Faculty papers Division of Pulmonary and Critical Care Medicine

Multidisciplinary Approach to Reduce Ventilator Associated Pneumonia

James Gibson, BS, RRT et al. — Wed, 09 Jan 2013 11:45:26 PST

Presented at: Institute for Healthcare Improvement

Context

As part of a quality improvement effort to reduce hospital acquired infections (HAI) at Thomas Jefferson University Hospital (TJUH), a multidisciplinary team consisting of physicians, staff nurses, clinical nurse specialists, respiratory therapists, pharmacists, infection control practitioners and administrators representing all special care units was charged with reducing ventilator associated pneumonia rates to zero.

Correlation Between Adherence to a Ventilator Weaning Protocol and Successful Extubations in an Intensive Care Nursery

James Gibson, BS, RRT et al. — Wed, 09 Jan 2013 11:38:25 PST

Presented at: American Association of Respiratory Care.

Background

Chronic lung disease (CLD) is a multi-factorial respiratory disease of the preterm neonate for which mechanical ventilation is a significant contributor. Mechanical ventilator weaning protocols have been shown to reduce the duration of mechanical ventilation. A ventilator weaning protocol (VWP) based on Level I-III evidence was instituted in 2004. Compliance with existing VWP is unknown. CLD rates in our unit have increased over the past 3 years. Assessment of and understanding protocol compliance is an important first step in identifying internal factors which may contribute to CLD. Based on increasing rates of CLD, we hypothesize that compliance with existing VWP falls below 80%.

Evaluation of a Mechanical Ventilator Education Program for Intern Physicians in an Intensive Care Nursery

William Bucher et al. — Wed, 09 Jan 2013 11:34:32 PST

Thomas Jefferson University Hospital is a large urban Academic Medical Center with a level III Intensive Care Nursery (ICN). A new group of pediatric interns rotate through the ICN every year and receive limited education on mechanical ventilation. We developed a live, one hour training session performed by a Respiratory Therapist and a Respiratory Challenge Test to be completed by the physicians before and after each session. Clinical training was defined as routine training acquired during daily rotation in the ICN. We hypothesized that classroom and clinical training would be more effective than clinical training alone.

Saddle pulmonary embolism: is it as bad as it looks? A community hospital experience.

Alejandro Sardi et al. — Fri, 02 Dec 2011 11:24:00 PST

BACKGROUND: Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients.

OBJECTIVE: To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%).

CONCLUSIONS: Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

The diagnosis of adrenal insufficiency in the critically ill patient: does it really matter?

Paul E. Marik — Mon, 27 Sep 2010 08:42:38 PDT

Near fatal posterior reversible encephalopathy syndrome complicating chronic liver failure and treated by induced hypothermia and dialysis: a case report.

Rashmi Chawla et al. — Mon, 27 Sep 2010 08:13:36 PDT

INTRODUCTION: Posterior reversible encephalopathy syndrome is a clinico-neuroradiological entity characterized by headache, vomiting, altered mental status, blurred vision and seizures with neuroimaging studies demonstrating white-gray matter edema involving predominantly the posterior region of the brain. CASE PRESENTATION: We report a 47-year-old Caucasian man with liver cirrhosis who developed posterior reversible encephalopathy syndrome following an upper gastrointestinal hemorrhage and who was managed with induced hypothermia for control of intracranial hypertension and continuous veno-venous hemodiafiltration for severe hyperammonemia. CONCLUSION: We believe this is the first documented case report of posterior reversible encephalopathy syndrome associated with cirrhosis as well as the first report of the use of induced hypothermia and continuous veno-venous hemodiafiltration in this setting.