Sepsis is a common cause of death, but outcomes in individual patients are difficult to predict. Elucidating the molecular processes that differ between sepsis patients who survive and those who die ...may permit more appropriate treatments to be deployed. We examined the clinical features and the plasma metabolome and proteome of patients with and without community-acquired sepsis, upon their arrival at hospital emergency departments and 24 hours later. The metabolomes and proteomes of patients at hospital admittance who would ultimately die differed markedly from those of patients who would survive. The different profiles of proteins and metabolites clustered into the following groups: fatty acid transport and β-oxidation, gluconeogenesis, and the citric acid cycle. They differed consistently among several sets of patients, and diverged more as death approached. In contrast, the metabolomes and proteomes of surviving patients with mild sepsis did not differ from survivors with severe sepsis or septic shock. An algorithm derived from clinical features together with measurements of five metabolites predicted patient survival. This algorithm may help to guide the treatment of individual patients with sepsis.
Sedatives and analgesics are commonly used in mechanically ventilated patients in the intensive care unit. Sedation guidelines have been shown to improve sedation management as well as various ...patient outcomes. The main objective was to evaluate adherence to a sedation guideline with both sedative prescribing and documentation of Richmond Agitation-Sedation Scale (RASS) scores.
In a retrospective chart review, data was collected on 111 medical intensive care unit patients mechanically ventilated via endotracheal tube for 12 hours or greater at Brigham and Women's Hospital. Fifty-seven patients were evaluated pre-guideline implementation and 54 patients were evaluated post-guideline.
Significant increases were seen in the post-guideline group in goal-directed sedation with a patient-specific RASS goal in the sedation order: 21.3 vs 85.4% (P < 0.001), and mean number of sedation assessments per 24 hours using the RASS: 4.7 vs 11.4 (P < 0.001). Similarly, this group experienced a higher percentage of RASS scores at their sedation goal: 31.4 vs 44.1% (P < 0.001). No difference was seen in other clinical endpoints.
Implementation and routine application of a hospital pain and sedation guideline was associated with significantly improved sedation metrics, such as goal-directed sedation, as well as frequency of sedation level assessment and documentation. An increase was observed in the time that post-guideline patients spent at or near their RASS goal.
Subjects with asthma have higher concentrations of exhaled nitric oxide (NO) than normal individuals. It has been demonstrated that in asthmatics, repeated FVC maneuvers reduce NO. Although the cause ...of this phenomenon is not known, it has been hypothesized that deep breaths associated with FVC maneuvers reduce exhaled NO by affecting neural sources of NO, possibly via a mechanism related to the pathobiology of asthma. To establish whether FVC maneuvers influence NO concentrations in normal individuals, we measured exhaled NO at baseline values and after FVC maneuvers performed every 15 min for 1 h in subjects without asthma. To investigate the role of deep breaths in reducing exhaled NO, we compared these results with concentrations of exhaled NO after plethysmography. Repeated FVC maneuvers over 60 min produced a decrease in NO concentrations in mixed expired gas (F(E)NO; 24.6 +/- 5.1% decrease for F(E)NO, p < 0. 01 versus baseline). In contrast to the results after spirometry, repeated specific airway conductance (sGaw) maneuvers do not have a significant effect on F(E)NO (p = 0.16). These results, which demonstrate that in nonasthmatic subjects FVC maneuvers-but not panting maneuvers-produce a fall in NO, suggest that the mechanism responsible for the reduction in exhaled NO after FVC maneuvers is related to volume history of the lung rather than the pathobiology of asthma.
Despite the potential advantages, implementation of mobile devices and ongoing management pose challenges in the hospital environment. Our team implemented the PROSPECT (Promoting Respect and Ongoing ...Safety through Patient-centeredness, Engagement, Communication and Technology) project at Brigham and Women's Hospital. The goal of PROSPECT is to transform the hospital environment by providing a suite of e-tools to facilitate teamwork among nurses, physicians, patients and to engage patients and care partners in their plan of care. In this paper, we describe the device-related decisions and challenges faced including device and accessory selection, integration, information and device security, infection control, user access, and ongoing operation and maintenance. We relate the strategies that we used for managing mobile devices and lessons learned based on our experiences.
Permanent neurologic impairment following cardiac arrest is often severely debilitating, even after successful resuscitation. Therapeutic hypothermia decreases anoxic brain injury and subsequent ...cognitive deficits. Current practice guidelines recommend therapeutic hypothermia in comatose survivors of cardiac arrest. To address the multifacets of therapeutic hypothermia, we assembled a multidisciplinary task force including members from various specialties to create an evidence-based guideline with transparency across disciplines and consistency of care. We describe our institutional guidelines for the initiation and management of induced hypothermia in patients successfully resuscitated from a cardiac arrest.
Nitric oxide (NO) is known to be present in measurable quantities in the exhaled air of normal subjects and at higher concentrations in asthmatic subjects not treated with glucocorticoids. We ...confirmed these findings by analyzing the mean mixed expired NO concentrations of 43 stable asthmatics and 90 normal subjects; NO levels were higher in the asthmatic population (13.9 parts per billion ppb versus 6.2 ppb, p < 0.001). Although the effects of glucocorticoids on the NO content of mixed expired air are known, it is not known if beginning systemic glucocorticoid therapy reduces exhaled NO levels in a given individual. To examine this question, seven patients needing emergency therapy for asthma underwent repeated measurements of mixed expired NO levels during their course of treatment with glucocorticoids. All patients had a reduction in mixed expired NO concentration (p = 0.002) and an accompanying improvement in airway obstruction. The decrease in exhaled NO was evident as early as 48 h after the initiation of therapy (p = 0.05). These data suggest mixed expired NO concentrations may prove useful as an index of asthma severity and treatment efficacy for an individual patient.
We sought to test the hypothesis that patients with decompensated heart failure (HF) lose a compensatory process whereby nitric oxide (NO) maintains pulmonary vascular tone.
Exhaled nitric oxide ...(eNO) partially reflects vascular endothelial NO release. Levels of eNO are elevated in patients with compensated HF and correlate inversely with pulmonary artery pressures (PAP), reflecting pulmonary vasodilatory activity.
We measured the mean mixed expired NO content of a vital-capacity breath using chemiluminescence in patients with compensated HF (n = 30), decompensated HF (n = 7) and in normal control subjects (n = 90). Pulmonary artery pressures were also measured in patients with HF. The eNO and PAP were determined sequentially during therapy with intravenous vasodilators in patients with decompensated HF (n = 7) and in an additional group of patients with HF (n = 13) before and during administration of milrinone.
The eNO was higher in patients with HF than in control subjects (9.9 ± 1.1 ppb vs. 6.2 ± 0.4 ppb, p = 0.002) and inversely correlated with PAP (r = −0.81, p < 0.00001). In marked contrast, patients with decompensated HF exhibited even higher levels of eNO (20.4 ± 6.2 ppb) and PAP, but there was a loss of the inverse relationship between these two variables. During therapy (7.3 ± 6 days) with sodium nitroprusside and diuresis, hemodynamics improved, eNO concentrations fell (11.2 ± 1.2 ppb vs. before treatment, p < 0.05), and the relationship between eNO and PAP was restored. After milrinone, eNO rose proportionally with decreased PAP (p < 0.05).
Elevated eNO may reflect a compensatory circulatory mechanism in HF that is lost in patients with clinically decompensated HF. The eNO may be an easily obtainable and quantifiable measure of the response to therapy in advanced HF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract only
Background:
The concurrent use of therapeutic hypothermia (TH) following cardiac arrest and mechanical circulatory support (MCS) for cardiogenic shock is becoming increasingly common. ...Little is known however, about the combined use of TH and MCS for patients after ROSC following a cardiac arrest who remain in cardiogenic shock. Therefore we describe the experience with concomitant use of TH and MCS from a large academic tertiary care center in Boston.
Methods:
Baseline characteristics and clinical outcomes at hospital discharge were reported for patients undergoing TH following cardiac arrest who also received MCS for cardiogenic shock. MCS included Intra-aortic balloon pump (IABP) two percutaneous ventricular assist devices (Impella, and TandemHeart), and extracorporeal membrane oxygenation (ECMO). Clinical outcomes included mortality as well as cerebral performance category (CPC) at hospital discharge.
Results:
There were a total of 14 patients who underwent concomitant TH and MCS following a cardiac arrest. Baseline characteristics and clinical outcomes are noted in the Figure. 9 patients underwent placement of IABP, 2 patients an Impella pump, 2 patients a TandemHeart, and 1 patient ECMO. All 14 cardiac arrests were due to cardiovascular etiologies; 9 of 14 had STEMI. 9 of 14 patients had an initial shockable rhythm. Mean age was 56 years (+/- 19), mean downtime was 35 minutes (+/- 24). All patients were vasopressor dependent. Bleeding events are noted in the table. 8 patients survived to hospital discharge, all with good neurologic outcome. These rates were comparable to the survival rates and neurologic outcomes among 82 patients who underwent TH post cardiac arrest (from cardiovascular etiologies) without concomitant MCS (Figure).
Conclusion:
Based on our experience from a large academic tertiary care center, concomitant use of TH and MCS is both safe and feasible with an encouraging rate of cardiac and neurologic recovery.
Previous studies have raised the possibility that the measurement of nitric oxide (NO.) concentrations in expired air may represent a noninvasive measure of lower airway inflammation. To address the ...question of whether the elevated NO. recovered in mixed expired air from asthmatic subjects is a reflection of the pulmonary airway microenvironment or merely nasopharyngeal contamination, mixed expired NO. determinations were performed in five normal and five asthmatic subjects before and after orotracheal intubation (thereby isolating the lower airway gas from ambient air contamination or gas conditioned in the nasopharynx). The mixed expired NO. concentrations determined in patients with asthma were significantly elevated (p < 0.05 or less) above those of normal subjects in both the pre- and postintubation samples. After intubation, mixed expired NO. levels were 4.7 +/- 1.3 ppb and 13.2 +/- 2.0 ppb in normal and asthmatic individuals, respectively; the difference in these values was statistically significant (p < 0.01). Lower airway gas, sampled through the bronchoscope during a breathhold, was found to contain NO. concentrations of 7.0 +/- 1.2 ppb and 40.5 +/- 5.6 ppb at the tracheal carina of normal and asthmatic individuals, respectively. The asthmatic values were significantly (p < 0.01) elevated above those found in normal subjects. These findings indicate that the difference in mixed expired NO. of normal subjects and asthmatics reflects a difference in NO. concentration present in the lower airway.
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