-2.10), and liver cirrhosis (OR 2.48, 95% CI 1.53-4.02) were statistically significantly associated with greater odds of any SSI. Surgical sub-group analyses found higher intra-operative oxygen exposure was associated with higher odds of SSI in the neurosurgical and spine populations. CONCLUSION: Increased intra-operative inspired fraction of oxygen was not associated with a reduction in SSI. These findings do not support the practice of increasing FIO2 for the purpose of SSI reduction in patients with clean surgical incisions.

Successful Treatment of Refractory Hypoxemia Secondary to Disseminated Histoplasmosis Using Extracorporeal Membrane Oxygenation Support.

Refractory hypoxemia secondary to acute respiratory distress syndrome (ARDS) is associated with high mortality. Extracorporeal membraneoxygenation (ECMO) is an accepted strategy for treating refractory hypoxemia in patients with ARDS but is relatively contraindicated in the setting of systemic infections. We present a case of successful ECMO use in a host with refractory hypoxemia secondary to disseminated histoplasmosis with fungemia and discuss our management approach to this difficult patient.

Right Coronary Artery Septic Embolization Secondary to Aerococcus urinae Native Mitral Valve Endocarditis.

Septic embolization to the coronary arteries from infective endocarditis is a rare occurrence. Appropriate treatment is not yet fully determined. We report a case of mitral valve endocarditis due to Aerococcus urinae presenting as acute inferior myocardial infarction.

Measuring intensive care unit performance after sustainable growth rate reform: An example with the National Quality Forum metrics.

BACKGROUND: Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States. AIM: We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine. CONCLUSION: Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care.

Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection.

BACKGROUND: Surgical site infections (SSI) contribute to surgical patients' morbidity and costs. Operating room traffic may be a modifiable risk factor for SSI. We investigated the impact of additional operating room personnel on the risk of superficial SSI (sSSI). PATIENTS AND METHODS: In this matched case-control study, cases included patients in whom sSSI developed in clean surgical incisions after elective, daytime operations. Control subjects were matched by age, gender, and procedure. Operating room personnel were classified as (1) surgical scrubbed, (2) surgical non-scrubbed, or (3) anesthesia. We used conditional logistic regression to test the extent to which additional personnel overall and from each work group were associated with infection. RESULTS: In total, 474 patients and 803 control subjects were identified. Each additional person among total personnel and personnel from each work group was significantly associated with greater odds of infection (all personnel, odds ratio [OR] = 1.082, 95% confidence interval [CI] 1.031-1.134, p = 0.0013; surgical scrubbed OR = 1.132, 95% CI 1.029-1.245, p = 0.0105; surgical non-scrubbed OR = 1.123, 95% CI 1.008-1.251, p = 0.0357; anesthesia OR = 1.153, 95% CI 1.031-1.290, p = 0.0127). After adjusting for operative duration, body mass index, diabetes mellitus, and vascular disease, additional personnel and sSSI were no longer associated overall or for any work groups (total personnel OR = 1.033, 95% CI 0.974-1.095, p = 0.2746; surgical scrubbed OR = 1.060, 95% CI 0.952-1.179, p = 0.2893; surgical non-scrubbed OR = 1.023 95% CI 0.907-1.154, p = 0.7129; anesthesia OR = 1.051, 95% CI 0.926-1.193, p = 0.4442). CONCLUSION: The presence of additional operating room personnel was not independently associated with increased odds of sSSI. Efforts dedicated to sSSI reduction should focus on other modifiable risk factors.

Time to extubation during propofol anesthesia for spine surgery with sufentanil compared with fentanyl: a retrospective cohort study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study compares time to extubation between major spine surgery patients anesthetized with fentanyl versus sufentanil infusions in combination with propofol. SUMMARY OF BACKGROUND DATA: In patients undergoing spinal fusion with intraoperative electrophysiological monitoring of the spinal cord, total intravenous anesthesia with a propofol/opioid combination results in better electrophysiological signals compared with volatile anesthetics. Pharmacokinetic data suggest that total intravenous anesthesia with sufentanil should lead to more rapid emergence from anesthesia than with fentanyl. However, this has never been tested in the spine surgery patient population. METHODS: With institutional review board approval, all major spine patients receiving a propofol-based total intravenous anesthesia with fentanyl were compared with those receiving sufentanil. Time to extubation, defined as the time from surgical closure to tracheal extubation, was the study outcome. Relevant demographic, anthropomorphic, anesthetic, and surgical data were collected. Association between type of opioid and time to extubation was tested for statistical significance. Multiple linear regression analysis was used to control for confounders. RESULTS: A total of 167 patients met inclusion criteria (fentanyl = 72, sufentanil = 95). There was no statistically significant difference between the 2 groups in terms of baseline characteristics. Time from surgical closure to extubation in the fentanyl versus sufentanil groups was not statistically different (mean [SD]: 40.2 [26.7] min vs. 45.0 [36.9] min; P = 0.36). On multivariate analysis, total dose of propofol and male sex were associated with increased time to extubation. CONCLUSION: The use of sufentanil may not reduce time to extubation compared with fentanyl despite its favorable pharmacokinetic profile. Higher doses of propofol and male sex were associated with longer time to extubation and seem to play a greater role than choice of opioid. LEVEL OF EVIDENCE: 3.

The impact of O(2) on the Fe-S cluster biogenesis requirements of Escherichia coli FNR.

In this study, the functions of two established Fe-S cluster biogenesis pathways, Isc (iron-sulfur cluster) and Suf (sulfur mobilization), under aerobic and anaerobic growth conditions were compared by measuring the activity of the Escherichia coli global anaerobic regulator FNR. A [4Fe-4S] cluster is required for FNR activity under anaerobic conditions. An assay of the expression of FNR-dependent promoters in strains containing various deletions of the iscSUAhscBAfdx operon revealed that, under anaerobic conditions, FNR activity was reduced by 60% in the absence of the Isc pathway. In contrast, a mutant lacking the entire Suf pathway had normal FNR activity, although overexpression of the suf operon fully rescued the anaerobic defect in FNR activity in strains lacking the Isc pathway. Expression of the sufA promoter and levels of SufD protein were upregulated by twofold to threefold in Isc(-) strains under anaerobic conditions, suggesting that increased expression of the Suf pathway may be partially responsible for the FNR activity remaining in strains lacking the Isc pathway. In contrast, use of the O(2)-stable [4Fe-4S] cluster FNR variant FNR-L28H showed that overexpression of the suf operon did not restore FNR activity to strains lacking the Isc pathway under aerobic conditions. In addition, FNR-L28H activity was more impaired under aerobic conditions than under anaerobic conditions. The greater requirement for the Isc pathway under aerobic conditions was not due to a change in the rate of Fe-S cluster acquisition by FNR-L28H under aerobic and anaerobic conditions, as shown by (55)Fe-labeling experiments. Using [(35)S]methionine pulse-chase assays, we observed that the Isc pathway, but not the Suf pathway, is the major pathway required for conversion of O(2)-inactivated apo-FNR into [4Fe-4S]FNR upon the onset of anaerobic growth conditions. Taken together, these findings indicate a major role for the Isc pathway in FNR Fe-S cluster biogenesis under both aerobic and anaerobic conditions.