Munish Goyal - Academia.edu (original) (raw)

Papers by Munish Goyal

Annals of Emergency Medicine, 2010

Emergency Medicine Clinics of North America, 2008

Journal of Critical Care, 2015

The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsi... more The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsis admitted from the emergency department to a non-intensive care unit (ICU) setting and identify risk factors associated with adverse outcomes. This was a single-center retrospective cohort study conducted at a tertiary, academic hospital in the United States between 2005 and 2009. The primary outcome was a composite outcome of ICU transfer within 48 hours of admission and/or 28-day mortality. Of 1853 patients admitted with severe sepsis, 841 (45%) were admitted to a non-ICU setting, the rate increased over time (P < .001), and 12.5% of these patients were transferred to the ICU within 48 hours and/or died within 28 days. In multivariable models, age (P < .001), an oncology diagnosis (P < .001), and illness severity as measured by Acute Physiologic and Chronic Health Evaluation II (P = .04) and high (≥4 mmol/L) initial serum lactate levels (P = .005) were associated with the primary outcome. Patients presenting to the emergency department with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Of 8 patients admitted to the hospital ward, one was transferred to the ICU within 48 hours and/or died within 28 days of admission. Factors present at admission were identified that were associated with adverse outcomes.

Resuscitation, 2012

Therapeutic hypothermia (TH) has revolutionized the management of comatose post-cardiac arrest sy... more Therapeutic hypothermia (TH) has revolutionized the management of comatose post-cardiac arrest syndrome (PCAS) patients. The 2008 ILCOR/AHA Consensus Statement for the treatment of PCAS suggests that goal-directed therapy, targeting mean arterial pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation (ScvO(2)), should be employed to normalize oxygen delivery. However, the optimal PCAS haemodynamic management strategy has not been defined and few objective data exist to guide clinicians. To describe the haemodynamic strategies used in TH implementation studies. A Medline search (time period, 3/2002 to 3/2010) was performed using the terms cardiac arrest and hypothermia, induced, then limited post-search to implementation studies of TH in comatose adults. The identified studies were examined for explicit definitions of the following terms: MAP; systolic blood pressure (SBP), CVP, ScvO(2), pulmonary artery catheter (PAC), echocardiogram (ECHO), lactate, and volume status. Forty-four implementation studies were identified and 43% (19/44) of them mentioned haemodynamics in any fashion. At least one haemodynamic goal was specifically defined in 16/44 (36%). The median number defined was 4 (range 1-6); individual goals as follows: MAP, 13/44 (30%); SBP, 3/44 (7%); CVP, 5/44 (11%); ScvO(2), 4/44 (9%); PAC, 7/44 (16%); ECHO, 7/44 (16%); lactate, 5/44 (11%); and volume status, 8/44 (18%). Specific haemodynamic goals are defined in a minority of published TH implementation studies. Given the volatile haemodynamics of the PCAS and lack of consensus on an optimal resuscitation strategy, explicit description of haemodynamic goals should be provided in future studies.

The Journal of Emergency Medicine, 2010

Annals of Emergency Medicine, 2010

Academic Emergency Medicine, 2012

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care unit... more Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.

Annals of Emergency Medicine, 2005

Annals of Emergency Medicine, 2010

Emergency Medicine Clinics of North America, 2008

Journal of Critical Care, 2015

The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsi... more The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsis admitted from the emergency department to a non-intensive care unit (ICU) setting and identify risk factors associated with adverse outcomes. This was a single-center retrospective cohort study conducted at a tertiary, academic hospital in the United States between 2005 and 2009. The primary outcome was a composite outcome of ICU transfer within 48 hours of admission and/or 28-day mortality. Of 1853 patients admitted with severe sepsis, 841 (45%) were admitted to a non-ICU setting, the rate increased over time (P < .001), and 12.5% of these patients were transferred to the ICU within 48 hours and/or died within 28 days. In multivariable models, age (P < .001), an oncology diagnosis (P < .001), and illness severity as measured by Acute Physiologic and Chronic Health Evaluation II (P = .04) and high (≥4 mmol/L) initial serum lactate levels (P = .005) were associated with the primary outcome. Patients presenting to the emergency department with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Of 8 patients admitted to the hospital ward, one was transferred to the ICU within 48 hours and/or died within 28 days of admission. Factors present at admission were identified that were associated with adverse outcomes.

Resuscitation, 2012

Therapeutic hypothermia (TH) has revolutionized the management of comatose post-cardiac arrest sy... more Therapeutic hypothermia (TH) has revolutionized the management of comatose post-cardiac arrest syndrome (PCAS) patients. The 2008 ILCOR/AHA Consensus Statement for the treatment of PCAS suggests that goal-directed therapy, targeting mean arterial pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation (ScvO(2)), should be employed to normalize oxygen delivery. However, the optimal PCAS haemodynamic management strategy has not been defined and few objective data exist to guide clinicians. To describe the haemodynamic strategies used in TH implementation studies. A Medline search (time period, 3/2002 to 3/2010) was performed using the terms cardiac arrest and hypothermia, induced, then limited post-search to implementation studies of TH in comatose adults. The identified studies were examined for explicit definitions of the following terms: MAP; systolic blood pressure (SBP), CVP, ScvO(2), pulmonary artery catheter (PAC), echocardiogram (ECHO), lactate, and volume status. Forty-four implementation studies were identified and 43% (19/44) of them mentioned haemodynamics in any fashion. At least one haemodynamic goal was specifically defined in 16/44 (36%). The median number defined was 4 (range 1-6); individual goals as follows: MAP, 13/44 (30%); SBP, 3/44 (7%); CVP, 5/44 (11%); ScvO(2), 4/44 (9%); PAC, 7/44 (16%); ECHO, 7/44 (16%); lactate, 5/44 (11%); and volume status, 8/44 (18%). Specific haemodynamic goals are defined in a minority of published TH implementation studies. Given the volatile haemodynamics of the PCAS and lack of consensus on an optimal resuscitation strategy, explicit description of haemodynamic goals should be provided in future studies.

The Journal of Emergency Medicine, 2010

Annals of Emergency Medicine, 2010

Academic Emergency Medicine, 2012

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care unit... more Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.

Annals of Emergency Medicine, 2005