Outcomes after decrease in hypothermia usage for out of Hospital Cardiac arrest after targeted temperature management study.

OBJECTIVE: Evaluate trends in targeted temperature management with regards to temperature selection, its effect on neurologic outcomes at discharge, and compare this with recent large randomized controlled trial outcomes. DESIGN: Retrospective cohort study between January 2010 and December 2019. SETTING: Single large tertiary academic community hospital. PATIENTS: 634 adult non-traumatic patients presenting with out of hospital cardiac arrest with persistent comatose state treated with active targeted temperature management. INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS: 473 patients received hypothermia of 33 °C and were compared to 161 patients who received targeted normothermia of 36.5 °C. The primary outcome was Cerebral Performance Category (CPC) at hospital discharge, with levels 1 or 2 considered good outcomes. Mortality, ICU days, ventilator days, and overall hospital stay length were secondary outcomes. Patients receiving T33 had more favorable CPC outcomes when compared to patients receiving T36.5 (OR = 2.4 [1.3, 4.6], p = 0.006). Subgroup analysis of initial non-shockable rhythms demonstrated improved CPC scores (OR = 2.5, p = 0.04), however this was not maintained in the shockable rhythm group. T33 patients had a shorter length of stay. Mortality, ICU days, and ventilator days did not differ between the groups. CONCLUSIONS: Out of hospital cardiac arrest patients with persistent comatose state treated with hypothermia of 33 °C had improved odds of discharge with good neurologic outcomes when compared to those treated with targeted normothermia. This improvement of outcomes appears to have been driven by the improved outcomes in the patients who had presented with non-shockable rhythm.

Feasibility of Tele-Training to Acquire Sublingual Microcirculatory Images.

Background: Recent advances in device technology and image analysis software used to assess the sublingual microcirculation have expanded clinicians' understanding of hemodynamics beyond assessments of blood pressure and end-organ function to provide unique insight into blood flow at the tissue level. Similarly, significant advances in virtual education and telemedicine have transpired recently, especially during the coronavirus disease (COVID-19) pandemic. However, the training of clinicians to acquire microcirculation images continues to rely on in-person instruction, which can be limited by available local expertise and resources, as well as geographic access to instructors. Objective: Our project aimed to test the feasibility of deploying an online curriculum in combination with tele-guidance versus an in-person guided approach to instruct novices to understand basic principle of microcirculatory function and to acquire sublingual microcirculatory images. Methods: After participating in brief didactics, 14 participants were divided into two groups to acquire microcirculatory images on a healthy volunteer. Each participant either 1) obtained images after an in-person demonstration or 2) obtained images with tele-guidance by using FaceTime technology. We recorded individual microcirculation quality scores, necessary time to acquire each image, percentage of correct theoretical questions on assessments, participant satisfaction with the curriculum, and participants' degree of confidence with image acquisition. Results: Participants' image quality scores (14.7 vs. 23.6, P = 0.3) and time to acquire images (191.2 vs. 199.4 s) did not significantly differ. In addition, participants' scores on theoretical knowledge assessments improved over the course of training (19.0% vs. 54.8%, P < 0.05). Conclusion: This feasibility study provides a novel framework for how to successfully deploy asynchronous education and telemedicine to direct novices to acquire sublingual microcirculatory images. Using technological advances to teach microcirculation may enhance wide-scale adoption of a promising clinical monitoring tool for critically ill patients.

Retrospective Review of Transpulmonary Pressure Guided Positive End-Expiratory Pressure Titration for Mechanical Ventilation in Class II and III Obesity.

OBJECTIVES: Acute respiratory distress syndrome is treated by utilizing a lung protective ventilation strategy. Obesity presents with additional physiologic considerations, and optimizing ventilator settings may be limited with traditional means. Transpulmonary pressure (PL) obtained via esophageal manometry may be more beneficial to titrating positive end-expiratory pressure (PEEP) in this population. We sought to determine the feasibility and impact of implementation of a protocol for use of esophageal balloon to set PEEP in obese patients in a community ICU. DESIGN: Retrospective cohort study of obese (body mass index [BMI] ≥ 35 kg/m2) patients undergoing individualized PEEP titration with esophageal manometry. Data were extracted from electronic health record, and Wilcoxon signed rank test was performed to determine whether there were differences in the ventilatory parameters over time. SETTING: Intensive care unit in a community based hospital system in Newark, Delaware. PATIENTS: Twenty-nine mechanically ventilated adult patients with a median BMI of 45.8 kg/m2 with acute respiratory distress syndrome (ARDS). INTERVENTION: Individualized titration of PEEP via esophageal catheter obtained transpulmonary pressures. MEASUREMENTS AND MAIN RESULTS: Outcomes measured include PEEP, oxygenation, and driving pressure (DP) before and after esophageal manometry at 4 and 24 hr. Clinical outcomes including adverse events (pneumothorax and pneumomediastinum), increased vasopressor use, rescue therapies (inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and new prone position), continuous renal replacement therapy, and tracheostomy were also analyzed. Four hours after PEEP titration, median PEEP increased from 12 to 20 cm H2O (p < 0.0001) with a corresponding decrease in median DP from 15 to 13 cm H2O (p = 0.002). Subsequently, oxygenation improved as median Fio2 decreased from 0.8 to 0.6 (p < 0.0001), and median oxygen saturation/Fio2 (S/F) ratio improved from 120 to 165 (p < 0.0001). One patient developed pneumomediastinum. No pneumothoraces were identified. Improvements in oxygenation continued to be seen at 24 hr, compared with the prior 4 hr mark, Fio2 (0.6-0.45; p < 0.004), and S/F ratio (165-211.11; p < 0.001). Seven patients required an increase in vasopressor support after 4 hours. Norepinephrine and epinephrine were increased by 0.05 (± 0.04) µg/kg/min and 0.02 (± 0.01) µg/kg/min on average, respectively. CONCLUSIONS: PL-guided PEEP titration in obese patients can be used to safely titrate PEEP and decrease DP, resulting in improved oxygenation.

Intubation Timing in COVID-19 Based on ROX Index and Association With Patient Outcomes.

BACKGROUND: Timing of intubation in COVID-19 is controversial. We sought to determine the association of the ROX (Respiratory rate-OXygenation) index defined as [Formula: see text] divided by [Formula: see text] divided by breathing frequency at the time of intubation with clinical outcomes. METHODS: We conducted a retrospective cohort study of patients with COVID-19 who were intubated by using a database composed of electronic health record data from patients with COVID-19 from 62 institutions. Multivariable logistic regression was used to evaluate the impact of ROX index score on mortality. We analyzed the ROX index as a continuous variable as well as a categorical variable by using cutoffs previously described as predicting success with high-flow nasal cannula. RESULTS: Of 1,087 subjects in the analysis group, the median age was 64 years, and more than half had diabetes; 55.2% died, 1.8% were discharged to hospice, 7.8% were discharged to home, 27.3% were discharged to another institution, and 7.8% had another disposition. Increasing age and a longer time from admission to intubation were associated with mortality. After adjusting for sex, race, age, comorbidities, and days from admission to intubation, an increasing ROX index score at the time of intubation was associated with a lower risk of death. In a logistic regression model, each increase in the ROX index score by 1 at the time of intubation was associated with an 8% reduction in odds of mortality (odds ratio 0.92, 95% CI 0.88-0.95). We also found an odds ratio for death of 0.62 (95% CI 0.47-0.81) for subjects with an ROX index score ≥ 4.88 at the time of intubation. CONCLUSIONS: Among a cohort of subjects with COVID-19 who were ultimately intubated, a higher ROX index at the time of intubation was positively associated with survival.

Sublingual Microcirculatory Characteristics of a Case of Profound Chemotherapy-Induced Anemia Treated With a Hemoglobin-Based Oxygen Carrier.

Handheld vital microscopy (HVM) can deepen our understanding of hematologic diseases and therapeutics. However, limited reports have assessed human microcirculation during profound anemia, and response to hemoglobin-based oxygen carriers (HBOCs). A 58-year-old woman presented with constitutional symptoms and was diagnosed with acute myeloblastic leukemia. Subsequently, the patient clinically decompensated and was found to have a hemoglobin of 1.9 g/dL. Human blood product administration was not consistent with her beliefs, and she received supportive care with HBOC-201. Concomitantly, her sublingual microcirculation revealed a markedly low microvascular flow index (2.59±0.26), proportion perfused vessels (66.8±18.8%), perfused vessel density (4.41±0.56 mm/mm2), and total vessel density (6.93±1.91 mm/mm2). HVM imaging is a promising point-of-care device for various hematologic conditions, with the potential to understand tissue-level perfusion in novel clinical scenarios, including profound anemia and HBOC administration, as illustrated in this case report.

E-cigarette or Vaping Product Use Associated Lung Injury Among Three Young Adults: A Retrospective Case Series From Delaware.

BACKGROUND: E-cigarette or vaping associated lung injury (EVALI) is a lung disease associated with an inflammatory response to the vaping fluid. Currently, diagnosis remains elusive without definitive biomarkers. CASE PRESENTATION: Herein, we describe three cases of EVALI among 18- to 21-year-old patients ranging from mild to severe. All cases presented with a combination of respiratory, gastrointestinal, and constitutional symptoms. Oxygen support and level of medical care varied based on disease severity. Bilateral pulmonary opacities were observed on chest imaging in each case. Additionally, each case had markedly elevated inflammatory markers, specifically C-reactive protein (CRP). None of these patients improved with intravenous (IV) antibiotics and all required IV corticosteroid therapy to achieve clinical improvement. CONCLUSION: EVALI should be suspected among young, otherwise healthy patients who present with new-onset hypoxia, non-specific gastrointestinal symptoms, and endorse a history of vaping. Though considered a diagnosis of exclusion, diagnosing EVALI requires thorough history taking. Inflammatory studies, CRP, and erythrocyte sedimentation rate (ESR) should be considered adjunctive biomarkers to aid clinicians when the diagnosis remains unclear. Corticosteroids are the mainstay of treatment and patients should have close follow-up whether or not they require hospitalization.

The Reproducibility of the Point of Care Microcirculation (POEM) Score When Used to Assess Critically Ill Patients: A Multicenter Prospective Observational Study.

BACKGROUND: The current standard of analyzing microcirculatory video microscopy is time-consuming and occurs away from the patient, limiting its clinical utility. Point-of-care assessment with incident dark field (IDF) microscopy, however, may offer greater clinical applicability. We aimed to determine the reproducibility of the Point of Care Microcirculation (POEM) tool when used at the bedside in critically ill patients. METHODS: A multinational, multicenter, prospective observational study of adult intubated patients was undertaken during a 9-month period in Germany, the United Kingdom, and the United States. A user recorded a batch of four standardized video clips from each patient, calculated a POEM score and recorded the time for image acquisition. A second user blinded to the first repeated this process. Patients with video clips of poor quality were excluded. At a later date, the two users again blinded themselves to reassess both their own clips and those of the other user. Basic demographic information was recorded. Intrauser reliability (an individual user rescoring the same batch of videos after blinding), interuser reliability (a second user rescoring the other user's video batch after blinding), and test-retest reliability (two users individually capturing videos and recording POEM scores) were assessed using a linearly weighted kappa statistic for ordinal data. RESULTS: Sixty-five patients were included in the final analysis. Observer agreement was substantial for all tests. Intrauser agreement was 0.73 (0.95 CI 0.64-0.81), interuser agreement 0.71 (0.95 CI 0.63-0.79), and test-retest agreement 0.75 (0.95 CI 0.65-0.86). Average time to record videos and assess POEM scores 7:34 ± 3:37 minutes. CONCLUSIONS: Point-of-care assessment of the microcirculation using IDF video microscopy and POEM scoring appears to be both a feasible and reproducible approach to microcirculatory assessment. Testing of the score in critically ill patients showed substantial agreement within and between investigators, but further studies should validate its utility as a tool to guide shock resuscitation.

A Survey of Academic Intensivists' Use of Neuromuscular Blockade in Subjects With ARDS.

BACKGROUND: Our Cooling to Help Injured Lungs (CHILL) trial of therapeutic hypothermia in ARDS includes neuromuscular blockade (NMB) as an inclusion criterion to avoid shivering. NMB has been used to facilitate mechanical ventilation in ARDS and was shown to reduce mortality in the ACURASYS trial. To assess the feasibility of a multi-center CHILL trial, we conducted a survey of academic intensivists about their NMB use in patients with ARDS. METHODS: We distributed via email a 16-question survey about NMB use in patients with ARDS including frequency, indications, and dosing strategy. RESULTS: 212 (24.3%) of 871 respondents completed the survey: 94.7% were board-certified in internal medicine, 88% in pulmonary and critical care; 90.3% practiced in academic medical centers, with 87% working in medical ICUs; 96.6% of respondents who treat ARDS use NMB, and 39.7% use NMB in ≥ 50% of these patients. Of 4 listed indications for initiating NMB in ARDS, allowing adherence with lung-protective ventilator strategies and patient-ventilator synchrony were cited as the most important reasons, followed by the results of the ACURASYS trial and facilitating prone positioning. CONCLUSIONS: We conclude that NMB is frequently used by academic intensivists to facilitate mechanical ventilation in patients with moderate to severe ARDS.

Rapidly progressive interstitial lung disease due to anti-melanoma differentiation associated protein-5 requiring a bilateral lung transplant, and complicated by kennel cough.

The association between inflammatory myopathies anti-synthetase syndrome and interstitial lung disease has been recognized since the 1950s. Patients generally present with gradual onset of symptoms and slow progression of fibrosis over months to years. Herein, we describe a previously well 51-year-old man who presented with three months of progressive small joint arthritis, cough, dyspnea, and eventually hypoxemic respiratory failure following a viral prodrome. He continued to decompensate despite high dose corticosteroids and mycophenolate mofetil, ultimately requiring extracorporeal membranous oxygenation as a bridge to bilateral lung transplantation. Clinically amyopathic dermatomyositis (CADM) was confirmed through serum positivity for anti-Melanoma Differentiation Associated Protein-5 (MDA-5) antibody. Interestingly, his post-operative course was complicated by a zoonotic infection with Bordetella bronchiseptica. This case highlights the importance of identifying rare autoimmune diseases, and the utility of transfer to a lung transplant center.

Mechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study.

BACKGROUND: There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment. METHODS: This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS. RESULTS: We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality. CONCLUSIONS: Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.