Analyses of electronic health records utilization in a large community hospital.

INTRODUCTION: The Electronic Health Record (EHR) has become an integral component of healthcare delivery. Survey based studies have estimated that physicians spend 4-6 hours of their workday devoted to EHR. Our study was designed to use computer software to objectively obtain time spent on EHR. METHODS: We recorded EHR time for 248 physiciansover 2 time intervals. EHR active use was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. We recorded total time and % of work hours spent on EHR, and differences in those based on seniority. Physicians reported duty hours using a standardized toolkit. RESULTS: Physicians spent 3.8 (±2) hours on EHR daily, which accounted for 37% (±17%), 41% (±14%), and 45% (±12%) of their day for all clinicians, residents, and interns, respectively. With the progression of training, there was a reduction in EHR time (all p values <0.01). During the first academic quarter, clinicians spent 38% (± 8%) of time on chart review, 17% (± 7%) on orders, 28% (±11%) on documentation (i.e. writing notes) and 17% (±7%) on other activities (i.e. physician hand-off and medication reconciliation). This pattern remained unchanged during the fourth quarter. CONCLUSIONS: Physicians spend close to 40% of their work day on EHR, with interns spending the most time. There is a significant reduction in time spent on EHR with training and greater experience, although the overall amount of time spent on EHR remained high.

High-Frequency Percussive Ventilation Rescue Therapy in Morbidly Obese Patients Failing Conventional Mechanical Ventilation.

BACKGROUND: Morbidly obese patients with respiratory failure who do not improve on conventional mechanical ventilation (CMV) often undergo rescue therapy with extracorporeal membrane oxygenation (ECMO). We describe our experience with high-frequency percussive ventilation (HFPV) as a rescue modality. METHODS: In a retrospective analysis from 2009 to 2016, 12 morbidly obese patients underwent HFPV after failing to wean from CMV. Data were collected regarding demographics, cause of respiratory failure, ventilation settings, and hospital course outcomes. Our end point data were pre- and post-HFPV partial pressure of arterial oxygen and PaO2 to fraction of inspired oxygen (PF) ratios measured at initiation, 2, and 24 hours. RESULTS: Twelve morbidly obese patients required HFPV for respiratory failure. Causes of respiratory failure overlapped and included cardiogenic pulmonary edema (n = 8), pneumonia (n = 5), septic shock (n = 5), and asthma (n = 1). After HFPV initiation, mean fraction of inspired oxygen FiO2 was tapered from 98% to 82% and 66% at 2 and 24 hours, respectively. Mean PaO2 increased from 60.9 mm Hg before HFPV to 175.1 mm Hg (P < .05) at initiation of HFPV, then sustained at 129.5 mm Hg (P < .05) and 88.1 mm Hg (P < .005) at 2 and 24 hours, respectively. Mean PF ratio improved from 66.1 before HFPV to 180.3 (P < .05), 181.0 (P < .05) and 148.9 (P < .0005) at initiation, 2, and 24 hours, respectively. The improvement in mean PaO2 and PF ratios was durable at 24 hours whether or not the patient was returned to CMV (n = 10) or remained on HFPV (n = 2). Survival to discharge was 66.7%. CONCLUSION: In our cohort of morbidly obese patients, HFPV was successfully utilized as a rescue therapy precluding the need for ECMO. Despite our small sample size, HFPV should be considered as a rescue therapy in morbidly obese patients failing CMV prior to the initiation of ECMO. Our retrospective analysis supports consideration for HFPV as another form of rescue therapy for obese patients with refractory hypoxemia and respiratory failure who are not improving with CMV.

Left Ventricular Outflow Tract Obstruction From Preserved Leaflet After Mitral Valve Replacement.

Left ventricular outflow tract obstruction (LVOTO) can be caused by multiple factors. One of the rare causes of LVOTO is preserved anterior mitral valve leaflet and chordal apparatus after mitral valve replacement. We describe a case of a patient with worsening chronic congestive heart failure secondary to LVOTO from systolic anterior motion of residual native anterior mitral leaflet. In this patient, LVOTO was surgically corrected by excision of anterior leaflet and chordal apparatus through the aortic root.

Convergent ablation for persistent atrial fibrillation: Single center experience.

BACKGROUND: Endocardial catheter ablation has been shown to be effective in patients with paroxysmal atrial fibrillation (AF), and significantly less effective in patients with persistent AF (PAF). Lately, there is a trend toward a hybrid approach in the treatment of PAF that may be a more durable treatment for patients with PAF. In this manuscript we report our experience with the convergent ablation procedure in a PAF cohort. METHODS: This is a single center retrospective analysis of 31 patients with PAF who underwent the convergent procedure. All patients underwent surgical epicardial ablation of the posterior left atrial through a subxiphoid approach, followed by radiofrequency endocardial ablations on the same day. Patients were followed at 6 months intervals with static electrocardiograms or implanted devices. RESULTS: Sinus rhythm was achieved intraoperatively in all patients. Recurrence was defined according to Hearlt Rhythm Society definitions. At a median follow up of 17.7 months (IQR 11-24), the recurrence of atrial tachyarrhythmia (AF and atrial flutter) by Kaplan-Meier event free survival analysis occurred in 9 (29%) patients at 1-year follow up and 15 (48%) patients at 2-year follow up with or without the use of antiarrhythmic drugs. Recurrence of AF alone occurred in 4 (13%) patients at 1-year follow up and 9 (29%) patients at 2-year follow up patients. Complication rate in perioperative period was 12.9%. CONCLUSION: Our experience showed the hybrid procedure is a relatively safe and effective option for patients with PAF. Further studies are needed to better determine its long-term outcomes.

Ondansetron induced torsades de pointes.

A single dose of oral Ondansetron can precipitate torsades de pointes and other arrhythmias in patients with risk factors that may prolong QTc interval.

Distal Perfusion Cannulation and Limb Complications in Venoarterial Extracorporeal Membrane Oxygenation.

The utility of distal perfusion cannula (DPC) placement for the prevention of limb complications in patients undergoing femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is poorly characterized. Patients undergoing femoral VA ECMO cannulation at two institutions were retrospectively assessed. Patients were grouped into those who did and those who did not receive a DPC at the time of primary cannulation. The primary outcome was any limb complication. Secondary outcomes included successfully weaning ECMO and in-hospital mortality. A total of 75 patients underwent femoral cannulation between December 2010 and December 2017. Of those, 65 patients (86.7%) had a DPC placed during primary cannulation and 10 patients (13.3%) did not. Baseline demographics, indications for ECMO, and hemodynamic perturbations were well matched between groups. The rate of limb complications was 14.7% (11/75) for the overall cohort and did not differ between groups (p = .6). Three patients (4%) required a four-compartment fasciotomy for compartment syndrome in the DPC group; no patients without a DPC required fasciotomy. Of the three patients who required a thrombectomy for distal ischemia, two were in the DPC group and one was in the no-DPC group (p = .3). Two patients (2.7%) underwent delayed DPC placement for limb ischemia with resolution of symptoms. The in-hospital morality rate was 59.5% and did not differ between groups (p = .5). Patients in the present study, undergoing femoral VA ECMO without preemptive DPC placement did not experience a higher rate of limb complications. However, the two patients who underwent delayed DPC placement for post-cannulation ischemia experienced resolution of symptoms, suggesting that a DPC may be used as an effective limb salvage intervention.

Complete Myocardial Function Recovery with ECMO in a Woman Presenting with Cardiogenic Shock during Peripartum Period.

Peripartum cardiomyopathy is a potentially life-threatening cause of heart failure (HF) that affects women toward the end of pregnancy or in months after delivery. Treatment is similar to the treatment for HF with reduced ejection fraction (EF). Most women make full myocardial function recovery within 6 months on conventional HF therapy. In rare instances, catastrophic presentations may occur with hemodynamic instability requiring the use of mechanical support. Because of the small patient population, limited information is available regarding the recovery of myocardial function in women who received mechanical support. We present a case of a woman in her peripartum period who presented with cardiogenic shock and made complete myocardial function recovery after 4 days of extracorporeal membrane oxygenation (ECMO). Our patient's EF at the time of catastrophe was 5-10%, which improved to 60% on day 4 on ECMO.

High-Frequency Percussive Ventilation Facilitates Weaning from Extracorporeal Membrane Oxygenation in Adults.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an invaluable rescue therapy for patients suffering from cardiopulmonary arrest, but it is not without its drawbacks. There are cases where patients recover their cardiac function, yet they fail to wean to mechanical conventional ventilation (MCV). The use of high-frequency percussive ventilation (HFPV) has been described in patients with acute respiratory failure (RF) who fail MCV. We describe our experience with five patients who underwent VA-ECMO for cardiopulmonary arrest who were successfully weaned from VA-ECMO with HFPV after failure to wean with MCV. Weaning trials of HFPV a day before decannulation or at the time of separation from VA-ECMO were conducted. Primary endpoint data collected include pre- and post-HFPV partial pressures of oxygen (PaO2) and PaO2/FIO2 (P/F) ratios measured at 2 and 24 hours after institution of HFPV. Additional periprocedural data points were collected including length of time on ECMO, hospital stay, and survival to discharge. Four of five patients were placed on VA-ECMO subsequent to percutaneous coronary intervention. One patient had cardiac arrest secondary to RF. Mean PaO2 (44 ± 15.9 mmHg vs. 354 ± 149 mmHg, p < .01) and mean P/F ratio (44 ± 15.9 vs. 354 ± 149, p < .01) increased dramatically at 2 hours after the initiation of HFPV. The improvement in mean PaO2 and P/F ratio was durable at 24 hours whether or not the patient was returned to MCV (n = 3) or remained on HFPV (n = 2) (44 ± 15.9 mmHg vs. 131 ± 68.7 mmHg, p = .036 and 44 ± 15.9 vs. 169 ± 69.9, p < .01, respectively). Survival to discharge was 80%. The data presented suggest that HFPV may be used as a strategy to shorten time on ECMO, thereby reducing the negative effects of the ECMO circuit and improving its cost efficacy.

Use of High-Frequency Percussive Ventilation to Expand Organ Donor Pool.

A 34-year-old woman was brought in to the emergency department after a motor vehicle accident. She had signs of traumatic head injury with Glasgow Coma Scale score of 3, and her neurological examination was consistent with brain death. She was persistently hypoxic on conventional mechanical ventilation and high-frequency percussive ventilation was initiated. The patient's oxygenation improved and was sustained long enough to provide time for organ procurement. This is the first case portraying high-frequency percussive ventilation as a bridge for donors failing on conventional mechanical ventilation.

High-frequency percussive ventilation in cardiac surgery patients failing mechanical conventional ventilation.

OBJECTIVES: Failure of mechanical conventional ventilation (MCV) after cardiac surgery portends a dismal prognosis, with extracorporeal membrane oxygenation frequently utilized as a salvage therapy. We describe our experience with high-frequency percussive ventilation (HFPV) as a rescue therapy for hypoxaemia refractory to MCV after cardiac surgery. METHODS: In a 6-year retrospective analysis from 2009 to 2015, we identified 16 subjects who required HFPV after cardiac surgery. Data regarding demographics, intraoperative details, postoperative ventilatory settings including length of time on HFPV and postoperative outcomes were collected. The primary outcome was improvement in oxygenation as measured by pre- and post-HFPV partial pressures of oxygen (pO2) and ratio of pO2 to fraction of inspired oxygen (P/F ratio). RESULTS: Sixteen patients required HFPV after cardiac surgery. Operative procedures included coronary artery bypass surgery (n = 6), aortic aneurysm or dissection repair (n = 5), valve with bypass surgery (n = 2), aortic valve replacement (n = 2) and extracorporeal membrane oxygenation (n = 1). Median pO2 increased from 61 to 149.5 mmHg (P < 0.001) and the median P/F ratio improved from 62 to 169 (P < 0.001). The improvement in pO2 and P/F ratio was durable at 24 h whether the patient was returned to MCV (n = 4) or remained on HFPV (n = 12) with pO2 and P/F ratio increasing from 61 to 104 mmHg (P < 0.001) and from 62 to 193.5 (P < 0.001), respectively. Survival to discharge was 81%. CONCLUSIONS: In our cohort of cardiac surgical patients, HFPV was successfully utilized as a rescue therapy, obviating the need for extracorporeal membrane oxygenation. Although further studies are warranted, HFPV should be considered in cardiac surgical patients failing MCV.

Transcatheter Aortic Valve Replacement in Type B Aortic Dissection.

Transcatheter aortic valve replacement (TAVR) has become an acceptable alternative to surgical aortic valve replacement in high-risk and inoperable patients. Several technical and anatomical considerations can increase the complexity and risk of the procedure, and therefore are considered as contraindications to TAVR. Patients with significant aortic disease such as aortic dissection are not usually considered for TAVR due to risk of aortic rupture or retrograde extension of the dissection. Herein is presented a report of the first successful TAVR in a patient with extensive type B dissection.

Simultaneous Two-Vessel Subacute Stent Thrombosis Caused by Clopidogrel Resistance from CYP2C19 Polymorphism.

Clopidogrel resistance from CYP2C19 polymorphism has been associated with stent thrombosis in patients undergoing percutaneous coronary intervention with drug-eluting stents. We present a case of a 76-year-old male who received drug-eluting stents to the right coronary artery and left anterior descending artery for non-ST elevation myocardial infarction and was discharged on dual antiplatelet therapy with aspirin and clopidogrel. He subsequently presented with chest pain from anterior, anteroseptal, and inferior ST segment elevation myocardial infarction. An emergent coronary angiogram revealed acute stent thrombosis with 100% occlusion of RCA and LAD that was successfully treated with thrombus aspiration and angioplasty. Although he was compliant with his dual antiplatelet therapy, he developed stent thrombosis, which was confirmed as clopidogrel resistance from homozygous CYP2C19 polymorphism.

Superior vena cava syndrome from an invasive thymoma with transcaval invasion to the right atrium.

Invasive thymoma with transcaval extension to the right atrium is a rare cause of superior vena cava syndrome. We present a case on a 74-year-old female presenting with dyspnea on exertion, and facial and upper extremity swelling. Physical examination revealed mild facial swelling, non-pitting edema involving the upper extremities and distention of superficial veins of the anterior chest wall and jugular veins. An echocardiogram showed moderate right atrial dilation with a mobile mass in the atrial cavity prolapsing through the tricuspid valve. Cardiac magnetic resonance imaging revealed a 9.9 × 4.3 cm heterogeneous mass in the anterior mediastinum compressing the superior vena cava and endovenously extending into the right atrium. Tissue biopsy of the mediastinal mass revealed a type B1 thymoma, further staged as a Masaoka IVa invasive thymoma that underwent successfulen blocresection followed by removal of intracaval and right atrial mass.

A Bridge to a Woman's Heart as the Cause of Recurrent Chest Pain: A Case on Myocardial Bridge.

Myocardial bridge is a congenital structural variant of the coronary arteries where a segment of the epicardial vessel is surrounded by the myocardium. It is an uncommon entity that may go unnoticed in patients with recurrent chest pain. We present a case on a 36-year-old woman with recurrent chest pain. Initial workup revealed normal routine laboratory test results, cardiac biomarkers, electrocardiogram, and an echocardiogram showing preserved ejection fraction with no valvulopathies. A dobutamine myocardial perfusion stress test was performed; this induced chest pain in the patient with electrocardiogram changes evident for 1-mm ST segment elevation in lead V5 and V6 consistent with myocardial ischemia. Perfusion imaging revealed a small fixed myocardial perfusion defect of the apical inferior wall. A cardiac catheterization revealed moderate-to-severe myocardial bridging involving the middle left anterior descending artery. Treatment with metoprolol and ranolazine resolved her symptoms. This case portrays the importance of recognizing myocardial bridge as the potential cause of recurrent chest pain and its ability to cause myocardial ischemia under stress.

Cardiac Amyloidosis Presenting With Cardiogenic Shock.

Cardiac amyloidosis is an infiltrative disorder of the myocardium. It is the result of one of 4 types of amyloidosis: primary systemic (immunoglobulin light chain), secondary, familial (hereditary), or senile. Cardiac amyloidosis ultimately causes congestive heart failure due to irreversible restrictive cardiomyopathy. Because of the rapid progression of the disease, early recognition and determination of underlying etiology are important for tailored therapy. Current interventions range from conservative heart failure management to autologous stem cell and heart transplantation. We present a case of cardiac amyloidosis accompanying undiagnosed multiple myeloma to illustrate the rapid progression of the disease and the complexities of diagnosing and treating this disorder.

Fogarty Maneuver to Restore Coronary Flow in ST-Segment Elevation Myocardial Infarction: Desperate Times Call for Desperate Measures.

Nonatherosclerotic embolism is a rare cause (4%-7%) of coronary occlusion in ST-segment elevation myocardial infarction (STEMI) patients, approximately half of which occur in inadequately anticoagulated patients with prosthetic valves. We report a rare case of a patient with severe rheumatic heart disease and 3 mechanical valves presenting with STEMI that was successfully managed by Fogarty maneuver thrombus extraction after failed thrombus aspiration and balloon angioplasty. A 56-year-old woman presented with an acute anterior STEMI and Killip class III heart failure. She had severe rheumatic heart disease with mechanical tricuspid, mitral and aortic valve prostheses, and atrial fibrillation on warfarin anticoagulation. The international normalized ratio on admission was 1.1. Emergency coronary angiography revealed normal right and circumflex coronary arteries and a total occlusion in the mid left anterior descending artery with a meniscus appearance. Multiple attempts at thrombus aspiration and balloon angioplasty failed to restore flow in the left anterior descending artery. Ultimately, a Fogarty maneuver using a compliant balloon inflated at a low pressure was performed successfully, removing the thrombus into the guiding catheter. There was Thrombolysis in Myocardial Infarction flow grade 3 and near-normal myocardial blush at the end of the procedure. Signs and symptoms of heart failure resolved quickly.