Barry Fuchs | University of Pennsylvania (original) (raw)

Papers by Barry Fuchs

Critical Care Medicine, 2011

cute lung injury (ALI) and the acute respiratory distress syndrome are major causes of morbidity,... more cute lung injury (ALI) and the acute respiratory distress syndrome are major causes of morbidity, mortality, and cost in intensive care units (ICUs) worldwide. Lung protective ventilation (LPV), using low tidal volumes and alveolar pressures, has been shown to reduce mortality in these patients compared with traditional mechanical ventilation (1, 2). However, the practice of LPV has not been widely adopted (3-6). For example, at our own institution, we found that approximately 60% of patients with ALI did not receive LPV from 2000 to 2002 (7). One reason for underuse of LPV in eligible patients is underrecognition of ALI (7, 8). We recently demonstrated that an automated electronic system that screened for ALI using laboratory, radiographic, and demographic data from our electronic hospital information systems identified intubated patients with ALI in a cohort of ICU patients with major trauma with 86.8% sensitivity and 89% specificity compared with a reference standard established by two physician reviewers when patients with congestive heart failure (CHF) were excluded (9). Because our prior validation study was performed in a uniform population of patients with major trauma from a single ICU, the results may not have been generalizable to a more diverse population of critically ill patients. The primary purpose of this study was to prospectively assess the performance of our automated electronic ALI screening system in all ICU patients at risk for ALI in our hospital. METHODS Setting. This study was performed at the Hospital of the University of Pennsylvania, an academic medical center and one of the National Institutes of Health, National Heart, Lung and Blood Institute Acute Respiratory Distress Network Clinical Trials (ARDSNet) centers from 1994 to 2006. This study protocol was reviewed and approved by the Institutional Review Board of the University of Pennsylvania with a waiver for the requirement of written informed consent from participating subjects or their legally authorized representatives. *See also p. 209.

Journal of Surgical Research, 2013

We report a novel approach to mortality review using a 360° survey and a multidisciplinary mortal... more We report a novel approach to mortality review using a 360° survey and a multidisciplinary mortality committee (MMC) to optimize efforts to improve inpatient care. In 2009, a 16-item, 360° compulsory quality improvement survey was implemented for mortality review. Descriptive statistics were performed to compare the responses by provider specialty, profession, and level of training using the Fisher exact and chi-square tests, as appropriate. We compared the agreement between the MMC review and provider-reported classification regarding the preventability of each death using the Cohen kappa coefficient. A qualitative review of 360° information was performed to identify the quality opportunities. Completed surveys (n = 3095) were submitted for 1683 patients. The possibility of a preventable death was suggested in the 360° survey for 42 patients (1.40%). We identified 502 patients (29.83%) with completed 360° surveys who underwent MMC review. The inter-rater reliability between the provider opinions regarding preventable death and the MMC review was poor (kappa = 0.10, P < 0.001). Of the 42 cases identified by the 360° survey as preventable deaths, 15 underwent MMC review; 3 were classified as preventable and 12 were deemed unavoidable. Qualitative analyses of the 12 discrepancies did reveal quality issues; however, they were not deemed responsible for the patients' death. The mortality survey yielded important information regarding inpatient deaths that historically was buried with the patient. Poor agreement between the 360° survey responses and an objective MMC review support the need to have a multipronged approach to evaluating inpatient mortality.

Critical Care Medicine

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well descri... more Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well described in surgical patients. Large-volume resuscitation is thought to be a risk factor for IAH/ACS in this group. However, little is known of the incidence of IAH/ACS in critically ill medical patients. The authors aim to ascertain the incidence of ACS in critically ill medical patients receiving large-volume resuscitation. Over an 8-month study period, the authors performed a prospective cohort study of medical intensive care unit (ICU) patients with a minimum net positive fluid balance of 5 L within the preceding 24 hours. The primary outcome of interest is the development of ACS, defined as an intra-abdominal pressure (IAP) > or = 20 mm Hg associated with new organ dysfunction. IAP was measured by transducing bladder pressure and was recorded along with fluid balance at enrollment and every 12 hours thereafter up to 96 hours. The setting is a medical ICU at a major university hospital. Of the 468 medical ICU admissions screened, 40 (8.5%) were identified who met the 24-hour fluid balance inclusion criterion. Upon enrollment, this cohort had a mean Acute Physiology And Chronic Health Evaluation II score of 23 and a median positive fluid balance of 6.9 L. Thirty-four of the 40 study patients (85%) had intra-abdominal hypertension (IAP > or = 12 mm Hg). During the study period, 13 of the 40 (33%) patients developed IAP > or = 20 mm Hg and 10 (25%) met the criteria for ACS. None underwent laparotomy. ACS is frequently found in critically ill medical patients receiving large-volume resuscitation. The clinical significance of this finding remains unclear. However, routine monitoring of IAP should be considered in medical patients with a 5-L net positive fluid balance in 24 hours. Future studies are warranted to evaluate clinical outcomes of medical patients with ACS and risk factors for its development.

We report a case of ventilator auto-triggering resulting from tuberculous bronchopleural fistula ... more We report a case of ventilator auto-triggering resulting from tuberculous bronchopleural fistula being managed with chest tube suction. Early recognition of bronchopleural fistula-related auto- triggering is extremely important. Auto-triggering can lead to serious adverse effects, including severe hyperventilation and inappropriate escalation of sedatives and/or neuromuscular blockers (administered to reduce spontaneous breathing efforts). Auto-triggering was confirmed in our patient when tachypnea

Respiratory care, 2009

Endotracheal suctioning is required but can have adverse effects, and could affect cardiorespirat... more Endotracheal suctioning is required but can have adverse effects, and could affect cardiorespiratory variables that are used to predict whether the patient is ready for extubation. In a prospective cohort study in a university hospital's medical intensive care unit, we measured the impact of closed-system suctioning on cardiopulmonary variables in spontaneously breathing patients weaning from mechanical ventilation. All spontaneously breathing, mechanically ventilated patients were screened for enrollment at the initiation of weaning from mechanical ventilation. Before, during, and after standardized closed-system endotracheal suctioning we measured minute volume, heart rate, arterial oxygen saturation, mean arterial pressure, respiratory frequency, oxygen saturation, and tidal volume. Twenty-nine patients were enrolled after a median of 5 (interquartile range [IQR] 3-9) ventilator days. Twenty-five patients (86%) were spontaneously breathing on pressure-support ventilation when...

The Lancet, 2008

Approaches to removal of sedation and mechanical ventilation for critically ill patients vary wid... more Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely. Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie, daily interruption of sedatives-with spontaneous breathing trials (SBTs). In four tertiary-care hospitals, we randomly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT (intervention group; n=168) or with sedation per usual care plus a daily SBT (control group; n=168). The primary endpoint was time breathing without assistance. Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00097630. One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up. Seven patients in the control group discontinued their assigned protocol, and two of these patients were lost to follow-up. Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group (14.7 days vs 11.6 days; mean difference 3.1 days, 95% CI 0.7 to 5.6; p=0.02) and were discharged from intensive care (median time in intensive care 9.1 days vs 12.9 days; p=0.01) and the hospital earlier (median time in the hospital 14.9 days vs 19.2 days; p=0.04). More patients in the intervention group self-extubated than in the control group (16 patients vs six patients; 6.0% difference, 95% CI 0.6% to 11.8%; p=0.03), but the number of patients who required reintubation after self-extubation was similar (five patients vs three patients; 1.2% difference, 95% CI -5.2% to 2.5%; p=0.47), as were total reintubation rates (13.8%vs 12.5%; 1.3% difference, 95% CI -8.6% to 6.1%; p=0.73). At any instant during the year after enrolment, patients in the intervention group were less likely to die than were patients in the control group (HR 0.68, 95% CI 0.50 to 0.92; p=0.01). For every seven patients treated with the intervention, one life was saved (number needed to treat was 7.4, 95% CI 4.2 to 35.5). Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials (ie, interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice.

Medical Care, 2008

To estimate the actual cost savings that could be achieved through reductions in intensive care u... more To estimate the actual cost savings that could be achieved through reductions in intensive care unit (ICU) length of stay and duration of mechanical ventilation by determining the short-run marginal variable cost of an ICU and ventilator day. Retrospective cohort study in a university-affiliated teaching hospital. All patients receiving mechanical ventilation in the ICU for more than 48 hours (n = 1778) from July 1, 2005 to June 30, 2006. The hospital's administrative and cost databases were used to determine total costs, variable costs, and direct-variable costs for each patient on each individual ICU and hospital day. Direct-variable costs comprised 19.3% of total ICU costs and 18.4% of total hospital costs. Marginal direct-variable costs (the cost of each additional ICU day) were small compared with the average daily total cost ($649 to 839vs.839 vs. 839vs.1751, in US dollars). In survivors with ICU lengths of stay more than 3 days, the mean direct-variable cost of the last ICU day was 397,whilethemeandirect−variablecostofthefirstwarddaywas397, while the mean direct-variable cost of the first ward day was 397,whilethemeandirect−variablecostofthefirstwarddaywas279, for a mean cost difference of 118(95118 (95% CI, 118(9521-$190). Reducing ICU and hospital length of stay by 1 day in all survivors with ICU lengths of stay more than 3 days would result in an immediate cost savings of only 0.2% of all hospital expenditures for these patients. Marginal variable ICU costs are relatively small compared with average total costs and are only slightly greater than the cost of a ward day.

The Journal of Trauma: Injury, Infection, and Critical Care, 2007

Airway pressure release ventilation and biphasic positive airway pressure ventilation are being u... more Airway pressure release ventilation and biphasic positive airway pressure ventilation are being used increasingly as alternative strategies to conventional assist control ventilation for patients with acute respiratory distress syndrome (ARDS) and acute lung injury. By permitting spontaneous breathing throughout the ventilatory cycle, these modes offer sev-eral advantages over conventional strategies to improve the pathophysiology in these patients, including gas exchange, cardiovascular function, and reducing or eliminating the need for heavy sedation and paralysis. Whether these surrogate outcomes will translate into better patient outcomes remains to be determined. The purpose of this review is to summarize the rationale behind the use of these ventilatory strategies in ARDS, the clinical experience with the use of these modes, and their future applications in trauma patients.

Journal of Intensive Care Medicine, 2007

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well descri... more Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well described in surgical patients. Large-volume resuscitation is thought to be a risk factor for IAH/ACS in this group. However, little is known of the incidence of IAH/ACS in critically ill medical patients. The authors aim to ascertain the incidence of ACS in critically ill medical patients receiving large-volume resuscitation. Over an 8-month study period, the authors performed a prospective cohort study of medical intensive care unit (ICU) patients with a minimum net positive fluid balance of 5 L within the preceding 24 hours. The primary outcome of interest is the development of ACS, defined as an intra-abdominal pressure (IAP) > or = 20 mm Hg associated with new organ dysfunction. IAP was measured by transducing bladder pressure and was recorded along with fluid balance at enrollment and every 12 hours thereafter up to 96 hours. The setting is a medical ICU at a major university hospital. Of the 468 medical ICU admissions screened, 40 (8.5%) were identified who met the 24-hour fluid balance inclusion criterion. Upon enrollment, this cohort had a mean Acute Physiology And Chronic Health Evaluation II score of 23 and a median positive fluid balance of 6.9 L. Thirty-four of the 40 study patients (85%) had intra-abdominal hypertension (IAP > or = 12 mm Hg). During the study period, 13 of the 40 (33%) patients developed IAP > or = 20 mm Hg and 10 (25%) met the criteria for ACS. None underwent laparotomy. ACS is frequently found in critically ill medical patients receiving large-volume resuscitation. The clinical significance of this finding remains unclear. However, routine monitoring of IAP should be considered in medical patients with a 5-L net positive fluid balance in 24 hours. Future studies are warranted to evaluate clinical outcomes of medical patients with ACS and risk factors for its development.

Journal of Intensive Care Medicine, 2008

Intraabdominal pressure is measured conventionally at end-expiration; however, the significance o... more Intraabdominal pressure is measured conventionally at end-expiration; however, the significance of forced exhalation on this measurement has not been evaluated previously. Using data from a previous prospective cohort study of the incidence of intraabdominal hypertension and abdominal compartment syndrome in medical intensive care unit patients, the authors evaluated 65 strip-chart recordings obtained from 28 patients who had measurements of intraabdominal pressure and airway pressures taken simultaneously. Forced exhalation was identified by a rise in intraabdominal pressure during exhalation. Forced exhalation was observed in 4 patients; with a mean intraabdominal pressure increase of 14.3 +/- 1.3 mm Hg at end-exhalation, compared with a decrease of -2.5 +/- 1.2 mm Hg in 24 patients without forced exhalation and absolute pressures of 28.0 +/- 6.6 versus 13.8 +/- 3.9 mm Hg (P < .001). However, there was no difference in end-inspiratory values. Forced exhalation is not uncommon in acutely ill, mechanically ventilated medical intensive care unit patients and may increase intraabdominal pressure significantly to values that exceed the diagnostic threshold for abdominal compartment syndrome.

Critical Care Medicine, 2005

Previous investigations have identified significant interobserver variability in the measurements... more Previous investigations have identified significant interobserver variability in the measurements of central venous pressure and pulmonary artery occlusion pressure in critically ill patients. Large interobserver variability in the measurement of vascular pressures could potentially lead to inappropriate treatment decisions. We postulated that adding an airway pressure signal (Paw) to pressure tracings of central venous pressure and pulmonary artery occlusion pressure would improve interobserver agreement by facilitating identification of end-expiration. To test this hypothesis, six independent experts used a standard protocol to interpret strip-chart recordings of central venous pressure and pulmonary artery occlusion pressure with or without Paw. Two observers were said to agree if their measurements were within 2 mm Hg of each other. SETTING/SUBJECTS/INTERVENTIONS: A total of 459 strip-chart recordings (303 without Paw and 156 with Paw) were obtained from 121 patients enrolled in the ARDSnet Fluids and Catheters Treatment Trial (FACTT) in 16 different hospitals. Agreement within 2 mm Hg between two measurements was 79% for central venous pressure strips without Paw vs. 86% with Paw. For pulmonary artery occlusion pressure, agreement increased from 71% without Paw to 83% with Paw. The increase in agreement with the addition of Paw was greater for strips demonstrating >8 mm Hg phasic respiratory variation compared with strips demonstrating less phasic respiratory variation. Paw display is a simple, inexpensive method to facilitate the identification of end-expiration that can significantly improve interobserver agreement.

Critical Care Medicine, 2002

Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richar... more Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. ...

Critical Care, 2008

Patients triaged to tertiary care centers frequently undergo rotary-wing transport and may be exp... more Patients triaged to tertiary care centers frequently undergo rotary-wing transport and may be exposed to additional risk for adverse events. The incidence of physiologic adverse events and their predisposing factors in mechanically ventilated patients undergoing aeromedical transport are unknown. We performed a retrospective review of flight records of all interfacility, rotary-wing transports to a tertiary care, university hospital during 2001 to 2003. All patients receiving mechanical ventilation via endotracheal tube or tracheostomy were included; trauma, scene flights, and fixed transports were excluded. Data were abstracted from patient flight and hospital records. Adverse events were classified as either major (death, arrest, pneumothorax, or seizure) or minor (physiologic decompensation, new arrhythmia, or requirement for new sedation/paralysis). Bivariate associations between hospital and flight characteristics and the presence of adverse events were examined. Six hundred eighty-two interfacility flights occurred during the period of review, with 191 patients receiving mechanical ventilation. Fifty-eight different hospitals transferred patients, with diagnoses that were primarily cardiopulmonary (45%) and neurologic (37%). Median flight distance and time were 42 (31 to 83) km and 13 (8 to 22) minutes, respectively. No major adverse events occurred during flight. Forty patients (22%) experienced a minor physiologic adverse event. Vasopressor requirement prior to flight and flight distance were associated with the presence of adverse events in-flight (P < 0.05). Patient demographics, time of day, season, transferring hospital characteristics, and ventilator settings before and during flight were not associated with adverse events. Major adverse events are rare during interfacility, rotary-wing transfer of critically ill, mechanically ventilated patients. Patients transferred over a longer distance or transferred on vasopressors may be at greater risk for minor adverse events during flight.

Cancer Biology & Therapy, 2009

The systemic inflammatory response syndrome (SIRS) criteria have not been validated in patients w... more The systemic inflammatory response syndrome (SIRS) criteria have not been validated in patients with hematologic malignancies (HM). To determine whether daily assessment of SIRS criteria allows early identification of HM patients who will develop septic shock (SS). Observational, single-center,nested case-control study. Oncology unit of a tertiary care center. 547 consecutive, hospitalized, HM subject were enrolled. Using incidence-density sampling, 184 controls were matched to 46 SS cases. The study exposure was the SIRS score. The study outcome was the development of SS during the hospitalization. 8.4% of subjects developed SS. SIRS scores measured 24 hours prior to SS were significantly higher in cases than in controls (2.1 vs. 1.4,p<0.0001). Using standard SIRS cutpoints, fever, tachypnea and tachycardia were each associated with the onset of SS. Population-specific SIRS criteria were empirically derived. Single-center study. Further validation is warranted. SIRS can identify HM patients at risk for SS at least 24 hours before SS onset. These data may lead to evidence-based guidelines using routine vital signs to risk-stratify HM patients for SS.

Annals of Emergency Medicine

Respiratory care

Physicians often fail to use lung-protective ventilation (LPV) in patients with acute lung injury... more Physicians often fail to use lung-protective ventilation (LPV) in patients with acute lung injury. To use physician documentation to identify why physicians did not initiate or continue LPV in patients with acute lung injury. This was a retrospective cohort study in a university hospital. The study period was September 2000 through November 2002. In our primary analysis, LPV was defined as use of a tidal volume < or = 7.5 mL/kg predicted body weight (PBW). We also conducted a sensitivity analysis in which we defined LPV as use of a tidal volume < or = 6.0 mL/kg PBW. In our primary analysis, in 42 (56%) of 75 cases, physicians used or intended to use LPV. Of these 42 subjects, 12 received LPV transiently, and 6 never received LPV, despite the fact that the physician ordered or documented LPV use. In 21 of the 33 remaining cases the physicians documented concerns or clinical criteria that may explain why LPV was not used: relative contraindications to LPV (n = 2), change of care...

Annals of the American Thoracic Society, Jan 19, 2015

We implemented an electronic early warning and response system (EWRS) to improve detection of and... more We implemented an electronic early warning and response system (EWRS) to improve detection of and response to severe sepsis. Sustainability of such a system requires stakeholder acceptance. We hypothesized clinicians receiving such alerts perceive them to be useful and effective. To survey clinicians following EWRS notification about perceptions of the system. For a 6 week study period one month after EWRS implementation in a large tertiary referral medical center, bedside clinicians including providers (physicians, advanced practice providers) and registered nurses (RNs) were surveyed confidentially within 2 hours of an alert. For the 247 alerts that triggered, 127 (51%) providers and 105 (43%) RNs completed the survey. Clinicians perceived most patients as stable before and after the alert. Approximately half (39% providers, 48% RNs) felt the alert provided new information, and about half (44% providers, 56% RNs) reported changes in management as a result of the alert, including c...

B104. TRANSLATING SEPSIS: EPIDEMIOLOGY TO MECHANISMS, 2011

Critical Care Medicine, 2011

cute lung injury (ALI) and the acute respiratory distress syndrome are major causes of morbidity,... more cute lung injury (ALI) and the acute respiratory distress syndrome are major causes of morbidity, mortality, and cost in intensive care units (ICUs) worldwide. Lung protective ventilation (LPV), using low tidal volumes and alveolar pressures, has been shown to reduce mortality in these patients compared with traditional mechanical ventilation (1, 2). However, the practice of LPV has not been widely adopted (3-6). For example, at our own institution, we found that approximately 60% of patients with ALI did not receive LPV from 2000 to 2002 (7). One reason for underuse of LPV in eligible patients is underrecognition of ALI (7, 8). We recently demonstrated that an automated electronic system that screened for ALI using laboratory, radiographic, and demographic data from our electronic hospital information systems identified intubated patients with ALI in a cohort of ICU patients with major trauma with 86.8% sensitivity and 89% specificity compared with a reference standard established by two physician reviewers when patients with congestive heart failure (CHF) were excluded (9). Because our prior validation study was performed in a uniform population of patients with major trauma from a single ICU, the results may not have been generalizable to a more diverse population of critically ill patients. The primary purpose of this study was to prospectively assess the performance of our automated electronic ALI screening system in all ICU patients at risk for ALI in our hospital. METHODS Setting. This study was performed at the Hospital of the University of Pennsylvania, an academic medical center and one of the National Institutes of Health, National Heart, Lung and Blood Institute Acute Respiratory Distress Network Clinical Trials (ARDSNet) centers from 1994 to 2006. This study protocol was reviewed and approved by the Institutional Review Board of the University of Pennsylvania with a waiver for the requirement of written informed consent from participating subjects or their legally authorized representatives. *See also p. 209.

Journal of Surgical Research, 2013

We report a novel approach to mortality review using a 360° survey and a multidisciplinary mortal... more We report a novel approach to mortality review using a 360° survey and a multidisciplinary mortality committee (MMC) to optimize efforts to improve inpatient care. In 2009, a 16-item, 360° compulsory quality improvement survey was implemented for mortality review. Descriptive statistics were performed to compare the responses by provider specialty, profession, and level of training using the Fisher exact and chi-square tests, as appropriate. We compared the agreement between the MMC review and provider-reported classification regarding the preventability of each death using the Cohen kappa coefficient. A qualitative review of 360° information was performed to identify the quality opportunities. Completed surveys (n = 3095) were submitted for 1683 patients. The possibility of a preventable death was suggested in the 360° survey for 42 patients (1.40%). We identified 502 patients (29.83%) with completed 360° surveys who underwent MMC review. The inter-rater reliability between the provider opinions regarding preventable death and the MMC review was poor (kappa = 0.10, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Of the 42 cases identified by the 360° survey as preventable deaths, 15 underwent MMC review; 3 were classified as preventable and 12 were deemed unavoidable. Qualitative analyses of the 12 discrepancies did reveal quality issues; however, they were not deemed responsible for the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; death. The mortality survey yielded important information regarding inpatient deaths that historically was buried with the patient. Poor agreement between the 360° survey responses and an objective MMC review support the need to have a multipronged approach to evaluating inpatient mortality.

Critical Care Medicine

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well descri... more Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well described in surgical patients. Large-volume resuscitation is thought to be a risk factor for IAH/ACS in this group. However, little is known of the incidence of IAH/ACS in critically ill medical patients. The authors aim to ascertain the incidence of ACS in critically ill medical patients receiving large-volume resuscitation. Over an 8-month study period, the authors performed a prospective cohort study of medical intensive care unit (ICU) patients with a minimum net positive fluid balance of 5 L within the preceding 24 hours. The primary outcome of interest is the development of ACS, defined as an intra-abdominal pressure (IAP) &amp;amp;gt; or = 20 mm Hg associated with new organ dysfunction. IAP was measured by transducing bladder pressure and was recorded along with fluid balance at enrollment and every 12 hours thereafter up to 96 hours. The setting is a medical ICU at a major university hospital. Of the 468 medical ICU admissions screened, 40 (8.5%) were identified who met the 24-hour fluid balance inclusion criterion. Upon enrollment, this cohort had a mean Acute Physiology And Chronic Health Evaluation II score of 23 and a median positive fluid balance of 6.9 L. Thirty-four of the 40 study patients (85%) had intra-abdominal hypertension (IAP &amp;amp;gt; or = 12 mm Hg). During the study period, 13 of the 40 (33%) patients developed IAP &amp;amp;gt; or = 20 mm Hg and 10 (25%) met the criteria for ACS. None underwent laparotomy. ACS is frequently found in critically ill medical patients receiving large-volume resuscitation. The clinical significance of this finding remains unclear. However, routine monitoring of IAP should be considered in medical patients with a 5-L net positive fluid balance in 24 hours. Future studies are warranted to evaluate clinical outcomes of medical patients with ACS and risk factors for its development.

We report a case of ventilator auto-triggering resulting from tuberculous bronchopleural fistula ... more We report a case of ventilator auto-triggering resulting from tuberculous bronchopleural fistula being managed with chest tube suction. Early recognition of bronchopleural fistula-related auto- triggering is extremely important. Auto-triggering can lead to serious adverse effects, including severe hyperventilation and inappropriate escalation of sedatives and/or neuromuscular blockers (administered to reduce spontaneous breathing efforts). Auto-triggering was confirmed in our patient when tachypnea

Respiratory care, 2009

Endotracheal suctioning is required but can have adverse effects, and could affect cardiorespirat... more Endotracheal suctioning is required but can have adverse effects, and could affect cardiorespiratory variables that are used to predict whether the patient is ready for extubation. In a prospective cohort study in a university hospital's medical intensive care unit, we measured the impact of closed-system suctioning on cardiopulmonary variables in spontaneously breathing patients weaning from mechanical ventilation. All spontaneously breathing, mechanically ventilated patients were screened for enrollment at the initiation of weaning from mechanical ventilation. Before, during, and after standardized closed-system endotracheal suctioning we measured minute volume, heart rate, arterial oxygen saturation, mean arterial pressure, respiratory frequency, oxygen saturation, and tidal volume. Twenty-nine patients were enrolled after a median of 5 (interquartile range [IQR] 3-9) ventilator days. Twenty-five patients (86%) were spontaneously breathing on pressure-support ventilation when...

The Lancet, 2008

Approaches to removal of sedation and mechanical ventilation for critically ill patients vary wid... more Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely. Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie, daily interruption of sedatives-with spontaneous breathing trials (SBTs). In four tertiary-care hospitals, we randomly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT (intervention group; n=168) or with sedation per usual care plus a daily SBT (control group; n=168). The primary endpoint was time breathing without assistance. Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00097630. One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up. Seven patients in the control group discontinued their assigned protocol, and two of these patients were lost to follow-up. Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group (14.7 days vs 11.6 days; mean difference 3.1 days, 95% CI 0.7 to 5.6; p=0.02) and were discharged from intensive care (median time in intensive care 9.1 days vs 12.9 days; p=0.01) and the hospital earlier (median time in the hospital 14.9 days vs 19.2 days; p=0.04). More patients in the intervention group self-extubated than in the control group (16 patients vs six patients; 6.0% difference, 95% CI 0.6% to 11.8%; p=0.03), but the number of patients who required reintubation after self-extubation was similar (five patients vs three patients; 1.2% difference, 95% CI -5.2% to 2.5%; p=0.47), as were total reintubation rates (13.8%vs 12.5%; 1.3% difference, 95% CI -8.6% to 6.1%; p=0.73). At any instant during the year after enrolment, patients in the intervention group were less likely to die than were patients in the control group (HR 0.68, 95% CI 0.50 to 0.92; p=0.01). For every seven patients treated with the intervention, one life was saved (number needed to treat was 7.4, 95% CI 4.2 to 35.5). Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials (ie, interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice.

Medical Care, 2008

To estimate the actual cost savings that could be achieved through reductions in intensive care u... more To estimate the actual cost savings that could be achieved through reductions in intensive care unit (ICU) length of stay and duration of mechanical ventilation by determining the short-run marginal variable cost of an ICU and ventilator day. Retrospective cohort study in a university-affiliated teaching hospital. All patients receiving mechanical ventilation in the ICU for more than 48 hours (n = 1778) from July 1, 2005 to June 30, 2006. The hospital&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s administrative and cost databases were used to determine total costs, variable costs, and direct-variable costs for each patient on each individual ICU and hospital day. Direct-variable costs comprised 19.3% of total ICU costs and 18.4% of total hospital costs. Marginal direct-variable costs (the cost of each additional ICU day) were small compared with the average daily total cost ($649 to 839vs.839 vs. 839vs.1751, in US dollars). In survivors with ICU lengths of stay more than 3 days, the mean direct-variable cost of the last ICU day was 397,whilethemeandirect−variablecostofthefirstwarddaywas397, while the mean direct-variable cost of the first ward day was 397,whilethemeandirect−variablecostofthefirstwarddaywas279, for a mean cost difference of 118(95118 (95% CI, 118(9521-$190). Reducing ICU and hospital length of stay by 1 day in all survivors with ICU lengths of stay more than 3 days would result in an immediate cost savings of only 0.2% of all hospital expenditures for these patients. Marginal variable ICU costs are relatively small compared with average total costs and are only slightly greater than the cost of a ward day.

The Journal of Trauma: Injury, Infection, and Critical Care, 2007

Airway pressure release ventilation and biphasic positive airway pressure ventilation are being u... more Airway pressure release ventilation and biphasic positive airway pressure ventilation are being used increasingly as alternative strategies to conventional assist control ventilation for patients with acute respiratory distress syndrome (ARDS) and acute lung injury. By permitting spontaneous breathing throughout the ventilatory cycle, these modes offer sev-eral advantages over conventional strategies to improve the pathophysiology in these patients, including gas exchange, cardiovascular function, and reducing or eliminating the need for heavy sedation and paralysis. Whether these surrogate outcomes will translate into better patient outcomes remains to be determined. The purpose of this review is to summarize the rationale behind the use of these ventilatory strategies in ARDS, the clinical experience with the use of these modes, and their future applications in trauma patients.

Journal of Intensive Care Medicine, 2007

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well descri... more Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well described in surgical patients. Large-volume resuscitation is thought to be a risk factor for IAH/ACS in this group. However, little is known of the incidence of IAH/ACS in critically ill medical patients. The authors aim to ascertain the incidence of ACS in critically ill medical patients receiving large-volume resuscitation. Over an 8-month study period, the authors performed a prospective cohort study of medical intensive care unit (ICU) patients with a minimum net positive fluid balance of 5 L within the preceding 24 hours. The primary outcome of interest is the development of ACS, defined as an intra-abdominal pressure (IAP) &amp;amp;gt; or = 20 mm Hg associated with new organ dysfunction. IAP was measured by transducing bladder pressure and was recorded along with fluid balance at enrollment and every 12 hours thereafter up to 96 hours. The setting is a medical ICU at a major university hospital. Of the 468 medical ICU admissions screened, 40 (8.5%) were identified who met the 24-hour fluid balance inclusion criterion. Upon enrollment, this cohort had a mean Acute Physiology And Chronic Health Evaluation II score of 23 and a median positive fluid balance of 6.9 L. Thirty-four of the 40 study patients (85%) had intra-abdominal hypertension (IAP &amp;amp;gt; or = 12 mm Hg). During the study period, 13 of the 40 (33%) patients developed IAP &amp;amp;gt; or = 20 mm Hg and 10 (25%) met the criteria for ACS. None underwent laparotomy. ACS is frequently found in critically ill medical patients receiving large-volume resuscitation. The clinical significance of this finding remains unclear. However, routine monitoring of IAP should be considered in medical patients with a 5-L net positive fluid balance in 24 hours. Future studies are warranted to evaluate clinical outcomes of medical patients with ACS and risk factors for its development.

Journal of Intensive Care Medicine, 2008

Intraabdominal pressure is measured conventionally at end-expiration; however, the significance o... more Intraabdominal pressure is measured conventionally at end-expiration; however, the significance of forced exhalation on this measurement has not been evaluated previously. Using data from a previous prospective cohort study of the incidence of intraabdominal hypertension and abdominal compartment syndrome in medical intensive care unit patients, the authors evaluated 65 strip-chart recordings obtained from 28 patients who had measurements of intraabdominal pressure and airway pressures taken simultaneously. Forced exhalation was identified by a rise in intraabdominal pressure during exhalation. Forced exhalation was observed in 4 patients; with a mean intraabdominal pressure increase of 14.3 +/- 1.3 mm Hg at end-exhalation, compared with a decrease of -2.5 +/- 1.2 mm Hg in 24 patients without forced exhalation and absolute pressures of 28.0 +/- 6.6 versus 13.8 +/- 3.9 mm Hg (P &amp;amp;lt; .001). However, there was no difference in end-inspiratory values. Forced exhalation is not uncommon in acutely ill, mechanically ventilated medical intensive care unit patients and may increase intraabdominal pressure significantly to values that exceed the diagnostic threshold for abdominal compartment syndrome.

Critical Care Medicine, 2005

Previous investigations have identified significant interobserver variability in the measurements... more Previous investigations have identified significant interobserver variability in the measurements of central venous pressure and pulmonary artery occlusion pressure in critically ill patients. Large interobserver variability in the measurement of vascular pressures could potentially lead to inappropriate treatment decisions. We postulated that adding an airway pressure signal (Paw) to pressure tracings of central venous pressure and pulmonary artery occlusion pressure would improve interobserver agreement by facilitating identification of end-expiration. To test this hypothesis, six independent experts used a standard protocol to interpret strip-chart recordings of central venous pressure and pulmonary artery occlusion pressure with or without Paw. Two observers were said to agree if their measurements were within 2 mm Hg of each other. SETTING/SUBJECTS/INTERVENTIONS: A total of 459 strip-chart recordings (303 without Paw and 156 with Paw) were obtained from 121 patients enrolled in the ARDSnet Fluids and Catheters Treatment Trial (FACTT) in 16 different hospitals. Agreement within 2 mm Hg between two measurements was 79% for central venous pressure strips without Paw vs. 86% with Paw. For pulmonary artery occlusion pressure, agreement increased from 71% without Paw to 83% with Paw. The increase in agreement with the addition of Paw was greater for strips demonstrating &gt;8 mm Hg phasic respiratory variation compared with strips demonstrating less phasic respiratory variation. Paw display is a simple, inexpensive method to facilitate the identification of end-expiration that can significantly improve interobserver agreement.

Critical Care Medicine, 2002

Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richar... more Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. ...

Critical Care, 2008

Patients triaged to tertiary care centers frequently undergo rotary-wing transport and may be exp... more Patients triaged to tertiary care centers frequently undergo rotary-wing transport and may be exposed to additional risk for adverse events. The incidence of physiologic adverse events and their predisposing factors in mechanically ventilated patients undergoing aeromedical transport are unknown. We performed a retrospective review of flight records of all interfacility, rotary-wing transports to a tertiary care, university hospital during 2001 to 2003. All patients receiving mechanical ventilation via endotracheal tube or tracheostomy were included; trauma, scene flights, and fixed transports were excluded. Data were abstracted from patient flight and hospital records. Adverse events were classified as either major (death, arrest, pneumothorax, or seizure) or minor (physiologic decompensation, new arrhythmia, or requirement for new sedation/paralysis). Bivariate associations between hospital and flight characteristics and the presence of adverse events were examined. Six hundred eighty-two interfacility flights occurred during the period of review, with 191 patients receiving mechanical ventilation. Fifty-eight different hospitals transferred patients, with diagnoses that were primarily cardiopulmonary (45%) and neurologic (37%). Median flight distance and time were 42 (31 to 83) km and 13 (8 to 22) minutes, respectively. No major adverse events occurred during flight. Forty patients (22%) experienced a minor physiologic adverse event. Vasopressor requirement prior to flight and flight distance were associated with the presence of adverse events in-flight (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Patient demographics, time of day, season, transferring hospital characteristics, and ventilator settings before and during flight were not associated with adverse events. Major adverse events are rare during interfacility, rotary-wing transfer of critically ill, mechanically ventilated patients. Patients transferred over a longer distance or transferred on vasopressors may be at greater risk for minor adverse events during flight.

Cancer Biology & Therapy, 2009

The systemic inflammatory response syndrome (SIRS) criteria have not been validated in patients w... more The systemic inflammatory response syndrome (SIRS) criteria have not been validated in patients with hematologic malignancies (HM). To determine whether daily assessment of SIRS criteria allows early identification of HM patients who will develop septic shock (SS). Observational, single-center,nested case-control study. Oncology unit of a tertiary care center. 547 consecutive, hospitalized, HM subject were enrolled. Using incidence-density sampling, 184 controls were matched to 46 SS cases. The study exposure was the SIRS score. The study outcome was the development of SS during the hospitalization. 8.4% of subjects developed SS. SIRS scores measured 24 hours prior to SS were significantly higher in cases than in controls (2.1 vs. 1.4,p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). Using standard SIRS cutpoints, fever, tachypnea and tachycardia were each associated with the onset of SS. Population-specific SIRS criteria were empirically derived. Single-center study. Further validation is warranted. SIRS can identify HM patients at risk for SS at least 24 hours before SS onset. These data may lead to evidence-based guidelines using routine vital signs to risk-stratify HM patients for SS.

Annals of Emergency Medicine

Respiratory care

Physicians often fail to use lung-protective ventilation (LPV) in patients with acute lung injury... more Physicians often fail to use lung-protective ventilation (LPV) in patients with acute lung injury. To use physician documentation to identify why physicians did not initiate or continue LPV in patients with acute lung injury. This was a retrospective cohort study in a university hospital. The study period was September 2000 through November 2002. In our primary analysis, LPV was defined as use of a tidal volume < or = 7.5 mL/kg predicted body weight (PBW). We also conducted a sensitivity analysis in which we defined LPV as use of a tidal volume < or = 6.0 mL/kg PBW. In our primary analysis, in 42 (56%) of 75 cases, physicians used or intended to use LPV. Of these 42 subjects, 12 received LPV transiently, and 6 never received LPV, despite the fact that the physician ordered or documented LPV use. In 21 of the 33 remaining cases the physicians documented concerns or clinical criteria that may explain why LPV was not used: relative contraindications to LPV (n = 2), change of care...

Annals of the American Thoracic Society, Jan 19, 2015

We implemented an electronic early warning and response system (EWRS) to improve detection of and... more We implemented an electronic early warning and response system (EWRS) to improve detection of and response to severe sepsis. Sustainability of such a system requires stakeholder acceptance. We hypothesized clinicians receiving such alerts perceive them to be useful and effective. To survey clinicians following EWRS notification about perceptions of the system. For a 6 week study period one month after EWRS implementation in a large tertiary referral medical center, bedside clinicians including providers (physicians, advanced practice providers) and registered nurses (RNs) were surveyed confidentially within 2 hours of an alert. For the 247 alerts that triggered, 127 (51%) providers and 105 (43%) RNs completed the survey. Clinicians perceived most patients as stable before and after the alert. Approximately half (39% providers, 48% RNs) felt the alert provided new information, and about half (44% providers, 56% RNs) reported changes in management as a result of the alert, including c...

B104. TRANSLATING SEPSIS: EPIDEMIOLOGY TO MECHANISMS, 2011