Oral Abstract Session: Neurology 1 2 3 4

Oral Abstract Session: Neurology 1

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ACTIVATION OF POLY(ADP-RIBOSE) POLYMERASE-1 CONTRIBUTES TO NADⴙ DEPLETION AND IMPAIRED NADⴙ DEPENDENT MITOCHONDRIAL RESPIRATION FOLLOWING STATUS EPILEPTICUS

IN VIVO EVOLUTION OF MICROVASCULAR INFLAMMATION AFTER TRAUMATIC BRAIN INJURY: AN INTRAVITAL MICROSCOPY STUDY

Yi-Chen Lai, Texas Children’s Hospital, Rebecca Searle, Cain Foundation, William Craigen, Anne Anderson, Baylor College of Medicine Introduction: Activation of poly(ADP-ribose) polymerase-1 (PARP-1) contributes to neuronal damage in many neurological insults. Poly-ADP-ribosylation reaction consumes nicotinamide adenine dinucleotide (NAD⫹). NAD⫹ serves as an important energy substrate and a co-factor for Complex I (CI) of the electron transport chain. Therefore, PARP-1 activation can result in impaired energy metabolism further exacerbating injury. Whether PARP-1 activation contributes to energy failure in status epilepticus (SE) remains undefined. Hypothesis: PARP-1 activation contributes to NAD⫹ depletion, impaired CI respiration and hippocampal neuronal damage following SE. Methods: SE was induced in male rats (100 –150 g) using intraperitoneal kainate (15 mg/kg, i.p.). PARP-1 inhibitor (PJ-34, 15 mg/kg, i.p.) or vehicle was given prior to SE induction. Animals remained in SE for 1h. Twenty-four hours following SE, hippocampal NAD⫹ was measured using an enzymatic cycling assay. Mitochondrial O2 consumption was measured using CI substrates. Neuronal damage was assessed using Fluoro-Jade B (FJB) 72h following SE. Data were analyzed using ANOVA with post hoc Tukey. Results: SE was associated with decreased NAD⫹ (100⫾3.4% v. 73.6⫾4.1%, sham v. SE, mean⫾SEM, n ⫽ 9/group, p⬍0.001) and impaired CI respiration (100.0% v. 76.7⫾4.8%, sham v. SE, n ⫽ 6/group, p⬍0.05). FJB positive neurons were observed in the CA1 and CA3 regions of SE animals, none in sham (n ⫽ 2/group). PARP-1 inhibition preserved NAD⫹ (73.6⫾4.1% v. 88.3⫾3.2%, vehicle v. PJ-34, n ⫽ 9/group, p⬍0.001) and CI respiration (76.7⫾4.8% v. 100⫾10.2%, vehicle v. PJ-34, n ⫽ 6/group, p⬍0.05). PARP-1 inhibition was associated with decreased FJB positive neurons in CA1 region, but not in CA3. Conclusions: Our data suggest that PARP-1 activation occurs following SE, contributes to NAD⫹ depletion and impairs NAD⫹ dependent mitochondrial respiration. Our data also suggest that PARP-1 activation contributes to CA1 damage. These findings suggest that PARP-1 activation may play an important role in the hippocampal neuronal damage following SE. Support: K08NS063117, R01NS039943, R01NS049427.

Shenghui Li, University of Pennsylvania School of Medicine, Joshua Marks, Thomas Jefferson University Hospital, Paymon Sanati, Rachel Eisenstadt, Wanfeng Gong, Kevin Browne, Douglas Smith, Lance Becker, Jose Pascual, University of Pennsylvania School of Medicine Introduction: Evolving microvascular inflammation in the penumbra of traumatic brain injury (TBI) is thought to account for progressive cerebral tissue injury in the hours following trauma. Although tissue inflammation has been observed in vivo in multiple tissues following local injury, no study to date has evaluated whether brain leukocyte-endothelial (LEU-EC) interactions increase over time following TBI. Hypothesis: We hypothesized that LEU-EC interactions would progressively increase in the area surrounding a site of TBI. Methods: 30 male CD-1 mice (25–30 g) were randomly assigned to undergo TBI-controlled cortical impact (CCI, speed 6 m/s, depth 1 mm) or sham (SH) craniotomy. Cerebral microvessels (20 –50 micron diameter) were visualized at 0h, 3h, 6h, 12h, 24h and 72h post CCI, via pial intravital microscopy through a cranial window placed over the frontal-parietal cortex adjacent to the injured site. After cannulation of the internal jugular vein and carotid artery, rhodamine 6G was injected intravenously to label circulating LEU and observe their interactions (rolling, adhesion) with venular EC. Mean LEU rolling and adhesion in each group was compared and analyzed with the Mann– u-Whitney statistic and significance was considered at p⬍0.05. Results: Baseline characteristics (animal weight, craniotomy size, surgical time, blood pressure, anesthetic administration) were similar in CCI and SH groups. CCI induced immediate venular stasis at the injured site. In vivo LEU rolling/adhesion to EC in the peri-CCI penumbra area, was similar in sham and CCI animals immediately after surgery. Mean rolling LEU significantly increased 3h post CCI (7.56 ⫾ 2.18 vs. 1.83 ⫾1.47, CCI vs. SH, p ⫽ 0.017) and beyond, peaking at 24h post injury (12.18 ⫾ 2.71 vs. 3.67 ⫾ 0.68, p ⫽ 0.001). Mean adherent LEU increased throughout the observed time period with significantly greater numbers in CCI animals than SH at 12 hours post injury (3.33 ⫾ 0.33 vs. 1.67 ⫾ 0.33, p ⫽ 0.032). Conclusions: TBI results in progressively increased in vivo pial LEU-EC interactions in the first 72 hours after injury. Blunting LEU, EC interactions following TBI to reduce injury progression may be useful.

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ALTERED CARDIAC CONDUCTION AND INCREASED ARRHYTHMOGENIC POTENTIAL AS A CANDIDATE MECHANISM FOR SUDDEN UNEXPLAINED DEATH IN EPILEPSY

MONOAMINE RELATIONSHIP TO BLOOD LOAD FOLLOWING ANEURYSMAL SUBARACHNOID HEMORRHAGE

Yi-Chen Lai, Texas Children’s Hospital, Sufen Wang, The Methodist Hospital, Rebecca Searle, Cain Foundation, Miguel Valderrabano, The Methodist Hospital, Anne Anderson, Baylor College of Medicine Introduction: Longitudinal, prospective study suggested decreased life expectancy in children with epilepsy. Significant deaths were attributable to sudden unexplained death in epilepsy (SUDEP). Many mechanisms have been proposed to contribute to SUDEP including sudden cardiac death, which could result from arrhythmias. Sudden cardiac death could also arise from altered cardiac structure and function leading to impaired output. Whether these factors occur in epilepsy remains undefined. Hypothesis: We evaluated sudden death, altered cardiac structure and function, and arrhythmia in an animal model of temporal lobe epilepsy. Methods: Status epilepticus was induced using intraperitoneal pilocarpine (pilo, 300 mg/kg) in male Sprague-Dawley rats along with age-matched sham (100 –150 g). Cardiac structure and function were assessed using either MRI (sham ⫽ 3, pilo ⫽ 4) or echocardiogram (n ⫽ 3/group). Cardiac rhythm was assessed using surface EKG (n ⫽ 15/group). Action potential and conduction velocity (CV) were examined using ex vivo optical mapping. Data were analyzed using Student’s t test. Results: Epileptic rats exhibited decreased survival time (20 mo v. 26 mo, epileptic ⫽ 25 v. sham ⫽ 30, p⬍0.001). No differences in cardiac structure and function were observed between epileptic and sham rats. Epileptic rats exhibited increased resting HR (273⫾16.5 v. 238⫾3.6 beats/min, epileptic v. sham, p⬍0.05), prolonged QRS (89⫾5 v. 73⫾5 ms, epileptic v. sham, p⬍0.05) and QTc (336⫾11 v. 289⫾11 ms, epileptic v. sham, p⬍0.01) intervals. Optical mapping showed slower CV in epileptic rats. Stimulation induced ectopic beats in the epileptic but not in the sham heart preparation. Conclusions: Under baseline conditions, no discernible differences in cardiac structure and function were observed between epileptic and sham rats. However, subtle rhythm changes occurred in the epileptic rats as reflected in the EKG findings. Under stimulated conditions, the myocardium of the epileptic rats exhibited increased arrhythmogenicity, likely exacerbated by the underlying conduction abnormalities. Together, these findings recapitulate clinical observations and further support cardiac arrhythmia as a cause for SUDEP. Support: R01NS049427, R01NS039943, Epilepsy Foundation.

Crit Care Med 2011 Vol. 39, No. 12 (Suppl.)

Marilyn Hravnak, Bhavani Thampatty, Samuel Poloyac, University of Pittsburgh, Jeffrey Yao, Univeristy of Pittsburgh, Elizabeth Crago, Michael Horowitz, University of Pittsburgh Introduction: Catecholamines are hypothesized to surge at the time of aneurysmal subarachnoid hemorrhage (aSAH) rupture, but the degree of surge and persistence relative to aSAH blood load is unclear. Hypothesis: Using an assay for endogenous tryptophan and tyrosine and their metabolites in pathways upstream from serotonin and dopamine/epinephrine respectively, we hypothesized that monoamine levels would be not only greater with higher Fisher grade aSAH, but remain persistently so during recovery. Methods: This prospective longitudinal study recruited 128 patients diagnosed with aSAH, admitted to the neurovascular ICU, and with monoamine data. Fisher grading was assigned by the attending neurosurgeon based on admission computed tomography scan. High-pressure liquid chromatography coupled with a coulometric multi-electrode array system determined tryptophan (serotonin pathway) and its metabolite 5-hydroxyindole3-acetic acid (5-HIAA), and tyrosine (dopamine/epinephrine pathway) and its metabolite homovanillic acid (HVA) levels in 24-hour urine samples for each of days 1–5. Results: Overall Fisher grade prevalence was 2 ⫽ 39%, 3 ⫽ 45%, 4 ⫽ 16%. A two-way ANOVA testing the equality of log-transformed monoamine means in the Fisher grade groups over time showed significantly persistently higher levels for higher Fisher grade groups for tryptophan and 5-HIAA (p ⫽ 0.005 and p ⫽ 0.001 respectively) across all 5 days. A similar analysis revealed significantly persistently higher levels for tyrosine and HVA in higher Fisher grade groups across all 5 days (both p ⫽ 0.001). Conclusions: Tryptophan and its metabolite 5-HIAA, and tyrosine and its metabolite HVA remained significantly and persistently elevated over days 1–5 in patients with higher Fisher grade. Thus the degree of catecholamines excreted in both the serotonin and dopamine/ epinephrine pathways, and their persistence, appears to be related to blood load. This suggests higher grade aSAH patients experience an ongoing stress state in the recovery period that deserves further study, particularly with regard to complications and outcomes. Funding NHLBI R01HL074316.

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ELEVATED CEREBROSPINAL FLUID METALLOPROTEINASE-9 IS ASSOCIATED WITH POOR 6-MONTH OUTCOME FOLLOWING SUBARACHNOID HEMORRHAGE

OPTIC NERVE SHEATH DISTENSION ON BEDSIDE ULTRASOUND IS LESS PREDICTIVE OF INTRACRANIAL HYPERTENSION WHEN INTRACRANIAL PRESSURE IS ACUTELY FLUCTUATING

Sherry Chou, Steven Feske, Rose Du, Suzanne Simmons, Susannah Orzell, David Bauer, Brigham and Women’s Hospital, Andrea Marckmann, Eng Lo, MingMing Ning, Massachusetts General Hospital Introduction: There is growing evidence supporting the role of inflammation in early brain injury (EBI) and vasospasm (VSP) following subarachnoid hemorrhage (SAH). Matrix metalloproteinases (MMP) are released by inflammatory cells and can mediate EBI via disruption of the extracellular matrix and mediate VSP by cleaving endothelin-1 into vasoactive fragments. Hypothesis: MMP-9 in human cerebrospinal fluid (CSF) is associated with VSP and SAH outcome, and therefore a potential clinical biomarker. Methods: We enroll consecutive SAH subjects, bank serial CSF samples, and evaluate their 6-month outcome using modified Rankins score (mRS). VSP is defined as ⬎50% vessel caliber reduction on angiography 6 – 8 days post SAH. Poor outcome is defined as mRS⬎2. We compared CSF MMP-9 by ELISA on post-SAH days 0 –1, 2–3, 4 –5, 6 – 8, and 10 –14 in a SAH cohort (N ⫽ 35) with and without VSP and poor outcome at 6-months. Continuous variables were compared using t-test or Wilcoxan rank sum test depending on data normality. Repeated measurements were analyzed using longitudinal regression. Results: The study cohort has a mean age of 53 years, with 59% subjects presenting with Hunt and Hess grade (HH) 3 and above, 54% developed VSP, and 21% had poor 6-month outcome. Elevation of CSF MMP-9 throughout post-SAH days 0 –14 was associated with poor 6-month outcome (p ⫽ 0.007). Specifically, CSF MMP-9 elevation on postSAH day 0 –1 was associated with poor 6-month outcome (p ⫽ 0.02). After adjustment for SAH clinical severity (HH grade), neither CSF MMP-9 levels nor HH grade were independently associated with 6-month outcome. CSF MMP-9 did not show strong association with VSP. Conclusions: Early elevation of CSF MMP-9 is associated with poor 6-month outcome but not with VSP in SAH. CSF MMP-9 may mediate EBI in SAH via mechanisms independent of VSP. Incorporation of CSF MMP-9 removes the predictive effect of HH grade on SAH outcome, suggesting that CSF MMP-9 may be in the mechanistic pathway that mediates the effect of high HH score on SAH outcome. Further studies are necessary to determine the source of CSF MMP-9, the mechanism by which it mediates SAH outcome, and to validate CSF MMP-9 as a predictive biomarker for SAH outcome.

Venkatakrishna Rajajee, Jeffrey Fletcher, Lauryn Rochlen, Teresa Jacobs, University of Michigan Introduction: Optic Nerve Sheath Diameter (ONSD) measurement with bedside ultrasound has been shown in many studies to accurately detect high intracranial pressure (ICP) in the ICU. Recent laboratory investigation suggests that reversal of optic nerve sheath distension may be impaired following bouts of intracranial hypertension. ONSD may therefore be less accurate when ICP acutely fluctuates from high to low. Hypothesis: Accuracy of ONSD for detection of high ICP will be lower in patients with fluctuation of ICP between high and normal during the period of evaluation, compared to patients with stable ICP. Methods: Patients with invasive ICP monitors in the ICU underwent ONSD measurement with simultaneous blinded recording of ICP from the invasive monitor. 3 measurements were made in each eye. Group 1 consisted of ONSD measurements in patients whose invasive ICP fluctuated from ⬎20 to ⬍20 mmHg during the time taken to perform the 6 measurements and Group 2 consisted of ONSD measurements in patients whose ICP remained stable at ⬎20 or ⬍20 mmHg during the 6 measurements. ROC curves were constructed to compare the accuracy of ONSD for the detection of ICP⬎20 mmHg in each group. Results: 616 measurements (158 in Group 1 and 455 in Group 2) were made in 73 patients. There was a significant difference (P⬍0.001) in the median magnitude of ICP fluctuation (highest-lowest invasive ICP within each group of 6 measurements) between Group 1 (12 mmHg, IQR 7.5–20 mmHg) and Group 2 (3 mmHg, IQR 2–5 mmHg). ROC analysis in Group 1 revealed Area Under Curve (AUC) ⫽ 0.94(95%CI 0.83– 0.94), P(AUC ⫽ 0.5)⬍0.0001. Optimal ONSD for detection of ICP⬎20 mmHg was ⬎0.47cm- Sensitivity 94%(95% CI 87– 98%), Specificity 74%(63– 83%), Positive Predictive Value (PPV) 76%(66 – 84%) and Negative Predictive Value (NPV) 94%(85–98%). In Group 2, AUC was 0.99(0.98 – 0.99), P(AUC ⫽ 0.5)⬍0.0001, optimal ONSD was ⬎0.47cm Sensitivity 96%(89 –99%), Specificity 98%(96 –99%), PPV 89%(80 –95%) and NPV 99%(98 –100%). Difference between AUCs of the ROC curves was 0.10 (P ⫽ 0.0001). Conclusions: Specificity and PPV of ONSD for ICP⬎20 mmHg are substantially less in patients demonstrating acute fluctuation of ICP between high and normal. This may be because of delayed reversal of nerve sheath distension.

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APOE GENOTYPE, INFLAMMATION AND DELIRIUM IN ICU PATIENTS

EFFICACY OF ANTICONVULSANTS FOR THE MANAGEMENT OF ELECTROGRAPHIC SEIZURES IN CRITICALLY ILL CHILDREN

Sheila Alexander, Judith Tate, University of Pittsburgh, Dianxu Ren, University of Pittsburgh School of Nursing, Scott Gunn, UPP-CCM, Yvette Conley, University of Pittsburgh School of Nursing Introduction: Delirium occurs in up to 80% of ICU patients but the biologic cause remains elusive. Recent evidence suggests inflammation promotes delirium. The increased frequency of delirium in patients with an Apolipoprotein E (APOE) 4 allele may be due to the prolonged inflammation. The purpose of this project was to explore the relationship between APOE, inflammation and delirium in ICU patients. Hypothesis: We hypothesize those individuals with the APOE4 allele will have a pro-inflammatory state and be more likely to develop delirium. We also hypothesize that serum apoE will correlate with serum interleukins, particularly in subjects with the APOE4 allele. Methods: Subjects were recruited from a Surgical Trauma and Medical ICU. There were 48 subjects age 18 –75 intubated 24 –96 hours without preadmission cognitive disorder/dysfunction. Blood was drawn and delirium was assessed, with the Confusion Assessment Method- ICU (CAM-ICU), daily for 5 days. Serum apoE and interleukin concentrations were quantified with commercially available ELISA kits. Genotyping was performed using Restriction Fragment Length Polymorphism, gel electrophoresis and visualization techinques. The sample was dichotomized based on delirium presence and APOE4 allele presence for analyses. Data were analyzed using univariate, bivariate and multivariate analyses. Results: The sample was primarily female (n ⫽ 25; 52.1%) and Caucasian (n ⫽ 45; 93.8%) with a mean age of 47.8 years old (SD ⫽ 16.8). Twenty eight (58.3%) subjects had delirium; 11(22.9%) had at least one copy of the APOE4 allele. APOE genotype, but not APOE4 allele presence, was associated with Delirium. Daily apoE correlated with IL8 and IL10, but not IL6. These correlations held up over time and were stronger when controlling for APOE4 presence and delirium. Conclusions: Increased pro-inflammatory cytokines IL8 and IL10 were correlated with apoE. This relationship became stronger in the presence of the APOE4 allele and delirium. Our findings suggest that apoE promotes inflammation and delirium in a genotype specific manner. Patients with delirium and the APOE4 allele have a stronger pro-inflammatory profile. This project supported by NIH R03NR11052 and the SCCM Norma J. Shoemaker Grant.

Alexis Topjian, Ana Gutierrez-Colina, Robert Berg, Dennis Dlugos, Nicholas Abend, The Children’s Hospital of Philadelphia Introduction: Electrographic seizures (eSz) are common in critically ill children with acute encephalopathy and are treated with a variety of anticonvulsants (ACs). It is unclear whether specific ACs are more effective to terminate eSz in this select patient population. We aimed to determine 1) which ACs are used to manage eSz in critically ill children and 2) the efficacy of first administered ACs for eSz termination. Hypothesis: We hypothesized that there would be no difference in efficacy of ACs for eSz termination. Methods: This was a prospective observational cohort study. Critically ill children with acute encephalopathy underwent clinically indicated electroencephalography (EEG) monitoring in the intensive care unit in a tertiary care children’s hospital. If eSz were identified, the critical care and neurology consult services managed the patient according to usual clinical practice utilizing phenytoin/fosphenytoin (PHT), phenobarbital (PB), and levetericetam (LEV). Clinical information obtained included eSz occurrence, ACs utilized, and AC efficacy. Results: 200 non-neonatal children underwent EEG monitoring, eSz occurred in 42% (84), and 80 received ACs. First administered ACs terminated seizures in 46% (37/80) of patients, second in 22%, third in 30%, while 24% of eSz were refractory (ⱖ4 ACs). The most commonly used first ACs were LEV 37% (30/80), PB 31% (25/80), and PHT 28% (22/80). The median age of children receiving PB as a first AC was 3 months IQR [2,6] compared to PHT: 55 months IQR [21, 120] and LEV: 65 months IQR [13,121] (p⬍0.001).There was no difference in first AC efficacy (LEV 40% (12/30), PB 64% (16/25), PHT 36% (8/22), p ⫽ 0.19), even when controlling for age and acute neurologic disorder. There was no difference in frequency of AC administered based on underlying acute neurologic disorder (p ⫽ NS), and no difference in mortality or short-term neurologic outcome based on initial AC administered. Conclusions: In this large cohort, eSz are terminated by the first AC in almost half of children and are refractory in one quarter. PHT, PB, and LEV are commonly used and have similar observational efficacy.


Oral Abstract Session: Sepsis 9

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ROLE OF CXCR3 IN THE PATHOGENESIS OF ACUTE SEPTIC SHOCK

HEMOADSORPTION MODULATES LEUKOCYTE TRAFFICKING IN DIFFERENT COMPARTMENTS DURING SEPSIS

Daniela Herzig, Brandon Driver, Geping Fang, Edward Sherwood, University of Texas Medical Branch

Zhiyong Peng, Jeffery Bishop, Xiaoyan Wen, Feihu Zhou, Ata Murat Kaynar, John Kellum, University of Pittsburgh

Introduction: NK, NKT and T lymphocytes have been shown to facilitate systemic inflammation and physiologic dysfunction in experimental models of severe sepsis. We demonstrated that NK cells migrate into the peritoneal cavity early during intraabdominal sepsis caused by cecal ligation and puncture (CLP) but the trafficking of NKT and T cells after CLP has not been determined. Furthermore, the factors that regulate lymphocyte trafficking during sepsis are currently unknown. Hypothesis: Our hypothesis is that CXCR3 regulates lymphocyte trafficking during CLP-induced sepsis and that neutralization of CXCR3 attenuates septic shock caused by CLP. Methods: Bacterial clearance, systemic cytokine production, core temperature and lymphocyte migration were evaluated in CXCR3 knockout mice and wild type mice treated with neutralizing antibodies against CXCR3 as well as appropriate controls. For survival studies, mice were monitored every 12 hours and mortality was recorded out to 144 hours after CLP. The expression of CXCR3 by lymphocytes was measured using flow cytometry. All experiments were performed with and without antibiotics. Results: This study shows that concentrations of the CXCR3 ligands CXCL9 and CXCL10 increase in plasma and peritoneal lavage fluid after CLP, peak at 8 hours postinfection and are higher in the peritoneal cavity than in plasma. The numbers of CXCR3⫹ NK cells progressively decreased in spleen after CLP with a concomitant increase within the peritoneal cavity, a pattern that was ablated in CXCR3deficient mice. CXCR3-dependent recruitment of T cells was also evident at 16 hours post-CLP. Treatment of mice with anti-CXCR3 and antibiotics significantly attenuated CLP-induced hypothermia, decreased systemic cytokine production and improved survival. Conclusions: These results indicate that CXCR3 regulates NK and T cell trafficking into the peritoneal cavity during severe sepsis caused by CLP and that CXCR3 neutralization attenuates sepsis-associated immunopathology.

Introduction: To explore how hemoadsorption regulates leukocyte trafficking in different compartments during sepsis. Hypothesis: Hemoadsorption will improve leukocyte trafficking toward the peritoneal cavity and away from the lungs in abdominal sepsis. Methods: Fifty two rats were randomly assigned to either hemoadsorption or sham treatment 18h after cecal ligation and puncture induced sepsis. Hemoadsorption consisted of a single 4 h intervention using CytoSorbTM via a veno-venous circuit. Forty animals were sacrificed 48h after treatment. Fluids from peritoneal lavage (PF) and bronchoalveolar lavage (BAL) as well as blood were collected for leukocyte counts, leukocyte function, chemokines, and bacterial culture. Lungs were collected for myeloperoxidasemeasurements. Polymorphonuclear leukocytes (PMNs) from animals themselves (collected after treatment) or from septic donors were labeled with Tracker Red, and infused back into twelve animals.The lungs were collected after 24h and imaged using fluorescence microscopy. Results: After treatement, the ratios of PF to blood chemokines were significantly higher (8.51 vs 1.65 for CINC-1, 7.17 vs 2.32 for MIP-2, and 3.56 vs 1.69 for MCP-1, P⬍0.05), and the ratios of BAL to blood chemokines were lower (0.52 vs 2.37 for CINC-1, 0.94 vs 1.69 for MIP-2 and 0.27 vs 1.82 for MCP-1, P⬍0.05) with hemoadsorption compared to sham. Hemoadsorption significantly enhanced leukocyte recruitment into the peritoneal cavity (4.0 x10 vs. 0.97 x10/ml for PMNs, P ⫽ 0.03) and improved bacterial clearance (6.05 x10 vs 52.15 x10 cfu/ml, p ⫽ 0.04), but decreased PMN recruitment into the lung (1.16 x105 vs 4.0 x105 per ml, P ⫽ 0.01). Hemoadsorption also significantly reduced myeloperoxidase contents in the lung (0.80 vs 1.95 u/ml/g, P ⫽ 0.01). Fewer PMNs were seen in lungs taken from hemoadsorption -treated animals. Hemoadsorption did not affect PMN function (chemotaxis, phagocytosis and oxidative burst). Conclusions: Hemoadsorption enhanced leukocyte recruitment into peritoneal cavity and reduced PMN infiltration in the lung, which improved bacterial clearance and decreased secondary lung injury. This effect appears to be caused by changes in chemokine gradients rather than the direct effects on leukocytes.

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ROBO1 BINDING RECEPTOR IS UPREGULATED BY VASOPRESSIN DURING SEPTIC SHOCK LEADING TO DECREASED SEPSIS INDUCED CARDIAC DYSFUNCTION IN A MURINE LPS SEPSIS MODEL.

CHANGES IN NON-LINEAR HEMODYNAMICS WITH EARLY AGGRESSIVE FLUID RESUSCITATION IN SEPSIS

Josh Douglas, Rani Agrawal, Stanford University Medical Center, James Russell, The University of British Columbia, Andrew Patterson, Stanford University Medical Center

Introduction: Aggressive fluid resuscitation has been shown to improve outcomes in septic shock. Sepsis causes alterations in nonlinear hemodynamic parameters such as heart rate variability. Hypothesis: Aggressive fluid resuscitation will improve heart rate variability and blood pressure variability in a murine model of sepsis. Methods: Radio-transmitters were implanted into the aorta of C57/BL6 mice for continuous hemodynamic monitoring (n ⫽ 32). After 72 hours of recovery, baseline heart rate recordings were captured for 24 hours. Sepsis was induced by cecal ligation and puncture and continuous recordings taken for the next 48 hours or death. All mice received antibiotics (ceftriaxone and clindamycin) every 6 hours. Septic mice received one of two resuscitation regimens: LOW 0.9% NaCl 35 ml/kg bolus intra-operative only (n ⫽ 16) or HIGH 0.9% NaCl 35 ml/kg boluses every 6 hours after surgery (n ⫽ 16). Volatility was used as a measurement of variability. Heart rate volatility (HRV) and blood pressure volatility (BPV) measurements were compared between groups. Results: Measurement of linear hemodynamic parameters during sepsis showed a mean HR of 353 beats per minute (bpm) in the HIGH group and 397 bpm in the LOW group and a mean SBP of 69.6 mmHg in the HIGH group and 67.3 mmHg in the LOW group. Aggressive fluid resuscitation was associated with improved HRV. Normal HRV was found during 33.3% of intervals in the HIGH group and only 22.6% of intervals in the LOW group (p⬍0.001). BPV did not improve with fluid resuscitation. Normal BPV was found during 58.8% of intervals in the HIGH group and 63.2% of intervals in the LOW group (p⬍0.001). Five animals (31.25%) in the HIGH resuscitation group and 2 animals (12.5%) in the LOW group survived to 48 hours ( p ⫽ 0.39). Conclusions: In a murine model of sepsis early aggressive fluid resuscitation was associated with improved heart rate variability. Heart rate variability may be a useful marker to assess response to fluid resuscitation during sepsis. Blood pressure variability, however, did not improve with fluid resuscitation. While heart rate variability has prognostic significance, blood pressure variability may not be a useful marker for resuscitation during sepsis.

Introduction: Severe sepsis is a major cause of morbidity and mortality in the United States with mortality approaching 50%. Sepsis is characterized by cytokine induced hemodynamic alterations leading to capillary leak, increased then decreased vascular tone and depressed cardiac contractility. Vasopressin has been proven as a catecholamine sparing effect in septic shock. The Slit2-Robo4 pathway is a soluble ligand-endothelial cell receptor that has been proposed to block VEGF mediated endothelial cell permeability. Hypothesis: We sought to explore whether vasopressin with and without hydrocortisone manipulates the SLIT2-Robo4 receptor pathway to strengthen the vascular barrier leading to improved sepsis induced cardiac depression. Methods: 100 male WT C57 and 120 male WT FVB mice between 8 –10weeks of age were randomized to receive saline vs intraperitoneal LPS with and without hydrocortisone. Mice were randomized after 4hours to vasopressin or saline and after 6hours and 48hours sacrificed for PV loop analyses using a Millar PV catheter. Four mice in each group underwent cardiac gene expression using microarray analyses. Results: Vasopressin lead to upregulation in Robo1, the co-receptor for Robo4 in LPS exposed mice at 10hr (C57: 0.9206 ⫾ 0.03280 N ⫽ 4 vs 1.185 ⫾ 0.1749 N ⫽ 2; P ⫽ 0.0887 and FVB: 0.9742 ⫾ 0.01147 N ⫽ 4 vs 1.056 ⫾ 0.03145 N ⫽ 3; P ⫽ 0.0403). PV loop data showed also a decrease in the slope of the LV end diastolic PV relationship (C57: 4.870 ⫾ 1.000 N ⫽ 8 vs 1.460 ⫾ 0.4100 N ⫽ 5; P ⫽ 0.0258 and FVB: 4.450 ⫾ 0.7900 N ⫽ 19 vs 2.480 ⫾ 0.5800 N ⫽ 7; P ⫽ 0.1608), an effect that is synonymous with increased compliance or decreased diastolic dysfunction. Catenin, the immediate downstream regulator of Robo4-Robo1 activation showed enhanced expression (C57: 0.5325 ⫾ 0.04843 N ⫽ 4 vs 0.9288 ⫾ 0.05458 N ⫽ 2; P ⫽ 0.0077 and FVB: 0.5449 ⫾ 0.01843 N ⫽ 4 vs 0.9764 ⫾ 0.04260 N ⫽ 3; P ⫽ 0.0001). Conclusions: In a murine model of septic shock, vasopressin induced upregulation of Robo1, the co-receptor for Robo4, increases catenin expression leading to improved cardiac compliance and diastolic dysfunction. Vasopressin therefore may function to inhibit cardiac permeability improving sepsis induced cardiac dysfunction.


Michael Kwiatt, Robert Perez, Joe LaChant, Sergio Zanotti-Cavazzoni, Steven Hollenberg, Cooper University Hospital

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EFFECTS OF RESUSCITATION FLUIDS ON EXPERIMENTAL SEPSIS-INDUCED ACUTE KIDNEY INJURY

ROLE OF LIVER X RECEPTOR ALPHA IN MODULATING INFLAMMATION IN A MOUSE MODEL OF SEPSIS INDUCED LUNG INJURY

Feihu Zhou, Zhiyong Peng, Jeffery Bishop, Kai Singbartl, John Kellum, University of Pittsburgh Medical Center Introduction: In North America, 0.9% saline is the most commonly used resuscitation fluid, especially for patients with sepsis. Large volume saline infusion produces metabolic acidosis by increasing the plasma chloride concentration relative to the plasma sodium concentration . Hyperchloremic acidosis increases inflammatory molecule release, which could contribute to acute kidney injury(AKI). Conversely, balanced crystalloids should have no effect on plasma pH and might attenuate AKI. In this study, we tested the effect of a balanced crystalloid solution (Plasmalyte) versus 0.9% saline on acid-base and renal function in a model of sepsis induced by cecal ligation and puncture (CLP). Hypothesis: We hypothesized that Plasmalyte would lead to less acidosis, and reduced AKI compared to 0.9% saline. Methods: 30 adult male Sprague-Dawley rats were subjected to CLP (25% cecum length, 2 punctures with a 25 gage needle). 18h later they were randomly assigned to receive either: 0.9% saline (n ⫽ 15) or Plasmalyte (n ⫽ 15), 30 ml/kg over 4 hours. Arterial blood gases, serum creatinine (SCr), urea, cystatin C and serum/urine neutrophil gelatinase associated lipocalin (NGAL) were measured at baseline, 18h after CLP (before resuscitation), after resuscitation and 24h after resuscitation. AKI severity was assessed with RIFLE criteria based on the increase in SCr: R, Risk (50%-99%); I, Injury (100%199%); F, Failure (200% or greater). Survival time was measured up to 24 hrs after fluid resuscitation. Results: Saline-treated animals showed significantly higher levels of serum chloride, lactate, urea and cystatin C after fluid resuscitation (p⬍0.05). Meanwhile, saline resuscitation significantly decreased pH and base excess; and increased AKI severity (AKI-I/F, 82% vs 27%), compared to Plasmalyte resuscitation (p⬍0.01). Both plasma and urine NGAL increased after CLP while urine NGAL increased further in saline-treated animals after fluid resuscitation (318.46 ng/ml vs 208.42 ng/ml) (p⬍0.05). There was a trend in 24 hrs survival favoring Plasmalyte resuscitation (73% Vs 60%, p ⫽ 0.10). Conclusions: Compared with 0.9% saline, volume resuscitation with Plasmalyte was associated with less acidosis and AKI in this experimental animal model of sepsis.

Gabriela Botez, Cincinnati Children’s Hospital Introduction: LXR␣ is a nuclear receptor with a role in cholesterol homeostasis. Activation of LXR␣ has anti-inflammatory effects in models of lung inflammation. Hence, we investigated the effects of genetic ablation of LXR␣ on lung inflammation in polymicrobial sepsis. Hypothesis: We hypothesized that LXR␣ deletion would increase lung inflammation and impact survival in polymicrobial sepsis. Methods: LXR␣ deficient (LXR␣-/-) and wild type (LXR␣⫹/⫹) male mice were subjected to cecal ligation and puncture (CLP). We assessed the degree of lung inflammation by measuring myeloperoxidase (MPO) activity, an index of neutrophil infiltration up to 18h after CLP. To discern a mechanism, the nuclear content of lung LXR␣ and activation of NF-␬B (p65 subunit) was determined after CLP by western blot and transcription factor assay respectively. Survival following CLP was monitored for 10 days. Results: Lung neutrophil infiltration was similar in the two genotypes at 3h and 6h after CLP. However, at 18h neutrophil infiltration was higher on LXR␣-/- mice when compared to wild type (383⫾20 vs. 200⫾10 u/100 mg tissue, p⬍0.05) suggesting the inability to mitigate the inflammatory process in the lung. Western blot revealed a timedependent reduction in LXR␣ expression at 6h in wild type mice with return to baseline at 18h. NF-␬B activation was similar in both groups of mice at 3h and 6h after CLP. However, at 18h LXR␣-/- mice has a significant increase in NF-␬B activation when compared to wild type. Surprisingly, survival rate was similar in both genotypes. Conclusions: Our data suggest that LXR␣ deletion increases lung neutrophil infiltration and is associated with an activation of NF-␬B. Hence, LXR␣ may serve as a modulator of lung inflammation and mitigate lung injury following polymicrobial sepsis. (Work supported by NIH grant R01 GM067202 to BZ.)

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RED CELL DISTRIBUTION WIDTH IS A PROGNOSTIC FACTOR IN SEVERE SEPSIS AND SEPTIC SHOCK

EARLY INNATE IMMUNE FUNCTION PREDICTS OUTCOMES FROM PEDIATRIC CRITICAL ILLNESS

Taegyun Kim, You Hwan Jo, Kyuseok Kim, Jae Hyuk Lee, Kyeong Won Kang, Kwang Pil Rim, Hyun Sook Lee, Min Ji Lee, Seoul National University Bundang Hospital

Ryan Nofziger, Jennifer Muszynski, Nationwide Children’s Hospital, Jyotsna Nateri, Lisa Hanson, Kristin Greathouse, Lisa Steele, The Research Institute at Nationwide Children’s Hospital, David Marquardt, Sunrise Children’s Hospital, Mark Hall, Nationwide Children’s Hospital

Introduction: Red cell distribution width is easily available and routinely measured in the complete blood count panel, and has been known to be associated with inflammation. Hypothesis: We hypothesized that red cell distribution width would be higher in nonsurvivors than in survivors and would be an independent predictor of 28-day mortality in severe sepsis and septic shock. Methods: We performed a prospective observational study at an urban, tertiary care, emergency department from Aug 2008 to Jul 2011. We prospectively included consecutive adult patients who were diagnosed with severe sepsis and septic shock. In all cases, blood sample tests including red cell distribution width were performed at admission to the emergency department. The red cell distribution width was categorized as ⱕ14.1%, 14.2 to 15.8%, and ⬎15.8%. Adjusted odds ratios were estimated with multivariate logistic regression analysis after adjusting for age, sex, congestive heart failure, white blood cell count, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, blood urea nitrogen, creatinine, albumin, and Acute Physiology and Chronic Health Evaluation II score. Cox proportional hazards regression analysis was conducted to identify predictors of mortality during a 28-day follow-up period. Results: A total of 514 patients were enrolled and overal mortality rate was 31.7%. Patients with a red cell distribution width of ⱕ14.1%, 14.1 to 15.8%, and ⬎15.8% had a 28-day mortality rate of 14.3%, 29.7%, and 52.1%, respectively (p⬍.001). Compare to the patients with a red cell distribution width of ⱕ14.1%, the adjusted odds ratios for mortality were significantly higher than those of 14.2 to 15.8% (odds ratios [OR], 1.96; 95% confidence interval [CI], 1.04 –3.68; p⬍.0001), and those of ⬎15.8% (OR, 4.91; 95% CI, 2.52–9.57; p⬍0.001). In Cox proportional hazards analysis, red cell distribution width of 14.2 to 15.8% and ⬎15.8% were associated with 1.7- and 2.7-fold increased risk of death during the 28-day, respectively (hazard ratio [HR], 1.65; 95% CI, 1.01–2.70; p⬍.001, and HR, 2.74; 95% CI, 1.69 – 4.45; p⬍0.001). Conclusions: Red cell distribution width is an independent predictor of 28-day mortality in severe sepsis and septic shock.

Introduction: A reduced ability of whole blood to make TNF␣ upon ex vivo stimulation has been associated with adverse outcomes when present after the first 3 days of critical illness in children. The significance of earlier values (from days 1–3) is unclear as are the relationships between age and innate immune function. Hypothesis: Reduced TNF␣ production capacity within the first 72hrs of critical illness will be associated, in an age-related way, with nosocomial infection (NI) and death in children. Methods: Whole blood was sampled within 72hrs of PICU admission (single center) and stimulated with LPS (500pg/ml) for 4hrs at 37°C. Supernatants were analyzed for TNF␣ by chemiluminescence. Clinical and outcomes data were recorded. Age was evaluated as a continuous and categorical variable (⬍1yr, 1– 4yrs, 5–10yrs, ␮11yrs). Data represent median (IQR). Results: 200 critically ill children were studied (age: 7 [1–13] yrs; diagnoses: MODS [n ⫽ 22], severe sepsis/septic shock [n ⫽ 97], trauma [n ⫽ 58], cardiopulmonary bypass [n ⫽ 23]). TNF␣ production capacity was lower in children who went on to develop NI (n ⫽ 43) in the next 14 days (342 [210 –740] pg/ml vs. 683 [361–1167] pg/ml, p ⫽ 0.001) with a value of 520 pg/ml predicting NI by ROC analysis (AUC ⫽ 0.66, p ⫽ 0.001, RR: 3.6 [1.9 – 6.6]). This relationship was even stronger for 28-day mortality, with nonsurvivors (n ⫽ 9) being lower than survivors (205 [89 –245] pg/ml vs. 646 [331–1113] pg/ml, p ⫽ 0.0003) and a value of 258 pg/ml predicting death (AUC ⫽ 0.85, p ⫽ 0.0003, RR: 29 [3.7–227]). Age was not associated with TNF␣ production capacity after adjusting for steroid and immunosuppressant use, diagnosis, PRISM III score, and absolute monocyte count (p ⫽ 0.46; multivariable regression). Upon ROC analysis by age category, early TNF␣ production capacity was most predictive of NI in children ␮11 yrs (AUC ⫽ 0.87, p⬍0.0001). Values of 297 and 237 were predictive of 28-day mortality in infants and adolescents, respectively (pⱕ0.028). Conclusions: Our data suggest that reductions in innate immune function as early as days 1–3 of critical illness can predict outcomes in children, and a single mortality threshold (around 250 pg/ml) may be applicable across the pediatric age range.


Oral Abstract Session: Cardiovascular Basic Science 17

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CARDIAC PPAR-GAMMA PROTECTS AGAINST MYOCARDIAL ISCHEMIA-REPERFUSION INJURY.

THE EFFECT OF HYPEROXIA IN PORCINE MODEL OF RUPTURED ABDOMINAL AORTIC ANEURYSM REPAIR

Michael Hobson, Paul Hake, Giovanna Piraino, Basilia Zingarelli, Cincinnati Children’s Hospital Medical Center

Jan Hruda, St. Anna University Hospital and ICRC Brno, Pavel Suk, Ivan Cundrle, Martin Helan, Jan Krbusik, Zdenek Konecny, St. Anna University Hospital, Masaryk University and ICRC Brno, Michal Vlasin, University of Veterinary and Pharmaceutical Sciences and ICRC Brno, Martin Matejovic, Charles University Hospital Pilsen, Pavla Rotterova, Czech Bioptical Laboratory Pilsen, Vladimir Sramek, St. Anna University Hospital, Masaryk University and ICRC Brno

Introduction: The nuclear transcription factor peroxisome proliferator-activated receptor gamma (PPAR-gamma) is a key regulator of the inflammatory response to an array of pathophysiologic insults. We have previously established that PPAR-gamma ligands reduce myocardial ischemia-reperfusion (I/R) injury. In the current study, we directly determined the role of cardiomyocyte PPARgamma in I/R injury, employing a cardiomyocyte-specific PPAR-gamma knockout model. Hypothesis: The presence of the myocardial PPAR-gamma gene is protective against myocardial I/R injury. Methods: A conditional cardiomyocyte-specific PPAR-gamma knockout (Cre⫹/⫹ PPAR-/-) mouse model was developed using a tamoxifen inducible Cre-LoxP mediated gene targeting strategy. Knockout mice were generated with tamoxifen treatment (30 mg/kg ip x 4 days), whereas Cre-/- PPAR⫹/⫹ wild-type mice were treated with vehicle. Animals underwent thirty minutes of left anterior descending coronary artery occlusion followed by two hours of reperfusion. Results: Western blot analysis revealed reduced myocyte expression of PPAR-gamma after induction of the Cre-LoxP phenotype with tamoxifen, but not with vehicle. Cre⫹/⫹ PPAR-/- mice displayed worsened myocardial neutrophil infiltration following I/R compared to Cre-/- PPAR⫹/⫹ wild-type animals, as shown by myeloperoxidase activity (78.0 ⫾ 11.0 vs 49.6 ⫾ 7.6 U/100 mg tissue, p ⫽ 0.05). Furthermore, relative to wild-type animals, Cre⫹/⫹ PPAR-/- mice had significantly elevated plasma levels of cardiac troponin (52.5 ⫾ 5.1 vs 40.1 ⫾ 2.8 ng/ml, p ⫽ 0.04) as well as IL-1␤ (102 ⫾ 9.6 vs 71 ⫾ 9.9 pg/ml, p ⫽ 0.001) and IL-6 (77,337 ⫾ 2,624 vs 63,315 ⫾ 1,725 pg/ml, p ⫽ 0.07). Lastly, tissue histology showed marked disruption of myofibril architecture of Cre⫹/⫹ PPAR-/- myocardium compared to the histology of Cre-/- PPAR⫹/⫹ tissue. Conclusions: Myocardial loss of the PPAR-gamma gene in a tissue-specific knockout model results in enhanced myocardial I/R injury. Thus, PPAR-gamma may represent an ideal target for future modulation of I/R injury.Supported by NIH grants GM067202 and AG 027990.

Introduction: The pathophysiology of abdominal aortic aneurysm (AAA) rupture comprises mechanisms of both haemorrhagic shock and ischaemia/reperfusion injury. The opinion on administration of oxygen in these conditions has been repeatedly reviewed over the past years with remaining controversy. The aim of the study was to evaluate the effect of hyperoxia (100% inhaled oxygen) in a porcine model of ruptured AAA repair. Hypothesis: Administration of 100% oxygen will alter the inflammatory response to the simulation of AAA rupture, resulting in different levels of detectable markers of oxidative stress. Methods: Twenty-eight male pigs weighting 38 (37–39) kg were separated to normoxemia (FiO2 ⫽ 0.25) and hyperoxia (FiO2 ⫽ 1.0) group. Under general anaesthesia, 9 pigs in each group underwent the simulation of AAA rupture, while 5 other were shamoperated. After 2 hrs of stabilization following the initial instrumentation, AAA rupture was simulated by bleeding the pigs to 45 mmHg mean arterial pressure (MAP) and abdominal cavity was filled with warm saline infusion to reach intra-abdominal pressure of 20 mmHg. Hyperoxia started within this period in hyperoxia groups. After 4 hrs of shock, repair surgery phase was simulated by infrarenal aortic clamping for 90 min and hemodynamics was resuscitated with shed blood. Intensive care then followed for 11 hrs. Hemodynamic data and blood samples were collected at defined timepoints. The data was processed with non-parametrical tests. Results: Hyperoxia led to increased cardiac output in hyperoxia group (182 ml/kg/min vs. 141 ml/kg/min in normoxemia; p⬍0.05) and it also decreased mean pulmonary artery pressure (20.96 mmHg in hyperoxia vs. 25.03 mmHg in normoxemia group; p⬍0.01) in later phases of the experimental protocol. There were no statistically significant differences in arterial lactate levels, nor in plasma levels of TBARS, MDA and isoprostane levels between the groups. There were also no differences in the level of iNOS expression in organs (heart, liver, kidney). Conclusions: Although it induces detectable hemodynamic changes, administration of 100% oxygen shows no significant effect on markers of inflammation and oxidative stress in this porcine model of AAA rupture.

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THE EFFECTS OF ALLOGENEIC CARDIAC STEM CELLS (CSCS) IN LEFT VENTRICULAR GEOMETRY AND FUNCTION IN A RAT MODEL OF MYOCARDIAL INFARCTION

COMPARISON OF CARDIAC STEM CELLS AND MESENCHYMAL STEM CELLS TRANSPLANTATION ON THE CARDIAC ELECTROPHYSIOLOGY IN RAT MODEL OF MYOCARDIAL INFARCTION IN THE SHORT-TERM AND MEDIUM-TERM PERIOD

Fangcheng Li, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Yinlun Weng, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; Weil Institute of Critical Care Medicine, Changqing Zhou, Tong Wang, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University Introduction: The development of heart failure after acute myocardial infarction (MI) may be related to pathological left ventricular (LV) structural remodeling and the resulting exacerbated systolic and diastolic dysfunction. Cardiac stem cells (CSCs) might provide a new option for the treatment of MI resulting from the regeneration of injury myocardial. Hypothesis: To investigate the effect of CSCs on structural and functional alteration after acute myocardial infarction. Methods: Myocardial infarction was induced in 20 rats by ligation of the left anterior descending coronary artery (LAD). Two weeks after ligation of LAD, animals were randomized to receive injection of 5 ⫻ 106 of PKH labeled CSCs in PBS or PBS alone into left anterior infarcted ventricle wall. The type, magnitude, and time course of changes in LV geometry and function were echocardiographic ally measured prior to ligation of LAD, prior to, 2 and 4 weeks after injection of CSCs or PBS. At 4th week after injection of CSCs, left ventricle pressure, mean aortic pressure were also invasively measured, and then hearts were harvested for tracing of CSCs in cryostat section under fluorescent microscope. Results: Two weeks after ligation of LAD, there were significant decreases in interventricular septal systolic/diastolic thickness (IVSTs/d), while increases in LV systolic/diastolic dimension (LVDs/d). Consequently, this contributed to decreases in ejection fraction (EF), fractional shorting (FS) when compared to baseline. With the treatment of CSCs for 4 weeks, ejection fraction (EF), fractional shorting (FS) were progressively improved when compared to control group (80 ⫾ 11 vs 72 ⫾ 8, p ⫽ 0.02; 47 ⫾ 8 vs 35 ⫾ 8, p⬍0.01) in conjunction with a reduction of LV systole/diastole dimension (LVDs/d) (3.08 ⫾ 0.58 vs 4.30 ⫾ 0.72; 6.64 ⫾ 0.68 vs 7.98 ⫾ 0.73, p⬍0.01 for each). Besides, a significant improvement in the maximal rate of LV pressure development and decline (peak ⫹dP/dt and -dP/dt, respectively) was observed (5033 ⫾ 381 vs 3863 ⫾ 387; 4293 ⫾ 287 vs 3582 ⫾ 285, p⬍0.01 for each). Conclusions: CSCs significantly prevented structural and functional deterioration after MI.


Tong Wang, Shaoxin Zheng, Changqing Zhou, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Jian Chen, Suihua Huang, The Fifth Affiliated Hospital of Sun Yat-sen University, Yinlun Weng, The Sun Yat-sen Memorial Hospital, Sun Yat-sen University; Weil Institute of Critical Care Medicine, Wei Wu, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Shijie Sun, Weil Institute of Critical Care Medicine, Jingfeng Wang, The Second Affiliatied Hospital of Sun Yat-sen University, Wanchun Tang, Weil Institute of Critical Care Medicine Introduction: Whether transplanted cardiac stem cells (CSCs) and mesenchymal stem cells (MSCs) improved ventricular fibrillation threshold (VFT) similarly and whether severe malignant ventricular arrhythmia is induced in the myocardial infarction (MI) model in the short-term and medium-term period are still unclear. We sought to compare the effects of the CSCs and MSCs transplantation on the electrophysiological characteristics and VFT. Hypothesis: CSCs are superior to MSCs in modulating the electrophysiological abnormality and improving the VFT in rat model of MI in the short-term and medium-term period. Methods: MI was induced in 60 male Sprague-Dawley rats. 2 weeks later, animals were randomized to receive 5 ⫻ 106 CSCs or 5 ⫻ 106 MSCs labeled with PKH26 in phosphate buffer solution (PBS) or PBS alone injection into the infarct anterior ventricular free wall. 2 weeks (short-term) and 6 weeks (medium-term) after the CSCs, MSCs or PBS injection, VFT were measured. Labeled CSCs and MSCs were observed in 5 ␮m cryostat sections from each harvested heart. Results: The VFTs (mA) were improved in the CSCs group compared with the MSCs group and the PBS group in the short-term (infarct area: 10.2⫾2.4 vs. 3.1⫾0.9 vs.3.7⫾0.9, p⬍0.001; infarct marginal zone: 8.9⫾1.9 vs. 3.0⫾0.9 vs. 3.6⫾1.6, p⬍0.001; non-infarct zone: 7.8⫾2.2 vs. 4.9⫾2.2 vs. 2.3⫾0.7, p⬍0.001) and medium-term (infarct area: 8.4⫾3.0 vs. 4.2⫾1.6 vs. 4.0⫾1.6, p⬍0.001; infarct marginal zone: 6.4⫾2.5 vs. 2.9⫾1.9 vs. 2.5⫾0.8, p⬍0.001; non-infarct zone: 7.0⫾2.6 vs. 5.1⫾2.6 vs. 3.4⫾1.0, p⬍0.01) period. Labeled CSCs and MSCs were identified in the infarct zone and infarct marginal zone. Labeled CSCs express Connexin-43 and ␣-sarcomeric actin, while Labeled MSCs express ␣-sarcomeric actin in vivo. Conclusions: CSCs are superior to MSCs in improving the VFT in rats with MI in the short-term and medium-term period. CSCs and MSCs express markers that suggest muscle phenotypes in vivo, but MSCs rarely express Connexin-43.

Oral Abstract Session: Cardiovascular Clinical Medicine 21

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MITOCHONDRIAL TARGETING OF ANTIOXIDANTS WITH ANTI-APOPTOTIC ACTION IN PEDIATRIC ASPHYXIAL CARDIAC ARREST

SIMPLE STEPSTOOL ADJUNCTS IMPROVE DURATION OF AHA GUIDELINE-COMPLIANT CHEST COMPRESSIONS AND REDUCE RESCUER SUBJECTIVE FATIGUE

Sophie Baart, University of Pittsburgh, Jing Ji, Children’s Hospital of Pittsburgh, Peter Wipf, University of Pittsburgh, Robert Clark, Children’s Hospital of Pittsburgh, Henry Alexander, University of Pittsburgh, Patrick Kochanek, University of Pittsburgh Medical Center, Valerian Kagan, University of Pittsburgh, Hulya Bayir, Children’s Hospital of Pittsburgh

Shirley Viteri, Michael McBride, Robert Sutton, Frances Nadel, Dana Niles, Akira Nishisaki, Xuemei Zhang, Stephen Paridon, Robert Berg, Vinay Nadkarni, The Children’s Hospital of Philadelphia

Introduction: Mitochondrial reactive oxygen species have become a target for drug discovery since their production is characteristic of early stage apoptosis. This stage of apoptosis requires redox interactions of cytochrome c with cardiolipin leading to mitochondrial membrane permeabilization. Prevention of this chain of events by mitochondria-targeted electron scavengers could protect against apoptosis. Hypothesis: A mitochondria-targeted electronscavenger–a conjugate of hemigramicidin S (GS) with a nitroxide radical, 4-amino-2,2,6,6,-tetramethylpiperidine-N-oxyl, (XJB-5–131) will act as a potent anti-apoptotic agent after asphyxial cardiac arrest (ACA) in postnatal day (PND)17 male rats. Methods: Mitochondrial partitioning of XJB-5–131 was evaluated by electron paramagnetic resonance spectroscopy (EPR) of nitroxide radical in cells, and mitochondrial and cytosolic fractions in rat cortical neurons. For pharmacokinetic studies, ascorbate and nitroxide radical of the homogenized cortex and plasma from PND17 rats were assessed by EPR after 10 mg/kg XJB-5–131 iv dosing. Additional rats were divided into 4 groups as ; sham; ACA (9 min)⫹XJB-5–131 (10 mg/kg iv 10 min after ACA), ACA⫹vehicle (n ⫽ 4 –5/grp). Apoptosis was assessed by caspase 3/7 activity at 3h and 24h. Results: The characteristic triplet EPR signal of GS-nitroxide was detected almost exclusively in the mitochondrial fraction of neurons treated with XJB-5–131 in vitro, without affecting cell viability. Nitroxide radical signals were detectable in plasma immediately after XJB-5– 131 treatment and the signal lasted for 10h in naive rats. In the brain, the presence of XJB-5–131 was evident by the appearance of ascorbate radical resulting from the ascorbate-XJB-5–131 interaction. Caspase 3/7 activity increased 10-fold at 24h after ACA vs and sham (p⬍0.01) but not at 3h. XJB-5–131 attenuated ACA-induced activation of caspase 3/7 at 24h (p⬍0.01). Conclusions: XJB-5–131 crosses the blood-brain-barrier, localizes to mitochondria, and prevents caspase 3/7 activation after ACA. Histological and functional outcome analysis of XJB-5–131 as a new therapy for treatment of ACA is warranted. Support: NS061817, HD045968, HL70755, U19AI068021.

Introduction: AHA guideline-compliant chest compressions (CCs) during cardiac arrest improve survival. Few studies assess optimal use of stepstools (adjuncts) to reduce rescuer energy expenditure (EE) and subjective fatigue. Hypothesis: Stepstool use will reduce rescuer EE and perception of fatigue during delivery of AHA guideline-compliant CCs in a pediatric cardiac arrest manikin model. Methods: IRB-approved prospective, randomized trial conducted on healthcare providers who routinely deliver CCs at work. Volunteers performed 2 sessions of continuous CCs on a pediatric manikin, in random order on separate days. CCs were performed with vs. without use of a 13cm stepstool on a standard-height hospital stretcher (70cm) until maximal fatigue or 10 min. Quality parameters were recorded using a CPR-sensing automated feedback-enabled defibrillator. Metabolic data (heart rate [HR], respiratory exchange ratio [RER], minute oxygen consumption [VO2]) were measured using a metabolic cart. Fatigue scores were reported by participants using a visual analog scale at defined intervals. “AHA guideline-compliant” CCs were defined by achieving all 3 criteria: average depth ⱖ38 mm, rate 90–120CC/ min, and residual leaning force in ⬍20% of CCs. Analysis included descriptive summaries, Student’s t-test, Poisson regression, and Cox regression. Results: All 21 providers completed both sessions: 62.5% male; median age 34 years, range 28–60; median height 173cm, range 163–190cm. Median time to failure (duration) to perform AHA guidelinecompliant CCs was significantly longer with stepstools (6.0 min) than without stepstools (3.5 min) (HR 1.53; CI: 1.06, 2.21; p ⫽ 0.023). With stepstool, subjects had lower HR by 5 beats per minute (p ⫽ 0.015), had lower RER (p⬍0.0001), and reported less fatigue at the time of failure (p ⫽ 0.03). There was no significant difference in VO2, maximal fatigue score, or EE at the point of subjective maximal fatigue. Conclusions: Although stepstool adjunct did not reduce rescuer EE at the point of maximal fatigue, its use facilitated the delivery of AHA guideline-compliant CCs for close to twice as long while simultaneously reducing rescuer perception of fatigue in this pediatric cardiac arrest manikin model.

23 USE OF THERAPEUTIC HYPOTHERMIA AFTER IN-HOSPITAL CARDIAC ARREST Mark Mikkelsen, Jason Christie, Scarlett Bellamy, Benjamin Abella, Meeta Prasad, Barry Fuchs, William Schweickert, University of Pennsylvania, Robert Berg, Children’s Hospital of Philadelphia, Vincent Mosesso, University of Pittsburgh School of Medicine, David Gaieski, for the American Heart Association’s Get With the Guidelines-Resuscitation (NRCPR) Investigators Introduction: In the United States, approximately 200,000 in-hospital cardiac arrests occur annually, the rate appears to be increasing, and less than 1 in 5 of these patients will survive to hospital discharge. The American Heart Association guidelines recommend that therapeutic hypothermia (TH) be considered after in-hospital cardiac arrest. The rate of use of TH after in-hospital cardiac arrest, and in which patients and hospitals it is being used, are unknown. Hypothesis: We examined the use of TH after adult in-hospital cardiac arrest, investigated whether a trend exists towards increased use over time, and evaluated which patient characteristics and hospital-related factors were associated with the use of TH. Methods: We examined the use of TH in patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest over the study period 2003–2009 using the National Registry of Cardiopulmonary Resuscitation. We tested whether the rate of use of TH increased over time using the non-parametric test for trend. We identified factors associated with the use of TH using multivariable logistic regression and adjusting for center-level effects. Results: Of 67,498 patients at 538 hospitals who had ROSC after in-hospital cardiac arrest, TH was initiated in 1,367 (2.0%). The use of TH increased from 0.7% in 2003 to 3.3% in 2009 (p⬍0.001). When we limited our analyses to the 112 hospitals contributing data for all years of the study period, we found a similar increase in the use of TH over time (0.6% in 2003 to 3.0% in 2009, p⬍0.001). In multivariable analyses, we found that younger age (p⬍0.001) and occurrence in a non-Intensive Care Unit location (p⬍0.001), on a weekday (p ⫽ 0.01), and in a teaching hospital (p ⫽ 0.002), were associated with an increased likelihood of TH being initiated. Initial cardiac rhythm was not associated with the use of TH, except that TH was significantly less likely to be initiated if the initial rhythm was unknown (p ⫽ 0.003). Conclusions: After in-hospital cardiac arrest, TH is used rarely. The rate of use increased over time, but remained low. Factors associated with TH use included patient age, time and location of occurrence, and type of hospital.


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THE EFFECT OF GLUTAMINE ON CEREBRAL ISCHEMIC INJURY AFTER CARDIAC ARREST

CELL SAVER FOR VOLUME REPLACEMENT IN CHILDREN FOLLOWING CARDIOPULMONARY BYPASS REDUCES THE NUMBER OF RBC AND BLOOD PRODUCT TRANSFUSIONS AND DONOR EXPOSURES.

Kyung Su Kim, Gil Joon Suh, Woon Yong Kwon, Hui Jai Lee, Ki Young Jeong, Yong Ho Kwak, Sang Hoon Na, Seoul National University Hospital Introduction: Recent studies have demonstrated that enhanced heat shock proteins (Hsp) can protect against ischemic brain injury and glutamine can enhance the expression of Hsp. Purpose of the study was to investigate whether glutamine attenuates brain injury in rat arrest model and this is associated with enhancement of Hsp. Hypothesis: We hypothesized that glutamine would enhance the expression of Hsp and thereby attenuate neuronal injury due to cardiac arrest. Methods: In Sprague-Dawley rats, cardiac arrest was induced using transesophageal alternating current. After 6 minutes of no flow time, animals were resuscitated by chest compression and subsequent defibrillation (8,9, or 10 min). One minute after return of spontaneous circulation, 0.75 g/kg of glutamine (CPR⫹GLN, n ⫽ 6) or normal saline (CPR, n ⫽ 6) was administered via tail vein. Six rats were used for sham group. Neurologic deficit score (NDS, 0 [brain death] to 80 [normal]) was checked at 24-hr and 72-hr. Rats were euthanized and the brain was harvested for Western blot analysis (phosphorylated heat shock factor-1 [p-HSF-1], Hsp25, Hsp72, and cleaved caspase-3), H&E and TUNEL staining 72-hr after cardiac arrest. Kruskal-Wallis test and Mann-Whitney U post-hoc test with Bonferroni correction were used for the analysis. Results: There was no difference regarding resuscitation parameters between CPR and CPR⫹GLN. NDS in CPR⫹GLN was higher than that in CPR (p⬍0.017) and lower than that in sham (p⬍0.017) at both 24-hr and 72-hr. P-HSF-1, Hsp25, and Hsp72 expressions were elevated (p⬍0.017) in CPR⫹GLN than sham and CPR. Cleaved caspase-3 expression in CPR was higher (p⬍0.017) than in sham and CPR⫹GLN. Histopathologic examination revealed that neuronal death and apoptosis was more frequently observed in CPR than in CPR⫹GLN. Conclusions: Glutamine attenuates cerebral ischemic injury in cardiac arrest model of rats. This is associated with the enhancement of Hsp25 and Hsp72.

Jill Cholette, Karen Powers, Golisano Children’s Hospital, University of Rochester, George Alfieris, Ronald Angona, Kelly Henrichs, Neil Blumberg, University of Rochester Introduction: Children typically require large numbers of red blood cell (RBC) and blood component therapy following repair or palliation of cardiac defects with cardiopulmonary bypass (CPB). Cell savers remove heparin and cytokines from CPB salvage, and are now available for pediatrics. The impact of cell saver infusion on RBC and component therapy in pediatric cardiac surgery has not been explored. Hypothesis: Utilization of cell saver for volume replacement in children undergoing cardiac surgery for congenital heart defects with CPB reduces post-operative allogeneic RBC and blood component transfusions, and donor exposures. Methods: A prospective, randomized controlled trial of cell saver v. allogeneic RBC and crystalloid/colloid for post-operative volume replacement in children undergoing cardiac surgery with CPB.Subjects: Children ⱕ20 kg undergoing CPB, stratified by weight and surgical severity.Study Group: Residual CPB volume was processed by the Fresinius Continuous Auto Transfusion System® and collected as cell saver. Cell saver was infused for anemia, or for volume replacement if hemoglobin (Hb) ⬍13 g/dL. Albumin or crystalloid was given for volume replacement if Hb ⬎/⫽ 13 g/dL.Control Group: Allogeneic RBC, albumin, or crystalloid was given for anemia or volume replacement per the current standard of care. Blood component therapy was transfused in each group per the standard of care. Results: 34 cell saver and 31 control subjects were studied. Post-operatively until hospital discharge, the cell saver group received a mean of 1.9 ⫹/⫺ 1.5 allogeneic RBC transfusions v. 3.6 ⫹/⫺ 2.5 in the control group (p⬍0.001). The cell saver group received 2.1 ⫹/⫺ 1.6 total post-operative transfusions (FFP, cryo, plts) v. 4.3 ⫹/⫺ 3.2 in the control group (p⬍0.001). Mean post-operative donor exposures were 1.6 ⫹/⫺ 1.6 for the cell saver group and 3.2 ⫹/⫺ 2.8 for the control group (p⬍0.001). There was no significant difference in RBC storage age or clinical outcomes. Conclusions: Infusion of cell saver for volume replacement in children following CPB reduces the number of allogeneic RBC and blood product transfusions and donor exposures, and may reduce complications from blood product transfusions.

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RED BLOOD CELL TRANSFUSION IN CRITICALLY ILL MEDICAL PATIENTS WITH ISCHEMIC OR NONISCHEMIC CARDIAC DISEASE

EXTRA CORPOREAL MEMBRANE OXYGENATION (ECMO) AND CEREBRAL BLOOD FLOW VELOCITY (CBFV) IN CHILDREN

Rohan Goswami, James Krinsley, Stamford Hospital

Nicole O’Brien, Nationwide Children’s Hospital, The Ohio State University

Introduction: Red blood cell transfusion (T) in critically ill patients has been guided over the last decade by the results of the TRICC trial (NEJM, 1999) that showed no increase in mortality (M) with a restrictive hemoglobin threshold (7 vs 9 mg/dL) for T. It is unclear whether this applies to patients with cardiac disease (CARD) and whether T has a different implication for M in CARD patients with and without acute coronary syndrome (ACS). Hypothesis: T is independently associated with increased M in CARD and non-cardiac (NON) critically ill patients. Methods: This is a retrospective review of prospectively collected information abstracted from the unit’s clinical database. Our cohort includes 2928 patients admitted without GI bleeding between 10/1/05 and 5/31/11 to a 16 bed mixed ICU of a university affiliated hospital. Diagnostic groups included acute coronary syndrome (ACS, n ⫽ 407), non-ACS CARD (NACS, n ⫽ 592) and NON (n ⫽ 1929). Multivariate analsysis included APACHE IV predicted mortality % (APIV PM) and ICU LOS. Results: Comparison of patients ACS NACS NONLOS (median, IQR) 1.2 (0.8 –2.0) 1.7 (0.8 –3.5) 2.0 (1.0 –5.0) APIV PM (%) 11.2 33.0 28.6T (%) 5.4 11.5 9.6 M (%) 6.4 25.8 24.1 Multivariate analysis (OR [95% CI]) demonstrated that T in NON 1.65 (1.10 –2.49) p ⫽ 0.0161 and NACS 2.89 (1.40 –5.93) p ⫽ 0.0040 was independently associated with increased M. However, this was not seen in ACS: 0.40 (0.05–3.03) p ⫽ 0.3770. Conclusions: T was independently associated with increased risk of mortality in critically ill patients admitted with non-cardiac and non-ACS cardiac diagnoses. However, T in ACS patients had no independent association with mortality. These data may help guide T practice in critically ill patients with various cardiac diseases and provide a rationale for conducting a randomized trial to assess T thresholds and associated mortality in patients with cardiac disease.

Introduction: ECMO is commonly used in children with refractory cardiorespiratory failure. Intracranial hemorrhage is a major cause of death and long term disability in ECMO patients. Relationships between CBFV and neurologic complications on ECMO are unknown. Hypothesis: CBFV is reduced while on ECMO therapy. Methods: In this ongoing prospective, observational study, children on ECMO support undergo measurement of systolic, diastolic, and mean flow velocities (Vs, Vd, Vm) in bilateral middle cerebral arteries daily while on ECMO as well as following decannulation. Values are measured using a 2 MHz Doppler ultrasound (Sonara, Viasys, Madison, WI). Relevant clinical data are also noted. Data represent mean (SEM). Results: 12 patients have been studied to date (age 38 (22) months, venovenous neck n ⫽ 3, venoarterial (VA) neck n ⫽ 5, VA chest n ⫽ 4). On ECMO, CBFV was decreased compared to expected values: 62⫾6% pred., 58⫾8% pred., 58⫾6% pred. for Vs, Vd, Vm respectively. After decannulation, Vs and Vm were significantly higher than while on ECMO: 85⫾6% pred., 77⫾6% pred. (p ⱕ0.004 vs ECMO values), though they remained lower than normal. Patients who developed cerebral hemorrhage (VA neck n ⫽ 1, VA chest n ⫽ 2) had higher Vs, Vd, and Vm compared to those who did not: 105 vs 62% pred., 115 vs 58% pred., 111 vs 58% pred. (p ⫽ .01 for all values). High flow velocities were noted 2–5 days before clinical recognition of cerebral hemorrhage. There were no significant differences in blood pressure, circuit flow, or PaCO2 between the children who had cerebral hemorrhage and those who did not. Conclusions: In most children, CBFV was lower than normal while on ECMO support and increased after decannulation. However, children who developed cerebral hemorrhage had higher than normal CBFV in the days prior to clinical recognition of bleeding. CBFV measurement may represent a portable, non-invasive way to predict cerebral complications of ECMO and deserves further study.


28 THE DIAGNOSTIC ACCURACY OF INFERIOR VENA CAVA COLLAPSIBILITY IN DETERMINING VOLUME RESPONSIVENESS IN EMERGENCY DEPARTMENT PATIENTS WITH SHOCK Kevin Williams, Enyo Ablordeppey, Daniel Theodoro, Brian Fuller, Brian Wessman, Washington University School of Medicine, Tom Ahrens, ICU-USA, Jennifer Williams, Richard Hotchkiss, Stephanie Charshafian, Christopher Holthaus, Washington University School of Medicine Introduction: Inferior vena cava collapsibility (IVCc) with respirations and stroke volume changes with passive leg raise testing (PLRT) have been proposed as reliable means for predicting volume responsiveness (VR). Hypothesis: In Emergency Department (ED) patients undergoing fluid resuscitation for shock, IVCcⱖ50% is a sensitive and specific indicator of VR when compared to PLRT cardiac index (CI) or stroke volume index (SVI) changes ⱖ15%. Methods: Pilot data analysis from an ongoing prospective randomized controlled trial of fluid optimization conducted at an urban, academic tertiary care ED with 90,000 visits/year (“EFFORT”-ED Flow-directed Fluid Optimization Resuscitation Trial; ClinicalTrials.gov ID:NCT01128413). Inclusion criteria are age ⱖ18 with hypotension (SBPⱕ90 or MAPⱕ65) despite 20 ml/kg fluids OR vasopressor use OR lactate ⱖ2.5 mmol/L. Patients are randomized to receive IV fluids via: 1) Routine Care or 2) Fluid Optimization via 500 ml normal saline boluses if the CI or SVI increases ⱖ15% with PLRT (Cheetah NICOM®). In both study arms, PLRT was performed immediately before and after each fluid bolus or at 30 minute intervals when not receiving a fluid bolus. While in the upright PLRT baseline stage, six second cine-loop B-mode IVC ultrasound clips were recorded. The longitudinal anteriorposterior IVC diameter was measured ⱖ3cm distal to the right atrium-IVC junction for an IVCc% ⫽ [Maximum IVC(cm)-Minimum IVC(cm)]/Maximum IVC(cm). The PLRT percent change (%⌬) was calculated as %⌬SVI ⫽ (Maximum Challenge SVI-Average Baseline SVI)/(Average Baseline SVI). 2x2 tables were constructed for IVCc ␮/⬍50% and SVI or CI ⱖ/⬍15%. Results: 15 patients (10 male) with a median age of 59 yrs (range 20 –90) underwent 405 IVC cine clips paired to 114 PLRTs. The median IVCc was 31% (IQR 22– 44). The median PLRT SVI and CI %⌬ were 17 (IQR 6 –32) and 16 (IQR 5–30) respectively. 68/114 (60%) PLRTs had a SVI or CI %⌬ⱖ15% while 21/114 (18%) paired ultrasounds had an IVCcⱖ50% yielding a 9% sensitivity, 67% specificity, 33% negative predictive value, and 29% positive predictive value. Conclusions: In this pilot study of ED patients with shock, the diagnostic accuracy of IVCcⱖ50% performed suboptimally in determining VR when compared to PLRT.


Oral Abstract Session: Patient and Family Support 29

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DO PERSONAL PREFERENCES FOR LIFE-SUSTAINING TREATMENT INFLUENCE MEDICAL DECISION MAKING AMONG PEDIATRIC INTENSIVISTS?

PHYSICIAN ATTIRE IN THE ICU AND ITS EFFECT ON FAMILIES

Jennifer Needle, Oregon Health & Science University, Richard Mularski, Center For Health Research Kaiser Permanente Northwest, Thuan Nguyen, Erik Fromme, Oregon Health & Science University

Introduction: Physician attire is one modifiable variable in the communication process that has been demonstrated in non-ICU environments to affect the patient-physician relationship, but little is known about the ICU. Hypothesis: We hypothesized that physician appearance alters perceived quality of care and that most family members prefer traditional physician attire with a white coat. Methods: We constructed a survey for ICU patient family members to inquire about perceptions of physician attire. The survey was administered to families of patients admitted to the medical-surgical ICUs at 3 Calgary hospitals between November 2010 and August 2011. Participants were asked to rate the importance of 10 aspects of physician appearance using a 5 point Likert scale and to select the physician who would be most likely to provide high quality care from pictures of physicians in four different dress styles (traditional white coat, scrubs, suit, casual clothing). Results: The survey was offered to 370 family members and 249 (67%) agreed to participate. A majority of respondents felt that professional dress (59%), neat grooming (68%) and visible nametags (78%) were important, while a minority felt similarly about physicians wearing a white coat (29%). Conversely, when selecting their preferred physician from a panel of pictures, respondents strongly favored physicians’ wearing traditional attire with the white coat (traditional 52%, scrubs 26%, suit 11%, casual 11%, p⬍0.001). Physicians in traditional dress were seen as most respectful, likely to explain treatment options and to act in the best interest of patients. Conversely, physicians in scrub dress were seen as most competent to perform a life saving procedure. Conclusions: Our results suggest that while families of patients admitted to ICU did not feel that physician attire influenced their perceptions of doctors, families associated certain dress styles with specific physician attributes. Given the importance of effective communication in the ICU, physicians should recognize that their attire may influence family rapport, trust and confidence.

Introduction: Withholding and withdrawal of life-sustaining treatment (LST) by physicians is influenced by a variety of factors; the role of physicians’ personal preferences for LST has not previously been explored. Hypothesis: We hypothesized that physicians who had a preference for more LST for themselves would find it more acceptable to recommend LST for their patients and those who preferred less LST would find it more acceptable to recommend withholding and withdrawal of LST for their patients. Methods: Cross-sectional national anonymous mail survey of all Board certified/eligible pediatric intensivists. A Personal Preference Score was calculated from responses to personal preference questions for life-sustaining treatments adapted from “Your Life, Your Choices,” by Pearlman et al. Physicians were asked to consider the “acceptability” of offering and recommending treatment options involving LST in a hypothetical scenario of a 2 year-old with a high cervical spinal cord transection. Logistic regression controlling for sociodemographic characteristics computed odds ratios for the independent association between physicians finding an option “acceptable” to a one standard deviation change in the Personal Preference Score (higher or lower preference for LST). Results: A total of 471 (30%) were returned. Physicians who had a higher Personal Preference Score (higher preference for LST) were more likely to consider it acceptable to recommend performing a trachestomy (1.38 [1.35–1.41] p ⫽ ⬍0.01) and to recommend reintubation if the patient failed extubation (1.87 [1.81–1.94] p ⫽ ⬍0.01). Intensivists who had a lower Personal Preference Score (lower preference for LST) were more likely to consider it acceptable to recommend that the patient not be reintubated if extubation failed (1.42 [1.39 –1.46] p ⫽ ⬍0.01) and to recommend Do Not Resuscitate status (1.34 [1.31–1.37] p ⫽ ⬍0.01). Conclusions: Among pediatric intensivists, personal preferences for LST were significantly associated with scenario-based responses to acceptability of withholding and withdrawal of LST.

Selena Au, Henry Stelfox, Farah Khandwala, University of Calgary

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THE CHALLENGE OF ASSESSING SYMPTOMS IN SERIOUSLY ILL INTENSIVE CARE UNIT PATIENTS: CAN PROXY REPORTERS HELP?

A PATIENT FAMILY CENTERED CARE PROGRAM IMPROVES FAMILY SATISFACTION IN THE ICU

Kathleen Puntillo, University of California San Francisco, John Neuhaus, University of California, San Francisco, Shoshana Arai, University of California San Francisco School of Nursing, Steven Paul, University of California, San Francisco, Michael Gropper, Neal Cohen, University of California San Francisco Medical Center, Christine Miaskowski, University of California Introduction: Determine agreement among ICU patients (PTs) and family members (FMs), RNs, & MDs (proxies) regarding PT symptoms; compare symptom intensity and distress levels. Hypothesis: None Methods: Cross-sectional survey of PTs & proxies about PT symptom intensity & distress for 10 symptoms rated from 0 –3 (no, mild, moderate, severe). Agreement levels assessed by within-patient-set correlations estimated using moment-based methods that account for clustering of assessments within PTs as well as missing values. Differences among informants in intensity & distress levels assessed using mixedeffects ordinal logistic regression models. Results: Of 245 PTs, 171 rated their own symptoms. 243 FMs, 104 RNs, and 92 MDs were proxies for the 245 PTs. Correlation coefficients ⬎than .35 were viewed to indicate important agreement between two informants. Such magnitudes in intensity ratings were found between PT and FM for six out of 10 symptoms: pain, shortness of breath (SOB), restless, anxious, sad, and scared. No intensity ratings between PTs and RNs had correlation coefficients ⬎.32. Pain, tired, SOB had intensity correlation coefficients of ⬎.36 between PTs and MD. Correlation coefficients between PTs and FMs were ⬎.40 for five symptom distress scores: pain, SOB, restless, scared, and thirsty. No symptoms had distress correlation coefficients of ⬎.35 between PT and RN. Anxious and thirsty had symptom distress correlation coefficients between PT and MD ratings at ⬎.39. FMs and clinician proxies reported higher intensity and distress scores than PTs for most symptoms, with ⬍1 point difference between PTs and proxies. Conclusions: PT-FM correlations were sufficiently robust to consider using FMs to help assess PTs’ symptoms. They may be able to provide clinically important information about symptoms in non-reporting PTs and to track changes in symptoms over time. Relatively low correlations between clinicians’ and PTs’ symptom ratings suggest that some proxy raters over-estimate, while some under-estimate PTs’ symptoms. Proxy overestimation of PT symptom scores warrants further study since this may influence decisions about treating patients’ symptoms.


Cynthia Koslosky, Jacob Rube, Steven Gannon, Wayne State University School of Medicine, Robert Dario, Andrea Dorman, Ethel Howell, Harper Hospital, Steven Tennenberg, Wayne State University School of Medicine, Dept of Surgery Introduction: The ICU is intimidating for family members interacting with caregivers of their loved ones during critical illness. In an effort to improve family satisfaction (FS), our hospital implemented a comprehensive patient family centered care (PFCC) program in its ICUs. We sought to determine if FS in the ICU improved over time after implementation of the PFCC program. Hypothesis: A comprehensive PFCC program will improve FS in the ICU. Methods: A multifaceted PFCC program was implemented in Feb. 2010 in the 40 bed, 4 unit ICU of Harper University Hospital. The program consisted of staff education, unrestricted visitation for a designated family spokesperson, patient/family advocates and promotion of a positive environment among all staff in their patient and family interactions. Over time, continued education and improved delivery of its elements were emphasized. FS was measured using the FS-ICU survey (FS-ICU 24, Heyland et al.) one month prior and in three staggered months after program implementation. Surveys were distributed to one family member of patients with an ICU length of stay ⬎48 hours. Survey responses were standardized to a 100 point scale. Comparisons were made between pre- and post-intervention months using a total composite and two component scores assigned to each survey. Results: Total composite scores over the four months studied, Jan (pre-intervention), April, July and Oct (post-intervention), were 65⫾33, 77⫾22, 73⫾24, and 82⫾20 respectively (mean⫾SD, N ⫽ 30 – 44/month, p ⫽ 0.04 by ANOVA, p ⫽ 0.03 Jan vs Oct by post-hoc/Tukey). In the survey’s two main components, there were significant improvements comparing Jan to Oct (satisfaction with care: 63⫾37 vs 85⫾20; satisfaction with decision making: 65⫾33 vs 85⫾20, p ⫽ 0.005 and 0.014, respectively by MANOVA-Tukey). Conclusions: A comprehensive PFCC program improves FS in the ICU in a short timeframe. Increasing scores over time imply ongoing improvement in FS as a result of the program.

Oral Abstract Session: Therapeutics 33

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INCREASING WEIGHT IS PREDICTIVE OF VANCOMYCIN DOSING INACCURACY IN PATIENTS ADMITTED TO THE INTENSIVE CARE UNIT

MULTIPLE-DOSE PHARMACOKINETICS OF DAPTOMYCIN DURING CONTINUOUS VENOVENOUS HEMODIAFILTRATION

Brian Fuller, Washington University School of Medicine, Lee Skrupky, BarnesJewish Hospital, Nicholas Mohr, University of Iowa, Craig McCammon, BarnesJewish Hospital Introduction: When treating methicillin-resistant S. aureus infections, weightbased dosing of vancomycin is recommended. There is minimal data to guide clinicians on empiric dosing of vancomycin in critically ill obese patients. Hypothesis: Increasing weight is predictive of vancomycin dosing inaccuracy in critically ill Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU). Methods: Retrospective observational cohort study of 662 patients who received vancomycin in the ED (over an 18 month period) and were admitted to the ICU. Patients administered vancomycin were identified via query of the ED automated dispensing system. Analysis with a generalized logit model, fit by maximum likelihood where the variances are adjusted to account for multiple dosing events within each patient, was used to create a multivariable model from clinically and statistically significant predictors identified in a univariable model. Odds ratios (OR) with 95% confidence intervals were generated for significant contrasts, and P values ⬍0.05 are statistically significant. Results: 516/662 (77.9%) patients received vancomycin doses in the ED that were outside of the appropriate range (defined as 15–20 mg/kg). In the univariable model, significant predictors of dosing inaccuracy included: increasing age (p ⫽ 0.016), weight (p⬍0.0001), serum creatinine (p ⫽ 0.004), non white race (p ⫽ 0.007), and male sex (p ⫽ 0.008). The multivariable model revealed that only increasing weight was predictive of dosing inaccuracy. Comparing correct vs. overdose, correct vs. under dose, and overdose vs. under dose, for each 10kg increase in patient weight, yielded OR of .12 (0.03- 0.41), p ⫽ 0.0007, 9.65 (4.91–19.0), p⬍0.0001, 81.7 (15.3- 436), p⬍0.0001. Conclusions: In this largest study to date examining empiric vancomycin dosing in critically ill ED patients admitted to the ICU, correct dosing was uncommon. Initial ED dosing of this common antibiotic may be important to achieve the pharmacokinetic and pharmacodynamic goals of vancomycin dosing. Obese patients deserve special attention, as each 10kg increase in patient weight is associated with a significant increasing likelihood of being incorrectly dosed.

Judith Wenisch, Brigitte Meyer, Valentin Fuhrmann, Katrin Saria, Clara Zuba, Medical University of Vienna, Peter Dittrich, University of Graz, Florian Thalhammer, Medical University of Vienna Introduction: Due to its bactericidal efficacy against otherwise resistant Grampositive pathogens, daptomycin is an attractive antimicrobial substance in critically ill patients. Although intensive care patients requiring renal replacement therapy are in particular at risk of Gram-positive infections, no data on pharmacokinetics of daptomycin in continuous venovenous hemodiafiltration (CVVHDF) are available. Hypothesis: To develop dosing recommendations for critically ill patients receiving CVVHDF, this prospective, open-label pharmacokinetic study was performed. Methods: A total of nine patients with CVVHDF due to acute renal failure were included. Once daily a dose of 6 mg/kg of daptomycin was infused. During the 72h study phase of CVVHDF, blood and effluent samples were collected. Daptomycin concentrations were determined by highpressure liquid chromatography. Equations describing a two-compartment, open-pharmacokinetic model were fitted to each subject’s daptomycin concentration–time data and pharmacokinetic parameters were determined by standard methods. Results: Peak plasma concentrations after infusion of 6 mg/kg daptomycin were 72.8 ⫾ 20.3, 78.2 ⫾ 21.7 and 86.9 ⫾ 28.4 mg/L at the post-filter port on days 1, 2 and 3, respectively. The mean arterial area under the curve (AUC0 –24) of the study population was 578 (95% CI 406 –751) mg.h/L, the total clearance 0.4 ⫾ 0.3 mL/min, the apparent volume of distribution in the peripheral compartment 4.1 ⫾ 2.3 L and the apparent volume of distribution in the central compartment 4.7 ⫾ 4.2 L. The elimination half-life was 17.8 ⫾ 9.7 h. Daptomycin was filtered and CVVHDF resulted in a substance loss of about 17%. Although peak concentrations were favourable with 6 mg/kg, accumulation resulted when it was given every 24h. Therefore simulations of 6 mg/kg and 8 mg/kg every 48h were performed. Daptomycin at 8 mg/kg given every 48h resulted in adequate levels without accumulation. Conclusions: Although peak concentrations were favourable with 6 mg/kg, lower through levels and prevention of accumulation could be achieved with higher doses given in greater intervals. Therefore we suggest daptomycin infusions of 8 mg/kg every 48h in patients on CVVHDF.

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EARLY VERSUS DELAYED INITIATION OF PHARMACOLOGICAL VENOUS THROMBOEMBOLISM PROPHYLAXIS FOLLOWING AN INTRACEREBRAL HEMORRHAGE

PROLONGED VS. INTERMITTENT INFUSION OF MEROPENEM, PIPERACILLIN-TAZOBACTAM, AND CEFEPIME FOR THE TREATMENT OF LIFE THREATENING GRAMNEGATIVE INFECTIONS IN THE INTENSIVE CARE UNIT

Andrew Faust, Methodist University Hospital, Dept. of Pharmacy, Christopher Finch, April Hurdle, Methodist University Hospital Introduction: Intracerebral hemorrhage (ICH) accounts for up to 20% of all strokes with an approximate 50% 30-day mortality. Those who do survive often have some form of neurological deficit. The risk of venous thromboembolic events (VTEs) is markedly higher in patients with ICH compared to ischemic strokes; however, the optimal timing to initiate pharmacological prophylaxis after an ICH is not clear. Hypothesis: Early initiation of VTE prophylaxis, when compared to delayed initiation, would decrease VTE rates but increase rebleeding rates. Methods: Retrospective chart review of all patients admitted for a nontraumatic ICH who were initiated on pharmacological VTE prophylaxis during their first 30 hospital days. Early prophylaxis was defined as within 48 hours from hospital admission. Rebleeding was defined as a new hemorrhage or expansion of the initial hemorrhage after the initial follow-up computed tomography scan (i.e., after the first 24 hours). Results: Of the 793 patients evaluated, 400 were included [142 (35.5%) early]. Rebleeding event rates were similar for early versus late [8 (5.6%) vs. 13 (5.0%), P ⫽ 0.80] and rates of hospital-acquired VTEs were not statistically different [1 (0.7%) vs. 8 (3.1%), P ⫽ 0.17]. After censoring data from patients who died during their initial hospitalization or were discharged to hospice, the rate of 30-day readmission for VTE was similar between early and late groups [4 (3%) vs. 6 (2.6%), P ⫽ 1.0]. The median time from admission to the first dose of pharmacological prophylaxis was similar in patients who experienced rebleeding versus those that did not [74 (38 –110.5) vs. 63 (45–90.5) hours, P ⫽ 0.69]. There was a longer median time from admission to the first dose of pharmacological prophylaxis in patients who developed a VTE during the initial hospitalization versus those who did not [108 (73.3–187) vs. 63 (44.5–90) hours, p ⫽ 0.005]. Conclusions: Initiation of early pharmacological prophylaxis in ICH patients did not appear to increase the risk of rebleeding nor decrease the risk of VTE; however, among those patients who did develop VTEs during their hospitalization, there was a longer median time from admission to the first dose of pharmacological VTE prophylaxis.

Heather Arnold, Scott Micek, James Hollands, Lee Skrupky, Jennifer Smith, Richard Reichley, Barnes-Jewish Hospital, Nicholas Hampton, BJC Healthcare, Justin Hoffman, Alex Hoban, Barnes-Jewish Hospital, Marin Kollef, Washington Univ. School of Medicine Introduction: Meropenem (M), piperacillin-tazobactam (P), and cefepime (C) demonstrate time-dependent killing. Prolonged and continuous infusions of these agents are commonly utilized to optimize T⬎MIC despite limited evidence suggesting improved clinical results. Hypothesis: 3 hr Prolonged infusion (PI) will lead to improved clinical outcomes over 30 min intermittent infusion (II). Methods: Before-after cohort study at Barnes-Jewish Hospital in St. Louis, Missouri. M 1 g IV q8h, C 2 g IV q8h, and P 4.5 g IV q6h II over 30 minutes (1/1/10 –7/31/10) were compared to PI of 3 hours (8/1/10 –1/31/11) when used for the treatment of Gram-negative bacteremia or pneumonia in critically ill medical or surgical patients. Subjects with negative cultures or a CrCl ⬍30 mL/min were excluded from the analysis. Results: 75 patients were enrolled into the II group; 84 into the PI group. There were no differences in baseline characteristics including the incidence of shock, renal dysfunction or percentage of patients administered appropriate initial antibiotics. Approximately 50% of patients in each group received C, 30% M and 20% P. The MIC distributions were similar between groups; 6 patients in the II and 2 in the PI group demonstrated elevated MICs within the susceptible range as determined by the 2011 CLSI standards. Pseudomonas aeruginosa was the most prevalent pathogen and pneumonia the most common site of infection in each group. Median time to defervescence was 2.4 vs. 1.8 days, p ⫽ 0.105; time to WBC normalization was 2.4 vs 1.4 days, p ⫽ 0.019, in the II and PI groups, respectively. There was no difference observed in clinical failure, hospital or 14 day mortality. 30-day survival by the Kaplan-Meier analysis was significantly higher in the II group (Log rank, p⬍0.001) with clear delineation between groups beginning after day 4. Conclusions: PI is associated with faster time to WBC normalization, but may be associated with worsened long term mortality as compared to II when used to treat Gram-negative infection in critically ill patients. However, a small sample of infections with elevated MICs was included, which may limit this finding.


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INTRAVENOUS METOPROLOL VERSUS DILTIAZEM FOR RATE CONTROL IN NON-CARDIAC, NON-THORACIC POST-OPERATIVE ATRIAL FIBRILLATION

ASSOCIATION BETWEEN COLISTIN DOSE AND MICROBIOLOGIC OUTCOMES IN PATIENTS WITH MULTI-DRUG RESISTANT GRAM-NEGATIVE BACTEREMIA

Heather Personett, Dustin Smoot, Joanna Stollings, Lance Oyen, Mayo Clinic

Giulia Vicari, Community Health Network, Seth Bauer, Simon Lam, Elizabeth Neuner, Cleveland Clinic

Introduction: Little guidance exists on how to effectively manage post-operative atrial fibrillation (POAF) following non-cardiac, non-thoracic (NCNT) surgery, relative to other populations. The purpose of this study was to identify if a difference exists between intravenous (IV) metoprolol and diltiazem when used to achieve hemodynamically stable rate control in POAF following NCNT surgery. Hypothesis: Authors hypothesized a difference would exist in efficacy and safety of agents. Methods: This retrospective cohort study examined critically ill adult surgical patients experiencing POAF with rapid ventricular response. Patients were assigned to groups based on initial treatment with metoprolol or diltiazem. Pacing, cardioversion and simultaneous new rate control interventions were reasons for exclusion. The primary endpoint was hemodynamically stable rate control, defined by heart rate ⬍110 beats per minute and blood pressure ⬎90 mmHg, maintained for 6 hours. Each group required 55 patients to find a 25% difference when ␣ ⫽ 0.05 and ␤ ⫽ 0.3. Results: Metoprolol (N ⫽ 66) and diltiazem (N ⫽ 55) patients were similar in age, comorbidities, surgical procedure distribution, acuity of illness and rate and rhythm control medications used at home. Continuation of these medications during hospitalization did not differ between groups. Seventy-six percent of diltiazem treated patients achieved hemodynamically stable rate control, compared with only 53% of those who received metoprolol (p ⫽ 0.0049). More patients in the diltiazem group achieved the primary endpoint by the third hour of therapy (61% vs 39%, p ⫽ 0.039). Safety endpoints were similar between groups, including portion requiring a new vasopressor or fluid bolus for hemodynamic support, length of stay and mortality. Medication dosing strategies were non-standardized. In both groups, non-responders to initial therapy received higher doses than responders. Mean (standard deviation) bolus doses of 0.2 (0.12– 0.3) mg/kg were administered to 81% of diltiazem patients. Conclusions: Study outcomes suggest IV diltiazem may more effectively control heart rate and hemodynamics compared to metoprolol in POAF occurring in NCNT surgery patients. Neither therapy appeared safer than the other.

Introduction: Colistin (COL) is increasingly being used for the treatment of multi-drug resistant gram negative infections. However, COL dosing varies greatly in clinical practice and the optimal way to dose COL has not been elucidated. The purpose of this study was to determine if COL dosing is associated with outcomes in patients with gram-negative bacteremia. Hypothesis: It was hypothesized that a higher microbiological eradication rate would be observed with increasing COL doses. Methods: This retrospective chart review included patients with gram negative bacteremia treated with intravenous COL ⱖ72 hours. The primary objective was to determine if COL dose (mg/kg/day of colistin base activity) independently predicts microbiological success 7 days after the initiation of therapy. Microbiological success was defined as clearance of bloodstream infection or documented clinical improvement. Secondary objectives included evaluation for an association between COL dose and 7 day mortality, 28 day mortality, and the development of acute kidney insufficiency (AKI). Results: Seventy-six patients were included in the analysis, with 52 patients (68%) achieving 7-day microbiological success. The median COL dose was significantly higher in patients who achieved microbiological success (2.9 vs. 1.5 mg/kg/day; p ⫽ 0.011). After adjusting for baseline severity of illness and concomitant tigecyline use in multivariate analysis, higher COL dose remained significantly associated with microbiological success (aOR ⫽ 1.705; 95% CI 1.085– 2.679; p ⫽ 0.021). The median COL dose was also significantly higher among patients that survived at day 7 (2.7 vs. 1.5 mg/kg/day; p ⫽ 0.007). However, no difference was seen in COL dose when comparing survivors and non-survivors at day 28. A significantly higher COL dose was given to patients that developed AKI during therapy (3.8 vs. 1.6 mg/kg/day, p⬍0.001). Conclusions: Higher COL dose independently predicted microbiological success, which may partially explain the similar association with 7 day mortality. However, higher COL dose may also precipitate worsening renal function.

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ACTIVATED PROTEIN C AND SEPTIC SHOCK: A PROPENSITY-MATCHED COHORT STUDY

THE EFFECTS OF ERYTHROMYCIN ON NUTRIENT ABSORPTION AND SMALL INTESTINAL TRANSIT IN THE CRITICALLY ILL

Emily Rimmer, Anand Kumar, Donald Houston, University of Manitoba, Steve Doucette, Capital District Health Authority, Ryan Zarychanski, University of Manitoba Introduction: Septic shock is an inflammatory and pro-coagulant state with a high mortality. In a single randomized controlled trial, recombinant human activated protein C (rhAPC) reduced mortality in patients with severe sepsis at high risk of death. Further trials have failed to reproduce these results, and the effectiveness of rhAPC remains the subject of ongoing debate. Insufficient data exists regarding the use of rhAPC outside of a clinical trial. Hypothesis: We hypothesized that the early administration of rhAPC to patients with septic shock is associated with a reduced mortality. Methods: We conducted a retrospective, 2:1 propensity-matched, multicenter cohort study in 28 academic and community ICUs. Propensity scores were based on variables associated with rhAPC use. Our primary outcomes were mortality over 30 days and 30-day mortality stratified by APACHE II quartile. Results: Using a propensity-matched Cox proportional hazard model we observed a 7% absolute reduction in 30-day mortality associated with the use of rhAPC [107/310 (34.5%) vs. 257/620 (41.5%), HR 0.80, 95% CI 0.64 –1.00, p ⫽ 0.05]. Subgroup analysis revealed a significant reduction in mortality in patients in the lowest APACHE II quartile (APACHE II 5–19: 9.5% vs. 22.0%, HR 0.4, p ⫽ 0.04) and consistent, albeit non-significant, reductions in mortality among all remaining APACHE II quartiles (APACHE II 20 –25: 21.8% vs 31.4%, HR 0.65, p ⫽ 0.12; APACHE II 26 –30: 37.5% vs. 40.2%, HR 0.94, p ⫽ 0.79; and APACHE II 31–35: 61.8% vs. 66.7%, HR 0.87, p ⫽ 0.42). Hospital and ICU mortality were significantly reduced among patients who received rhAPC compared to matched controls. We observed a significant interaction between the time to appropriate antibiotics after documented hypotension and 30-day mortality, such that, increasing delays in the provision of appropriate antibiotic therapy was associated with greater reductions in mortality associated with rhAPC (p ⫽ 0.03). Conclusions: In this multicenter cohort study the use of rhAPC in patients with septic shock was associated with significant reductions in mortality. Ongoing prospective clinical trials evaluating the efficacy of rhAPC will serve to further define the role of rhAPC in patients with septic shock.


Adam Deane, Matthew Summers, Antony Zaknic, Gerald Wong, Anna Di Bartolomeo, Jennifer Sim, Marianne Chapman, Robert Fraser, Michael Horowitz, University of Adelaide Introduction: During intragastric feeding gastrokinetic drugs, such as erythromycin, are commonly administered to the critically ill to augment nutrient delivery to the small intestine. However, erythromycin has been reported to increase the prevalence of diarrhoea, which may reflect reduced absorption and/or accelerated small intestinal transit. The aims of this study were to evaluate the effects of erythromycin on small intestinal nutrient absorption and transit. Hypothesis: Erythromycin would reduce glucose and/or lipid absorption, via accelerated small intestinal transit, and, consequently, glycemic excursions would also be reduced. Methods: Critically ill patients were studied in a prospective, randomised, blinded, crossover fashion. IV erythromycin (200 mg) or placebo was administered between t ⫽ -20 to 0 min. At t ⫽ 0 liquid nutrient, labeled with 3-OMethylglucose (3-OMG), 13C-triolein, and 20 MBq99 mTc-sulphur colloid, was administered directly into the small intestine at 2kcal/min for 30 min. Plasma 3-OMG and exhaled 13CO2 are indices of glucose and lipid absorption respectively, with samples taken from t ⫽ 0 – 480 min and Areas Under Curve (AUC) calculated. Dynamic anterior scintigraphic images were recorded to determine transit. Data are median (range) and analysed using Wilcoxon signed-rank test. The protocol was approved by the local Research Ethics Committee. Consent was obtained from patient’s next-of-kin prior to study enrolment. Results: Twentyfour critically ill patients [53 (20 –77)years] were studied. Glycemia was comparable at baseline [erythromycin 6.6 (4.2–12.9) vs. placebo 6.4 (4.7–10.3)mmol/l; P ⫽ 0.33], but erythromycin increased glycaemia throughout the study [AUC480: 3289 (2630 – 4656) vs. 3043 (2337– 4932)mmol/l.min; p⬍0.05]. There were trends to increased glucose absorption [3-OMG AUC480: 123(39 – 182) vs. 108 (64 –148)mmol/l.min; P ⫽ 0.07], but reduced lipid absorption [13CO2 AUC480: 756 (45– 8114) vs. 1735 (96 –10255)%dose.min; P ⫽ 0.12] with erythromycin. Erythromycin had no effect on small intestinal transit [240 (78 –360) vs. 324 (57–360)min; P ⫽ 0.40]. Conclusions: While its effects may vary depending on the type of macronutrient, erythromycin does not reduce overall small intestinal nutrient absorption.

Oral Abstract Session: Pulmonary 41

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THE INFLUENCE OF PRE-HOSPITAL SYSTEMIC CORTICOSTEROID USE ON DEVELOPMENT OF ACUTE LUNG INJURY AND HOSPITAL OUTCOMES

MFG-E8 ATTENUATES NEUTROPHIL INFILTRATION VIA DOWN-REGULATION OF CXCR2 IN ACUTE LUNG INJURY

Lioudmila Karnatovskaia, Augustine Lee, Ognjen Gajic, Emir Festic, Mayo Clinic Introduction: The role of systemic corticosteroids (SCS) in pathophysiology and treatment of acute lung injury (ALI) is very controversial. Hypothesis: Use of pre-hospital systemic steroid therapy may prevent development of ALI and improve hospital outcomes. Methods: The US Critical Illness and Injury Trials Group had evaluated 5584 patients admitted to 22 acute care hospitals with at least one risk factor for ALI, and developed and validated the Lung Injury Prediction Score (LIPS). This is a pre-planned exploratory subgroup analysis of the prospectively identified LIPS cohort. Baseline characteristics and risk factors for ALI were determined. Primary outcome was the development of ALI. Secondary outcomes included need for invasive ventilation, intensive care unit (ICU) and hospital mortality. Adjusted risk for ALI development and secondary outcomes were determined in a multivariate logistic regression model. Results: Out of 5584 patients, 458 (8%) were on SCS at the time of hospitalization. Incidence of ALI was 7.4% and 6.7% for patients on SCS and not on SCS, respectively (p ⫽ 0.56). Univariate analyses showed that patients on SCS were more likely to be older, Caucasian, have diabetes, chronic pulmonary disease, malignancy, and previous chest radiation. They were more likely to be on a statin, inhaled steroid, inhaled beta agonist, proton pump inhibitor, ACE inhibitor, angiotensin receptor blocker, and insulin. They were less likely to abuse alcohol or tobacco and had a lower body mass index. After adjusting for all significant covariates, SCS were not independently associated with development of ALI (OR 1.16, CI 0.72–1.79, p ⫽ 0.52) or need for invasive ventilation (OR 0.93, CI 0.69 –1.23, p ⫽ 0.59). However, systemic steroid use was an independent predictor of ICU (OR 2.33, CI 1.4 –3.8, p ⫽ 0.001) and hospital mortality (OR 1.7, CI 1.1–2.6, p ⫽ 0.02). Conclusions: Pre-hospital use of SCS does not prevent the development of ALI. However, it is associated with increased ICU and hospital mortality in a population of patients who have at least one risk factor for ALI at the time of hospitalization.

43 ROLE OF MMP-8 IN BACTERIAL PNEUMONIA Ma Bernardita Gamallo, Vivian Wolfe, Hector Wong, Cincinnati Children’s Hospital Medical Center, Lesley Doughty, Cincinnati Children’s Hospital Introduction: Matrix metalloproteinase-8 (MMP-8), or neutrophil collagenase, is one of a group of zinc-dependent endoproteases, involved in extracellular matrix turnover and degradation, as well as in the inflammatory response seen in sepsis. In recent studies, MMP-8 deficiency improved survival and decreased cytokine induction in sepsis models. In contrast, in ALI models, MMP-8 deficiency was detrimental possibly due to decreased suppression of MIP-1␣ induction. No studies have been done to investigate the role of MMP-8 in bacterial pneumonia. Hypothesis: We hypothesize that MMP-8 deficiency will improve survival and diminish cytokine production in a mouse model of bacterial pneumonia. Methods: Wild-type (WT) and MMP-8-/- mice were inoculated with 5 x 109 S. aureus via intratracheal (IT) aspiration. Survival was monitored for 7 days. For analysis of cytokines and bacterial culture, WT and MMP-8-/- mice were inoculated with 1x108 S. aureus (IT). After 24 hours, serum and lung cytokines and bacterial cultures were measured. Results: Survival was improved in MMP8-/- mice (62%) compared to WT (38%). Lung MPO was reduced in MMP-8-/compared to WT (488 ⫹/⫺ 78 vs. 820 ⫹/⫺ 92 Units/100 mg; p ⫽ ⬍0.001). Lung KC and IL-6 were also reduced in MMP-8-/- compared to WT (3.4 ⫹/⫺ 0.6 vs 4.5 ⫹/⫺ 0.8 ng/ml; p ⫽ .02) and (2.4 ⫹/⫺ 0.8 vs 6.4 ⫹/⫺ 3.8 ng/ml; p ⫽ 0.03). However, lung bacterial counts were higher in MMP-8-/- than in WT (17.4 ⫹/⫺ 18 x 106 vs 1.2 ⫹/⫺ 0.3 x 106 cfu; p ⫽ 0.02). Lung TNF, serum TNF, serum KC and serum IL-6 were not different between the 2 groups. All blood cultures were negative. Conclusions: MMP-8 deficiency improved survival and reduced the inflammatory response to bacterial pneumonia even though bacterial clearance was reduced. Our data support that MMP-8 plays an important role in the pro-inflammatory response and bacterial clearance. It also supports a role for MMP-8 in maintaining a protective balance between bacterial clearance and the inflammatory response. Supported by NIH R01 GM085063.

Monowar Aziz, Akihisa Matsuda, Weng-Lang Yang, Asha Jacob, Ping Wang, North Shore University Hospital and Long Island Jewish Medical Center Introduction: Excessive neutrophil infiltration to the lungs is a hallmark of acute lung injury (ALI) and serves as a therapeutic target to attenuate inflammation in ALI. Recently, Milk fat globule EGF factor 8 (MFG-E8), a secreted glycoprotein, has been shown to have a direct anti-inflammatory activity. However, whether MFG-E8 can regulate neutrophil function to alleviate inflammation has not been explored yet. Hypothesis: We hypothesized that MFG-E8 plays an important role in regulating neutrophil migration to the lungs after ALI. Methods: C57BL/6J wild type (WT) and MFG-E8 knock-out (KO) mice were subjected to intratracheal LPS (5 mg/kg) instillation to induce ALI. After 24 h, lung tissue and broncheoalveolar lavage (BAL) were collected. Tissue damage was assessed by HE staining. Neutrophils were counted by hemacytometer. Myeloperoxidase (MPO) activity was determined spectrophotometrically. Expression levels of chemokine receptor CXCR2 and it’s regulator G protein coupled receptor kinase 2 (GRK2) in BAL and bone marrow derived neutrophils (BMDN) were measured by flow cytometry, indicated as mean fluorescence intensity (MFI). Results: The injury score of the lung in MFG-E8 KO mice was more severe than that of WT mice 24 h after LPS instillation. The numbers of neutrophils and surface CXCR2 expression in BAL, and lung MPO activity of ALI MFG-E8 KO mice were significantly higher than ALI WT mice (5.5 ⫾ 0.2 ⫻ 106 vs. 3.1 ⫾ 0.2 ⫻ 106, MFI: 75.6 ⫾ 2.3 vs. 62.2 ⫾ 1.3, and 102 ⫾ 2 vs. 57 ⫾ 1 U/g tissue, respectively, p⬍0.05). Pretreatment of recombinant mouse MFG-E8 (rmMFG-E8) decreased the numbers of neutrophils and surface CXCR2 expression in BAL of the ALI WT mice. BMDN isolated from MFG-E8 KO mice exhibited higher CXCR2 and lower GRK2 expression than WT mice. Incubation with rmMFG-E8 resulted in a decrease of CXCR2 and an increase of GRK2 expressions in BMDN isolated from WT mice. In addition, the migration rate of BMDN isolated from MFG-E8 KO mice was 1.7-fold higher than WT mice. Conclusions: MFG-E8 deficient mice exhibit more sensitivity to ALI than WT mice. rmMFG-E8 attenuates CXCR2 expression in neutrophils via GRK2 induction. Thus, MFG-E8 may provide a potentially therapeutic effect to treat patients with ALI.

44 A SHORTENED DURATION OF ANTIMICROBIAL THERAPY MAY BE INADEQUATE IN THE SETTING OF VENTILATORASSOCIATED PNEUMONIA SECONDARY TO NON-LACTOSE FERMENTING BACILLI Tammy Kopelman, Gina Shirah, Maricopa Medical Center, Patrick O’Neill, Maricopa Medical Cneter, Sydney Vail, Paola Pieri, Melissa Pressman, Maricopa Medical Center Introduction: An 8-day duration of antimicrobial therapy for ventilator-associated pneumonia (VAP) has been proven efficacious; however, higher rates of recurrence have been demonstrated when the infecting pathogens are non-lactose fermenting gram-negative bacilli (NLF GNB). Hypothesis: We hypothesized that a shortened antibiotic course (8-days) in the case of NLF GNB would actually result in an inadequate duration of therapy and persistent primary infection rather than recurrence. Methods: Retrospective review was performed of all bronchoalveolar lavage (BAL)-diagnosed VAP patients who underwent subsequent BAL during the antimicrobial treatment course at a level I trauma center admitted over a 4 1⁄2 year time period. Based upon initial BAL pathogen, patients were classified into 2 groups: Group A, NLF GNB and Group B, all others (Enterobacteriaceae (ENT), MRSA, and community-acquired pathogens (CAP) including Hemophilus spp, MSSA, and Streptococcus spp). Persistent primary infection was defined as a less than 2-log10 decrease of the initial species on subsequent BAL. Chi-squared with Yates’ correction for continuity was applied for comparison of the 2 proportions expressed as percentages; 2-tailed p values ⬍0.05 were considered statistically significant. Results: 77 patients met study criteria. Appropriate empiric antibiotic therapy was chosen in 99% of patients and de-escalation occurred with final culture results. Day of subsequent BAL averaged antibiotic day 7 (range, 3–14) with 48% (37/77) being performed after ⬎8 days of therapy. Within Group A, persistent primary infection was noted after ⬎8 days of appropriate antimicrobial therapy in 69% of patients (Pseudomonas aeruginosa, 7/9; Acinetobacter baumannii, 2/4) versus only 8% of Group B patients (ENT, 2/12; MRSA 0/4; CAP 0/8); p ⫽ 0.0004). Importantly, within Group A, 56% (5/9) of the pathogens obtained on repeat BAL remained sensitive to the treatment antimicrobial. Conclusions: A shortened antibiotic course will frequently lead to persistent primary infection in patients with NLF GNB VAP. Repeat BAL should be considered during therapy to tailor duration of antimicrobial therapy and to re-assess for changes in resistance profiles.


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HFOV RESCUE IN SEVERE ACUTE RESPIRATORY DISTRESS SYNDROME: OXYGENATION IMPROVEMENT PREDICTS OUTCOME

EFFECTS OF PATIENT-INITIATED MUSIC LISTENING ON ANXIETY IN MECHANICALLY VENTILATED PATIENTS

Samantha Tarras, Carl Haas, James Blum, Kimberly Bauser, Elizabeth Jewell, Craig Meldrum, Krishnan Raghavendran, Lena Napolitano, Pauline Park, University of Michigan Health System Introduction: In patients with severe ARDS (PaO2/FiO2 ⬍100), failure to improve oxygenation on high frequency oscillatory ventilation (HFOV) is associated with increased mortality. Specific threshold parameters predictive of outcome with HFOV use are not described. Hypothesis: Failure to reach threshold values of serial P/F ratio and oxygenation index (OI) during the first 48 hours of HFOV will be associated with increased mortality. Methods: Retrospective review of patients with severe ARDS receiving at least 48 hours of HFOV in our ECMO referral Surgical ICU. Patients were excluded from study if baseline P/F ratio was ⱖ100, or if on ECMO support, transition to conventional ventilation, withdrawal of care or death occurred within the first 48 hours. Demographic information, ventilator and oxygenation data was collected at 0, 1, 12, 24 and 48 hours following HFOV initiation. Results: Between 2005 and 2011, 112 patients were placed on HFOV as part of a standardized ARDS treatment algorithm and 58 met criteria for study entry. In the study group, the mean P/F ratio at baseline was 58.3 ⫾ 13.1 and the mean OI at baseline was 51.5 ⫾ 13.6. Hospital mortality in the study group was 41.3%. In univariate analysis, failure to reach the threshold P/F ⱖ100 after 48 hours of HFOV was associated with a 3-fold higher mortality rate (75% vs. 24.3%, p ⫽ 0.008). Evaluation of this threshold in predicting survival yielded a sensitivity of 82.4%, a specificity of 62.5%, a positive predictive value of 75.7%, and a negative predictive value of 71.4%. Similarly, a significant mortality rate was identified at a threshold OI ⱖ25 at 48 hours (75% vs. 28.6%, p ⫽ 0.006). A multivariate logistic regression model was constructed incorporating age, APACHE and number of days of mechanical ventilation prior to onset of HFOV. Failure to improve P/F ⱖ100 remained significantly associated with mortality (OR ⫽ 5.23, CI 95%: 1.2–22.2, p ⫽ 0.025); AUC for the receiver operator curve for model performance was 0.774. Conclusions: In patients with severe ARDS undergoing rescue HFOV, failure to improve P/F ⱖ100 at 48 hours is independently associated with higher mortality.

Linda Chlan, University Of Minnesota School Of Nursing, Craig Weinert, Univ. of Minnesota, Annie Heiderscheit, University of Minnesota, Debra Skaar, University of Minnesota College of Pharmacy, Mary Fran Tracy, University of Minnesota Medical Center, Fairview, Kay Savik, University of Minnesota Introduction: Anxiety is a frequently occurring symptom in mechanically ventilated ICU patients. Interventions without adverse side effects are needed to manage this common symptom. Hypothesis: We hypothesized that ventilated patients who initiate listening to preferred music will report less anxiety over time than patients who do not listen to music. Methods: Patients were receiving acute mechanical ventilation for respiratory failure in 1 of 12 ICUs in 5 hospitals in the Minneapolis-St Paul area from 2006 –2010. Patients had sufficient cognitive capacity to understand an informed consent discussion and participate in music selection. Enrolled patients (n ⫽ 373) for this clinical trial were randomly assigned to: 1) preferred music; 2) noise-canceling headphones only (control 1); or 3) usual care (control 2). Anxiety was assessed daily with a visual analog scaleanxiety (VAS-A). Group 1 had music preferences assessed at study entry and daily by a music therapist who compiled CDs for each patient which were placed at the bedside with headphones. Patients were encouraged to listen to the music whenever desired at least twice daily for 30 min. Results: Enrolled sample was Caucasian (86%), female (52%), age 59⫹/⫺14, APACHE III 63⫹/⫺21.6. Mean days on protocol was 5.7⫹/⫺6.4; group 1 listened to music for a mean of 79 min/day. Mean baseline VAS-A 48.8⫹/⫺29.3. Controlling for covariates: illness severity [␤(se(␤)) .17(.07); p ⫽ .01]; aggregate sedative exposure [␤(se(␤)).81(.41); p ⫽ .046]; and sedative medication frequency [␤(se(␤)).59(.41); p ⫽ .049]; mixed models analysis showed that patients assigned to preferred music had decreasing levels of anxiety over time compared to the usual care control group [␤(se(␤)) -26.3(7.1); p⬍.001]. Conclusions: Ventilated patients were able to select preferred music and listen to music when desired. Music intervention reduced anxiety 26 points over time compared to the usual care control group regardless of sedative medications received. Since music intervention has no documented side effects and uses readily available technology, ICU clinicians should integrate music listening interventions for ventilated patients to reduce anxiety. Supported by grant R01-NR009295.

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RANDOMIZED TRIAL OF INITIAL TROPHIC VS. EARLY ADVANCEMENT TO FULL ENTERAL FEEDING IN PATIENTS WITH ACUTE LUNG INJURY (ALI) (EDEN)

THE USE OF NEAR INFRARED SPECTROSCOPY DURING A PRE- EXTUBATION PRESSURE SUPPORT BREATHING TRIAL AS A PREDICTOR OF EXTUBATION OUTCOME

Todd Rice, Vanderbilt University, Arthur Wheeler, Vanderbilt University Medical Center, Boyd Thompson, Massachusetts General Hospital, Jay Steingrub, Baystate Medical Center, R. Hite, Wake Forest University Health Sciences, Marc Moss, University of Colorado, Alan Morris, Intermountain Medical Center, Ning Dong, Massachusetts General Hospital, Peter Rock, University of Maryland School of Medicine, for the NHLBI ARDS Network, National Institutes of Health

Cortney Foster, Robert McCarter, Yao Cheng, John Berger, Children’s National Medical Center

Introduction: The best amount of enteral nutrition in patients with acute lung injury (ALI) remains unknown. Hypothesis: We hypothesized that initial lowervolume trophic enteral feeding, rather than higher-volume full enteral feeding will decrease gastrointestinal intolerances and increase ventilator-free days in patients with ALI. Methods: We randomized 1000 patients within 48 hours of developing ALI to either lower-volume trophic or higher volume full enteral feeding for the first 6 days of mechanical ventilation. The most common exclusions were chronic lung disease, inability to obtain consent, and more than 48 hours since onset of ALI. The primary outcome measure was ventilator-free days to day 28. Results: Baseline characteristics were similar between trophic (n ⫽ 508) and full-feeding groups (n ⫽ 492). The % of calculated caloric goal received through enteral calories during the first 6 days was 25% in the trophic and 80% in the full-feeding groups (P⬍0.001). Ventilator-free days were similar in the trophic (15.8 ⫾ 10.9) and full-feeding groups (15.9 ⫾ 10.6) (P ⫽ 0.89) as was 60-day mortality (23.2% vs 22.2%; P ⫽ 0.77). Other organ-failure free days, ICU-free days, and incidence of infections were also similar in the trophic and full-feeding groups. Despite receiving more pro-kinetic agents during the first 6 days, the full-feeding group experienced more vomiting (2.2 vs. 1.7% of patient feeding days; P ⫽ 0.05), elevated gastric residual volumes (4.9 vs. 2.2% of feeding days; P⬍0.001) and constipation (3.1 vs. 2.1% of feeding days; P ⫽ 0.003). Aspiration was rare in both groups (0.3% full vs. 0.2% trophic; P ⫽ 0.08). Mean plasma glucose values and average hourly insulin administration were both higher in the full-feeding group over the first 6 days. Conclusions: Initial lower-volume trophic enteral feeding for up to 6 days results in similar clinical outcomes, including ventilator-free days and 60-day mortality, as initial full-volume enteral feeding, with fewer episodes of gastrointestinal intolerance.


Introduction: A significant number of pediatric cardiac surgery patients fail initial extubation. Clinical predictors of extubation failure have not been consistently reliable. We sought to evaluate the measurement of cerebral and somatic regional oxygen saturation (rSO2) during a pressure support breathing trial (PSBT) to determine if either would assist in predicting extubation failure. Hypothesis: A 10% decline in cerebral or somatic rSO2 as measured by cerebral and somatic near-infrared spectroscopy (NIRS) during a PSBT would be predictive of extubation failure. Methods: This study was a prospective observational study of post-operative cardiac surgery patients intubated for ⬎12 hours. Regional SO2 values were recorded using NIRS at baseline, during a two hour PSBT and in the first two hours post extubation. Patients who passed the PSBT were extubated at the discretion of the clinical team without regard to rSO2. Logistic regression and receiver operating characteristic (ROC) analyses were performed to assess impact of rSO2 on extubation outcome. Results: Ninety-nine PSBTs were conducted in 82 patients (median age 120 days). Eighty-six extubations occurred following successful PSBTs, and 13 (15%) of these extubations were failures. Adjusting for baseline somatic rSO2, logistic regression analysis demonstrated that patients with a decline in somatic rSO2 of at least 10% during a PSBT had a 6 times greater odds (p ⫽ 0.02) of extubation failure. ROC curve analysis demonstrated that a 12% decline in rSO2 best predicted extubation failure. A 12% decline in somatic rSO2 was associated with 50% sensitivity and 91% specificity for extubation failure. Conclusions: A 12% decline in somatic rSO2 during a PSBT is associated with an increased risk of extubation failure following a successful trial. The addition of somatic rSO2 measurements to a PSBT improves the ability to predict extubation outcome.

Oral Abstract Session: Nutrition 49

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FIBRONECTIN-INTEGRIN INTERACTION: ROLE IN L-GLUTAMINE’S INTRACELLULAR TRANSPORT AND IN ITS’ MOLECULAR CYTOPROTECTIVE MECHANISMS IN HEAT STRESSED INTESTINAL EPITHELIAL-6 CELLS

SMALL BOWEL PERMEABILITY INCREASES IN HEMORRHAGIC SHOCK: A POSSIBLE ROLE FOR PANCREATIC-DERIVED INFLAMMATORY PEPTIDES

Stefanie Niederlechner, Jelena Klawitter, Uwe Christians, Paul Wischmeyer, University of Colorado Introduction: Glutamine (GLN) seems to mediate protection against critical illness related gut injury via many key pathways. These include fibronectinintegrin interaction, phosphoinositide 3-kinase (PI3-K)/mitogen-activated protein kinase (MAPK) pathways, and activation of the heat shock protein (HSP) response. Hypothesis: We investigated if there may be a relationship between these pathways mediating GLN’s protection in intestinal epithelial-6 cells (IEC-6) after an injury, such as heat stress (HS). We also assessed if the fibronectin-integrin interaction had an impact on GLN transport. Methods: IEC-6 cells were treated for 15 min with GLN, with/without the fibronectinintegrin interaction inhibitor GRGDSP (50␮M), inactive control peptide GRGESP (50␮M), or p44/42 MAPK (ERK1/2) inhibitor PD98059 (50␮M). Cell survival was measured via MTS assay 24h post-HS (44°Cx50 min). Total ERK1/2, p38 MAPK, AKT and HSF-1, [T(P)202/ Y(P)204]ERK1/2, [T(P)180/Y(P)182]p38 MAPK, [S(P)473]AKT, [S(P)303]HSF-1, HSP32, HSP70, BAX, Bcl-2, cleaved caspase-3 and PARP levels were determined via Western blot, and GLN transport via LC-MS after non-lethal HS (43°Cx45 min). Statistics were calculated via students t-test. Results: GRGDSP did not affect GLN transport into IEC-6 cells (p⬍0.05; n ⫽ 3). GRGDSP, but not GRGESP, and PD98059 attenuated GLN-mediated protection after lethal HS shown by MTS and increased cleaved caspase-3, cleaved PARP and BAX/Bcl-2 ratio levels (p⬍0.05; n ⫽ 4). GLN activated HSF-1 by attenuating its’ phosphorylation of serine 303. However, HS, GRGDSP⫹GLN and PD98059⫹GLN repressed HSF-1 by its’ phosphorylation of serine 303 (p⬍0.05; n ⫽ 3). ERK1/2, p38 MAPK and AKT were activated after HS. GLN increased Erk1/2 and AKT activation after HS, but decreased p38 MAPK activation. GRGDSP abolished GLN-mediated Erk1/2 and p38 MAPK activation, but not AKT (p⬍0.05; n ⫽ 4). GLNmediated increases in HSP70 and HSP32 were attenuated by GRGDSP after HS (p⬍0.05; n ⫽ 4). Conclusions: Fibronectin-integrin interaction is not required in GLN transport and GLN-mediated PI3-K signaling, but it is vital to GLN’s protective mechanism via MAPK signaling by activating ERK1/2, which activates HSF-1. This enhances HSP expression to prevent apoptosis in IEC-6 cells after HS.

Erik Kistler, University of California San Diego, Tom Alsaigh, University of California, San Diego, Geert Schmid-Schonbein, University of California San Diego Jacobs Introduction: Small intestine malperfusion and subsequent increased permeability may play an important role in the pathogenesis of shock. Among deleterious factors that may breach the mucosal barrier and achieve systemic access are inflammatory peptides, formed from pancreatic proenzymes and released into the intestinal lumen as part of normal digestion. We have isolated inflammatory peptides from pancreas but it is unknown whether these factors circulate systemically in shock. Hypothesis: Proteolytically-derived intestinal peptides reach the systemic circulation in shock. Methods: Rats were subjected to hemorrhagic shock (35 mmHg for 100 min) with laparotomy, and saline or the protease inhibitor nafamostat mesilate (NM), previously shown to decrease mortality in shock, was injected into the small bowel. Control animals were subjected to laparotomy without shock. 20kD FITC-dextrans was injected into the bowel during ischemia to measure intestinal permeability. In separate experiments, fluorescent casein was injected into the small bowel to determine a) the ability of the shocked bowel to proteolytically generate peptides and b) whether these peptides circulate systemically. Results: Permeability significantly increased after ischemia in all shock groups compared to controls as assessed by FITC-dextrans fluorescence in the mesenteric microcirculation and systemically (p⬍0.01). Proteolytically cleaved fluorescent casein-derived peptides also increased significantly in the microcirculation and systemically compared to controls (p⬍0.01) after shock. NM decreased permeability in both FITC-dextrans and casein groups in the microcirculation (p⬍0.01 both groups, and systemically (NS, FITC-dextrans, p⬍0.01 casein). Conclusions: These results demonstrate that in an experimental model of hemorrhagic shock, bowel permeability is significantly increased to factors of at least 20kD, including proteolytically derived peptides, and this increase is mitigated by enteral protease inhibition. Inflammatory proteolytically derived peptides in the bowel may reach the systemic circulation and contribute to the pathophysiology of gut-derived circulatory shock. Supported by HL67825, GM85072, and the ASCCA/FAER/ Hospira Physician Scientist Award.

51 GLUCOSE TOLERANCE AND THE HYPERMETABOLIC RESPONSE TO INSULIN TREATMENT IN A RAT BURN AND DISUSE MODEL Heather Pidcoke, University of Texas Health Science Center, San Antonio, Lisa Baer, University of Texas Health Science Center, Houston, Xiaowu Wu, US Army Institute of Surgical Research, Steven Wolf, UT Southwestern, Charles Wade, University of Texas Health Science Center At Houston Introduction: Insulin normalizes hyperglycemia after severe burn and attenuates the hypermetabolic response. Molecular mechanisms are poorly understood and established animal models do not fully reproduce the severe physiologic effects of injury and bedrest. A rat model combines burn and disuse components from two highly cited methodologies. Loss of body mass is similar to that of hypermetabolic burned humans, demonstrating that this model replicates the physiologic response to large burns. We now examine the effects of this dual insult on glucose metabolism and study the response to insulin. Hypothesis: Glucose tolerance tests (GTT) in hypermetabolic rats improve with insulin treatment and body mass loss is attenuated. Methods: Rats were housed in metabolic cages and assigned to two groups: vehicletreated burn (40% TBSA) with hindlimb unloading (VBH; n ⫽ 11), and insulintreated (IBH; n ⫽ 9). IBH rats received 12 days of subcutaneous insulin (5 units/kg/ day), and VBH rats received vehicle equivalents. Animals were fed ad libitum. After a 10 hour fast, GTT was performed on day 14. Body mass was recorded, a 2 g/kg glucose load administered, and glucose quantified at baseline, 10, 15, 30, 60, and 90 minutes (min). Significance was set at p⬍0.05. Results: Body mass was similar between groups at baseline (VBH ⫽ 327⫾10 g versus IBH ⫽ 331⫾6 g; p ⫽ 0.433); over time body mass loss was attenuated by insulin (day 14: VBH ⫽ 265⫾17 g; IBH ⫽ 283⫾14 g; p ⫽ 0.016). Insulin promoted food intake (VBH ⫽ 16.8⫾ SEM 0.3 g/day; IBH ⫽ 18.8⫾SEM 0.3 g/day; p⬍0.001), and increased glucose disposal. Baseline glucose levels at day 14 were lower in the IBH group (111⫾18 g/dL; 42⫾19 g/dL; p⬍0.001), but equalized after glucose loading (312⫾122 g/dL; 302⫾56 g/dL; p ⫽ 0.658). IBH disposal was faster within 15 min of glucose loading (5⫾19%; 27⫾6%; p ⫽ 0.003) and accelerated over time (90 min: 27⫾6%; 67⫾14%; p ⫽ 0.001). Conclusions: Insulin treatment after burn and disuse increased glucose disposal and attenuated loss of body mass, demonstrating that insulin effects in this model are similar to those seen in severely burned humans. Analysis of underlying molecular mechanisms may lead to alternate treatments providing the beneficial effects of insulin without hypoglycemic risk.


52 COMBINED ZINC SUPPLEMENTATION WITH C-PEPTIDE TREATMENT MODULATES THE INFLAMMATORY RESPONSE IN POLYMICROBIAL SEPSIS. Siarhei Slinko, Cincinnati Children’s Hospital, Giovana Piraino, CCMC, Paul Hake, CCHMC, Hector Wong, Cincinnati Children’s Hospital Medical Center, Basilia Zingarelli, Cincinnati Children’s Hospital Introduction: Zinc (Zn) is an essential micronutrient with significant effects on immune function. Zn supplementation or deficiency may affect the course of infection. The pro-insulin C-peptide exert beneficial effects in lung injury (LI) through activation of PPAR? in experimental models of endotoxemia and trauma. In vitro studies some of C-peptide activities are dependent upon activation with certain metal ions. Hypothesis: Zn-supplementation enhances the anti-inflammatory properties of C-peptide treatment during sepsis. Methods: Polymicrobial sepsis was induced in C57BL/6 male mice by cecal ligation and puncture (CLP). Mice received Zn-gluconate (1.3 mg/kg) intraperitoneally (ip) for 3 days before surgery. At 1 h after CLP, one group of animals received C-peptide (280 nmol/ kg) ip while another one received vehicle. Mice were sacrificed at 3, 6 and 18 h after CLP; separate cohort of mice was used for 6 days survival study. Results: In vehicle group, CLP resulted in LI with marked neutrophil infiltration and was associated with a 11% survival rate at 6 days after CLP. At molecular analysis, lung nuclear levels of PERK1/2 and DNA binding activity NF-␬B were significantly increased in vehicle-treated mice (0.116⫾0.044 optical density) when compared with sham animals (0.016⫾0.016 optical density, P⬍0.05) at 6 h after CLP. On the contrary, lung nuclear expression of PPAR? was decreased in comparison to sham animals. Zn supplementation combined with C-peptide (Zn/Cpeptide) treatment significantly improved survival rate (61%, P⬍0.05 by LogRank analysis) after sepsis when compared with C-peptide (6%) or Zn supplementation alone (32%). Zn/C-peptide treatment also ameliorated lung architecture, reduced neutrophil infiltration and these effects were associated with increased expression of PPAR?, reduction of PERK1/2 and NF-␬B binding activities (0.021⫾0.012 optical density) when compared with vehicle treatment, C-peptide or Zn supplementation alone (0.081⫾0.036 and 0.054⫾0.016 optical density, respectively, P⬍0.05). Conclusions: A short-term Zn supplementation prior the infectious insult potentiates the beneficial effects of C-peptide by facilitating modulation of inflammatory signaling pathways.


Oral Abstract Session: Outcomes 53

54

IMPACT OF ACTIVE SURVEILLANCE ON THE PROPORTION OF HOSPITAL-ACQUIRED METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) INFECTIONS IN INTENSIVE CARE UNITS.

DEVELOPMENT AND VALIDATION OF SEVERE HYPOXEMIA RELATED ICU MORTALITY PROGNOSTIC MODEL (SHRIMP) IN 1000 MECHANICALLY VENTILATED PATIENTS WITH REFRACTORY HYPOXEMIA

Lauren Pokomo, Univeristy of Texas Health Science Center at Houston School of Public Health, Virgie Fisher, Miriam Morales, Memorial Hermann Texas Medical Center, Luis Ostrosky-Zeichner, University of Texas Health Science Center at Houston Medical School

Sonal Rachmale, College of Medicine, Mayo Clinic, Pablo MorenoFranco, Mayo Clinic Rochester Mn, Guangxi Li, College of Medicine, Mayo Clinic, Gregory Wilson, Mayo Clinic, Ognjen Gajic, College of Medicine, Mayo Clinic

Introduction: MRSA contributes significantly to hospital-acquired infection (HAI) mortality and morbidity. Colonized individuals may contaminate the environment and facilitate transmission to other patients. Hypothesis: We sought to determine the impact of an ICU active surveillance intervention on the proportion of HAI ventilator associated pneumonias (VAPs) and blood stream infections (BSIs) caused by MRSA in 7 adult ICUs at a tertiary care center. Methods: The total number of hospital discharges, percent compliance for active surveillance, total HAI BSIs and VAPs, MRSA BSIs and VAPs, and total number of adult ICU admissions were analyzed from 2003–2010. Active surveillance was defined as PCR testing of nares for MRSA on admission, modified isolation while awaiting results, and full contact isolation for positive patients. A four-year pre-intervention period (2003–2006) and four-year intervention period (2007–2010) was defined to compare the proportion of MRSA HAIs before and after intervention. The annual intervention cost was calculated using the cost of MRSA testing and contact isolation supplies. Estimated cost avoidance was generated using attributable costs of HAIs. Results: There were 290,828 hospital discharges and 27,083 ICU admissions during the intervention. Average compliance for MRSA surveillance was 50%, with an increasing trend over time (28–63%). The incidence of MRSA-positive patients was 9–14%. The proportion of VAPs and BSIs attributed to MRSA was 9.85% at baseline and 6.38% after intervention (35.2% reduction, p ⫽ 0.04). The intervention was associated with a reduction in the proportion of MRSA HAI in the ICU (OR 0.62, 95% CI 0.39–0.99). The number-needed-to-treat (NNT) was 29. Based on the projected rate, 69 infections and 21 deaths were avoided during the intervention. The annual cost of program was estimated to be $264,059, the expected annual cost avoidance was $398,849, indicating a net savings of $134,790. Conclusions: Active surveillance and isolation precautions were effective in reducing the in-house proportion of MRSA HAI in our ICUs. The NNT of 29 and the annual net cost savings of $134,790 indicate a cost-effective measure.

Introduction: A model to predict mortality in patients with refractory hypoxemia (RH) early in the course of illness is critical for initiating rescue therapies (RT), resource utilization and potential enrollment in clinical trials. Hypothesis: A prognostic model based on clinical predictors available within 24 hours of the development of RH can predict mortality. Methods: Adult patients admitted to the ICUs of our institution between 2005 and 2007 were screened for RH (defined as a Murray lung injury score of ⱖ3 on at least one occasion.)1 For those who developed RH, demographic, co-morbidities, clinical variables and ICU outcome were abstracted from medical records. A logistic regression model was developed using clinical variables available within 24 hours of onset of RH as independent variables and survival or non-survival to ICU discharge as the dependent variable. Area under the receiver operator characteristic curve (AUC) and Hosmer-Lemeshow statistic (HLS) were used to assess discrimination and calibration, respectively. The model was validated in an independent cohort of similar patients admitted between 2008 and 2010. Results: Among 79,341 screened patients, 1032 developed RH. Mortality was 41% in the derivation cohort (n ⫽ 463) and 35% in the validation cohort (n ⫽ 576). The final model included the presence of hematologic malignancy, acute or chronic liver failure, history of aspiration, estimated dead space (Vd/Vt), oxygenation index, pH and mean BP. The AUCs (95% CI) of the SHRIMP model were 0.86 (0.81–0.9) and 0.80 (0.73–0.88) in the derivation and validation cohort, respectively. The HLS generated p values of 0.2 and 0.5 in the derivation and validation cohorts, indicating good calibration. A reduced SHRIMP model which included only physiologic variables related to the cardiopulmonary system performed similarly. Conclusions: The SHRIMP model utilizing comorbidities (hematologic malignancy, liver failure, and aspiration) and physiological variables (Vd/Vt, OI, pH and mean BP) on the day of developing RH can predict ICU mortality. Reference: Peek GJ, et al. Efficacy and economic assessment of conventional ventilation versus ECMO for severe adult respiratory failure (CESAR): Lancet 2009;374(9698):1351–63.

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CHANGES IN DISEASE-SPECIFIC MORTALITY OVER TWO DECADES IN A MULTI-INSTITUTIONAL ICU DATABASE

EARLY AND LATE POSITIVE FLUID BALANCE IN SEPSIS: ARE THEY BOTH RELATED TO MORTALITY AND ACUTE KIDNEY INJURY?

Jack Zimmerman, Andrew Kramer, Cerner Corporation, William Knaus, Univ. of Virginia School of Medicine Introduction: While it is widely assumed that hospital mortality after ICU treatment has declined over time, few studies have documented changes after adjustment for patient risk factors. Hypothesis: That hospital mortality within disease groups has decreased over the past two decades despite relatively constant severity of illness, a change compatible with improved quality of care. Methods: We retrospectively reviewed age, physiological, clinical, and outcome data using information collected in 166 ICUs for 122,555 admissions with 23 specific diagnoses from 1988 to 2009. All diagnoses had a ⬎10% mortality rate during 1988 –1989 and their definitions were unchanged during the study. Each ICU had participated in studies using APACHE III (1988 –2001) and/or APACHE IV (2002–2009). We examined disease-specific hospital mortality over the following time periods: 1988 – 89, 1993–96, 2000 – 01, 2002– 03, 2004 – 06, and 2007– 09. In addition, we calculated the mean APACHE III score for each time period. Results: Mortality declined by ⬎40 % for 10 (43.4%) of the 23 diagnostic groups. Seven of these were non-operative diagnoses: bacterial pneumonia (33–16%), COPD (30 –11%), acute myocardial infarction (10 –5%), sepsis (52– 27%), urinary sepsis (30 –15%), stroke (30 –17%) and seizures (15– 8%). The three post-operative diagnoses with a ⬎40% decrease in mortality included patients with aortic dissection (41–15%), intracranial hemorrhage (54 –21%), and subarachnoid hemorrhage (37– 4%). Decreases of 21%-39% were seen for nine other diagnostic groups. Mortality increased for patients after surgery for GI bleeding (15–17%). The average APACHE III score for each of the time periods given above was 50.0, 45.1 51.5, 51.2, 51.5, and 54.2. Conclusions: Mortality decreased for 22 (96%) of 23 ICU admission diagnoses over the last 21 years. This decrease was ⬎40% for 43% of the diagnoses. As the mean APACHE III score was fairly constant throughout this time span, these mortality reductions were likely due to improved therapy rather than differences in patient risk factors.

Fernando Oliveira, Flavio Freitas, Elaine Ferreira, Isaac Castro, Antonio Baffi, Miriam Jackiu, Bruno Mazza, Murillo Assuncao, Flavia Machado, Federal University of Sao Paulo Introduction: Recent studies demonstrate an association between positive fluid balance and sepsis mortality. However, timing of this positive balance was not clearly evaluated. Hypothesis: This study aim to evaluate the association between early and late positive fluid balance (FB) and the incidence of acute kidney injury and mortality in severe sepsis. Methods: Retrospective analysis of patients with severe sepsis or septic shock. Demographic, severity scores and main outcomes were registered. The fluid balances were evaluated on the first 6h (FB6), 12h (FB12), 24h (FB24) and between 24 and 48h (FB24 – 48) considering as baseline three different moments: installation of organ dysfunction, diagnosis of sepsis and the development of shock. The RIFLE score was defined as the worst value obtained on the first five days. Univariate and multivariate analysis were performed and results were considered significant if p⬍0. 05. Results: Between April 2007 and April 2009, 116 patients were enrolled (Group 1 (survivors, n ⫽ 44) and Group 2 (non-survivors, n ⫽ 72). In the univariate analysis non-survivors were older and had higher APACHE II score, SOFA (D0, D3 and D7) scores and Delta SOFA D7-D1. The FB24 – 48 was significantly higher, in all moments, among non-survivors. There was no difference in the FB6, FB12 and FB24 irrespectively of the moment. On a ROC curve, a FB24 – 48 ⱖ3400 mL better discriminate survivors and nonsurvivors (OR 5.74 (2.44 –13.53)). On a logistic regression model, a FB24 – 48h after shock ⱖ3400 mL (p ⫽ 0.052) and urine output ⱕ2.0L on D3 (p ⫽ 0.001) were the only factors independently associated with mortality. Group 2 scored worst on RIFLE than Group 1. Patients with RIFLE F or higher had, in every moment, a FB24 – 48h higher than patients with RIFLE less than F. We found no relation between RIFLE score and FB6 at any moment. Conclusions: Late positive fluid balance (FB24 – 48h) but not earlier ones (FB6, FB12 and FB24) was strongly associated with mortality and higher risk of severe acute kidney injury. Our data suggests that fluid resuscitation after the first 24h may be harmful.


Oral Abstract Session: Monitoring 57

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INNOVATIVE CONTINOUS NON INVASIVE CUFFLESS BLOOD PRESSURE MONITORING BASED ON PLETHYSMOGRAPHY TECHNOLOGY

INFERIOR VENA CAVA RESPIRATORY VARIABILITY BY ULTRASOUND, A PREDICTOR OF FLUID RESPONSIVENESS IN MECHANICALLY VENTILATED PEDIATRIC SEPTIC SHOCK PATIENTS

Jesus Caballero, Juan Carlos Ruiz-Rodriguez, Vall d’Hebron Hospital, Oriol Sol▫orales, Vicent Ribas, Sabirmedical SL, Adolf Ruiz-Sanmartin, Miriam de Nadal, Vall d’Hebron Hospital, Eloi Casals, Sabirmedical SL, Jordi Rello, Vall d’Hebron Hospital Critical Care CIBERES VHIR Barcelona Spain Introduction: Development and validation of a continuous non invasive cuffless blood pressure (BP) monitoring using plethysmography technology through pulseoximetry (PO). Hypothesis: Continuous non invasive cuffless BP monitoring can be inferred from PO. Methods: Prospective study from January 2010 to August 2011 where patients admitted to a teaching hospital’s Critical Care Department were screened. After Ethics Committee approval, patients with PO and invasive BP monitoring through arterial catheter were included. Following calibration, invasive BP and finger PO waves were recorded simultaneously over 30 minutes. Waves were post-hoc manually reviewed to discard signal or positional errors. Systolic, diastolic and mean BP were drawn from computer-assisted arterial pulse wave analysis. Demographic data, pathology, SOFA, APACHE II, and placement of arterial catheter were collected. Inherent characteristics of both waves were used to construct a Stochastic Neural Network (SNN) from a training cohort of patients. Waves from a second independent validation cohort were used to infer BP values from the PO wave. Mean squared error and agreement analysis were performed to test accuracy on the validation cohort. Results: A total of 451 patients were screened and recorded. 381 were finally included (366 training, 15 validation). For the validation cohort, mean age was 61.6 years (SD 11.9), mean SOFA 6.0 (SD 3.6), mean APACHE II 10.25 (SD 3.78), and mean arterial catheter age was 3.27 days (SD 3.5). Monitoring was mainly for infectious diseases (26.7%), neurologic impairment (13.3 %) or post-trasplantation (13.3 %). No differences were observed between the training and the validation samples except for sex (73 % men in validation cohort vs. 63 % in training). The mean prediction error for systolic, diastolic and mean BP were ⫺1.03 mmHg (SD ⫾ 8.75), CI (⫺18.18/16.12), 1.26 mmHg (SD ⫾ 6.60), CI (⫺11.68/14.20) and ⫺0.73 mmHg (SD ⫾ 7.22), CI (⫺14.88/13.42) respectively. Conclusions: Continuous non invasive cuffless BP monitoring can be accurately inferred from PO while using advanced SNN modeling techniques. The clinical use of this new monitoring device is innovative and promising, although it needs further clinical validation.

Kashif Majeed, Ayman Aleyadhy, King Saud University Introduction: Septic shock is a leading cause of Pediatric ICU admissions and mortality. Optimum fluid resuscitation is of key importance for survival of septic shock. Respiratory variation in inferior vena cava diameter has been demonstrated to be an acceptable predictor of fluid responsiveness in adults with sepsis but this hypothesis has not been evaluated in children yet. Hypothesis: We hypothesize that respiratory cycle variation in inferior vena cava diameter by ultrasound could predict fluid responsiveness beyond the initial 60 ml/Kg in mechanically ventilated pediatric septic patients as a first pilot study in Pediatric age group. Methods: We did a prospective observational study of 20 mechanically ventilated pediatric septic patients in our PICU from December to March 2011. Patients with conditions associated with increased intra- abdominal pressure and congenital heart disease were excluded. Fluid Response was defined as an increase in systolic and mean BP more than 10 % by invasive BP monitoring. No change in sedation, inotropic support and ventilation during study period. Results: Out of 20, 14 patients (70%) were responders and 6 (30%) were non- responders. No statistically significant difference in age, weight, sedation, ventilator settings ( PEEP, tidal volume/kg ), baseline hemodynamic parameters like heart rate, systolic, mean and diastolic BP between both groups. IVC distensibility index difference between responders and non-responders was statistically significant (P0.002), 40.21 ⫾18.01 and 15.6 ⫾2.65 respectively. IVC distensibility threshold value was calculated by generating ROC curve. When using 20% as a threshold value for IVC distensibility index, it results in Sensitivity of 100%, Specificity of 93%, PPV of 100% and NPV of 85%. Conclusions: IVC distensibility index by ultrasound is a feasible, simple, non-invasive and promising tool to detect fluid responsiveness in mechanically ventilated children with septic shock. Larger studies are needed to validate the role of US in sepsis and septic shock management guidelines and its effect on outcome.

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THE USE OF END-TIDAL CARBON DIOXIDE (ETCO2) GUIDANCE OF CLOSED CHEST COMPRESSION DEPTH AND RATE TO IMPROVE CPR SURVIVAL

ELEVATED INTRACRANIAL PRESSURE DIAGNOSED BY OPTIC ULTRASOUND IN THE SETTING OF NORMAL INTRAVENTRICULAR CATHETER PRESSURE MEASUREMENTS

JL Hamrick, JT Hamrick, JK Lee, RC Koehler, DH Shaffner, Johns Hopkins

Michael Monson, Walter Reed National Military Medical Center, Anthony Nations, Walter Reed Army Medical Center

Introduction: To determine if ETCO2-directed chest compression depth and rate will result in improved return of spontaneous circulation (ROSC) from cardiac arrest compared to standard CPR using PALS guidelines. Hypothesis: ETCO2-directed chest compressions will result in a superior rate of resuscitation compared to the standard CPR. Methods: Twenty, 2-kg, piglets underwent general endotracheal anesthesia with 10 piglets in 2 groups (ETCO2-directed vs. standard). Ventricular fibrillation was induced via a wire through a femoral sheath. After a 90 sec no-flow time manual, closed chest compressions were started. In the standard group, compressors were blinded to ETCO2 and compression depth was 1/3 of the original AP diameter at a rate of 100 per min. In the ETCO2-directed group, the compressor modified the compression depth and rate in real time to obtain a maximal ETCO2 level. After 10 min of CPR in both groups, resuscitation was attempted using a combination of external defibrillation and IV epinephrine (Epi) while compressions continued. Survivors had ROSC that persisted for 20 min without intervention. Non-survivors were piglets that failed to obtain ROSC after five defibrillations and three doses of Epi. ETCO2, temperature, CVP, arterial pressure, compression rate, and the number of defibrillations and doses of Epi given to each piglet were recorded. All piglets underwent autopsy and any trauma from CPR was noted. Results: Piglet age, sex, and weight were similar between groups. The mean ETCO2 at 10 min of CPR was 21.6 mmHg (standard ) and 26.4 mmHg (ETCO2-directed). ROSC rates were 6/10 (standard) and 8/10 (ETCO2-directed). Defibrillations required to achieve sinus rhythm were equivalent between groups (both 2.3). Mean Epi doses were 1.7 (standard) and 1.2 (ETCO2-directed). Injuries secondary to closed-chest CPR were similar between the two groups. Conclusions: ETCO2-directed closed-chest CPR is a novel approach to resuscitation based on an objective measure of the adequacy of compressions, rather than relying on subjective estimations of the AP diameter. Our preliminary data suggests that it is at least as effective as current AHA recommendations.


Case Report: One of the largest obstacles for physicians treating wounded service members is measuring intracranial pressure (ICP). Intraventricular catheters have long served as the “gold standard” of measuring, but are extremely invasive and difficult to maintain. Recent studies by Hansen HC, Blaivas M, Tayal V, Moretti R have shown that ultrasound measurement of the optic nerve sheath diameter can be used as a noninvasive way to gauge the ICP. We present the case of a wounded Marine who was diagnosed by ultrasound to have elevated ICP, in the setting of a normal intraventricular catheter pressure measurement. The patient is a 20 year old previously healthy male who was injured in an explosion causing multiple penetrating cranial wounds. Prior to arrival, he had undergone multiple surgeries, including a bifrontal craniectomy with intraventricular catheter placement for direct ICP monitoring. One week after arrival, the patient became acutely hypertensive and bradycardic, concerning for increasing ICP. The reading from the intraventricular catheter was discordant, however, showing a normal pressure. To assess help solve this diagnostic dilemma, a bedside ultrasound was performed of the orbit, which showed a markedly dilated optic nerve sheath diameter (6.9 mm with normal being less than 5.2 mm). The patient underwent a stat CT of the head, which showed a significant increase in size of a previously stable intracranial hemorrhage. He underwent arterial embolization, which he tolerated without complication. The intraventricular catheter did eventually show an elevated ICP, but not for another 2 hours. This case highlights the profound usefulness of the bedside ultrasound as a diagnostic modality in patients who have suffered traumatic brain injury. In this patient, whose vital signs and physical exam findings were conflicting, beside ultrasound of the optic nerve sheath was able to provide information leading to a definitive diagnosis prior to the “gold standard” of direct ICP measurement. We submit this case to bring to the attention of physicians the usefulness of a bedside ultrasound of the optic nerve sheath in evaluating for increased intracranial pressure.

Oral Abstract Session:Education 61

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IN-HOUSE ATTENDING COVERAGE DOES NOT ADVERSELY IMPACT PEDIATRIC CRITICAL CARE FELLOW AUTONOMY

SUCCESSFUL IMPLEMENTATION OF A REAL-TIME, INTERACTIVE, ANONYMOUS CRITICAL CARE MORBIDITY AND MORTALITY CONFERENCE USING AN INTERNET-BASED AUDIENCE RESPONSE SYSTEM

Kyle Rehder, Ira Cheifetz, David Turner, Duke University Medical Center Introduction: Supervision of housestaff is crucial for both education and patient care. However, the need for continuous in-house intensivist coverage is debated within the critical care community. Proponents of overnight in-house critical care attending (IHA) presence suggest improvement in both patient outcomes and trainee education, but data are limited, particularly in pediatric critical care. Hypothesis: We hypothesized that the implementation of an IHA pediatric critical care attending model would benefit fellow education, but decrease fellow autonomy. Methods: A pediatric critical care division consisting of ten faculty members and nine fellows implemented an IHA model to cover 29 beds across two units: the Pediatric Intensive Care Unit (PICU) and the Pediatric Cardiac Intensive Care Unit (PCICU). This model included a single faculty member remaining in-house overnight during a time that had been traditionally covered by attendings from home. Fellows were surveyed immediately before and nine months after implementation of the new model. Results: Survey response rate was 100%. Following successful implementation of the IHA model, fellows felt that that in-house coverage was better for patient care for the PICU (p ⫽ 0.0007) and PCICU (p ⫽ 0.004). They also reported that they would be more comfortable having a family member treated in each unit (PICU, p ⫽ 0.0007 and PCICU, p ⫽ 0.04). However, there was no difference for either unit in perceived autonomy (PICU, p ⫽ 0.59 and PCICU, p ⫽ 0.35), supervision (PICU, p ⫽ 0.68 and PCICU, p ⫽ 0.20), or effects of IHA on fellow education (PICU, p ⫽ 0.68 and PCICU, p ⫽ 0.68). Pre and post-implementation, there were no differences in the reported number of times the fellow spoke with their attending per night (2.2 vs. 2, p ⫽ 0.67 ) or the percentage of codes led by fellows ( 63% vs. 74% p ⫽ 0.18). No change in overall job satisfaction for trainees was noted (PICU, p ⫽ 0.59 and PCICU, p ⫽ 0.10). Conclusions: An IHA coverage model can be successfully implemented within a pediatric critical care training program without negatively impacting fellow autonomy or education. Opportunities may exist to utilize increased attending physician presence to enhance trainee education.

Ariel Shiloh, Ronen Dudaie, Purnema Madahar, Adam Keene, Lewis Eisen, Richard Savel, Montefiore Medical Center Introduction: The purpose of this project was to document the successful implementation of a real-time, anonymous, interactive critical care morbidity and mortality (M&M) conference. Hypothesis: We hypothesized that such a conference could be successfully implemented, would facilitate integration of the ACGME core competencies, and would enhance audience participation and satisfaction. Methods: Using a free internet-based audience response system (polleverywhere.com), we integrated interactive questions into a weekly critical care M&M. The software creates multiple-choice questions that can be embedded into Microsoft PowerPoint slide sets. Attendees responded using cell phones capable of text messaging. Smart phone users responded via the internet or Twitter. No new equipment purchases were required for the division. Results were immediately displayed as a bar graph and fostered further discussion. Questions focused on patient care, medical knowledge, system-based practice, professionalism, and interpersonal skills and communications (ACGME core competencies). As opposed to standard M&M conferences where there may be fear of embarrassment when responding, our conference allowed for complete anonymity. The data was automatically downloaded to a spreadsheet for further analysis. Results: A total of 15 meetings were held. There were 17⫹/⫺4 attendees per session, with 249 participants taking part: 34% were attending intensivists, 43% were fellows, 4% were resident physicians, 7% were physician assistants, and 11% were medical students. There were 3.2⫹/⫺0.9 educational questions per case conference. Compared with other forms of M&M conferences, 85% felt that this format was better and 89% of participants stated that they gained useful information. Conclusions: We implemented an interactive, anonymous, real-time, internet based critical care M&M conference. This no-cost enhancement to our fellowship was perceived to be of high values by the attendees, and improved integration of the ACGME core competencies.

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PEDIATRIC CRITICAL CARE AND EMERGENCY MEDICINE REGIONAL BOOT CAMP IMPROVES FELLOW CONFIDENCE IN ESSENTIAL SKILLS AND COMMUNICATION

DEVELOPMENT OF A MULTICENTER COLLABORATIVE FOR EDUCATION BASED RESEARCH–BIRTH OF THE EDUCATION IN PEDIATRIC INTENSIVE CARE (EPIC) INVESTIGATORS

Tonya Thompson, Univerisity of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Sanjiv Pasala, University of Arkansas For Medical Sciences/ Arkansas Children’s Hospital, Grace Gephardt, Beatrice Boateng, Arkansas Children’s Hospital, Stephen Schexnayder, University of Arkansas College of Medicine/Arkansas Children’s Hospital Introduction: Transitioning from general pediatrics residency into to sub-specialty training can be intimidating as the acuity and complexity of patients increases. Hypothesis: We hypothesized that intensive simulation training focusing on essential skills and communication will be effective in preparing 1st year fellows for clinical experiences by exposing them to cases and procedures they would encounter. We sought to measure their preparation for fellowship by assessing confidence intervals pre and post simulation training. Methods: A 2 1⁄2 day multi-institution simulation based “boot camp” for critical care medicine (CCM) and pediatric emergency medicine (PEM) fellows was held at the PULSE Simulation Center. Fellows participated 13 simulated cases involving shock, arrhythmias, anaphylaxis, seizure, traumatic brain injuries (TBI) and partial task trainers focusing on ultrasound guided line placement and critical airway management. Standardized participants were included in some simulations to allow fellows practice communicating with families in crisis. Fellows received feedback from faculty facilitators and standardized participants after each scenario. Fellows evaluated themselves in terms of their change in confidence level pre and post workshop, and the overall applicability of the boot camp. Results: Eight first year PEM and CCM fellows from two institutions participated in the regional boot camp. The participants confidence intervals improved (% change) in the areas of team leadership (43.7%), closed loop communication (50%), communication with families in crisis (37.5%), managing adult or difficult airways (31.3%), seizures (62.5%) and TBI (56.3%). All fellows indicated the boot camp was an essential experience for the transition from resident to fellow. The multidisciplinary nature between EM and CCM fellows and the inclusion of standardized participants was highlighted as the best part of the training by the participants. Conclusions: To the best our knowledge, this is the first multidisciplinary boot camp involving different specialties. Improved confidence in patient management, procedural skills, and better communication within and across disciplines will hopefully translate into improved patient outcomes.

David Turner, Duke University Medical Center, Denise Goodman, Children’s Memorial Hospital, for the Education in Pediatric Care (EPIC) Investigators Introduction: The relatively small size of pediatric critical care medicine (PCCM) fellowship programs leads to the development of educational curricula that are individualized and program specific. This individuality makes it difficult to determine the most effective, or even most common, educational strategies. Given that many of the educational needs across programs are similar, multicenter collaboration represents a potentially valuable strategy to improve trainee education. Hypothesis: We hypothesized that applying a model similar to that used by clinical research networks could successfully be undertaken to create a multi-center collaborative for education-based research. Methods: Two PCCM fellowship program directors (PDs) developed a proposed structure for an education-based research collaborative. This structure included guidelines for meetings, participation, project selection and implementation, and dissemination of results. Invitations to participate in this collaborative were then sent to all 66 PDs at accredited PCCM fellowship programs. Following an initial conference call for interested participants, the group was established and project development was undertaken. Results: A multi-center education-based research collaborative, the Education in Pediatric Intensive Care (EPIC) Investigators, was established over an 8 week period. The first conference call included 13 participants from 11 institutions. To date, the group has conducted 10 bi-monthly ‘meetings’ via conference call, including a total of 23 participants from 20 institutions. Over the course of 6 months, the structure of this collaborative was established and the first research project was successfully undertaken. Conclusions: Development of a multi-center collaborative focused on research in medical education is possible. The development of the EPIC Investigators represents a novel approach to pool resources and improve education-based research. Partnership of this nature in education-based research also has broad potential applicability across multiple disciplines and may become a new paradigm as we move toward an outcomesbased educational approach to curricular development in graduate medical education.


Posters: Research Citation Finalist 100

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THE IMPACT OF AN ICU SLEEP PROMOTION PROGRAM ON PATIENT SATISFACTION AND DELIRIUM PREVALENCE

SEVERE ENCEPHALOPATHY AND IMPENDING CEREBRAL HERNIATION IN ACETAMINOPHEN TOXICITY: RECOVERY WITH A NOVEL HYPERNATREMIC/HYPOTHERMIC PROTOCOL

Denise Rummelhart, Hildy Schell-Chaple, University of California San Francisco Medical Center Introduction: Sleep is essential for emotional and physical well being. In the ICU, sleep quality and quantity are often inadequate due to noise, lights, patient care activities, and pain. ICU survivors report that sleep deprivation ranks as a major source of anxiety and stress. Sleep disturbances are associated with the development of delirium in ICU patients. Hypothesis: Implementation of a sleep promotion program in the ICU can increase patients reports of sleep satisfaction and decrease the prevalence of delirium. Methods: Baseline data regarding sleep preferences and quality of sleep in the ICU were collected from interviews of ICU patients that were able to self report. A sleep assessment tool and care plan was developed and implemented. Staff education on the risks of sleep deprivation and use of the sleep preference assessment and care plan was completed via staff meetings, newsletters, and signage. Sleep promotion interventions such as “quiet time,” eye masks, and ear plugs were implemented. Delirium prevalence was monitored weekly. A post-intervention patient survey regarding sleep preferences and quality of sleep was completed. Results: Forty-two patient interview surveys were completed (21 pre- and 21 post-intervention). Recall of sleep assessment completion upon admission to the ICU increased from 24% to 57%. Recall of implementation of identified sleep preferences increased from 15% to 68%. The median sleep quality score improved from 5 to 7 (0 to 10 scale). Delirium prevalence decreased from 40% to 8% (median 13%) over the first 8 weeks after implementation of the sleep program. Conclusions: A sleep promotion program including assessment of sleep disorders and sleep aids or habits can improve implementation of individual patient sleep preferences, improve satisfaction with sleep quality in the ICU and potentially decrease prevalence of delirium.

Jessie Roske, University of Minnesota, Dept of Internal Medicine, William Browne, University of Minnesota Case Reports: As a transplant center, the challenging clinical situation of acetaminophen-induced fulminant liver failure in patients deemed not to be transplant candidates is encountered all too often, with the most feared complications being cerebral edema and herniation. A 37-year-old female with a past medical history significant for alcohol dependence presented with encephalopathy, coagulopathy and hyperbilirubinemia and was found to have a toxic acetaminophen level 48 hours after ingestion. Given refractory alcoholism with multiple failed courses of substance abuse treatment, the patient was considered not a candidate for liver transplantation. The patient’s neurologic status deteriorated with evidence of impending central herniation including extensor posturing, sustained clonus and bilateral Babinski sign. In an effort to avoid catastrophic neurologic sequelae, hypernatremia to 165 mmol/L and hypothermia to 32°C were urgently induced. Additional complications during the ICU stay included acute anuric renal failure requiring renal replacement therapy and further derangement in liver function tests with undetectably elevated INR. Given markedly elevated INR, placement of ICP monitor was felt to be contraindicated. Continuous renal replacement therapy was utilized for maintenance of hypernatremia. Ultimately, in the absence of direct ICP measurement, the patient was cooled for a total of 6 days, with timing of rewarming based on improving neurologic exam, corresponding improvement in liver function, and serial head CT scans. The patient was subsequently extubated and discharged on hospital day 32 with complete neurologic recovery and improving hepatic function. In this very challenging case, the efforts of a multidisciplinary team to extrapolate clinical experience and limited published literature to develop a novel induced hypernatremia/hypothermia protocol produced an extremely satisfactory outcome.

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LETHAL CYANIDE TOXICITY REVERSAL BY A NEW 3 MERCAPTOPYRUVATE PRODRUG

THE BENEFIT OF A STANDARDIZED SIMULATION-BASED APPROACH IN TEACHING ULTRASOUND-GUIDED CENTRAL VENOUS ACCESS

Harpreet Singh, David Beebe, Renu Adhikari, Jeyanthan Srikanthan, Steven Patterson, Kumar Belani, University of Minnesota Introduction: Cyanide (CN) poisoning is a serious chemical threat from accidental or intentional exposures. Current treatments suffer from significant side effects or serious limitations due to poor solubility. A new prodrug of 3 mercaptopyruvate (3 MCP) can provide effective quantities of sulphur needed to interact with CN to form non-toxic thiocyanate (SCN). This is possible because of the universal availability of large amounts of cytosolic 3 MCP sulphur transferase (3 MPST) in the cells. Hypothesis: The objective of the study was to test the efficacy of 3 MCP prodrug in reversing lethal cyanide toxicity in a rabbit model. Methods: After approval by IACUC, New-Zealand white rabbits (2– 4 kg) were anesthetized by an infusion of ketamine. Non-invasive monitors (pulse oximeter, ECG, rectal thermometer, exhaled carbon dioxide monitor) were applied to monitor oxygen saturation, heart rate & rhythm, temperature and breathing. Sodium cyanide (NaCN) was administered at an infusion rate of 2.2 mg/kg/hr in all rabbits until significant lactic acidosis, apnea and hypotension occurred. In one group of 6 rabbits (Group A) 3 MCP (0.178 g/kg) was administered intravenously. The second group of 6 rabbits (Group P) received intravenous normal saline as placebo. Data were reported as mean ⫾ SD. Significance (p⬍0.05) was determined by ANOVA and Fisher’s exact test. Results: The NaCN infusion increased the CN levels (0.043⫾0.023 to 4.835⫾1.260 mg/L; p⬍0.0001) and the serum lactate levels (0.6⫾0.2 to 14.6⫾0.6 mmol/L; p⬍0.0001) in all rabbits. The pH decreased from 7.37⫾0.05 to 7.06⫾0.10, p⬍0.0001. All the rabbits in Group A survived with CN levels decreasing to 0.229⫾0.065 mg/L, p⬍0.001; lactate levels decreasing to 0.7⫾0.1 mmol/L, p⬍0.001 and pH levels increasing to 7.38⫾0.02, p⬍0.001. All the rabbits in Group P died (p ⫽ 0.0022 vs Group A) with final values of CN and lactate levels higher (CN; 5.680⫾2.108 mg/L, p ⫽ 0.0001: lactate; 14.1⫾1.4 mmol/L, p⬍0.0001) & pH levels significantly lower (6.90⫾0.07; p⬍0.0001) than the animals that received the antidote. Conclusions: 3 MCP is effective in reversing acutely induced CN toxicity. This study confirms the reversibility of CN toxicity by 3-MCP prodrug in this species.


Tonya Jagneaux, Louisiana State University Health Sciences Center, Terrell Caffery, John Peter Smith Health Network, Glenn Jones, Louisiana State University Health Sciences Center Introduction: Simulation-based education for ultrasound-guided central venous access (UGCVA) is increasingly being used in residency training to achieve competency and reduce procedural complications. Hypothesis: We hypothesized that a standardized simulation-based UGCVA education protocol would; (1) improve overall residents’ knowledge base and procedural skills and (2) enable all residents regardless of post-graduate year (PGY) training level and prior experience to achieve equivalent knowledge base and skills sets. Methods: Residents at PGY levels 1–3 in internal and emergency medicine underwent pre- and posttraining evaluations with self-assessment questionnaires, written exams and skills exams. Educational training sessions included video, lectures, and skills training on simulators. Two independent observers graded residents’ UGCVA skills on simulators with a 16-point checklist. Additional skills parameters included skinto-vein time, number of attempts, and arterial punctures. Results: Performance data from 67 residents were analyzed (PGY1–29, PGY2–21, PGY3–18). Written exam scores (max 20) improved from pre-training [M ⫽ 16.248, CI 15.758 – 16.738] to post training [M ⫽ 19.210, CI 18.988 –19.432], (p⬍0.0001). Skills exam scores (max 16) improved from pre-training [M ⫽ 11.838, CI 11.264 – 12.412] to post training [M ⫽ 14.255, CI 13.923–14.587], (p⬍0.0001). Analyses of specific skills revealed reductions in: (1) skin to vein time from 44.6 [CI 27.6 – 61.7] to 21.2 [CI 10.7–31.6] seconds (p⬍0.029), (2) number of attempts required for venous puncture (p⬍0.003), and (3) arterial punctures (6 pre-training, 0 post-training; p⬍0.03). Junior residents (PGY 1–2) improved more than senior residents (PGY 3) in written and skills exams (p⬍0.009). Comparison of written and skills exam performance post-training revealed no difference (p⬍0.6) among any PGY levels (1–3). Conclusions: Standardized simulation-based education effectively improved knowledge and skills in our residents. Equivalent knowledge acquisition and skills performance among residents of all PGY levels can be achieved with standardized simulation-based education for UGCVA. Grant support: LSUHSC-New Orleans Academy for the Advancement of Educational Scholarship.

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CASE REPORT: USE OF ETOMIDATE INFUSION FOR ACUTE TREATMENT OF CUSHING’S SYNDROME

HYPERGLYCEMIA PROTECTS GLOMERULAR ENDOTHELIAL CELL MONOLAYERS FROM HYPOXIC INJURY

Ashley Stinnett, Kathryn Neill, University of Arkansas For Medical Sciences, Kendrea Jones, UAMS College of Pharmacy

Katie Schenning, Nabil Alkayed, Sharon Anderson, Michael Hutchens, Oregon Health & Science University

Case Report: A 48 year old female transferred to our ICU from an outside hospital for evaluation of possible necrotizing fasciitis. The patient had received numerous oral antibiotics as an outpatient for treatment of leg ulcers. Past medical history is significant for hypertension, heart failure, atrial fibrillation, pulmonary embolism and type 2 diabetes mellitus (diagnosed 5 months prior to admission). Surgical history is significant for removal of a pituitary adenoma (1992); the patient takes no chronic medications related to the surgery. Necrotizing fasciitis was ruled out, and it was determined the patient had cellulitis as a result of uncontrolled diabetes and poor hygiene. After admission, the patient’s mental status deteriorated; she was uncooperative with hospital staff and threatened to leave against medical advice. Cushing’s syndrome was suspected due to the presence of a round face, hirsutism, dorsocervical and supraclavicular fat pad, abdominal striae, recent weight gain, hypokalemia, weakness and mental status changes. Laboratory studies day 1 revealed an elevated serum cortisol (143 ␮g/dL) and an elevated 24 hour urine free cortisol (1120 ␮g/day). On day 2, ACTH was elevated (83 pg/mL). Computed tomography scan revealed grossly enlarged adrenal glands consistent with adrenal hyperplasia. On day 5, morning cortisol was 801 ␮g/dL. Due to severe hypercortisolemia and symptoms, an intravenous infusion of etomidate was started to provide a rapid decrease in cortisol levels. The infusion was given undiluted via a central line at 0.05 mg/kg/h over 6 hours. The patient was also started on oral metyrapone and ketoconazole. Etomidate infusion was repeated on days 6, 7, 9 and 11. Magnetic resonance imaging of the brain on day 8 showed a large pituitary adenoma which was removed on day 12. Serum cortisol levels markedly decreased to 53␮g/dL on day 4 of etomidate treatment. Levels were maintained with oral ketoconazole and metyrapone. The patient was discharged 40 days after admission.

Introduction: Hyperglycemia (HG) contributes to diabetic nephropathy, retinopathy, and cardiomyopathy. Paradoxically, studies have shown HG protects against ischemia/reperfusion injury (IRI) in retinal cells and cardiomyocytes (1,2). The effects of HG on glomerular endothelial cells (GenC) are poorly understood. We set out to determine if GenC monolayers are protected by HG from injury due to oxygen/glucose deprivation (OGD). Hypothesis: Chronic HG protects GenC monolayer integrity from the insult of OGD. Methods: GenC were cultured on transwells in normoglycemic (NG) (5.5 mM glucose) or HG conditions (25.5 mM glucose). After 7d, GenC were subjected to 8h of OGD. Transendothelial electrical resistance (TEER) and permeability to macromolecules (FITC conjugated to 70 kD Ficoll) were the measures of GenC monolayer integrity, and were assessed prior to OGD and during reoxygenation/glucose repletion. To differentiate between effects of acute vs. chronic HG, the protocol was repeated except the HG group of GenC was exposed to NG for 18h prior to OGD. Statistical analysis was performed using 2-tailed Student’s t-test. Results: Prior to OGD, GenC monolayers grown in NG had higher TEER (mean ⫹/⫺ SEM: 30.7 ⫹/⫺ 1.76 Ohms) compared to GenC grown in HG (24.3 ⫹/⫺ 0.42 Ohms; p⬍0.05, n ⫽ 6/group). GenC monolayers cultured in HG were more resistant to OGD (TEER 84.9% of baseline) than GenC monolayers cultured in NG (TEER 70.4% baseline; p⬍0.05, n ⫽ 3/group). When both groups of GenC were exposed to NG for 18h prior to OGD, there was no difference in TEER (p ⫽ 0.56) or macromolecular flux (p ⫽ 0.37). Conclusions: These data suggest while chronic HG is detrimental to the integrity of GenC monolayers in vitro, acute HG protects against the insult of OGD. Further, this protective effect is reversed by withdrawal of HG 18h prior to insult. Finally, the injury to HG and NG cells is similar if HG conditions are withdrawn 18h prior to insult. References: 1. Holman MC, Chidlow G, et al: The effect of hyperglycemia on hypoperfusion-induced injury. Inv Ophth Vis Sci 2010; 51:2197–207. 2. Pang Y, Hunton DL, et al: Hyperglycemia inhibits capacitative calcium entry and hypertrophy in neonatal cardiomyocytes. Diabetes 2002; 51:3461–7. Funded by: K08DK090754 & T32GM082770.

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RISK ASSESSMENT PROFILE TO SCREEN FOR VENOUS THROMBOEMBOLISM IN TRAUMA PATIENTS

INNATE IMMUNE RESPONSE IS IMPAIRED IN CHILDREN WITH SEVERE RESPIRATORY SYNCYTIAL VIRUS (RSV) INFECTION

Chad Thorson, Mark Ryan, Nicholas Namias, Christian Otero, Thai Vu, Ronald Manning, David Andrews, Alan Livingstone, Kenneth Proctor, University of Miami

Cesar Mella, Mari Suarez, Santiago Lopez, Nationwide Children’s Hospital, Lisa Hanson, The Research Institute At Nationwide Children’s Hospital, Mark Hall, Octavio Ramilo, Nationwide Children’s Hospital, Asuncion Mejias, Nationwide Childrens Hospital

Introduction: Rates of venous thromboembolism (VTE) as high as 65% have been reported in trauma patients without prophylaxis, but the incidence in those receiving prophylaxis is unknown. There is no routine VTE screening protocol. If Medicare adds VTE to the list of “preventable complications,” they will no longer reimburse to treat, which could have devastating effects on many urban centers. Hypothesis: We hypothesized that the Risk Assessment Profile (RAP) of Greenfield[1] and routine venous Duplex ultrasound (VDU) screening could identify asymptomatic VTE in trauma patients. Methods: With IRB approval, and waiver of consent, patients treated at a level I trauma center were prospectively screened using the RAP score upon admission to the intensive care unit. Those with RAP ⬎10 received VDU within 24 hours and weekly thereafter. Results: There were 414 patients screened and 80 identified as high risk. 80% sustained blunt injury, 69% were male, with a mean⫾SD Injury Severity Score of 29⫾12 and age 46⫾19 years. VTEs were detected in 15 (19%), including one pulmonary embolism. All developed despite thromboprophylaxis (heparin 5000 units every 8 hours or dalteparin 5000 units daily), and most were asymptomatic. The most common risk factors were transfusion of ⬎4 units of PRBCs (n ⫽ 12, 75%), Abbreviated Injury Score chest ⬎2 (n ⫽ 10, 63%), pelvic fracture (n ⫽ 9, 56%), surgical procedure ⬎2 hours (n ⫽ 8, 50%), and complex lower extremity fracture (n ⫽ 7, 44%). Average time to VTE identification was 10⫾8 days, with the majority identified upon admission (n ⫽ 2, 13%) or within the first (n ⫽ 3, 20%) or second (n ⫽ 7, 47%) weeks of hospitalization. Conclusions: Medicare’s inclusion of VTE in trauma patients as a “never event” should be questioned. Although routine VDU is probably not cost-effective for all trauma patients, screening using RAP yielded a cohort of patients at high risk for VTE despite standard prophylaxis. In addition, the current thromboprophylaxis regimen should be reevaluated in this high risk population.Supported by grants from the Office of Naval Research & US Army Medical Research & Material Command. Reference: Greenfield LJ, et al. Posttrauma thromboembolism prophylaxis. J Trauma. Jan 1997;42(1):100 –103.

Introduction: RSV LRTI is the leading cause of hospitalization in infants, with 10% of patients requiring PICU care. It is unclear whether the innate immune response to RSV infection is impaired in critically ill children presenting with the most severe forms of the disease. Hypothesis: Previously healthy children ⬍2 years of age with severe RSV LRTI requiring PICU admission have decreased immune function assessed by ex-vivo lipopolysaccharide(LPS)-induced production of innate immune cytokines compared with children hospitalized in the inpatient ward with moderate RSV LRTI. Methods: Children ⬍2 years hospitalized with RSV LRTI in the PICU or inpatient ward, as well as age/sex matched healthy controls were prospectively enrolled. Whole blood samples were obtained within 24 h of admission and TNF-␣, IL-6, and IL-8 concentrations measured pre and post LPS stimulation to assess functional immunity. Results: A total of 90 patients were enrolled: (PICU, n ⫽ 20; ward, n ⫽ 46; controls, n ⫽ 24). Baseline plasma IL-6 and IL-8 concentrations were significantly lower in healthy controls, but there were no significant differences between PICU and ward patients. Baseline TNF-␣ concentrations were not different among groups. However, compared with patients admitted to the ward, PICU patients had lower LPS-induced production of TNF-␣ (1000 vs 1511 pg/mL, p ⫽ 0.014), IL-6 (953 vs 1377 pg/mL, p ⫽ 0.03) and IL-8 (982 vs 1585 pg/mL, p ⫽ 0.03). Among PICU patients, TNF-␣ ␮800 pg/mL was associated with increased need for mechanical ventilation (RR ⫽ 5, 95% CI 2.6 –9.2, p⬍0.0001). Among all patients, TNF-␣ production of ⬍1000 pg/mL was associated with increased length of stay (5 vs 2 days, p ⫽ 0.003), increased duration of oxygen (4 vs 1.2 days, p ⫽ 0.002) and increased LRTI disease severity score at admission (10 vs 7, p ⫽ 0.001). Conclusions: PICU patients with severe RSV LRTI have lower innate immune responsiveness compared with patients with moderate RSV LRTI hospitalized in the ward. Lower ex-vivo production of TNF-␣ is associated with increased disease severity in all patients. Further studies are needed to elucidate the cause/effect relationship associated with innate immune suppression and disease severity in critically ill RSV infected children.


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A CASE CONTROL STUDY ON THE IMPACT OF VENTILATOR ASSOCIATED TRACHEOBRONCHITIS (VAT) IN THE PICU

DEFINING “NO ESCALATION OF CARE” PRIOR TO DEATH IN THE ICU

John Whitt, Michael Lake, John Butcher, MaryJo Giaccone, Brandy Seger, Marion Schulte, Derek Wheeler, Cincinnati Children’s Hospital Medical Center Introduction: Hospital-acquired infections (HAI) increase morbidity, mortality, and charges in the PICU. We implemented a quality improvement (QI) bundle directed at VAP in 2005. We observed an increase in VAT coincident with the near-elimination of VAP. The impact of VAT on critically ill children has not been previously described. Hypothesis: VAT is associated with increased length of stay (LOS), mortality, and hospital charges. Methods: We conducted a retrospective case control study, with IRB approval, of 77 consecutive cases of VAT admitted to our PICU from 2004 –2010. We matched each case with a control based on the following criteria (in rank order): age range (⬍30 days, 30 days–24 mos, 24 mos–12 yrs, ⬎12 yrs), admission PRISM II score ⫹/⫺ 10, number of ventilator days of control group (⬎75% of days until development of VAT), primary diagnosis, underlying organ system dysfunction, surgical procedure, and gender. The primary outcome measured was PICU LOS. Secondary outcomes included ventilator days, hospital LOS, mortality, and PICU and hospital charges. Data was analyzed using Stata SE/11 software and p⬍0.05 was considered significant. Results: We matched 45/77 VAT patients with controls. There were no significant differences in age, gender, diagnosis, or PRISM-II score between groups. VAT patients had a longer PICU LOS (median 21.5 days, IQR 24 days) compared to controls (median 18 days, IQR 17 days), although not statistically significant (p ⫽ 0.13). Ventilator days were also longer in the VAT patients (median 17 days, IQR 22 days) versus control (median 10.5 days, IQR 13 days) (p ⫽ 0.01). There was no significant difference in total hospital LOS (54 days vs 36 days, p ⫽ 0.69). PICU mortality was higher in the VAT group (15% vs 5%, p ⫽ 0.14), although not statistically significant. There was an increase in both median PICU charges ($197,393 vs $172,344, p⬍0.05) and hospital charges ($421,576 vs $350,649, p⬍0.05) for VAT patients compared to controls. Conclusions: VAT is a clinically significant HAI in the PICU and is associated with longer duration of mechanical ventilation and healthcare costs, possibly through causing a longer PICU LOS. QI efforts should be directed at reducing the incidence of VAT in the PICU.

Christopher Morgan, Khalid Almoosa, University of Texas Health Science Center at Houston Introduction: When goals of care in critically ill patients change from curative to palliative, a “no escalation of care” (NEOC) approach is sometimes used. We aimed to determine the prevalence of NEOC designation and identify which interventions are affected for ICU decedents. Hypothesis: The designation of “no escalation of care” prior to death in the ICU is not clearly defined and the interventions affected are not known. Methods: We performed a retrospective chart review of all patients who died in a 16-bed MICU at a single academic hospital from November 2008 to December 2010. Any patient who had a physician order or documentation in the progress notes as NEOC was included in our selection sample for study. The medical records of these patients were then reviewed in depth to determine which life-supporting therapies and interventions they were receiving and which were withdrawn or withheld around the time of this decision. Additional data on demographics and consultations were also obtained. Results: A total of 310 patients died in the MICU during the study period, of which 95 (30.6%) were designated as NEOC prior to death. In this NEOC group, interventions that were most likely to be continued included mechanical ventilation (94% continued), feeding (96%), fluids (90%), and antibiotics (88%), while blood products was least likely to be continued (6%). Dialysis and vasopressors were almost equally likely to be continued or withheld (continued 53% and 58%, respectively). Prior to death, 55% of NEOC patients had all life-support withdrawn (“comfort care”). A minority of subjects had a palliative care consult (15%), ethics consult (4%) or available advanced directive (6%) during their ICU stay. Time from NEOC designation to death averaged 0.8⫹1.1 days (range 0 to 5). Conclusions: NEOC designation occurs in a significant proportion of ICU decedents before death. Most interventions are continued after a NEOC decision, despite the short period to death.

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COMPARISON OF A LOW, FIXED DOSE AND A HIGH, WEIGHT BASED DOSE OF RECOMBINANT FACTOR VIIA IN THE TREATMENT OF WARFARIN-ASSOCIATED INTRACEREBRAL HEMORRHAGE.

NEED FOR POST-OPERATIVE MECHANICAL VENTILATION IN KIDNEY TRANSPLANT RECIPIENTS PREDICTS POOR SURVIVAL: A REVIEW OF THE UNITED STATES RENAL DATA SYSTEM

Adele Robbins, UMass Memorial Medical Center, Jeffrey Fong, Massachusetts College of Pharmacy, Wiley Hall, UMass Neurology, Stephen Rolfe, University of New England College of Pharmacy, Kristen Ditch, Melissa Miller, UMass Memorial Medical Center

Mark Dy-Liacco, Nino Dzebisashvili, Krista Lentine, Janet Tuttle-Newhall, Mark Schnitzler, Saint Louis University

Introduction: Recombinant activated Factor VII (rFVIIa) has been used for rapid INR normalization in patients with warfarin-associated intracerebral hemorrhage (WA-ICH). However, the optimal dosing to normalize INR has not been established. Hypothesis: A low, fixed dose of rFVIIa results in a similar INR normalization as a high, weight based dose in patients with WA-ICH. Methods: This is a retrospective review comparing two rFVIIa hospital WA-ICH protocols. Patients were included if they were ⬎18 years old, had a documented ICH and use of warfarin with INR ⬎1.5 upon admission. Exclusion criteria included: any disease state that increases risk of bleeding or clotting, or moribund status within 2 hours of receiving rFVIIa. Primary endpoint was time to INR normalization (INR ⬍1.3) from rFVIIa administration. Secondary endpoints included time to sustained INR normalization defined as time from rFVIIa dose to the second consecutive INR ⬍1.3, need for a second dose per fixed dose protocol and adverse drug reactions. Univariate statistical analyses were utilized. Results: Twenty-nine patients received a mean dose of 78.9 ⫾ 21 mcg/kg in the weight based rFVIIa group. Eighteen patients received a fixed 2 mg dose of rFVIIa (mean total dose 29.3 ⫾ 8.9 mcg/kg). Baseline characteristics were similar between both groups. The weight based group achieved INR normalization in 229.5 [102, 331] minutes (median [IQR]) vs. 103 [70, 262] minutes in the fixed dose group (p ⫽ 0.008). Time to sustained INR normalization was similar in both groups: 635 [440.5, 987.5] minutes in the weight based group vs. 530 [431.25, 1816.75] minutes in the fixed dose group (p ⫽ 0.859). Five patients in the fixed dose group required an additional dose of 1 mg per protocol. Adverse events included heart failure (n ⫽ 2) and hives (n ⫽ 1) in the weight based and myocardial infarction (n ⫽ 1) in the fixed dose group. Mortality and length of stay were not statistically different between groups. Conclusions: A low, fixed dose of rFVIIa appears to be as effective as a high, weight based dose in achieving INR normalization in patients with WA-ICH.


Introduction: Kidney transplantation is the most common solid organ transplant in the United States. Regulatory oversight for transplant programs mandate expected outcomes for graft and patient survival at one year of over 90% at one year. Our hypothesis is that need for mechanical ventilation after kidney transplant is a risk factor for poor outcomes. Hypothesis: Mechanical ventilation is a significant risk factor for poor outcomes after kidney transplant. Methods: Kidney transplant recipients from 1995–2008 with Medicare as a primary insurance were identified in the United States Renal Data System (n ⫽ 93,433). The sample included 68,484 deceased and 21,890 live donor graft recipients. Mechanical ventilation use within 30 days after transplantation was ascertained using ICD-9 codes in the USRDS claims database (ICD-9 codes: 96.71 & 96.72). The risk factors for mechanical ventilation and association of the use of mechanical ventilation with 30-day mortality were determined using logistic regression analysis. Covariates included recipient, donor and transplant characteristics. Results: Post-operative mechanical ventilation is associated with a 14 fold increase in 30-day mortality in renal transplant patients (Odds Ratio 13.7, P⬍0.0001). Transplant recipient risk factors associated with the need for mechanical ventilation include under age 18 and over age 45, black race, diabetes, hypertension, angina and physical disability. Cadaveric vs living donor increased the odds of mechanical ventilation by 65% (Odds Ratio 1.65, P⬍0.0001). The early posttransplant outcome of delayed graft function was also associated with the need for mechanical ventilation (Odds Ratio 1.71, P⬍0.0001). Conclusions: The need for post-operative mechanical ventilation is a prognostic marker for mortality in kidney transplant recipients. The comorbid diseases most likely to affect need for ventilation are diabetes, hypertension, cardiac ischemia and physical disability. Careful assessment of the potential kidney transplant recipient is necessary to ensure outcomes that meet national standards. Additive risk factors for postoperative respiratory failure must be seriously considered when assessing a patient’s candidacy for kidney transplant.

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DO STATINS INFLUENCE DVT RISK IN THE CRITICALLY ILL PATIENTS?

EARLY INTENSIVE CARE SEDATION PRACTICE PREDICTS LONG-TERM MORTALITY IN VENTILATED CRITICALLY ILL PATIENTS

Ryan Zarchanski, Wendy Lim, Marcelo Rocha, Lauralyn McIntyre, Francois Lamontagne, Peter Dodek, Menaka Pai, DJ Cooper, Jamal Alhashemi, Nicole Zytaruk, McMaster University Introduction: HMG CoA reductase inhibitors (e.g., statins), modulate dyslipidemia and inflammation, and reduce the risk of arterial thrombosis. The objective of this substudy was to examine the relationship between statins and proximal leg deep vein thrombosis (DVT) in medical-surgical critically ill patients enrolled in a thromboprophylaxis trial comparing unfractionated vs low molecular weight heparin (PROTECT, clinicaltrials.gov NCT00182143). Hypothesis: We hypothesized that statins would have no impact on DVT rates in the ICU. Methods: Proximal leg DVT was diagnosed by twice weekly compression leg ultrasound in 3764 medical-surgical patients in 67 ICUs in 6 countries. We collected extensive VTE risk factor data, including statin exposure, which was documented pre-hospitalization, pre-ICU admission and daily during the ICU stay. We conducted univariate and multivariate Cox regression analyses to determine the independent DVT predictors (both baseline characteristics and time dependent characteristics), allowing for censoring due to death or discharge and testing the assumption of non-proportional hazards. Results: The overall proximal leg DVT rate was 5.4%. Independent leg DVT risk factors were body mass index (hazard ratio 1.25, 1.06 –1.46, for each 10 unit increase, p ⫽ 0.006), and any statin exposure in the previous week (hazard ratio 0.46, 0.27– 0.77, p ⫽ 0.003). Conclusions: Given widespread inflammation and microvascular thrombosis during critical illness, these findings suggest that rigorous randomized trials are needed to confirm or refute the role of statins for DVT prevention, and to evaluate high-risk subgroups that may derive particular benefit (e.g., sepsis, acute lung injury). Funding: CIHR, Heart and Stroke Foundation of Canada.

Yahya Shehabi, University New South Wales, Rinaldo Bellomo, The Austin Hospital, Steve Webb, Royal Perth Hospital, Michael Reade, The Austin Hospital, Colin McArthur, Auckland Hospital, Ian Seppelt, Leonie Weisbrodt, Nepean Hospital, Frances Bass, Michael Bailey, Belinda Howe, ANZIC RC Introduction: The impact of sedation practice on long-term outcomes is poorly understood. Previous trials didn’t account for the effect of sedatives given early in the ICU admission on relevant outcomes. Hypothesis: Early (first 48 hrs) sedation choice and depth is predictive of time to extubation, delirium and mortality. Methods: A multicentre prospective longitudinal cohort study conducted in 25 centers in ANZ. Critically ill patients ventilated and sedated ⱖ24 hours were followed from ICU admission to hospital discharge with daily delirium (CAM-ICU during light sedation) and four-hourly (RASS) sedation assessments. Multivariable Cox regression proportional hazard was used to quantify relationships between early deep sedation (number of RASS ⱕ-3) and time to extubation and delirium in survivors after 48 hrs and hospital and 6 month mortality after adjusting for diagnosis, age, gender, APACHE II, operative, elective, hospital type, early use of vasopressors and dialysis. Results: We studied 251 patients with mean(SD) age 61.7(15.9) years and APACHEII score 20.8(7.8). Hospital, and 6 month mortality were 53(21.1%) and 64(25.8%) respectively. Midazolam and/or propofol were prescribed equally on ICU admission (53.8%). Over 2678 study days, 14637 RASS assessments were conducted. Deep sedation was used in 191(76%) patients within 4 hours of commencing ventilation and in 171(68%) patients at 48 hours. Delirium occurred in 111 (50.7%) of assessed patients with a median[IQR] duration of 2[1– 4] days. The majority of patients who developed delirium 86/96(90%) or died 39/40(98%) after 48 hours were deeply sedated in the first 48 hours. Using Cox regression, early deep sedation independently predicted time to hospital death (HR 1.11, 95%CI 1.02–1.20, P ⫽ 0.01), 6 month mortality (HR 1.08, 95% CI 1.01–1.16, P ⫽ 0.03) and time to extubation (HR 0.96, 95% CI 0.87– 0.94, p⬍0.001) but not time to delirium occurring after 48 hours (HR 1.03, 95%CI 0.98 –1.08, P ⫽ 0.19). Midazolam and fentanyl cumulative dose in the first 48 hrs was also predictive of time to extubation, independent of sedation depth. Conclusions: Early sedation depth independently predicts time to extubation and 6 month mortality, and should be considered in interventional studies.

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A PROSPECTIVE RANDOMIZED STUDY COMPARING SODIUM BICARBONATE WITH NORMAL SALINE TO PREVENT KIDNEY INJURY IN PATIENTS UNDERGOING CARDIAC SURGERY.

EPIDURAL ANALGESIA IN BLUNT THORACIC INJURYWHICH PATIENTS BENEFIT MOST?

Judith Kristeller, Wilkes University, Wilkes-Barre, PA, Russell Stahl, Community Medical Center, Scranton, PA, Gerald Zavorsky, Marywood University Introduction: Acute kidney injury (AKI) occurs in 30 –50% of cardiac surgery patients and is associated with reduced mortality. Mechanisms of injury may include production of methemoglobin and oxygen radicals in the acidic environment of the kidney. The purpose of this study was to determine if urinary alkalization could prevent kidney injury following cardiac surgery in patients with chronic kidney disease. Hypothesis: Perioperative infusion of IV sodium bicarbonate 150 meq/L in 5% dextrose will reduce the incidence of AKI compared to an IV infusion of 0.9% sodium chloride (NS). Methods: This was a prospective, randomized, double-blinded study of 92 patients (44 bicarbonate and 48 NS) undergoing cardiac surgery using cardiopulmonary bypass with a baseline glomerular filtration rate less than 60 ml/min/1.73 m2. The study medications were infused at 3 ml/kg/hr for 1 hour preoperatively followed by 1 ml/kg/hr during surgery and 6 hours following bypass. Mann Whitney U tests, independent t-tests, and Pearson chi-square tests were used to compare non-parametric independent samples, normally-distributed continuous data, and categorical variables, respectively. Results: Baseline characteristics (sex, age, comorbidities, ejection fraction, kidney function) were similar between the 2 groups. There was no difference between the groups in the primary outcome of AKI using AKI Network criteria (32% bicarbonate group vs. 42% saline group, p ⫽ 0.69). There was also no difference between the bicarbonate and NS groups in the highest postoperative creatinine (1.7 mg/dL vs. 1.6 mg/dL, p ⫽ 0.57), time on the ventilator (9.6 vs. 7.9 hrs, p ⫽ 0.69), use of postoperative blood products (50% vs. 48%, p ⫽ 0.84), postoperative RBCs transfused (2.4 vs. 2 units, p ⫽ 0.58), or postoperative length of stay (7.5 vs. 6.3 days, p ⫽ 0.16). No patients in the bicarbonate group died during hospitalization whereas 4 patients died in the NS group (8%, p ⫽ 0.05); however these deaths were unrelated to the study drug. Conclusions: A perioperative IV infusion of sodium bicarbonate 150 meq/L in 5% dextrose is not associated with a reduction in AKI when compared to a similar infusion of NS in patients with chronic kidney disease undergoing cardiac surgery with cardiopulmonary bypass.

Daniel Yeh, Massachusetts General Hospital, Matthew Kutcher, San Francisco General Hospital, Mary Knudson, Julin Tang, University of California San Francisco General Hospital Introduction: Epidural analgesia for blunt thoracic injury has been shown to improve pulmonary function and provide subjective pain relief, but optimal patient selection and timing of epidural placement remain unclear. Hypothesis: Early (⬍48 h) epidural analgesia (EA) compared with opiate patient-controlled analgesia (PCA) results in fewer pulmonary complications and shorter ICU and hospital length of stay (LOS) after blunt thoracic trauma. Methods: Retrospective 5-year review of non-intubated patients with blunt thoracic injury and ⱖ3 rib fractures. Data collected included demographic data (age, gender, comorbid medical conditions); trauma-related (injuries/ISS score, number of ribs fractured, location of ribs fractured, bilaterality of ribs fractured, presence of chest tube); hospital course and outcome measures (hospital length of stay, ICU length of stay, and pulmonary complications). Pulmonary complications were defined as pneumonia, empyema, hypoxia, and delayed intubation. Logistic regression was used to analyze characteristics associated with pulmonary complications. Results: 187 patients were included; early thoracic epidural was used in only 18% (n ⫽ 34). The mean delay between hospital arrival and epidural insertion was 17.9 hours (⫹/⫺ 13.2 h) and the mean duration of epidural use of 98.4 hours (⫹/⫺ 69.4 h). There were no differences in age, ISS, or complications; ICU and hospital LOS were longer in patients who received an epidural (p⬍0.01). Patients treated with an epidural more commonly had bilateral rib fractures, more total ribs fractured, and a longer ICU and hospital stay. Pulmonary complications were more common in older patients (p ⫽ 0.029) and those who required chest tubes (p ⫽ 0.012), regardless of analgesic modality was used. Conclusions: Early thoracic epidural analgesia use in eligible patients is low (18%). Contrary to published results, in our experience, early post-injury EA failed to reduce the incidence of pulmonary complications, ICU or hospital LOS. Elderly patients and those with tube thoracotomies are at greatest risk for pulmonary complications and may benefit most from epidural analgesia.


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“SEPSIS SPIDER”: AN ELECTRONIC NOTIFICATION SYSTEM TO IMPROVE COMPLIANCE WITH SEPSIS RESUSCITATION BUNDLES IN THE EMERGENCY DEPARTMENT

EFFECT OF TNF/FAS KNOCKOUT IN A NOVEL MODEL OF COMBINED CONTUSION/CONCUSSION BRAIN INJURY IN MICE

Amanda Woloszyn, University of Virginia Health Systems, Ryan Attwood, Massachusetts College of Pharmacy and Health Sciences, Adrian Garofoli, Matthew Baudoin, Alexander Berg, Vernon Smith, Christopher Russi, Maria Rudis, Mayo Clinic

Heda Dapul, Juyeon Park, Jimmy Zhang, Michael Whalen, Massachusetts General Hospital

Introduction: Sepsis resuscitation bundles (SRB) completed within 6 hours in the emergency department (ED) decrease mortality in patients with severe sepsis or septic shock but compliance is often poor, partly due to under-recognition of the disease state early in the ED. Hypothesis: We sought to determine if an electronic notification system (ENS) producing an icon (‘sepsis spider’) on the ED electronic tracking board alerting providers to a possible patient with severe sepsis or septic shock improved compliance with the ED SRB. Methods: The study was conducted in an ED of a large tertiary care academic medical center with 80,000 annual visits. The design was a prospective observational cohort (07/20/2010 –12/20/2010) study with historical controls (01/21/2009 – 06/20/ 2009). Potentially eligible patients for the prospective and retrospective cohorts were identified by an ENS. The ENS criteria were previously validated in our ED population. The prospective and retrospective cohorts were identified by application of the ENS criteria on the ED electronic tracking board in real-time and retrospectively, respectively. Patients were included if they had septic shock (defined as sepsis with hypotension refractory to the equivalent of ⱖ20 mL/kg crystalloid), or severe sepsis with a serum lactate ⱖ4 mmol/L. Patients were excluded if age ⬍18 years, refused central line placement, were involved in a trauma, or diagnosed with hemorrhagic shock or cardiogenic pulmonary edema. Compliance with all and individual components of the ED SRB were compared. Results: Of 1102 in the prospective cohort and 1016 in the control cohort who triggered the ENS, 72 patients were included in each cohort. Demographics and diagnoses were similar in both groups. Compliance with overall ED SRB (31% vs. 15%, p ⫽ 0.029), fluid administration, (85% vs. 65%, p ⫽ 0.007), antibiotic administered within 3 hours (89% vs. 78%, p ⫽ 0.07) and central line placement (43% vs. 28%, p ⫽ 0.055) improved in patients in the prospective vs. control groups. Conclusions: An ENS producing a sepsis icon, visible to all ED providers, aided in identification of patients with possible severe sepsis or septic shock and improved ED SRB compliance.

Introduction: Traumatic brain injury involves diverse pathologic mechanisms that result in neurologic dysfunction mediated in part by inflammatory pathways. We previously reported that TNF/Fas pathways are activated in brain after Controlled Cortical Impact (CCI, contusion model) and Closed Head Injury (CHI, concussion model) in mice. Genetic inhibition of TNF/Fas prior to CCI improves cognitive function but worsens it in a CHI model. Therapy targeting these pathways may thus be detrimental in concussion and beneficial in contusion, but how TNF/Fas inhibition affects patients with mixed contusion/concussion TBI is unknown. Hypothesis: We developed a new model of combined CCI/CHI and tested the hypothesis that TNF/Fas knockout mice would have worse functional outcome vs. wild type, similar to those that suffered CHI alone. Methods: Adult wild type and TNF/Fas knockout mice were subjected to CHI, CCI, combined (CCI⫹CHI or CHI⫹CCI) and sham injuries. Post-injury motor function was assessed by wire grip test, cognitive function by the Morris water maze (MWM) and lesion volume by image analysis. Loss of consciousness (LOC) time was also measured. Paired t-test or RM ANOVA (behavioral data) was used, followed by appropriate post hoc tests. Results: The combined injury model produced significantly longer LOC time and greater lesion volume (p⬍0.05, n ⫽ 10) compared to CCI or CHI alone in wild type mice, while motor and cognitive deficits were similar to the isolated CCI model. Lesion volume, LOC time, motor and MWM deficits did not differ whether CCI preceded or followed CHI in the combined model. In TNF/Fas knock-out mice, cognitive and motor performance did not differ, but lesion volume was smaller compared to wild type. Conclusions: Development of a combined contusion/concussion model can simulate the complex pathophysiology of TBI and be a useful platform for future therapeutic studies. Motor and cognitive deficits in the combined model closely mimic those of isolated contusion injury (CCI), not CHI. Effects of TNF/Fas inhibition in the combined model may be predicted by the CCI model. Data suggest that in the case of TNF/Fas, cerebral contusion mechanisms– not concussion– predominate to determine functional outcome.

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RED CELL DISTRIBUTION WIDTH AS A PROGNOSTIC MARKER IN PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA

VIEWS OF PEDIATRIC INTENSIVISTS ON ETHICS IN DONATION AFTER CARDIAC DEATH

Heajin Chung, Kyuseok Kim, Jae Hyuk Lee, You Hwan Jo, Joong Eui Rhee, Seoul National University Bundang Hospital Introduction: Red cell distribution width (RDW) is associated with mortality in patients with certain diseases, as well as in the general population. The relationship between RDW and mortality in patients with community-acquired pneumonia (CAP) is unknown. Hypothesis: We hypothesized that RDW would be associated with 30-day mortality and have prognostic significance in patients with CAP. Methods: Patients admitted with CAP from the ED were enrolled. RDW was categorized into quartiles. The pneumonia severity index (PSI) and CURB-65 were calculated. The primary outcome was 30-day mortality. Secondary outcomes were hospital length of stay, admission to the intensive care unit, vasopressor use and the need for the mechanical ventilation. Results: A total of 744 patients were included. The PSI and CURB-65 were higher in patients with a higher RDW. In multivariate logistic regression analysis, higher categories of RDW, PSI, CURB-65 and albumin were identified as statistically significant variables. Thirty-day mortality was significantly higher in patients with a higher RDW. Among secondary outcomes, hospital length of stay and vasopressor use were significantly different between groups. In a Cox-proportional hazard regression analysis, patients with higher categories of RDW had increased mortality before and after adjustment of the severity scales. Receiver operating characteristics curves showed improved mortality prediction when RDW was added to the PSI or CURB-65. Conclusions: RDW was associated with 30-day mortality, hospital length of stay and use of vasopressors in hospitalized patients with CAP, and improved the prognostic performance of the PSI or CURB-65.


Ajit Sarnaik, Jeff Clark, Kathleen Meert, Ashok Sarnaik, Children’s Hospital of Michigan Introduction: Donation after Cardiac death (DCD) has been endorsed by several professional organizations including the American Academy of Pediatrics (AAP) as a means of increasing the supply of transplantable organs. However, ethical concerns have been raised in the literature about DCD, especially in children. This study explores views of pediatric intensivists on ethics in pediatric DCD. Hypothesis: Unresolved ethical concerns amongst physicians regarding end-oflife care, potential conflict of interest, and determination of death persist in the practice of DCD. Methods: All members of the AAP Section of Critical Care were emailed an anonymous Likert-type survey, which consisted of 4 demographics questions and 17 questions designed to assess pediatric intensivists’ views on the ethics of DCD in children with respect to established principles of medical ethics. Respondents were also given the opportunity to provide free-text comments regarding their views. Results: 273 of 598 (46%) pediatric intensivists responded to the survey. Of these, 60% reported participating in one or more DCD attempts. 222 (84%) agreed or strongly agreed that it is not acceptable to recover organs prior to the determination of death, consistent with the Dead Donor Rule. However, 107 (41%) disagreed or strongly disagreed that the time of death in DCD can be conclusively determined. 29 (11%) agreed or strongly agreed that the DCD donor may feel pain or suffering during organ recovery. Neither the respondents’ experience level with DCD (p ⫽ 0.61, 0.09, 0.07, respectively) nor practicing in a transplant center (p ⫽ 0.84, 0.15, 0.27, respectively) was significantly associated with responses. 80 (13%) provided free-text comments. Common themes included general ethical concerns about pediatric DCD (n ⫽ 20, 25%), the determination of death (n ⫽ 13, 16%), who should initiate the discussion of DCD (n ⫽ 16, 20%), and delineating donor vs. recipient rights (n ⫽ 12, 15%). Conclusions: Pediatric intensivists hold a wide range of beliefs regarding the ethics of pediatric DCD. Most agree with the implementation of the Dead Donor Rule. However, many express concerns about their ability to determine time of death for the purposes of organ donation.

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END OF LIFE MEMENTO COLLECTION IN MEDICAL EXAMINER CASES

NO EXCUSES-A HOSPICE DESIGNED FOR THE NEEDS OF THE INTENSIVE CARE UNIT

Michal Pankratz, Thivakorn Kasemsri, Texas Tech University Health Sciences Center

Paul Feingold, Emory University, School of Medicine, Alyssa Majesko, Timothy Buchman, Emory University, Center for Critical Care, Tammie Quest, Emory University, Department of Palliative Care

Introduction: In Texas there are more than 1200 child deaths per year with potential referral to the medical examiner. Preservation of evidence is of utmost importance, but end-of-life mementos collected immediately after the death of a child can be helpful for grieving families. Hypothesis: We hypothesize there is no uniform procedure for child life specialists to collect end-of-life mementos in a medical examiner case, and referral to the medical examiner is a barrier to collection. Methods: A cross-sectional study was used to sample child life specialists via a Survey Monkey web-based questionairre following IRB approval. Contact information was obtained from the Child Life Council Database. Sixteen solicitations were sent with nine taking the survey and seven completing. Results: More than 50% of respondents are collecting mementos in 75–100% of all child death cases and 86% believe that end-of-life mementos should be collected in all cases. Approximately half report having a protocol in place though more than 70% still reports difficulty in obtaining end-of-life mementos in such cases. Of those without a protocol in place, 43% report a protocol is in development. Conclusions: Collection of end-of-life mementos is a common practice among child life specialists in Texas, but this practice becomes difficult when the case is referred to the medical examiner. In fact, in a minority of places it is still prohibited. Protocols, which can be helpful in facilitating collection in an effort to preserve evidence, are not universal but are becoming more prominent. We believe that the next step should be to examine this practice at the national level including validation of it’s benefit to the bereaved. If memento collecting is a common practice and is useful then, ultimately a dialogue between the healthcare provider community and the medical examiner community should take place to optimize this practice in medical examiner cases across the country.

Introduction: End of life care is frequently provided in the intensive care unit (ICU) because patients receiving life-sustaining treatments (LST) are often too unstable or unsuitable for transfer to home or community hospices. However, little is known about the utilization of novel in-hospital inpatient hospice units with the ability to accept critically ill patients on LST directly from the ICU setting. Hypothesis: Hospice utilization will improve if hospices can accept patients on LST. Methods: Retrospective chart review was performed on all ICU deaths at 2 Emory University Hospitals from 1/1/2011– 6/30/2011 where a separate in-hospital inpatient hospice facility with the ability to accept patients on LST was available 24 hours a day, 7 days a week. Missed opportunities for transfer to the inpatient hospice unit included patients admitted to the ICU for ⬎24 hrs and either: 1) expressed comfort care course adopted or 2) planned terminations of life-sustaining therapy. Patients were excluded if they were declared brain dead, were organ donors, required high-frequency ventilation, patient or surrogates that refused transfer to the hospice, or if there was insufficient information in the medical record to make a determination. Primary diagnosis was ascertained using ICD-9 codes. Results: During the study period, 34.9% of the 295 patient deaths in the ICU were identified as missed opportunities for inpatient hospice. For this group, 61.2% did not receive a palliative care consult and the mean hospital length of stay was 12.4 days (SD 13.0). Patients’ mean age was 60.8 years (SD 16.9), 53% were male, and 46% were white, 44% were black. The most common primary diagnosis for missed opportunities was septicemia (20%), followed by heart failure (5%) and acute myocardial infarction (4%). During the study period, over half of the patients admitted to inpatient hospice unit came from the ICU. Conclusions: The development of an inpatient hospice unit capable of receiving critically ill patients is a novel approach to end of life care. Despite the availability of palliative care services, proximity of the hospice unit, and the ability to continue LST, over one-third of planned deaths occurred in the ICU.

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USE OF CONTINUOUS CALCIUM DRIPS FOR CALCIUM REPLACEMENT IS ASSOCIATED WITH INCREASED THROMBOTIC RISK IN INFANTS FOLLOWING OPEN-HEART SURGERY.

SUCCESSFUL INTRODUCTION OF NASAL BUBBLE CPAP FOR PEDIATRIC PATIENTS IN FOUR GHANAIAN DISTRICT HOSPITAL CASUALTY WARDS

Stephen Tomek, Jill Cholette, George Alfieris, Deanna Macri, University of Rochester Medical Center

Patrick Wilson, Morgan Stanley Children’s Hospital, Easmon Otupiri, KNUST, Katherine Biagas, Columbia University, College of Physicians and Surgeons, Rachel Moresky, Columbia University

Introduction: Previous work has found an association between increased calcium replacement and morbidity in infants following cardiac surgery with cardiopulmonary bypass (CPB); the form of calcium replacement and the outcome of thrombosis were not studied. This review examines the association between the method of calcium replacement, calcium levels, and thrombosis in infants undergoing cardiac surgery with CPB. Hypothesis: Use of continuous calcium chloride drip and maintenance of elevated ionized calcium (iCa) levels is associated with thrombosis and poorer outcomes in infants following cardiac surgery. Methods: Retrospective review of infants ⬍6 months undergoing cardiac surgical repair/ palliation with CPB. Measurements included: use, timing and duration of calcium chloride continuous drip, total dose of calcium chloride administered, and mean and peak iCa levels. Outcome measures included: clinically-relevant thrombosis, hospital mortality, renal insufficiency, arrhythmias, and duration of mechanical ventilation and inotropes. Results: 142 infants were studied. Mean weight was 3.7 kg ⫹/⫺ 1.2 kg and mean age was 43 days ⫹/⫺ 51 days. The mean RACHS score was 3.4 ⫹/⫺ 1.3; 37 (25%) had single ventricle physiology, 87 (58%) were cyanotic, 5 (3.3%) had 22q11 locus deletion and 18 (12.6%) developed a thrombus. Use of a calcium drip for calcium replacement, largest doses of calcium (mg/kg), and highest peak iCa levels were significantly associated with thrombosis (p⬍0.02). Mean iCa levels and calcium drip duration were associated with mortality and arrhythmias (p⬍0.05), but not thrombosis or other clinical outcomes. Total calcium chloride dose (mg/kg) was also associated with renal insufficiency, arrhythmias, and ventilator and inotropic duration (p⬍0.03). Conclusions: The continuous administration of calcium chloride as a calcium replacement strategy immediately post-op is significantly correlated with the development of thrombosis. Infants receiving the greatest total doses of calcium and with the highest peak iCa levels appear at increased thrombotic risk. Prospective studies controlling for the form of calcium replacement and examining for thrombosis and clinical outcomes are needed to test this association.

Introduction: Nasal bubble continuous positive airway pressure (nCPAP) is a simple and inexpensive intervention for children presenting with acute respiratory distress and may decrease morbidity and mortality in resource-poor areas without access to invasive mechanical ventilation or supplemental oxygen. Hypothesis: The purpose of this study was to determine the feasibility and safety of providing nCPAP to children presenting in acute respiratory distress to the casualty wards of hospitals in a developing country. Methods: Protocolized use of nCPAP was introduced to 4 district hospitals in Ghana using instructive materials. Casualty ward nurses, doctors, and hospital administrators were educated on the physiological benefits of nCPAP in children and didactic and hands-on training were conducted. Two experienced neonatal intensive care nurses and a pediatric critical care fellow provided a 4 hour training session at each site using IntelliPAP CPAP(DeVilbiss Healthcare, Somerset, USA). After training was complete personnel at each site were observed placing pediatric patients on nCPAP. Results: For the training portion of the study, a total of 17 emergency ward nurses in Kintampo (n ⫽ 4), Mampong (n ⫽ 4), Nkoranza (n ⫽ 4), and Wenchi (n ⫽ 5) received training on nCPAP and demonstrated successful application of nCPAP on training dolls. 20 patients have been treated with nCPAP: Kintampo (n ⫽ 8), Mampong (n ⫽ 5), Nkoranza (n ⫽ 2) and Wenchi (n ⫽ 5). Trained nurses were successful in placing nCPAP 100% of the time without the need for physician intervention. No adverse events were reported with use of the device. Conclusions: nCPAP was successfully introduced and safely applied to pediatric patients in casualty wards of hospitals in a developing country. Moreover, application of nCPAP can be reliably accomplished using existing trained nursing personnel with minimal impact on or disruption of existing medical services. We are currently conducting a randomized controlled trial measuring the impact nCPAP has on respiratory rate and need for supplemental oxygen in children presenting with acute respiratory distress.This work was supported by a grant from the GE Foundation.


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OUTCOMES ASSOCIATED WITH A SCREENING AND TREATMENT PATHWAY FOR OCCULT HYPOPERFUSION FOLLOWING CARDIAC SURGERY

CHANGES IN OXYGEN TENSION AMONG PATIENTS WITH SINGLE VENTRICLE PHYSIOLOGY SUPPORTED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

Ran Xu, St. Luke’s Episcopal Hospital, Gregory Laine, Bee Bee Hu, Saint Luke’s Episcopal Hospital, R. Solis, Arthur Bracey, James Wilson, St. Luke’s Episcopal Hospital, Amy Miclat, St. Lukes Episcopal Hospital, Susan Baimbridge, St. Luke’s Episcopal Hospital, George Reul, St. Luke’s Episcopal Hospital and Texas Heart Institute

Andrew Smith, Daphne Hardison, Brian Bridges, Bret Mettler, Karla Christian, David Bichell, Monroe Carell Jr. Children’s Hospital at Vanderbilt

Introduction: Routinely monitored parameters such as blood pressure (BP) and heart rate may not reliably detect perfusion abnormalities. However, central venous oxygen saturation (ScvO2) and lactate (LA) levels can detect occult hypoperfusion (OH) and identify patients who may be at risk for complications. The purpose of this study was to assess the impact of an OH treatment pathway (OHTP) on morbidity and length of stay (LOS) post on-pump coronary bypass and valve surgery. Hypothesis: An OHTP guided by ScvO2 and LA can reduce morbidity and LOS. Methods: Prospective cohort observational study following the implementation of an OHTP, defined by ScvO2 ⬍70% and LA ⱖ18 mg/dL with systolic BP ⱖ90 mmHg upon ICU admission. Initial treatment included volume resuscitation and/or blood transfusion, followed by additional interventions when ScvO2 remained ⬍70%. Repeat LA was obtained 18hr postoperatively. Primary outcomes were ICU/hospital (H) LOS and complications. Results: Among 390 cases evaluated, 53 OH cases were identified and treated according to the OHTP. The 53 cases were compared with 21 OH cases prior to implementation of the pathway. Furthermore, 33 cases achieving the repeat LA goal (⬍18 mg/dL) were compared with 18 cases not achieving the LA goal.Comparing pre-implementation (n ⫽ 21) vs post-implementation (n ⫽ 53): ICU LOS was 117hr vs 64hr (p ⫽ 0.27); HLOS was 16 days vs 11 days (p ⫽ 0.049); ICU readmission rate was 28.6% vs 7.7% (p ⫽ 0.03); length of mechanical ventilation (LMV) was 64hr vs 44hr (p ⫽ 0.67); complication rate was 47.6% vs 26.4% (p ⫽ 0.10).Comparing achieving LA goal (n ⫽ 33) vs not achieving LA goal 18hr postoperatively (n ⫽ 14): ICU LOS was 50hr vs 105hr (p ⫽ 0.06); HLOS was 10 days vs 14 days (p ⫽ 0.17); ICU readmission rate was 9.1% vs 7.1% (p ⫽ 1.0); LMV was 18hr vs 117hr (p ⫽ 0.17); Complication rate was 15.2% vs 50.0% (p ⫽ 0.02). Conclusions: Implementation of an OHTP was associated with significantly shorter HLOS and lower ICU readmission rates, as well as a trend toward shorter ICU LOS and lower complication rate. Among patients managed by the OHTP, achieving the LA goal 18hr postoperatively was associated with a significantly lower complication rate, and a trend toward shorter ICU LOS/HLOS and LMV.

Introduction: Hyperoxemia following resuscitation has been described as an independent predictor of mortality. Hypothesis: Greater increases in oxygen tension following the institution of extracorporeal membrane oxygenation (ECMO) support are associated with an increase in odds of hospital mortality among children with a single ventricle physiology following congenital heart surgery. Methods: Records of all children with a single ventricle physiology receiving ECMO support following congenital heart surgery at a single institution was reviewed from January 2001 through December 2010. The ? pO2 was defined as change from immediate precannulation arterial pO2 to first arterial pO2 following ECMO cannulation. Results: Among 132 ECMO runs, data was incomplete in 17 cases and were excluded from further analysis. Among the remaining 115 cases, median age was 20 days (0 days-16 years), weight was 3.5 kg (2.1–35 kg). Most common operative procedures included Stage 1 palliation (n ⫽ 67), modified Blalock-Taussig shunt (n ⫽ 18), and Fontan palliation (n ⫽ 9). RACHS-1 classification was above 3 in 60%, with ECPR accounting for 36% of all ECMO runs. Median precannulation arterial pO2 was 34 mmHg (IQR 16), and did not differ significantly with respect to survival. Median duration of support was 3.0 days, median hospital LOS was 38 days, with survival to discharge of 37%. Among survivors, ? pO2 was significantly lower (70 mmHg, IQR 379) when compared to nonsurvivors (253 mmHg, IQR 393, p ⫽ 0.008). Clinically relevant covariates were included in a multivariate regression model, demonstrating that a ? pO2 ⱖ200 mmHg is independently associated with a greater than three-fold increase in odds of hospital mortality (OR 3.4, 95%CI 1.3– 8.8, p ⫽ 0.01). Conclusions: Changes in arterial pO2 of greater than 200 mmHg following institution of ECMO support in children with single ventricle physiology following congenital heart surgery is associated with an increase in hospital mortality, independent of established risk factors. A prospective investigation of more restrictive oxygen supplementation following institution of mechanical support among this patient population is indicated.

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CYCLIC AMP-RESPONSIVE ELEMENT-BINDING PROTEIN MODULATES CYTOKINE AND CHEMOKINE EXPRESSION IN BONE MARROW MACROPHAGES

EMERGENCY CRICOTHYROIDOTOMY: A RANDOMIZED CROSSOVER TRIAL COMPARING PERCUTANEOUS NEEDLE FIRST VERSUS NOVEL INCISION FIRST TECHNIQUES

Andy Wen, Mattel Children’s Hospital at UCLA, Lloyd Miller, Kathleen Sakamoto, David Geffen School of Medicine at UCLA

Hussein Kanji, University of British Columbia, Warren Thirsk, Sandy Dong, University of Alberta, Michael Szava-Kovats, University of Calgary, Cristina Villa-Roel, Mira Singh, Brian Rowe, University of Alberta

Introduction: Cyclic AMP-responsive element-binding protein (CREB) is a transcription factor that regulates cellular responses including proliferation, survival, and differentiation. Activated CREB has been shown to directly inhibit nuclear factor-kappa B (NF-␬B) activation by blocking the binding of CREB binding protein to the NF-␬B complex, thereby limiting proinflammatory responses. Hypothesis: We hypothesize that CREB overexpression leads to defective immune responses. Methods: Bone marrow cells were extracted from wildtype (wt) and homozygous CREB transgenic C57BL/6 mice, which have CREB overexpression in myeloid cells. Bone marrow-derived macrophages (BMMs) were generated and subsequently stimulated in vitro with the Toll-like receptor 4 (TLR4) ligand Lipid A (LPA). At various time points after activation, mRNA induction (fold change) of TNF-␣, KC, IL-1␤, IL-1RA, IL-6, IL-10, IL-12p40, MIP-2, MCP-1, and I?B␣ expression were measured by Q-PCR and TNF-␣ and KC protein levels were also measured by ELISA. All experiments were completed in triplicate with values expressed as mean ⫾ SD. Statistical significance (p⬍0.05) was determined using Student’s t-test. Results: BMMs from CREB transgenic mice compared with BMMs from wt mice had decreased mRNA expression (fold change) of IL-1␤ (186.1 ⫾ 46.8 vs. 139.7 ⫾ 39.8, p⬍0.05), KC (76.6 ⫾ 9.2 vs. 13.4 ⫾ 6.6, p⬍0.0001), and MCP-1 (24.5 ⫾ 4.3 vs 15.5 ⫾ 6.7, p⬍0.01) in response to LPA. CREB transgenic mouse BMMs compared with wt mice also had increased mRNA expression of IL-1RA (4.4 ⫾ 0.5 vs. 6.7 ⫾ 2.6, p⬍0.05) and IL-10 (3.2 ⫾ 0.8 vs. 4.3 ⫾ 1.7, p⬍0.05) in response to LPA. BMMs from CREB transgenic mouse compared with wt mice also had decreased KC protein levels (518.7 pg/ml ⫾ 43.8 vs. 1478.3 pg/ml ⫾ 35.2, p⬍0.001) in response to LPA. There were no statistical differences in expression of TNF-␣, IL-1␤, IL-12p40, MIP-2 and I?B␣. Conclusions: Altered cytokine and chemokine induction by TLR4 activation in BMMs from CREB transgenic mice may alter subsequent immune responses leading to an increased susceptibility to infections.T32 HD007512 Human and Molecular Development Training Grant.


Introduction: Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated or ventilated by conventional means. The literature remains divided on the best insertion technique, namely the open/surgical and percutaneous methods. Hypothesis: The two are not mutually exclusive and we hypothesized that an “Incision First” modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method. Methods: A randomized controlled cross-over design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision and dilatation attempts. Finally, proportions of successful intra-tracheal insertion and subjective ease of insertion were compared. Results: The mean time required for the NF technique was 89.3⫾5.0 seconds vs. 64.2⫾3.9 for the IF technique (p⬍.001). The mean number of needle insertions (1.9 vs. 1.2; p ⫽ 0.003) and dilation attempts (1.3 vs 1.0; p ⫽ 0.016) were also significantly higher for the NF technique; there was no significant difference with incision attempts (2.6 vs. 2.1; p ⫽ 0.08). Successful intra-tracheal insertion was documented in 87% and 100% of the NF and IF techniques, respectively (p ⫽ 0.04). All the study participants found the IF hybrid approach easier. Conclusions: The “incision first” modification allows faster and more successful airway access than the classic NF percutaneous technique in a validated model of cricothyroidotomy. We suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy.

129 EFFECTS OF REVERSAL OF HYPOTENSION ON CEREBRAL MICROCIRCULATION AND METABOLISM IN EXPERIMENTAL SEPSIS Fabio Silvio Taccone, Erasme Hospital, Fuhong Su, Laura Penaccini, Erasme University Hospital, Alessandro Devigili, Erasme Hospital, He Xinrong, Erasme University Hospital, Sabino Scolletta, Department of Intensive Care, Erasme Hospital, Jean-Louis Vincent, Daniel De Backer, Erasme University Hospital Introduction: Alterations of cerebral microvascular blood flow occur during septic shock and areassociated with a decrease in cerebral oxygenation and an altered brain metabolism. Hypothesis: Reversal of hypotension with vasopressor agents may improve cerebral microcirculation, oxygenation and metabolism in a clinically relevant experimental model of septic shock. Methods: In 8 sheep, peritonitis was induced by injection of feces into the abdominal cavity. At the onset of septic shock (mean arterial pressure, MAp⬍65 mmHg, unresponsive to fluid challenge), norepinephrine was titrated to restore a MAP ⱖ75 mmHg. The microcirculation of the cerebral cortex was evaluated using Side Dark-Field videomicroscopy. Brain partial pressure of O2 (PbO2) was measured by Clark’s electrodes (Lycox, Integra) and cerebral metabolism was assessed by microdialysis (CMA, Sweden). Measurements were obtained at baseline, 6 and 12 hours, at shock onset and 2 hours after the start of norepinephrine infusion. Results: Animals developed septic shock after a median time of 15 [14 –19] hours. The proportion of perfused vessels (PPV) decreased from 98⫾2% to 79⫾9%. Concomitantly, PbO2 significantly decreased (from 59⫾5 to 41⫾4 mmHg) while brain metabolism deteriorated: lactate/pyruvate ratio increased (LPR, from 19⫾5 to 47⫾13), as glutamate (from 8⫾4 to 17⫾ 11 mcM) and glycerol (from 14⫾6 to 19⫾11 mcM). Norepinephrine infusion (mean dose: 2.8 mcg/kg/min) increased MAP (to 77 [75– 83) mmHg]) and PbO2 (to 55⫾5 mmHg) while LPR decreased to 28⫾4. Alterations of microcirculation remained unchanged, while glutamate and glycerol brain levels further increased (23⫾16 and 25⫾13 mcM, respectively). Conclusions: In this model of septic shock, hypotension reversal with vasopressors improved cerebral oxygenation but not the alterations of brain microcirculation and cerebral metabolism.Grants:Bourse de Recherche Fondation Erasme, Integra Lifescience, European Society of Intensive Care Medicine.


Posters: Administration 130

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DO SOCIOECONOMIC DISPARITIES IMPACT 30 DAY READMISSION FOR SICU PATIENTS?

USE OF A TRANSFER CENTER TO MANAGE THE TRANSFER OF PEDIATRIC PATIENTS FROM THE EMERGENCY DEPARTMENT TO THE INTENSIVE CARE UNIT: A PILOT STUDY

Marites Cumba, Ilan Rubinfeld, Lisa Takis, Henry Ford Hospital, Avinash Narayana, Henry Ford Hosptial, Peter Perakis, Dionne Blyden, Mathilda Horst, Henry Ford Hospital Introduction: Thirty-day hospital readmission is a focus of quality improvement and harm reduction campaigns as this occurs in more than 20% of hospital discharges. Current intensive care unit (ICU) data focuses on readmission from the general practice floor and not readmission to the hospital. For many complications, including hospital readmission, surgical patients who require intensive care represent a high risk patient population. We aim to investigate socioeconomic status and its influence on readmission for surgical ICU patients. Hypothesis: We hypothesized that socioeconomic disparities would impact the rate of readmission of SICU patients. Methods: A retrospective analysis of an urban surgical intensive care unit’s patient discharge data from 2007–2010 was conducted. Utilizing corporate data stores, demographics, insurance status, and census tract, readmission data was analyzed using chi-square and student’s t-test. Analysis performed in SPSS 19 (IBM, NY) and Minitab 16 (Minitab, PA). Results: A total of 9259 SICU patients were analyzed, 1735 (18.7%) were readmitted within 30 days of discharge. In the total population, there were 5383 men (55.3%) and 3553 (36.5%) African American (AA) patients. Of those readmitted, 976 (56.2%) were male. Non AA patients had a 17.8% rate of readmission compared to 20.2% readmission rate in the AA population (p ⫽ 0.004). There was no significant difference for rehospitalization when comparing patients above and below the age of 65 years. Public-insured patients had the highest rate of readmission; 21.2%, compared to all other patients, 16.1% (p⬍0.001). Only 8.66% (38) of the 439 patients with no insurance were readmitted (P⬍0.001). Education, family income and median household income did not reveal any meaningful significant differences. Conclusions: More than 1 out of 6 surgical intensive care unit patients are readmitted within 30 days. African American patients had higher rates of readmission, while age did not impact readmission rate. Public-insured patients had higher readmission rate than patients with no insurance. Our population did not show significance with hospital readmission in regards to education, family income or median household income.

Marianne Hatfield, Amber Cocks, Robin Warnick, Daniel Hirsh, Children’s Healthcare of Atlanta, Atul Vats, Emory University School of Medicine and Children’s Healthcare of Atlanta Introduction: Transfer of care of patients is recognized as problematic. The transfer of care of patients from the Emergency Department (ED) to the Intensive Care Unit (ICU) has several aspects of transfer that operate independently (EDto-ICU physician transfer/handoff, nurse-to-nurse transfer, and bed placement) that can lead to delays in transfer to a higher level of care, delays in treatment, delays in care for other waiting ED patients, misinformation, and errors. Transfer centers (TC) have been utilized at many institutions to improve quality of care and efficiency for acceptance of patients from outside institutions. Hypothesis: Use of a TC to coordinate all ED to ICU patient transfers at an academic pediatric hospital will lead to decreased ED length of stay (LOS), decreased disposition to exit time (DTE), and decreased errors. Methods: Children’s Healthcare of Atlanta has a TC that was established in 2009 for referrals from outside centers. The study was performed on the Egleston campus which is affiliated with Emory University. The institution has an occurence notification system (ONS) utilized for reporting and monitoring patient care related occurrences and errors. The TC was implemented as a trial for all ED to ICU transfers from May 16 –July 11, 2011. DTE and ED LOS for the trial period were compared to same time period one year earlier (YE) and the same time period immediately prior (IP). ONS rates related to ED transfer of care were monitored. Results: 118 patients were transferred from the ED to ICU during the study period compared to 129 YE and 154 IP. Average DTE decreased to 69.9⫹47.5 minutes (78.3⫹48.7 YE, p ⫽ 0.17. 80.2⫹51.6 IP, p ⫽ 0.09) and ED LOS decreased to 215⫹99 minutes (229⫹110 YE, p ⫽ 0.281. 241⫹114 IP, p ⫽ 0.04). The campus ONS rate was 3.5/month in 2009 –2011. There were zero ONS reports during the study period. Conclusions: In this pilot trial of utilizing a TC to manage transfer of patients from the ED to ICU, there was a decrease DT and ED LOS in the time period immediately after initiation of the process change. The trial has also been associated with a decreased ONS rate. Further study is warranted to see if the results of this trial period are sustained.

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INTERNATIONAL TELEMEDICINE SUPPORT FOR POSTOPERATIVE CARE OF PEDIATRIC LIVER TRANSPLANT PATIENTS

RATES AND DETERMINANTS OF INFORMED CONSENT IN AN INTERNATIONAL THROMBOPROPHYLAXIS TRIAL

George Mazariegos, Children’s Hospital of Pittsburgh, Marco Spada, Giovanna Panarello, Antonio Arcadipane, Bruno Gridelli, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Luis Caicedo, Maria Agudelo, Fundaci▫ alle del Lili-Sede principal, Matthew Klevemann, Rakesh Sindhi, Raj Aneja, Children’s Hospital of Pittsburgh Introduction: Specialized transplant expertise for technically or medically challenging cases is limited by availability, logistics, or cost. Hypothesis: To describe the functionality and process for telemedicine support of international pediatric liver transplant programs. Methods: Over a two year period, telemedicine support was developed collaboratively between Children’s Hospital of Pittsburgh of UPMC (CHP) and two institutions: Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy and Fundacion Valle Lili (FVL) in Cali, Colombia. Telemedicine support consisted of two models: 1. Tele-ICU support for daily ICU tele-rounding among transplant team members of ISMETT and CHP. 2. FVL: Monthly case review (tele-pathology, case conference discussion) and annual site assessment. Information technology support included Polycom HDX7000 video conferencing equipment in Pittsburgh and Polycom CMA software in Palermo. LifeSize video conferencing equipment was used at FVL. Host site staff coverage included transplant surgeon and ICU attending coverage and surgeon/hepatology/pathology support. Results: In ISMETT, from 1/1/2011 to 9/1/2011, 5 pediatric transplant recipients were managed through a total of 45 ICU days. Patient and graft survival is currently 80%. In FVL, 124 patients were managed over a period of two years (2008 –2010). Patient and graft survival in patients ⬍10 kg improved to 75% as compared to 36% in historical controls. Conclusions: Current information technology functionality increases the availability of transplant expertise and may impact outcomes favorably in a cost effective manner. Telemedicine support maybe tailored to specific program needs and capacity and focus on peri-transplant issues, longterm follow-up or both.


Orla Smith, Nicole Zytaruk, Ellen McDonald, Denise Foster, France Clarke, Andrea Matte, Laurie Meade, Nicole Godfrey, Shirley Vallance, Leonie Weisbrodt, McMaster University Introduction: The successful completion of randomized trials in critical care is contingent upon ability to screen, consent, and enroll patients, both ethically and efficiently. Knowledge of predictors for consent is useful identifying modifiable factors in trial design and conduct. Hypothesis: To analyze informed consent rates and predictorys in an international trial of heparin thromboprophylaxis during critical illness (clinicaltrials.gov NCT00182143). Methods: Throughout the trial (May 2006 –June 2010), research personnel in 67 centers in 6 countries approached 4556 eligible critically ill patients or their families for informed consent. Whether consent was obtained or declined was documented on screening and case report forms. At the end of the trial, each site’s lead research coordinator provided data on local ICU characteristics and research infrastructure. Results: 3746 patients were enrolled in PROTECT. The overall consent rate was 82.3% (range 50 –100%) across centers, obtained from families and patients in 90.1% and 9.9% of cases respectively. Six factors were independently associated with higher informed consent rates. Consent rates were higher among persons with more experience (OR 3.84, 2.74 –5.38), for those with ⬎10 years of experience procuring consent in the ICU compared to persons new to ICU research, and OR 1.92 (1.50 –2.45) for persons with up to 10 years experience compared to persons new to ICU research (p⬍0.001). Consent rates were higher in ICUs with ⬍15 beds (p⬍0.001) and in centers with ⬎1 full-time research coordinator (p⬍0.001). Consent rates were lower in centers affiliated with the CCCTG or the ANZICS-CTG (OR 0.51, 0.38 – 0.69, p⬍0.001) compared to those that were not. Community-affiliated centers had higher consent rates than university-affiliated centers (OR ⫽ 1.70, 1.02–2.83, P ⫽ 0.04). The consent rate was highest during the PROTECT Pilot Trial; during the full trial, consent rates increased each year of recruitment thereafter. Conclusions: The majority of individuals approached for consent in the PROTECT trial agreed to participate. Characteristics of study centers and ICU research infrastructure, including research coordinator experience, play an important role in the high consent rate.

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AUTOMATED SCHEDULE GENERATION OF MD STAFFING FOR A PEDIATRIC ICU USING INTEGER PROGRAMMING TO ACHIEVE ENHANCED CONTINUITY

A SYSTEMATIC REVIEW OF ROUNDING PRACTICES IN INTENSIVE CARE

Hannah Smalley, Pinar Keskinocak, School of Industrial and Systems Engineering, Georgia Institute of Technology, Jana Stockwell, Children’s Healthcare Of Atlanta @ Egleston, Atul Vats, Emory University School of Medicine and Children’s Healthcare of Atlanta

Introduction: Effective rounding in the ICU is associated with improvements in patient outcomes and greater patient and provider satisfaction. Hypothesis: We describe a systematic review of the literature to identify current ICU rounding practices, facilitators and barriers to information exchange, and tools for improving the process. Methods: We searched Medline, Embase, CINAHL, and the Cochrane library to identify articles pertaining to rounding in the ICU. Both quantitative and qualitative articles were eligible for inclusion. Two reviewers independently extracted relevant data. Results: 4605 articles were identified by the initial search strategy. A review of the citations resulted in data abstraction from 38 articles. Seventeen (45%) focused on rounding structure, addressing issues such as the location or layout of rounds (1), the allocation of time or activities during rounds (3), or the composition of the rounding team (13). Communication was addressed by 16 (42%) of the citations, focusing on the content of rounds (1), the use or transfer of information (8), or the use of tools to improve communication (8). Standardization of rounding practice including the location for discussions, time for rounds, roles among the team, and presentation format were identified as facilitators for rounding. Multidisciplinary team composition and both goal oriented and open discussions were also identified as facilitators. Poor understanding of goals of care, interruptions, missing information, and team members not present during rounds were identified as barriers. Three tools for improving communication (daily goals checklist, rounds checklist, and immediate protocol adherence feedback) and 1 for improving efficiency (mobile computing stations) were identified. Five articles (13%) addressed inter professional relations from provider perspectives. Conclusions: A substantial body of literature exists regarding ICU rounding practices with varying degrees of evidence for facilitators, barriers and tools to improve the rounding process. This review will identify gaps in our current understanding and help to inform future quality improvement initiatives.Funding provided by the Health Quality Council of Alberta and Alberta Innovates.

Introduction: Continuity of care can improve patient satisfaction and outcomes, but care is increasingly fragmented (hour restrictions and lifestyle choices by MDs). Manual MD duty schedule construction is complex and time-consuming. An automated tool could be more efficient/effective in generating schedules with greater continuity and satisfy requirements/preferences. Hypothesis: An integer programming model (IP) can efficiently generate a schedule meeting all constraints and with a greater Handoff Continuity Score (HCS) than a manually generated schedule. Methods: A 6-month duty schedule was generated manually by an MD group with the goal of achieving a high HCS and conforming to predefined constraints (e.g., staffing model and MD requests). The HCS rates continuity on a scale of 0 –1 (1 ⫽ highest continuity) (CCM 2010 38(12) Sup111). An alternative schedule was generated using an IP with the same goals. Time spent for the generation of schedules was estimated. An HCS was calculated for each schedule. Results: The manually constructed schedule required a solution time of approximately 4 person-hours vs. approximately 2 computer-hours and 5 minutes preparation for IP model to generate schedule (using CPLEX 12.2). Entering IP solution into Excel and using a Macro to generate user-friendly duty schedule required ⬍5 minutes. HCS for the IP-generated schedule improved by 11% over manual schedule. When a change in MD staffing occurred (one MD removed from schedule pool), IP took ⬍5 seconds to reassign shifts to other MDs. Manual reassignment required approximately 30 minutes. While development of the mathematical model required a lengthy period of time for fine-tuning constraints and debugging, the resulting model is general (i.e. can easily accommodate varying MD groups and requests, or can be adapted to other MD groups, without requiring extensive modifications to underlying code). The model can be used for future schedules for this MD group or others. Conclusions: The IP generated an MD schedule in less time and with a greater HCS than the manually constructed schedule. Further study is needed to identify impacts (if any) of the automated schedule on MD satisfaction and outcomes.

Dan Lane, Mauricio Ferri, H. Tom Stelfox, University of Calgary

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AN ICU PROVIDER STAFFING MODEL UTILIZING ACUTE CARE NURSE PRACTITIONERS IMPROVES ACCESS TO HIGH QUALITY CRITICAL CARE SERVICES

COMPARING MATHEMATICAL MODELS FOR LENGTH OF STAY IN A CARDIAC INTENSIVE CARE UNIT

Lorraine Rosenthal, George Tseng, Mary Beyatte, Michael Havenar, Nicole Backes, Andreia Cage, Cory Hess, Anne French, Kathryn Neunaber, Walter Boyle, Washington University in Saint Louis

Introduction: Cardiac critical care units provide resource-intensive and life saving medical and surgical care. Demand for cardiac critical care beds fluctuates within medical institutions leading to cycles of clinical and economic inefficiencies and insufficiencies. The distribution of length of stay (LOS) of patients in a cardiac intensive care unit (ICU) is highly skewed. There are patients who spend weeks or even months in the ICU receiving care. Cardiac operating room utilization is complicated by variability inherent in ICU LOS. We investigated asymmetric mathematical distributions to determine which one was superior for modeling LOS in cardiac ICU. Hypothesis: We hypothesized cardiac ICU LOS would be well modelled by a 3 parameter lognormal model. Methods: With institutional approval, we studied admissions to a cardiac ICU following various cardiac surgeries at a teaching hospital. We modeled LOS for cardiac surgeries categorized by ICD-9 procedure codes. We modeled and tested 2,350 surgeries and 66 different ICD-9 codes performed by 23 different surgeons. We used Kolmogorov-Smirnov (KS) tests to test if data for each ICD-9 code were-consistent with one or more of 4 model distributions: normal (N), 3-parameter lognormal (3PLN), 3-parameter Gamma (3PGAM), and 3-parameter Weibull (3PWEIB). We compared overall performance of the 4 models using Friedman tests. Results: We tested, using KS tests, 66 different ICD-9 codes (those with sample sizes (n ⬎ 9) sufficient to fit a model distribution. The data fitted better the 3PLN ⬎3PGAM ⬎3PWEIB ⬎N model (Friedman tests, P⬍005). To illustrate these statistical models we plotted the actual (empirical) data (illustrated as a frequency histogram) with the fitted 3PLN, 3PGAM, 3PWEIB, and N models (see Figure). The cardiac ICU LOS illustrated is ICD-9 ⫽ 37.51, heart transplantation, n ⫽ 120 cardiac surgeries). Conclusions: Choosing an appropriate statistical model is an important step in forecasting ICU LOS with known precision. Our results help legitimize the use of log transforms to normalize LOS before hypothesis testing using linear statistical models or other tests to investigate factors affecting cardiac surgical scheduling and ICU capacity planning.

Introduction: The limited physician intensivist supply for the growing demands for high quality critical care services is well-described. Available data suggest that ICU staffing models utilizing non-physician practitioners have the potential to help fill this supply:demand gap. Hypothesis: The addition of surgical critical care beds staffed by Acute Care Nurse Practitioners (ACNPs), in collaborative practice with physician intensivists, will result in improved access to high quality critical care services. Methods: In 2010, the Perioperative Surgical Services Group at Barnes Jewish Hospital opened an 8 bed Critical Care Area (CCA) for post-procedure surgical patients expected to require ICU care for less than 24 hours, thereby allowing the more traditional ICU’s to care for patients expected to require longer ICU stays. The CCA was staffed 24X7 by ACNP’s, who documented and billed for the care they provided in collaborative practice with the Anesthesiology/Surgery Critical Care Group at Washington University School of Medicine. ICU patient flow and outcomes were compared in the 6 month periods immediately before and after opening the CCA. Results: During the first 6 months, the CCA admitted an average of 130 patients per month (PPM), with an average length of stay (LOS) of 23.6 hrs. Consistent with the mission of the CCA, the admission rate to one of the primary surgical ICUs decreased from 149 to 132 PPM, with an increase in the average LOS from 3.6 to 4.8 days. ICU readmission rates, one of the principal quality indicators, remained low with no significant statistical change following the opening of the CCA. Notably, there was a 2.4% increase in surgical case volume for the services that admit to the CCA and other surgical ICUs, with a dramatic 28% increase in the number of these patients cared for in one of these areas. There was also a dramatic 65% decrease in patient “holds” awaiting ICU beds in the post-anesthesia care unit (56 to 20 PPM). ACNP billing and reimbursement, while not sufficient to fully offset expenses, minimized CCA provider cost. Conclusions: This study demonstrates that an ICU provider staffing model utilizing ACNPs improved access to high quality critical care in a cost-effective manner.

David Strum, University of Pennsylvania, Luis Vargas, University of Pittsburgh


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THE IMPACT OF INTRODUCING A CLINICAL INFORMATION SYSTEM ON ICU WORKFLOW

REDUCING NON-ICU CODES EXPOSES CHALLENGES IN A LARGE FREE-STANDING CHILDREN’S HOSPITAL

Daniel Weiss, Yoram Weiss, Hadassah Hebrew University Medical Center

Ken Tegtmeyer, Cincinnati Children’s Hospital, Mary Giaccone, Derek Wheeler, Cincinnati Children’s Hospital Medical Center

Introduction: Computerized information systems (CIS) have been shown to reduce medical errors, adverse drug effects and even mortality. The term “workflow” has been coined in business sciences to define a series of interactions linked together to perform a task. CIS may augment and reorganizing long established workflow processes, hence, the common resistance among nurses and physicians to the change. We have used this methodology to study the activities of an ICU physician and nursing staff. Hypothesis: Introduction of a CIS will augment the workload and change ICU workflow processes. Methods: Using observation report sheets and a digital stopwatch, staff activities including movements, location (bedside, nurse station etc.) in the ICU and times at each location were recorded. The nursing staff was observed for a total of 35 hours and the physicians for 24 hours while using manual paper charts and again one year after CIS implementation. Data were categorized as direct patient care; charting and miscellaneous (MSC) activities (phone calls, teaching, paperwork, etc.). Results: Among physicians, working with the CIS prolonged the fraction of work time dedicated to charting (30⫾15% to 50⫾17%, P ⫽ 0.05) somewhat shortening patient care and MSC times. Among nurses, there were no significant changes in patient care, charting or MSC times. When observing the number of times accessing each location there were no significant differences between manual charting and CIS charting among nurses and physicians alike. A new element defined as “distant charting,” i.e. access to patient information from a remote computer, was found to be greatly utilized by physicians (50% of charting time) and less so by nurses (8% of charting time). Conclusions: The CIS did not result in either increased workload or major workflow reorganization among nurses and physicians. The increase in charting times among physicians can be explained by better accessibility to the hospital-wide CIS. Introducing a CIS had minimal impact on the ICU workflow process.

Introduction: As part of a global effort to reduce harm in health care institutions, the implementation of Rapid Response Teams were recommended by the IHI in 2003. In 2005 we implemented our Medical Response Team (MRT) and were able to document a dramatic decrease in preventable non-ICU codes. Further expansion of our MRT program by eliminating the PICU curbside, or consult has made preventable non-ICU codes a very rare event in our institution (averaging 18 months between events). In the mean time our monthly rate of MRT activations went from 9.2/month to 39.5/month. In recent months there has been a perception of an increased number of code team activations for adult non-patients. Hypothesis: The proportion of adult visitor or employee code team activations has become the majority of non-ICU codes (relative to pediatric aged or adult-aged pediatric patients) with the minimization of preventable codes. Methods: We performed a prospective review of our internal code team activations. All activations resulted in e-mail notifications to the co-chairs of the code committee, which we then used as a prompt to classify whether the code was on a patient or non-patient adult. Since some patients are adult aged, but continue to be followed by pediatric specialists, these patients were considered as patients as the physiology of their underlying disease would likely have made the pediatric specialists more comfortable with management. Data was maintained in an excel spreadsheet. Results: From March through August 2011 35 of 65 (54%) code team activations were for non-patient adult visitors or employees. The most common diagnoses included chest pain, hypoglycemia and syncope. Conclusions: In light of EMTALA, free standing children’s hospitals must be aware that given the large volume of adults present on the hospital campus adequate structures must be in place to deal with adult medical emergencies. Reduction of non-ICU preventable codes brought increased attention to these events that were previously buried by the larger number of pediatric codes.

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DOCUMENTATION OF PATIENT CARE TIME BY NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS IN THE INTENSIVE CARE UNIT

DEVELOPMENT OF SWARM AS A MODEL FOR RAPID PROBLEM-SOLVING AND INSTITUTIONAL LEARNING IN THE PEDIATRIC AND CARDIOVASCULAR INTENSIVE CARE UNITS

David Carpenter, Sara Gregg, Daniel Owens, Timothy Buchman, Craig Coopersmith, Emory Center for Critical Care Introduction: Many hospitals are using physician assistants and nurse practitioners (referred as “affiliates”) to staff ICUs. Despite the rising use of affiliates in the ICU, there is little data on how they allot their time. Hypothesis: To determine how affiliates allocate their time in the ICU. Methods: A prospective observation study of 39 affiliate providers in 7 ICUs in an academic hospital and a hybrid academic/community hospital. During a 6 month baseline period affiliates in each ICU self- documented their time devoted to patient care. A monetary incentive was then offered for each ICU where every affiliate documented 75% of time devoted to patient care and self reported data was collected for a further six months. Documentation included time associated with patient care charges (critical care, evaluation and management, and procedures) and a new category (“zero charge time”) which included other patient care activities that are not billable. Results: During the baseline period, none of the ICUs had documentation of 75% patient care time by all of its affiliates. Individual time documentation averaged 53% (range 21%–95%). In the six months where reporting was tied to a group incentive, six of the seven ICUs had every affiliate document greater than 75% of their time. Individual time documentation increased to 84% (range 61%–100%). Documentation of time spent on billable activities increased from 53% of an affiliate’s shift to 63%. Affiliates working day, evening, or night shift had similar time documented. Zero charge time accounted for an average of 21% of each shift. Rounding and sign-out were the most common reasons for zero charge time. Although not eligible for the monetary incentive, physician time documentation paralleled affiliate time documentation, increasing from 4.7 hours/day to 6.3 hours/day. Conclusions: Approximately two thirds of an affiliate’s shift is spent providing billable services to patients. Greater than 20% of each shift is spent providing equally important but non-reimbursable patient care services. Understanding how affiliates spend their time and what proportion of time is spent in billable activities can be used to plan the financial impact of staffing ICUs with affiliate providers.


Eric Williams, Baylor College of Medicine, Elizabeth Fredeboelling, Angela Morgan, Gay Matthews, Texas Children’s Hospital, Jeanine Graf, Baylor College of Medicine Introduction: Our purpose was to develop a high reliability system to empower frontline staff to share information regarding communication and process inefficiencies to rapidly develop solutions. Hypothesis: A systematic process for recognition, evaluation, and transparent feedback, could increase the use of problem-solving. Methods: A multidisciplinary team, led by a physician and nurse, developed an email strategy to let frontline staff identify problems in real time and solve and spread this knowledge throughout the ICU environments. These were outside the scope of institutional patient safety reporting. Unless immediate attention was required, the SWARM team evaluated entries weekly. Entries were categorized as: 1) Useful information to share with ICU staff; 2) More information needed to be obtained and personnel consulted; or 3) A multidisciplinary task force needed to generate consensus and evidence-based guidelines. Solutions were shared with ICU staff via direct email and a monthly newsletter. After 6 months we surveyed ICU staff with 5 questions regarding awareness, utility, and ease of use of the SWARM process. Staff were resurveyed after re-education and institution of leadership walk-rounds. Rates of SWARM entries before and after re-education were compared using Fisher’s Exact Test for proportions. *p⬍.05. Results: Of the total 95 SWARM entries, 35% were level 1, 47% were level 2 and 18% were level 3. Pre- and post- survey indicated that staff awareness increased from 70% to 91% and staff understanding of utility increased from 57% to 75%. After re-education, use in PICU increased by 514% (0.8/week to 3.9/week)*. Use in CVICU increased by 417% (0.7/week to 2.9/week)*. In total, use across critical care units increased by 457% (1.5/week to 6.8/week)*. The increased rate of use of the SWARM system has been sustained for 8 weeks after education. Conclusions: We developed a system to better manage quality through real-time awareness of our performance. The formal creation of a standardized context for information sharing has resulted in a significant increase in the performance of problem-solving. This multidisciplinary effort allows us to minimize the gap between what we are doing and what we should be doing.

142 IDENTIFYING “WASTE” IN THE ICU Khalid Almoosa, University of Texas Health Science Center at Houston, Katherine Luther, Institute for Healthcare Improvement, Bela Patel, UTHSC Houston Medical School Introduction: US Healthcare expenditures for 2009 were $2.47 trillion. It is estimated that 30 –50% of these costs is “waste,” resulting from preventable complications, unnecessary interventions, and simple inefficiency. Intensive care units (ICU) are estimated to cost $131 billion per year. We sought to determine the prevalence of and reasons for inappropriate use of Intensive Care Unit (ICU) beds using the new “waste” identification tool developed by the Institute for Healthcare Improvement (IHI). Hypothesis: A significant portion of hospital ICU beds are inappropriately utilized and contribute to “wasted” resources. Reasons for this misuse are multi-factorial and vary among different specialty ICUs. Methods: We determined the extent of and reasons for inappropriate use of hospital ICU beds using the IHI’s Hospital Inpatient Waste Identification Tool (Innovation Series 2011). We asked the ICU attending physicians on clinical service at both a 16-bed “closed” medical ICU (MICU) and a 10-bed “open” transplant surgical ICU (TSICU) to review daily all patients’ criteria for remaining in the ICU. For patients who did not meet ICU criteria and were not being transferred out (i.e. inappropriate ICU stay), the attending physicians identified the reason(s) and recorded them using the Waste tool. Results: Over a 3-month period (85 days), 583 patients (396 in MICU and 187 in TSICU) were admitted to both ICUs, for a total of 1631 patient-days. Physicians determined that 15% of MICU patient-days and 26% of TSICU patient-days were “waste.” The main reasons for the wasted days in both ICUs were delays in end-of-life decisionmaking and transfers out of the ICU (i.e. awaiting beds). Determination of “waste” also varied among the 7 Attending physicians who participated in this study and may reflect the subjective use of this tool. Conclusions: A significant proportion of hospital ICU days may be unnecessary and are mainly due to delays in transfers out of the ICU and end-of-life decision-making.

143 MIDLEVEL PROVIDERS IN THE ICU: CHALLENGES WITH STAFF RECRUITMENT AND RETENTION Rhonda D’Agostino, Stephen Pastores, Memorial Sloan-Kettering Cancer Center, Neil Halpern, Memorial Sloan-Kettering Cancer Ctr Introduction: Mid-level providers (MLP) (nurse practitioners [NP] and physician assistants [PA]) have supplemented the critical care medicine (CCM) resident staff and fellows in our adult medical-surgical ICU since January 2007. The MLP program covers the CCM service 24/7 and has steadily grown from 11 FTEs in 2007 to 23.6 in 2011 as the ICU bed numbers and programmatic responsibilities have increased. Since initiation, we have faced challenges with recruitment and retention of the CCM MLP staff. Hypothesis: The purpose of this study was to determine the reasons why MLPs resign from our CCM program. Methods: We identified the MLPs who resigned from the CCM program since its inception. Using personnel files and exit interviews, we retrospectively determined the reasons they resigned. Data collected included gender, professional training (NP or PA), dates of hire and resignation, and reasons for leaving (inability to pass the mandatory 6-month CCM training course, unsatisfactory work schedule, relocation, and personal reasons). Results: During the study period, 44 MLPs (43 NPs and 1 PA) were hired; 89% were female. Twenty (45%) MLPs resigned. Of these, 7 did not pass the 6-month CCM training course. The remaining 13 MLPs resigned after an average of 15 months. The reasons for their resignation were desire for a better work schedule (8; 62%), relocation (2; 15%), and personal reasons (3; 23%). Conclusions: Almost half of the MLPs left the CCM program. Selection of MLPs who will be qualified to pass the CCM training program is a limitation to recruitment. Satisfactorily creating the “perfect” schedule and recognizing that life events occur that may mandate voluntary resignation remain ongoing challenges to retention.


Posters: Basic Science: Cardiovascular 144

145

MURINE CARDIAC TROPONIN I SERINES 23 AND 24 ARE PHOSPHORYLATED BY PKC UNDER HYPOTHERMIA/REWARMING CONDITIONS

BLOOD PRESSURE REGULATION IS AGE AND GENDER DEPENDENT: AN OBSERVATIONAL STUDY OF 333 ELDERLY SUBJECTS PRESENTING FOR MAJOR SURGERY

Brage Haaheim, Universitetet i Tromso, Gary Sieck, Grace Arteaga, Mayo Clinic

Stephen Woodford, Macquarie University

Introduction: Severe hypothermia/rewarming (HR) results in myocardial dysfunction. The underlying mechanism is unclear. Previously, we have reported increased phosphorylation of troponin I (TnI) after HR. Hypothesis: TnI is phosphorylated by PKA and PKC pathways. By chemically blocking these pathways during HR, we hypothesize a decrease in TnI total and Ser23/24 phosphorylation of TnI. Methods: Isolated heart preparations of NTG CD-1 mice (n ⫽ 25) were separated in a control (n ⫽ 5) and a HR group (n ⫽ 20). The HR protocol involved 20 minutes of stabilization, 70 minutes of hypothermia at 15°C followed by 40 min of rewarming. The PKA and PKC inhibitors were given during rewarming. The HR subgroups included HR without inhibitors, HR with PKA inhibitors, HR with PKC inhibitors and HR with PKA/PKC inhibitors (all with n ⫽ 5). Cardiac function studies involved recording LVP, ⫾dP/dt, and rate pressure (RP) using a Millar catheter. The hearts were then flash frozen. Total TnI phosphorylation using Pro-Q Diamond stain and specific phosphorylation using Western Blot with p-Ser23/24 antibodies were investigated. Results: The myocardial function measured by RP was significantly decreased in the HR group (47.24%⫾7.24) compared to the control group (10.53%⫾7.24). No significant changes were seen in RP between the HR groups (PKA ⫽ 44.57%⫾7.24, PKC 35.67%⫾7.24 and PKA/PKC 65.76%⫾7.24). Total TnI phosphorylation was significantly increased in all the HR groups: HR (19.41⫾0.27), HR-PKA (20.72⫾2.71), HR-PKC (16.11⫾2.71), HR-PKA/PKC (24.02⫾2.71) in contrast to control (8.91⫾2.71). Ser23/24 phosphorylation in the control group was 0.115⫾0.059. The HR group (0.277⫾0.059) and the HR-PKA (0.430⫾0.059) were significantly increased compared to control. There were no significant differences between control and HR-PKC (0.157⫾0.059) and HR-PKA/ PKC (0.097⫾0.059). Conclusions: Myocardial function was decreased and the total TnI phosphorylation elevated in all HR groups compared to control and remained unchanged between the HR groups. Ser23/24 phosphorylation was blunted when PKC was inhibited without affecting the total TnI phosphorylation, suggesting that this pathway play a role in the myocardial dysfunction after HR.

Introduction: Published invasive haemodynamic data in the elderly is incomplete and scanty. Although gender and advancing age are relevant to intensive care survival, there is a dearth of information on the normal elderly circulation. Hypothesis: The study used a single measurement methodology (Flotrac APCO/ CVP) to quantify the nature and extent of hemodynamic change with age. Methods: Over 30 months, 333 elderly patients (155 female, 178 male) undergoing major elective or urgent surgery were studied prior to induction of anaesthesia. Values were collected every minute for ten minutes and averaged. Invasively derived parameters were graphed according to age and gender. Results: The systemic perfusion pressure (MAP-CVP) increases with advancing age, and is higher in females at any age. Resting SV/SVI,CO/CI and SVR/SVRI in premenopausal subjects is significantly different in male and female subjects. From the female menopause (48 – 60 yrs) there is a progressive fall in SV and CO, and a rise in SVR. 80% female subjects over 80 had a resting CI ⬍2.5. Average SVRI in female subjects was 3270, and 2400 in male subjects, but SVR/SVRI increased progressively each year following the menopause with no evidence of a plateau. SV falls and plateaus in the ninth decade, but SVR continues to rise. An identical change occurs in male subjects. A progressive reduction in SV and SV range occurs in all elderly subjects. Conclusions: The gender difference at any age implies hormonal modulation of BP and CO, and argues for age and gender specific hemodynamic targets in treatment delivery. Gender and age specific patterns of blood pressure regulation imply that inotropic and antihypertensive therapies should target relevant treatment goals. Age related decline in SV in both genders suggests diastolic dysfunction is a normal pattern of ageing, and that there is a progressive reduction in LV internal systolic and diastolic dimensions in ageing as a normal process. A hormonal influence on blood pressure regulation implies that hormonal strategies may be effective in modulating hypertensionin the elderly.

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LIPID SINK MECHANISM OF LIPID RESCUE EVIDENCED BY VOLTAGE-GATED PROTON CHANNELS

ENDOGENOUS MONOAMINE METABOLITES AND RELATIONSHIP TO GENDER AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Kotaro Hori, Tadashi Matsuura, Megumi Hasaka, Takashi Mori, Miyuki Kuno, Kiyonobu Nishikawa, Osaka City University Graduate School of Medicine Introduction: Lipid rescue therapy is established as a treatment of local anesthetic (LA) toxicity, especially for bupivacaine-induced cardiac arrest. However, its mechanism is still unclear. Since bupivacaine is highly lipophilic, “lipid sink” is considered to be the most putative underlying mechanism. We recently reported that LAs as weak bases inhibited voltage-gated proton channels by increasing intracellular pH, which could be estimated from reversal potentials (Vrev) of the channels. In other words, proton channels are useful tool to monitor the behaviors of LAs across cellular membranes. In an attempt to gain insight into the mechanism of lipid rescue, we studied how lipid emulsions recovered the bupivacaine-induced inhibitions of proton channel currents. Hypothesis: If the “lipid sink” is the main part of lipid rescue therapy, the inhibitory effects of bupivacaine on proton channels would be markedly and quickly recovered in lipid emulsioncontaining solutions. Methods: A whole-cell voltage clamp technique was used to record proton currents in a rat microglial cell line (GMI-R1). Bupivacaine was dissolved in standard or 4% lipid solution, which contained 20% intralipid® one-fifth of the solution. The inhibitory effects of bupivacaine on proton currents were examined in the absence and the presence of lipid. Data are means ⫾ SD. The statistical significances (p⬍0.05) were evaluated using one-way repeated measures ANOVA. Results: In standard external solution, 1 mM bupivacaine decreased proton currents to 33 ⫾ 10% of control and shifted Vrev more positive voltages (from -91 ⫾ 6 mV to ⫺72 ⫾ 13 mV). In 4% lipid solution, the currents recovered quickly to 79 ⫾ 2% of control and the Vrev returned to negative direction (to ⫺87 ⫾ 5 mV, n ⫽ 5, p⬍0.05). Since Vrev shift in positive direction imply intracellular protonation of base form bupivacaine, these results indicate the membrane permeable fraction of bupivacaine is markedly reduced in lipid solution. Conclusions: Our results suggest that lipid emulsions markedly and quickly remove bupivacaine from intracellular space, which support that “lipid sink” is the main mechanism of lipid rescue therapy.


Bhavani Thampatty, University of Pittsburgh, Samuel Poloyac, University of Pittsburgh School of Pharmacy, Jeffrey Yao, Univeristy of Pittsburgh, Elizabeth Crago, University Of Pittsburgh School of Nursing, Michael Horowitz, University of Pittsburgh Medical Center, Marilyn Hravnak, University of Pittsburgh Introduction: Catecholamines are thought to increase after aneurysmal subarachnoid hemorrhage (aSAH), but their degree of excretion and perseverance based on gender is under-explored. Hypothesis: We assayed endogenous monoamine metabolites in tryptophan and tyrosine pathways for 5 days following aSAH, and used group-based trajectory analysis to develop low and high level groups. Our null hypothesis was that gender would not impact elevated monoamine trajectories over short-term recovery (days 1–5). Methods: Prospective longitudinal study recruited 122 acute aSAH patients with monoamine data. High-pressure liquid chromatography coupled with a coulometric multi-electrode array system determined tryptophan and its metabolite 5-hydroxyindole3-acetic acid (5-HIAA), and tyrosine and its metabolite homovanillic acid (HVA) in 24-hour urine samples collected days 0 –5 after aSAH. Group-based trajectory analysis was performed with the PROC TRAJ macro in SAS V9.2 to identify distinct monoamine subgroups with similarly behaving patterns. Associations between monoamine trajectory groups and gender were determined using Pearson’s chi-square test. Results: The sample was 27% male and 73% female consistent with known gender-based aSAH prevalence. Trajectory analysis identified two distinct groups (low and high, all p⬍0.001) in the sample for each monoamine: tryptophan high (45%) and tryptophan low (55%), 5-HIAA high (65%) and 5-HIAA low (35%), tyrosine high (38%) and tyrosine low (62%), HVA high (77%) and HVA low (23%). There was a trend towards proportionally more men than women in the high trajectory groups for tryptophan (men 57% vs. women 38%, p ⫽ 0.06) and 5-HIAA (men 79% vs. women 62%, p ⫽ 0.08) that was not statistically significant. However, there were significantly higher proportions of men than women in the high trajectory groups for tyrosine (men 61% vs. women 29%, p ⫽ 0.001) and HVA (men 91% vs. women 73%, p ⫽ 0.05). Conclusions: Proportionally more men than women experience higher monoamine excretion and persistence following aSAH, and significantly so in the tyrosine pathway. Funding NHLBI R01HL074316.

148 CARDIAC TARGETING BY TRYPANOSOMA CRUZI Gary Fang, Conrad Epting, Children’s Memorial Hospital, David Engman, Northwestern University Introduction: Trypanosoma cruzi is the causative organism of Chagas cardiomyopathy, a leading cause of infectious cardiomyopathy worldwide and an emerging disorder in the United States. The intracellular parasite causes both inflammation and direct tissue injury, eventually resulting in heart failure. Although the parasite is capable of infecting many cell types, involvement of the heart and GI track innervation cause the majority of the pathology. The basis for asymmetric tissue distribution remains unknown. Hypothesis: We hypothesize that T. cruzi is cardiotropic and will have a higher affinity for cardiomyocytes as compared to other primary cells in a time dependent manner. We propose to demonstrate this affinity in an adult murine model both ex vivo and in vivo. Methods: To investigate the ex vivo association, adult murine cardiac myocytes were infected for various time points and compared to various primary cells. Cells were fixed, membranes stained with wheat germ agglutinin, and host cell and parasite nuclei labeled with DAPI. Association scores (# associated parasites/# host cells) were calculated for each cell type at various time points. In the in vivo model, 1e5 parasites were injected IV. The mice were perfused, and organs harvested for qPCR analysis to determine the relative amount of parasite DNA in various tissues at different time points. Results: Our work demonstrates an increasing association score for cardiac myocytes over time (1.8 –2 hr, 2.8 – 4 hr, 5.2– 6 hrs). This is in contrast to the other cell types whose association levels off over time. Our in vivo data shows notable enrichment of parasites in the heart, increasing over time, when compared to other tissues, including brain, kidney, colon, lung, and skeletal muscles. Conclusions: Using a unique model comparing syngenic tissues both ex vivo and in vivo, we demonstrate an affinity between T. cruzi and cardiac tissue. Our data suggest intrinsic differences in how cardiac tissue interacts with T. cruzi. We are investigating the basis for this differential affinity by blocking various surface interactions. Understanding the interacting surface molecules underlying tropism will inform future therapeutic targets to interrupt cardiac targeting.


Posters: Basic Science: Cell Biology (NO and Signal Transduction, Signal Transduction) 149

150

MOLECULAR EXPRESSION OF PROTEINS INVOLVED IN THE NEUROPROTECTIVE EFFECTS OF ERYTHROPOIETIN (EPO) AFTER EXPERIMENTAL TRAUMATIC BRAIN INJURY (TBI)

THE ROLE OF THE 2-PORE DOMAIN Kⴙ CHANNEL TREK-1 IN ALVEOLAR BARRIER FUNCTION

Jovany Cruz Navarro, Lucido Ponce, Leela Cherian, Mai Van, Hector Saucedo, J. Goodman, Claudia Robertson, Baylor College of Medicine Introduction: A large body of evidence has revealed that EPO exhibits neuroprotective effects against a wide variety of experimental TBI. In ischemia models, this protection may be mediated by hypoxia inducible factor 1 (HIF-1) activating its target genes EPO, EPO receptor (EPOR) and vascular endothelial growth factor (VEGF). Hypothesis: We studied the magnitude and time course of the proteins involved in the neuroprotective profile of EPO in experimental TBI. Methods: Controlled cortical impact (CCI) was induced in wild-type (WT) and endothelial nitric oxide synthase (eNOS) knock-out mice. Tissue samples from injured and non-injured cerebral hemispheres of WT and KO mice were analyzed for protein activity. Western blot analysis of HIF-1, EPO, EPOR, eNOS, VEGF, Bcl-xL, PI3-K, AKT, p-ERK, p-Raf and p-MEK was performed at 2, 6, 24, 48, and 72 hr, and 7 and 14 days. Serum nitric oxide (NO) levels were examined 2 hr after CCI. Results: Following CCI, EPO was significantly increased in KO mice compared to WT (p⬍0.05). eNOS activity was significantly diminished in the KO animals at 2 hrs after CCI (p⬍0.05). During the first 24 hrs after CCI, there was a transient increase in HIF-1 activity in the injured tissue that returned to levels comparable to the non-injured tissue. Increased HIF-1 in the non-injured tissue was observed only after 72 hrs of CCI. EPO was markedly elevated in the injured tissue by 24 hrs after injury and persisted at elevated levels up to 14 days. No difference was observed in EPOR expression. VEGF expression observed in the injured tissue was two times higher than the non-injured tissue during the first 24 hrs after CCI, and remained consistently higher (p⬍0.05). AKT expression was consistently higher in the injured tissue over time (p⬍0.001); moreover, PI3K showed a similar expression over time reaching its maximum by 7–14 days after CCI. NO serum levels were significantly higher in the WT mice. Conclusions: Our study supports the important role of eNOS and NO in the neuroprotective effects of EPO. The cellular hypoxia response is activated by CCI leading ultimately to increased EPO and NO. This signaling pathway provides several potential targets that may provide neuroprotection including HIF-1, EPO and eNOS.


Andreas Schwingshackl, University of Tennessee Le Bonheur Children’s Hospital, Bin Teng, Manik Ghosh, University of Tennessee, Christopher Waters, University of Tennessee Health Science Center Introduction: Loss of the alveolar epithelial barrier function is an important feature in the pathogenesis of Acute Lung Injury (ALI). Several experimental models of ALI have been developed, and both animal and clinical studies show that the loss of the epithelial barrier function correlates with patient mortality. While both mechanical ventilation and hyperoxia seem to induce loss of epithelial barrier function, the underlying mechanisms leading to fluid accumulation in the alveoli are incompletely understood. Recent literature suggests that stretch-activated ion channels, in particular 2-Pore Domain K⫹ channels (K2P), act as “mechano-sensors” and “mechano-transducers” in many body tissues. In this study we investigated the role of K2P channels in the loss of alveolar barrier function during conditions that resemble those encountered in ALI. Hypothesis: We propose that K2P channels co-localize with tight junction (TJ) proteins in areas of cell-to-cell contact and regulate epithelial barrier function. Results: We previously found regulation of TREK-1 expression by hyperoxia and mechanical stretch in alveolar epithelial cells (AECs) and now show using confocal microscopy and co-immunoprecipitation that TREK-1 co-localizes with the TJ protein zonula occludens-1 (ZO1) to areas of cell-to-cell contact in cultured mouse type II AECs (MLE-12) and in primary rat type II AECs (AT II). Treatment of MLE-12 and AT II cells with TNF-␣ caused a dose-dependent disruption of the epithelial barrier as indicated by a decrease in impedance across an epithelial monolayer using the Electric Cell-Substrate Impedance Sensing (ECIS) system. Targeted knockdown of TREK-1 in MLE-12 cells using shRNA ameliorated the TNF-␣-induced loss of impedance by 50%. Conclusions: These data suggest that TREK-1 channels may be important regulators of the alveolar epithelial barrier during ALI.This study was supported by the Le Bonheur Children’s Research Foundation and the NIH grant H094366.

Posters: Basic Science: GI/Nutrition 151 COMPARATIVE EFFECTS OF SMALL INTESTINAL NUTRIENTS ON SUPERIOR MESENTERIC ARTERY(SMA) BLOOD FLOW AND BLOOD PRESSURE(BP) IN HEALTHY ‘OLDER’ AND CRITICALLY ILL PATIENTS Jennifer Sim, Laurence Trahair, Rajendra Goud, Jonathan Fraser, Marianne Chapman, University of Adelaide, Tryvge Hausken, University of Bergen, Michael Horowitz, Karen Jones, Adam Deane, University of Adelaide Introduction: In health, the presence of nutrients in the small intestine increases Superior Mesenteric Artery (SMA) blood flow. In healthy ‘older’ subjects this increase in SMA flow is associated with a reduction in blood pressure. Enteral nutrition is standard of care for ‘older’ critically ill patients, but the effects of small intestinal nutrients on SMA blood flow and blood pressure in this group are not known. Hypothesis: Changes in SMA blood flow and blood pressure during small intestinal nutrients will be attenuated in ‘older’ critically ill patients. Methods: Subjects were fasted for 8h and a small intestinal catheter inserted. This was followed by an observation period (t ⫽ 0–60 min). 0.9%saline and glucose solutions(1kcal/ml) were then infused intraduodenally at 2 ml/min between t ⫽ 60–120 and 120–180 respectively. SMA blood flow was measured using Doppler ultrasonography during the observational period, and at t ⫽ 90&150 min. SMA blood flows at these latter time points are reported compared to fasting. Prior to SMA measurements intra-arterial systolic blood pressure was measured every 2 min and the mean for 10 min intervals determined. Data are median(range). Results: Ten mechanically ventilated critically ill patients [74 (69,79) y, 6 M, BMI 25(19, 32) kg/m2] and 9 healthy volunteers [70 (65,76) y, 7 M, 26(25, 28) kg/m2] were studied. Through the observation period SMA flows were greater in the critically ill [654 (431, 877) vs. 402 (325, 480) ml/min; P⬍0.01]. Intraduodenal saline did not change flows in either patients or healthy subjects [?90: 74(⫺140,289) vs 99(⫺35,232) ml/min; P ⫽ 1.0] In health SMA flows increased during small intestinal glucose infusion [?150: 836 (618,1054) ml/min], but this was not apparent in the critically ill [82 (⫺175, 338) ml/min; P ⫽ 0.02]. In health, there was a trend to decreased systolic blood pressure during intraduodenal glucose [⫺5.8(⫺14.4, 2.8) mmHg], which was not apparent in the critically ill [3.5 (⫺1.3, 8.3) mmHg; P ⫽ 0.07]. Conclusions: In ‘older’ critically ill patients SMA blood flow is increased during fasting, but the response to small intestinal nutrients attenuated. This may have implications for blood pressure during enteral nutrition. Ms Sim is supported by a Florey Honours Scholarship.


Posters: Basic Science: Hematology 152

153

ALBUMIN INHIBITS HISTONE-INDUCED PLATELET AGGREGATION: POTENTIAL IMPLICATIONS FOR SEPSIS-INDUCED THROMBOSIS

MULTIMERIC PATTERNS OF PLASMA VON WILLEBRAND FACTOR IN PEDIATRIC PATIENTS SUPPORTED ON ECMO

Fong Lam, Texas Children’s Hospital/Baylor College of Medicine, HonChiu Leung, Baylor College of Medicine, Rolando Rumbaut, Michael E. DeBakey Veterans Affairs Medical Center/Baylor College of Medicine, C Wayne Smith, Baylor College of Medicine Introduction: Histones are nuclear proteins that are released from activated neutrophils as well as necrotic and apoptotic cells. Recent data demonstrate that histones are mediators of death and thrombosis in animal models of sepsis [1]. In humans, circulating levels of nucleosomes, a surrogate marker for histones, have been associated with higher severity of sepsis [2]. Thus, understanding the impact of histones in inflammation and thrombosis is important. The purpose of our study is to define plasma factors that modulate histone-induced platelet aggregation. Hypothesis: Because histones contain a strong net positive charge, we hypothesize that albumin, which has a net negative charge, may inhibit histone-induced platelet aggregation. Methods: Citrated-whole blood collected from healthy adults was used to prepare washed platelets. These platelets were incubated with increasing concentrations of human serum albumin (HSA). Platelet suspensions were studied using platelet aggregometry in the presence of histone H4 and buffer control. To determine the importance of net charge on albumin’s inhibition of histone-induced aggregation, albumin was neutralized using N-ethyl-N’-(3-dimethylaminopropyl) carbodiimide hydrochloride. 2D-gel electrophoresis confirmed neutralization, and this neutralized albumin (nHSA; 10 mg/mL) was compared against HSA (10 mg/mL) in platelet aggregometry using increasing doses of histone H4. Results: HSA decreased maximal histone-induced aggregation in a dose-dependent manner (0, 2.5, 5, & 10 mg/mL albumin; 57, 28, 20, & 4% aggregation, respectively; p⬍0.005, n ⫽ 3, RM ANOVA). Furthermore, charge-neutralized albumin (pI change to ⬃7.1 (nHSA) from ⬃6.4 (HSA)) had diminished inhibition of histone-induced aggregation (maximal aggregation in nHSA vs HSA: 27 vs. 4%, 50 vs 36%, 53 vs 44% at 20, 40, & 80 ␮g H4/mL, respectively; p⬍0.05, n ⫽ 3, 2-way ANOVA). Conclusions: These data suggest a role for albumin as an inhibitor of histone-induced platelet aggregation, through a charge-dependent mechanism. References: [1]Xu et al. Nat. Med 2009, [2]Zeerleder et al. CCM 2003. Merit Review Grant from Dept. of Veterans Affairs.

154 EFFECTS OF IBUPROFEN ON PLATELET AGGREGATION AND COAGULATION FUNCTION IN VITRO Wenjun Martini, Rodolfo DeGuzman, US Army Institute of Surgical Research, Cassandra Moreno, Jessica Guerra, US Army Inst Surgical Research, Andrew Cap, US Army Inst Surg Research, Jill Sondeen, Michael Dubick, United States Army Institute of Surgical Research Introduction: Ibuprofen is a commonly used non-steroidal anti-inflammatory drug. Limited information is available about the effects of ibuprofen on hemostasis. Hypothesis: This study investigated the effects of ibuprofen on platelet aggregation and coagulation in vitro. Methods: Blood samples were collected in citrated tubes from 3 normal healthy pigs (35– 40 kg). Ibuprofen (CaldolorTM, IV solution, 100 mg/ml) was added to the whole blood samples at the doses of 0 ␮g/ml (control), 320 ␮g/ml (2⫻ the recommended oral doses), 640 ␮g/ml, and 960 ␮g/ml. Platelet aggregation was stimulated with arachidonic acid (0.5 mM), or collagen (2␮g/ml) and assessed using Chrono-Log 700 aggregometer. Coagulation function was assessed by clotting speed and clot strength using Rotem® thrombelastogram with Extem reagents. Measurements were made in whole blood at baseline and hourly for 5 h after the addition of ibuprofen. Results: In control samples, platelet aggregation and coagulation function in response to arachidonic acid or collagen remained unchanged during the 5h experimental period. At baseline, Ibuprofen doses of 320 ␮g/ml, 640 ␮g/ml, and 960 ␮g/ml completely inhibited arachidonic acid-stimulated platelet aggregation. For collagen stimulated platelet aggregation, ibuprofen dose of 320 ␮g/ml, 640 ␮g/ml, and 960 ␮g/ml inhibited platelet aggregation to 75% ⫾ 12%, 59% ⫾ 7%, and 36 ⫾ 5% of control values (p⬍0.05), respectively. These inhibitions remained unchanged for 5h. For coagulation function, clot strength at baseline from samples with ibuprofen doses of control, 320 ␮g/ml, 640 ␮g/ml, and 960 ␮g/ml was 67.0 ⫾ 2.2 mm, 65.2 ⫾ 2.2 mm, 67.2 ⫾ 1.6 mm, and 68.5 ⫾ 2.0 mm, respectively; clotting speed from samples with ibuprofen dose of control, 320 ␮g/ml, 640 ␮g/ml, and 960 ␮g/ml was 78.8 ⫾ 0.8°, 77.8 ⫾ 1.0°, 78.8 ⫾ 0.7°, and 79.5 ⫾ 0.5°, respectively. There were no changes observed in these parameters for 5h for any doses. Conclusions: Starting at twice the recommended doses, ibuprofen effectively inhibited in vitro platelet aggregation, without effects observed on clotting speed and clot strength. Future in vivo studies are needed to determine whether these effects of ibuprofen affect bleeding.


Sanjiv Pasala, University of Arkansas For Medical Sciences/Arkansas Children’s Hospital, Parthak Prodhan, Arkansas Children’s Hospital Introduction: ECMO is an important support modality for children with cardiopulmonary failure refractory to conventional therapies. Recent evidence in adults on ventricular assist devices indicates that an acquired von Willebrand (vWF) disease can result from a reduction in circulating vWF high molecular weight (HMW) multimers (1). This significantly increases the risk of bleeding in such patients. Changes in circulating vWF HMW multimers in children supported with ECMO have never been shown before. 1. Geisen U, Heilmann C, Beyersdorf F, et al. Non-surgical bleeding in patients with ventricular assist devices could be explained by acquired von Willebrand disease. Eur J Cardiothorac Surg 2008; 33: 679 – 84. Hypothesis: We hypothesized that vWF HMW multimers decrease in ECMO supported pediatric patients over time. Methods: This prospective, observational study from December 2010 to July 2011 included subjects 0 –21 years of age, who required ECMO support at our institution. Blood samples were obtained at time points prior to ECMO cannulation and at ECMO hour 1– 6, 12, 24, and 48. Samples were tested for vWF antigen, vWF ristocetin cofactor activity, vWF collagen binding, and vWF multimer size. Data on ECMO variables, clinical diagnoses, and patient demographics was collected. Group comparisons between time points made using chi-square analysis. Results: Six subjects on ECMO were enrolled. Mean age is 57 months (range 2 days-10 years). Primary diagnoses requiring ECMO support for subjects included PPHN, ARDS, and low cardiac output syndrome. vWF antigen, vWF ristocetin cofactor activity, and vWF collagen binding were normal or elevated in all subjects over time. Qualitative analysis of VWF multimers shows statistically significant loss of HMW multimers, 0 –10% of the total multimer density of multimer bands ⬎10, when samples at 6, 12, 24, and 48 hours after initiation of ECMO are compared to pre-ECMO samples (P⬍0.05). Conclusions: We conclude that vWF HMW multimers decrease in ECMO supported patients over time. This never before studied phenomenon is a significant step toward understanding hemostatic mechanisms in ECMO supported patients. Supported by a CUMG grant from Arkansas Children’s Hospital Research Institute.

Posters: Basic Science: Immunology 155

156

TREM-1 PROTECTS MONOCYTE FROM APOPTOSIS VIA MCL-1-DEPENDENT MECHANISM

REGULATION OF LYMPHOCYTE TRAFFICKING BY CXCL10 IN SEPSIS

XiangMing Fang, Qixing Chen, MeiTing Cai, Qiang Shu, Zhejiang University

Daniela Herzig, Brandon Driver, Geping Fang, Edward Sherwood, University of Texas Medical Branch

Introduction: Triggering receptor expressed on myeloid cells-1 (TREM-1) is a recently identified cell surface receptor expressed on neutrophils and monocytes. TREM-1 acts synergistically with TLRs and Nod-like receptors to enhance the inflammatory reaction. Blocking of TREM-1 obviously attenuated systemic inflammatory response and protected mice against lethality of septic shock. Elevated concentrations of a soluble form of TREM-1 (sTREM-1) were detectable in fluids from patients with infections, while a progressive decline of plasma sTREM-1 concentration indicates a favorable clinical evolution of sepsis. TREM-1 functions as an amplifier as well as a critical mediator of inflammatory response in the context of sepsis. However, the impact of TREM-1 mediated pathway on cell fate remained unclear. Hypothesis: Increased expression of TREM-1 influences on monocyte apoptosis. Methods: Recombinant TREM-1 expression adenovirus was constructed and infected THP-1 monocytes. After 72 hours of infection, the cells were cultured on TREM-1 antibody or isotype antibody coated plate for 24 hours, followed by staurosporine stimulation for 4 hours. The apoptosis was measured using flow cytomertry. The expression levels of TREM-1, signal transduction molecules ERK1/2 and AKT, as well as apoptosis related molecules (Bcl-2, Mcl-1, BAD, BAX and cytochrome c) were detected by means of Western-Blot analysis. Results: The recombinant adenovirus significantly enhanced the expression levels of TREM-1 in THP-1 cells. Cross link with the TREM-1 antibody activated the phosphorylation of the intracellular signal molecules ERK1/2 and AKT, increased the expression level of Mcl-1 and blocked the release of cytochrome c from the mitochondrion, and finally protected the cells from apoptosis. While, inhibition of ERK1/2 and AKT activation abolished the protective role of TREM-1 on apoptosis. Conclusions: TREM-1 protects monocyte from apoptosis in a Mcl-1-dependent mechanism, which may plays an important role in delayed apoptosis of monocyte during sepsis.

157 IMMUNE DYSREGULATION IN CHILDREN UNDERGOING SURGERY FOR CONGENITAL HEART DISEASE IS MARKED BY ALTERED ANTIGEN SENSING CAPABILITY Keng Wooi Ng, Martina Greco, Imperial College London, Meredith Allen, Ajay Desai, Duncan Macrae, Sarah Bacon, Royal Brompton and Harefield NHS Foundation Trust, Evelien Gevers, National Institute for Medical Research, David Inwald, Nazima Pathan, Imperial College London Introduction: Immune paresis following surgery for congenital heart disease (CHD) is known to be associated with secondary morbidity and adverse outcome, but its molecular mechanisms are unclear. We sought to investigate changes in antigen sensing and endotoxin responsiveness in children undergoing surgery for CHD using a combination of functional assays, flow cytometry and transcriptomics. Hypothesis: Immune paresis following surgery in children with CHD is related to impaired antigen sensing, predisposing them to secondary morbidity. Methods: Venous blood was obtained pre- and postoperatively from children undergoing CHD surgery. Whole blood samples were stained with fluorescently labeled antibodies to analyze median fluorescence intensity of cellsurface Toll-like receptor (TLR)2, TLR4 and human leukocyte antigen (HLA)DR. Aliquots of whole blood were also incubated for up to 24 hours in the presence of antigens (lipopolysaccharide [LPS] and phytohemagglutinin [PHA]) or culture medium (control). Further samples were processed for microarray analysis of messenger ribonucleic acid (mRNA) expression. Functional assays were analyzed using Mann-Whitney U Test. Microarray samples from 24 hours after surgery were compared to preoperative samples. Genes were filtered to select those with a fold change of ⬎2 and p⬍0.05 (paired t-test with correction for multiple testing). Results: Postoperative monocyte expression of TLR2, TLR4 and HLA-DR was significantly diminished (p⬍0.01 for each marker; n ⫽ 15). Neutrophil surface expression of TLR2 was also diminished (p⬍0.01) postoperatively. Whole blood response to LPS was retained (measured by Interleukin (IL)-6, IL-8 and IL-10 production). Response to the T cell stimulant PHA demonstrated impaired IL-10 and Interferon-gamma production after 24-hour incubation (p⬍0.05; n ⫽ 7). Transcriptomics demonstrated enrichment of T cell signaling and endotoxin sensing pathways (n ⫽ 17). Conclusions: Antigen sensing and processing are affected by cardiopulmonary bypass surgery in children with CHD. We observed a role for T cell involvement as well as alteration in LPS sensing pathways, although functional responses to LPS appeared to be retained.

Introduction: Our previous studies show that natural killer (NK) cells facilitate systemic inflammation during septic shock caused by cecal ligation and puncture (CLP). The chemokine receptor CXCR3 is expressed by NK cells and is activated by CXCL10 in some disease states. However, the role of CXCL10 in modulating NK cell functions during sepsis is unknown. Hypothesis: This study was undertaken to test the hypotheses that CXCL10 is an important regulator of NK cell function during sepsis and that neutralization of CXCL10 will attenuate CLP-induced pathobiology. Methods: Bacterial clearance, core temperature, cytokine production and survival were evaluated in wild type mice treated with anti-CXCL10 or isotypematched, nonspecific IgG as well as in CXCL10 knockout mice. Anti-CXCL10 treatment was given with and without antibiotics. Results: Our study shows that NK cell trafficking into the cavity was attenuated in CXCL10-deficent mice. Survival, core body temperature, bacterial counts and cytokine production were significantly improved in mice treated with anti-CXCL10 plus Primaxin compared to mice receiving non-specific IgG plus Primaxin whereas treatment with anti-CXCL10 without antibiotics did not improve the functional outcome compared to mice treated with IgG. However, bacterial clearance was improved and systemic cytokine production attenuated in CXCL10 knockout mice that did not receive antibiotics. Conclusions: These results indicate that CXCL10 participates in regulating NK cell trafficking during septic shock caused by CLP and that neutralization of CXCL10 attenuates sepsis-associated immunopathology, particularly when co-administered with antibiotics.

158 THE B CELL RESPONSE TO INTRA-ABDOMINAL SEPSIS Amy Reed, Hospital of the University of Pennsylvania, Alison Perate, Children’s Hospital of Philadelphia, Hooman Noorchashm, Hospital of the University of Pennsylvania, Clifford Deutschman, Ali Naji, University of Pennsylvania School of Medicine Introduction: Sepsis is a significant cause of morbidity in the ICU. The pathophysiologic changes that occur in predisposed individuals likely are driven by a multifactorial network of immunological mediators, including B cells. In this regard, the peritoneum is populated by a subset of B cells, B-1 B cells. The location of these B-1 cells and their capacity for rapid activation, robust differentiation and capacity to secrete anti microbial antibodies led us to examine their role in cecal ligation and puncture (CLP), an animal model of intra-abdominal sepsis. Hypothesis: B-1 B cells respond to intra-peritoneal fecal contamination with rapid activation, expansion and differentiation. Methods: C57Bl/6 mice were subjected to either CLP with two 24-gauge punctures or sham operations. Peritoneal washings and harvest of spleen, mesenteric and peripheral lymph nodes were performed 18 –24 hours post-procedure. Single cell preparations were examined by flow cytometry using monoclonal antibodies specific for B cell markers. Results: Washings from the peritoneal cavities of CLP mice contained significantly more activated mononuclear cells than did those from control or shamoperated mice. However, there was a notable absence of B-1 B cells suggesting either rapid activation and differentiation or transmigration out of the peritoneum. Despite the presence of fewer total B cells and T cells, the spleens of CLP mice contained an expanded population of B-1 B cells. Both the peripheral and mesenteric lymph nodes appeared to have proportional increases in the frequency of activated B cells. In contrast, T-cell activation was not observed. Conclusions: B cells, particularly B-1 B cells, are activated in the first 24 hours following CLP. This change is not confined to the peritoneal cavity, but also includes an expansion of splenic B-1 B cells and systemic B cell activation. The same systemic activation was not noted in T-cells. These data suggest that peritoneal B-1 B cells participate in the pro-inflammatory state seen in early abdominal sepsis. Therefore, modulation of the B1-B cell response may provide a basis for future therapeutic strategies.


159 EFFECTS OF RAPAMYCIN ON TNF PRODUCTION BY BACTERIALLY STIMULATED RAW264.7 MACROPHAGES Fabio Savorgnan, Thomas Spentzas, Elizabeth Meals, B. Keith English, University of Tennessee Introduction: Rapamycin (Sirolimus™) is a calcineurin inhibitor with many uses in stent implants, transplants and cancer treatment. It activates the immunophillin FKBP-12 (FK-binding protein 12) in a way similar to FK506, and subsequently inhibits the serine/threonine kinase mTOR (mammalian target of rapamycin). Inhibition of mTOR causes either induction (complex1) or suppression (complex 2) of the Akt phosphatidylinositol 3-kinase (PI-3k) pathway. The effects of rapamycin on macrophages are still unclear, although the effects on T cells have been well described. Hypothesis: To examine the effects of rapamycin on TNF secretion by RAW264.7 murine macrophages stimulated with bacteria or bacterial products. Methods: RAW264.7 murine macrophages were stimulated for 18 hrs with the MW2 USA400, LAC USA300 community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) at 106 to 107 cfu/ mL, lipopolysaccharide (LPS) 10 mcg/mL, or lipoteichoic acid (LTA) 100 ng/ml. Rapamycin was added at 0.1, 1, 10, and 100 ng/mL. The supernatants were collected and assayed for TNF concentration by ELISA. Results: Rapamycin had no effect on TNF secretion by unstimulated macrophages. Exposure of macrophages to higher concentrations of rapamycin (10 and 100 ng/mL) prior to stimulation with either the MW2, LAC CA-MRSA isolates, LPS, or LTA led to small but consistent reductions in TNF secretion (approximately 10% reduction). Conclusions: Our data indicate that rapamycin inhibits the secretion of TNF from macrophages stimulated with bacteria or bacterial products. We speculate that this effect may be related to the pro- and anti-apoptotic roles of mTOR. Additional studies are underway to determine the mechanisms and significance of this inhibition.


Posters: Basic Science: Infection 160 A COMBINATORIAL APPROACH THAT UTILIZES ANTIBIOTICS AND ANTIBODIES AGAINST INTEGRATION HOST FACTOR DISRUPTS BIOFILMS FORMED BY NONTYPEABLE HAEMOPHILUS INFLUENZAE Rabia Akbar, Nationwide Children’s Hospital, Glen McGillivary, Nationwide Children’s Hospital Research Institute, Steven Goodman, Herman Ostrow School of Dentistry at University of Southern California, Lauren Bakaletz, The Research Institute at Nationwide Children’s Hospital Introduction: Nontypeable Haemophilus influenzae (NTHI) is an important pathogen frequently detected in RSV-associated bronchiolitis and pneumonia. NTHI forms biofilms in the mammalian respiratory tract and these structures contain both extracellular DNA and the DNA-binding protein Integration Host Factor (IHF). IHF plays a critical role in the stability of NTHI biofilms and antibodies directed against IHF can debulk the NTHI biofilm matrix. Hypothesis: Antibodies directed against IHF can function synergistically with specific antibiotics to disrupt biofilms and kill NTHI. Methods: We used an in vitro chamber slide assay to establish biofilms with the well-characterized clinical isolate NTHI 86–028NP. Bacteria were grown in supplemented brain heart infusion (sBHI) broth for 24 hours at 37°C with 5% CO2, growth medium was removed and NTHI biofilms were incubated for an additional 16 hours under 1 of 4 conditions. Chamber slide wells contained sBHI alone, anti-IHF, antibiotic (amoxicillin, ampicillin, or cefdinir) at the minimal inhibitory concentration (MIC) of planktonic NTHI, or anti-IHF plus the sameantibiotic.Biofilmswerethenfixed,incubatedwithabacteriallive-deadviabilitystain and visualized by confocal microscopy. Results: NTHI biofilms previously resistant to the action of a given antibiotic showed markedly increased susceptibility when treated concurrently with anti-IHF, as determined by COMSTAT analysis of confocal images. Specifically, incubation of NTHI biofilms with anti-IHF and amoxicillin decreased the mean biofilm biomass from 11.8 ␮m3/␮m2 to 0.6 ␮m3/␮m2 (p-value ⫽ 0.03), compared to biofilms incubated with sBHI alone. Similarly, treatment of biofilms with anti-IHF and ampicillin also resulted in a statistically significant reduction in biomass (13.1 ␮m3/␮m2 to 0.2 ␮m3/␮m2, p-value ⫽ 0.01) as did antibody and cefdinir (18.2 ␮m3/␮m2 to 0.6 ␮m3/␮m2, p-value ⫽ 0.003). Conclusions: We demonstrated that synergistic application of anti-IHF and antibiotics diminished NTHI biofilms in vitro. Collectively, our data suggested that this combination treatment strategy could likely have significant therapeutic potential for treatment of acute and chronic infections caused by NTHI.


Basic Science: Neurology 162

163

ASSESSMENT OF ANTIOXIDANT RESERVES AND CASPASE ACTIVATION IN A MOUSE MODEL OF ADULT TRAUMATIC BRAIN INJURY

TEMPORAL CHANGES AND CELL-TYPE SPECIFIC LOCALIZATION OF ATP-BINDING CASSETTE/MULTI-DRUG RESISTANCE TRANSPORTERS AFTER TRAUMATIC BRAIN INJURY IN MICE

Erik Su, Childrens Hospital of Pittsburgh, Jing Ji, Elizabeth Brough, Jesse Lewis, Amin Chekhi, University of Pittsburgh, Patrick Kochanek, University of Pittsburgh Medical Center, Hulya Bayir, Children’s Hospital of Pittsburgh

Anthony Willyerd, Children’s Hospital of Pittsburgh of UPMC, Craig Smith, Children’s Memorial Hospital, Philip Empey, University of Pittsburgh, Patrick Kochanek, University of Pittsburgh Medical Center, Christina Hosler, Yaming Chen, Safar Center for Resuscitation Research, Robert Clark, Children’s Hospital of Pittsburgh

Introduction: A strong link between oxidative stress and apoptosis has been shown in developing rat brain after traumatic brain injury (TBI) [1]. However, there has been only limited exploration of this in rodent models of adult TBI. Hypothesis: We hypothesized that TBI leads to lower levels of endogenous ascorbate, total protein-thiols (PSH), and GSH, as well as activation of caspases in adult brain. Methods: Adult male C57/BL6 mice (n ⫽ 5/group were anesthetized, underwent left parietal craniotomy, and subjected to controlled cortical impact (5 m/s, 1.2 mm deflection). Five mice were used as controls. Ascorbate, GSH, and PSH (fluorescence assays) and Caspase 3 and 7 activity (chemiluminescence Caspase-Glo assay, Promega, WI) were measured at 3h and 24 h after injury. Groups were compared statistically using Student’s t-test. Results: Ascorbate and GSH levels decreased in ipsilateral pericontusional cortex in injured animals vs controls (32.67⫾8.76 v. 46.76⫾9.49 nmol/mg protein for ascorbate, p⬍0.05) (37.92⫾6.45 v. 63.31⫾17 nmol/mg protein for GSH, p⬍0.05) at 24 h but not at 3h. Protein thiol levels were not different between injured animals vs controls at both time points. Caspase activity was increased in injured vs controls (33.7⫾7.4 vs 21.6⫾6.2 AU/mg protein, p⬍0.05) at 24 h but not at 3h. Conclusions: These data demonstrate that antioxidant reserves are compromised in ipsilateral cortex correlating with evidence of temporally associated caspase activation at 24 h after TBI. Interestingly, the increase in caspase activity noted in adult brain is an order of magnitude lower than values reported in immature brain after TBI, suggesting the profile of apoptotic secondary injury following adult TBI differs from that of pediatric subjects. Support: T32HD040686, NS061817, US Army (W81XWH-09 – 0187) Reference: 1. Bayir H, et al., 2007.

Introduction: The ATP-binding cassette transporters p-glycoprotein (Abcb1) and multidrug resistance-associated proteins 1 and 2 (Abcc1 and 2) regulate substrate transport across cell membranes and are key components of the blood-brain barrier (BBB) and brain-CSF barriers. While these transporters influence the brain biochemical milieu under homeostatic and pathologic conditions, little is known about the impact of traumatic brain injury (TBI) on their expression or cellular localization. Hypothesis: Abcb1, Abcc1 and Abcc2 expression increases in multiple cell types after TBI in mice. Methods: Anesthetized adult male mice were subjected to moderate controlled cortical impact (1.2 mm depth, 6 m/s velocity) then killed at 6, 24 and 72 h (n ⫽ 4/group). Brains were removed and processed for immunohistochemistry using antibodies against Abcb1, Abcc1 and Abcc2; and dual-labeled for NeuN, GFAP and Glut1 to identify neurons, astrocytes, and endothelial cells (EC), respectively. Naive and sham injured mice served as controls. Immunoreactivity (IR) was scored in coronal brain sections through the dorsal hippocampus on a 0–4 scale. Changes in Abcb1 and Abcc1 were evaluated by western blot performed previously. Results: Baseline Abcb1, Abcc1 and Abcc2 IR was seen in EC, choroid plexus and ependymal cells. Abcc1 IR was increased at 24 and 72 h vs (p ⫽ 0.02; Kruskal Wallis/SNK) in EC and neurons in the pericontusional area. Abcc2 IR was increased over time vs. (p ⫽ 0.01; Kruskal Wallis) in neurons in the pericontusional area and ependymal cells throughout the brain. Abcb1 IR appeared increased at 24 and 72 h vs. naive (p ⫽ 0.1) in EC in the ipsi- and contralateral hemispheres, and neurons and astrocytes in the pericontusional area. Western blot for Abcb1 and Abcc1 was confirmatory. Conclusions: TBI induces temporal changes in Abcb1, Abcc1 and Abcc2 not only in cells lining the BBB and brain-CSF barriers, but also in neurons and in the case of Abcb1 astrocytes. These findings could have multiple implications for TBI related to transport of pharmacological and endogenous substrates (e.g. narcotics, antiepileptics, antibiotics, cytokines) in and out of the brain (and cells) after injury.

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AUTOREGULATION IS PRESERVED DURING HYPERTENSION IN A NEONATAL SWINE MODEL OF TRAUMATIC BRAIN INJURY

MODULATION OF INFLAMMATORY PHENOTYPE OF PRIMARY MICROGLIA BY ADENOSINE

Matthew Pesek, Texas Children’s Hospital, Kathleen Kibler, Texas Childrens Hospital, Blaine Easley, Menakshi Awasthi, Ken Brady, Texas Children’s Hospital

Elizabeth Newell, Children’s Hospital of Pittsburgh, Jennifer Exo, Children’s Hospital of Colorado, Jonathan Verrier, Delbert Gillespie, University of Pittsburgh, Keri Janesko-Feldman, Patrick Kochanek, Safar Center for Resuscitation Research, Edwin Jackson, University of Pittsburgh

Introduction: We tested the ability of the Pressure Reactivity index (PRx) to detect perturbations of cerebral blood flow (CBF) during hypertension in piglets after controlled cortical impact (CCI). Hypothesis: We hypothesized that PRx monitoring in piglets with CCI would demonstrate vascular passivity commensurate with the degree of CBF disturbance, quantified by a static rate of autoregulation derived from cortical laster-Doppler flux measurements (LDRoR). Methods: Neonatal piglets with CCI or sham surgery (9 injured and 11 sham) had monitoring of PRx, a moving linear correlation between intracranial pressure (ICP) and arterial blood pressure (ABP) while ABP was elevated to lethality using an aortic balloon catheter. ABP, ICP, and cortical laser-Doppler flux ipsilateral (1 mm from impact) and contralateral to the injury were recorded. LDRoR was calculated as the % change in cerebrovascular resistance/% change in the cerebral perfusion pressure (CPP). Comparisons were made of CBF changes, ICP, and PRx across both injury groups and CPP using two-way repeated measures ANOVA. PRx was compared to LDRoR by Spearman rank test using values averaged and binned across CPP. Results: CBF increased slightly with hypertension. CBF at CPP 100 mmHG was 103%⫾13% for sham, 111%⫾16% for ipsilateral, and 111%⫾17% for contralateral measurements (% baseline⫾S.D., p⬍0.0001). CBF changes with hypertension were not affected by the addition of injury (p ⫽ 0.76). ICP (means⫾S.D.) after recovery was 14⫾4 mmHg and 7⫾4 in the injured and sham groups, respectively, and was significantly higher in the injured group, but was not affected by CPP (p ⫽ 0.0007 and p ⫽ 0.21 for treatment and CPP effects respectively). PRx monitoring was not different between treatment groups, and was not affected by CPP (p ⫽ 0.39 and p ⫽ 0.58 for treatment and CPP effects respectively). Correlation between PRx and LDRoR was weak but significant in the injured animals (Spearman r ⫽ 0.35, p ⫽ 0.02). Conclusions: PRx evaluation was limited by our inability to provoke an upward inflection of CBF. Finding correlation between PRx and LDRoR is insufficient evaluation of the PRx during hypertension. The upper end of the piglet autoregulation curve shows no demarcated limit of autoregulation.


Introduction: Neuroinflammation after TBI may produce secondary injury. Microglia, the primary immune cells of the CNS, are integral to the inflammatory response and have both neurotoxic and neuroprotective potential. Mechanisms underlying this dual role are poorly understood. Adenosine, a retaliatory metabolite, is found extracellularly in large amounts after TBI and acts on microglia via multiple adenosine receptor subtypes. Hypothesis: Primary microglia can be induced by LPS to develop a pro-inflammatory phenotype. Adenosine and its precursors down-regulate the inflammatory phenotype via an adenosine receptor dependent mechanism. Methods: Mixed glial cultures were prepared from cerebral cortices of 0 –3 day old C57BL/6 mice. Primary microglia were isolated by trypsinization, and treated with LPS or PBS. The cytokine response was measured by Luminex assay. Next, microglia were stimulated with LPS and treated with adenosine, or its precursors 2’3’cAMP, 3’5’cAMP, 2’AMP, and 3’AMP. Production of the chemokine IP-10 (ELISA) served as a readout for LPS mediated microglial activation. Finally, adenosine receptor antagonists were used to determine if treatment effects were receptor dependent and to define the receptor subtype of primary importance. Results: Production of multiple cytokines and chemokines were increased upon LPS stimulation of microglia. The chemokine response predominated; in particular IP-10 (6956 pg/ml⫾602 vs. 1101 pg/ ml⫾174, p⬍0.001, MWRS). Treatment of LPS stimulated microglia with adenosine decreased IP-10 production (6956 pg/ml⫾602 vs. 3632 pg/ml⫾373, p⬍0.001). This effect was reversed by treatment with a non-selective adenosine receptor antagonist. Blockade of adenosine receptor subtypes suggests the A2A receptor is of primary importance to the anti-inflammatory effects of adenosine on LPS stimulated microglia. Conclusions: IP-10 production is increased in LPS stimulated primary microglia. Treatment of stimulated microglia with adenosine or its precursors decreased IP-10 production. This effect was mediated via adenosine receptors, with the A2A receptor of primary importance. Augmentation of A2A receptor activation after experimental TBI merits investigation. Support: NS070324.

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THERAPEUTIC SCREENING OF NEUROPROTECTIVE AGENTS IN COMBINED TRAUMATIC BRAIN INJURY PLUS HEMORRHAGIC SHOCK IN MICE: A PRELIMINARY REPORT

EFFECT OF HYPOXIA ON THE LEVELS OF PROTEINS INVOLVED IN THE REGULATION OF APOPTOSIS IN THE BRAIN OF NEWBORN PIGLETS IN A CARDIOPULMONARY BYPASS AND CIRCULATORY ARREST INJURY MODEL

Erik Brockman, Safar Center for Resuscitation Research and Children’s Hospital of Pittsburgh of UPMC Introduction: Traumatic brain injury (TBI) is often accompanied by secondary insults such as hemorrhagic shock (HS) which worsen outcome. This is true in civilian TBI and blast TBI in combat casualty care. However neuroprotective strategies addressing TBI⫹HS have rarely been explored. We developed a mouse model of TBI⫹HS and, as part of the DARPA PREVENT Blast program, are screening drugs that have shown promise in TBI alone. Mechanisms suggested to exacerbate secondary injury are mitochondrial failure, inflammation and axonal injury. Minocycline targets mitochondrial failure and inflammation; tacrolimus targets axonal injury; both show benefit in experimental TBI. Hypothesis: We hypothesized that either minocycline or tacrolimus will improve behavioral and neuropathological outcome after TBI⫹HS in mice. Methods: C57/BL6 male mice (n ⫽ 50) underwent controlled cortical impact (CCI) followed by severe HS to MAP of 25–27 mm Hg for 35 min. Mice (n ⫽ 10/group) were randomly given either 3 mg/kg tacrolimus; 20 mg/kg minocycline; tacrolimus vehicle; or minocycline vehicle followed by resuscitation to MAP ⬎70 with Lactated Ringers for 90 min mimicking pre-hospital care. The shed blood was re-infused and mice were recovered. Ten sham mice (surgery without CCI or HS) received no treatment. Outcome tests included Morris water maze (MWM) on d 14 –20 and volumetric analysis of tissue loss in the injured hemisphere on d 21. Results: Surprisingly, mortality was greatest in the tacrolimus treated mice (60%, p ⫽ 0.044, Chi Square). Final latency to find the hidden platform in the MWM was lowest in minocycline group 20.36⫾3.44 sec but highest in the tacrolimus group 45.88⫾7.71 sec (ANOVA p ⫽ 0.046). There was a trend towards reduced hemispheric volume loss (non-injured minus injured hemisphere) in the minocycline group vs. all other injury groups. Conclusions: We conclude that TBI⫹HS represents a unique insult, vs. TBI alone, which requires individualized therapeutic testing. Tacrolimus, at a dose shown to be beneficial in models of TBI, was deleterious in TBI⫹HS. Given the effects of minocycline, therapies targeting mitochondrial failure and neuroinflammation merit additional study in TBI⫹HS. Supported by DARPA N660001-10-C2124.

Gregory Schears, Mayo Clinic, Peter Pastuszko, Children’s Hospital of San Diego, William Greeley, Children’s Hosp. of Philadelphia, David Wilson, Anna Pastuszko, University of Pennsylvania Introduction: In neonates, apoptosis is the predominant mechanism involved in neuronal cell death related to hypoxic injury. The purpose of this study was to determine apoptotic activity in the striatum and hippocampus of newborn piglet brain in a cardiopulmonary bypass/deep hypothermic circulatory arrest (CPB/ DHCA) model of hypoxic/ischemic injury. Hypothesis: That pro-apoptotic proteins would be elevated in the striatum of piglets subjected to a clinically relevant duration of DHCA compared to control. Methods: Piglets were placed on CPB, cooled to 18oC, subjected to 30 min of DHCA and 1 hr of low-flow (20 ml/kg/min), rewarmed to 37°C, separated from CPB and monitored for 2 hrs. Striatum and hippocampus were then isolated for protein analysis. Changes in levels of proteins are presented in arbitrary units (mean⫾SE). Results: Striatum: CPB/DHCA significantly increased, as compared with sham-operated animals, levels of the pro-apoptotic proteins. Those included tumor necrosis factor family of receptors: death receptor-6 (DR-6) (68.4⫾12?143⫾27); Fas ligant (FasL) (17.9⫾8?60.9⫾18.7); Fas (432.2⫾60.3?612⫾60); tumor necrosis factor-related apoptosis-inducing ligands: TRAIL-R1 (44.7⫾9.5?80.7⫾23) and TRAIL-R2 (5.1⫾2.3?22.1⫾5.3). Second mitochondria derived activator of caspases (SMAC) (450⫾13?618⫾54) and caspase-3 (2.4⫾1.7?32.2⫾11.4) were increased as well. Anti-apoptotic protein Survivin was decreased (39.1⫾8.1?19.2⫾5). Hippocampus: There were no significant increases in any of the above proteins. The only significantly increased pro-apoptotic protein was BIM (464.4⫾29?699⫾23). As in the striatum, Survivin level was decreased (26.5⫾4.2?5.4⫾2.3). Conclusions: In a piglet model of brain hypoxia, the increase in pro-apoptotic regulatory proteins early after injury was significant higher in the striatum rather than hippocampus, possibly consistent with greater insult in this brain region. Thorough understanding of the involved mechanisms will help guide future therapies aimed to minimize hypoxic/ischemic neonatal brain injury.

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ETS-GS, A NOVEL VITAMIN E DERIVATIVE, AMELIORATES CEREBRAL ISCHEMIA/REPERFUSION INJURY IN RATS

USE OF NADH FLUORESCENCE IMAGING FOR EARLY DETECTION OF ENERGY FAILURE AND A PREDICTION OF INFARCTION

Hironori Koga, Oita Universty, Taichi Nishida, Satoshi Hagiwara, Junya Kusaka, Takayuki Noguchi, Oita University Introduction: Some studies have revealed that vitamin E derivatives, such as Trolox and EPC-K1, improve several ischemia/reperfusion (IR) injuries, which is due to the antioxidant effect. On the other hand, ETS-GS consisting of vitamin E, taurine, and glutathione, is a novel vitamin E derivative, however, it is unknown if ETS-GS has therapeutic effect for the IR injury. Hypothesis: In this study, we investigated whether ETS-GS improved resuscitation rate after artificially-induced cardiopulmonary arrest in rats, and has the neuroprotective effect against cerebral IR injury resulting from arrest and recovery. Methods: Wistar rats were pretreated with subcutaneous ETS-GS 10 mg/kg (ETS group) or normal saline 1 ml/kg (vehicle group). Cardiopulmonary arrest was induced by cessation of breathing following intravenous injection (IV) of pancuronium (0.1 mg/kg). Rats were resuscitated by IV epinephrine (0.02 mg/kg), chest compression and controlled ventilation with 100% oxygen after a 7-minute arrest. The recovered rats were sacrificed 24 h or 7 days after resuscitation and brains were removed for the observation of apoptosis induction and morphological assessment. Results: Resuscitation rate (vehicle vs. ETS) was 54.3% (19/35) vs. 78.3% (18/23). All animals which succeeded in resuscitation survived without overt motor paralysis until each sacrifice point. The micrographs of HE-stained CA1 pyramidal neurons in the hippocampal region 7 days after resuscitation showed marked neuronal loss and cytoplasmic vacuolation in vehicle group, however, ETS-GS pretreatment relieved the severe cerebral damages. Additionally, though increased apoptosis cells at the same region 24 h after resuscitation were observed in both groups, ETS group had fewer apoptosis cells than vehicle group. Conclusions: Our findings indicate that ETS-GS increases the success rate in resuscitation and has the neuroprotective effect against cerebral IR injury by inhibiting apoptosis, which suggests that ETS-GS can be a new life-saving agent.

Hiromichi Naito, Yoshimasa Takeda, Tetuya Danura, Okayama University Medical School, Naoki Morimoto, Tsuyama Central Hospital, Kiyoshi Morita, Okayama University Medical School Introduction: Neurological surgery sometimes leads to brain infarction. A monitoring technique is needed to detect energy failure before infarction. Under limited oxygen supply conditions (ischemia), reduced nicotinamide adenine dinucleotide (NADH) is accumulated in the mitochondria because of the accentuated anaerobic glycolysis. NADH fluoresces a 460-nm blue light of when excited with a 360-nm ultraviolet (UV) light; hence, ischemic area can be visualized using NADH fluorescence. This method is used for the early detection of energy failure and may be used for prediction of infarction. In this study, we examined the correlation between in vivo NADH fluorescence imaging of the brain surface and infarction surface area and volume after 90-min focal ischemia in rats. Hypothesis: NADH fluorescence imaging can be used for early detection of energy failure and prediction of infarction. Methods: We used 10 male Spague-Dawley rats. A large cranial window was made on the left parietal-temporal bone for measuring the area and intensity of NADH fluorescence. Ischemia was initiated by occlusion of both common carotid arteries and left middle cerebral artery for 90-min. The cortical surface was illuminated with UV light (360-nm). NADH fluorescence images were obtained using a charge-coupled device (CCD) camera with a 460-nm bandpass filter, mounted on a surgical microscope. The brain of each rat was enucleated and paraffin-embedded 24 hours after the onset of ischemia; coronary sections (5-␮m thick) were prepared at 1000-␮m intervals. Infarct surface areas and volumes were measured from the slices. Results: High-intensity areas of NADH fluorescence gradually formed from the proximal to distal region of the MCA, and then plateaued. The areas of the regions of ischemic depolarization at 90 min were 7216 ⫾ 1681 pixels. Infarct volume was 121 ⫾ 32 mm3; infarct surface area was 77.15 ⫾ 14 mm2. Correlation between NADH fluorescence images and infarct surface area was R ⫽ 0.79, and infarct volume was R ⫽ 0.60. Conclusions: NADH fluorescence images showed good correlation between infarct surface area and volume. NADH fluorescence imaging can be used for early detection of energy failure and prediction of infarction.


170 KAPPA OPIOID RECEPTORS: NEW FRONTIERS FOR COCAINE ADDICTION TREATMENT IN FEMALES Anabel Puig-Ramos, Alicia Fernandez-Sein, Annabell Segarra, UPR-School of Medicine Introduction: During the last years there has been an increase in female cocaine abusers. Women begin using cocaine at earlier ages, and in a laboratory setting, cocaine cues induced more craving in women than in men. In female rodents, estradiol potentiates the behavioral response to cocaine; however, the mechanism by which this is accomplished has not been elucidated. We reported that Kappa Opioid Receptors (KOPr) agonists diminish behavioral sensitization to cocaine only in ovariectomized rats that received estradiol replacement. Hypothesis: Estradiol modulates KOPr expression in brain areas of the reward pathway in female rats treated with cocaine. Methods: We evaluated the effects of cocaine on brain KOPr expression in female rats with and without estradiol. Adult rats were ovariectomized, half received silastic implants filled with estradiol benzoate (OVX-EB); the others, empty implants (OVX). A week later, animals were injected for five consecutive days with either saline or cocaine, and on day 13, they received a saline or cocaine injection. An hour later, animals were sacrificed; brains removed and stored at ⫺70°C until punches from the prefrontal cortex (PFC), nucleus accumbens (NAc), caudate-putamen (CPU) and ventral tegmental area (VTA) for western blot analysis were collected. Results: Estradiol diminished KOPr expression in the VTA. There is a trend toward an increase on KOPr expression in PFC and NAc in animals treated with cocaine, independently of estradiol levels. Cocaine increased KOPr expression in the CPU only in OVX rats. These data demonstrate that cocaine and estradiol modulate the expression of KOPr in females in a region dependent manner. Conclusions: We previously showed that KOPr activation diminished the behavioral sensitization to cocaine only in OVX-EB rats, suggesting that the modulator role of KOPr in the behavioral response to cocaine is dependent of estradiol levels. This type of study will provide clinical investigators with a better understanding of cocaine-induced changes in KOPr expression in brain areas of the reward pathway and may contribute to the development of improved pharmacotherapy to treat cocaine and opiod dependence and/or addiction in male and female addicts.


Posters:Basic Science: Pulmonary 171

172

SURFACTANT ADMINISTRATION AND ALVEOLAR RECRUITMENT DECREASE AIRSPACE OVERDISTENSION IN SURFACTANT DEPLETED RATS, AS MEASURED BY HYPERPOLARIZED GAS IMAGING

TLR-9 SIGNALING MEDIATES ACUTE INFLAMMATION IN A MOUSE MODEL OF LUNG CONTUSION

Maurizio Cereda, Kiarash Emami, Yi Xin, Puttisarn Mongkolwisetwara, Harrilla Profka, Stephen Kadlecek, Nicholas Kuzma, Rahim Rizi, University of Pennsylvania, Clifford Deutschman, Univ. of Pennsylvania Introduction: Hyperpolarized gas magnetic resonance imaging (MRI) of the lungs detects increases in the apparent diffusion coefficient (ADC) for 3He in the presence of atelectasis in ventilated rats, suggesting overdistension of residual aerated airspaces. We aimed to investigate the effects of alveolar recruitment on ADC in a model of surfactant depletion (SD). Hypothesis: We hypothesize that the combined use of positive end expiratory pressure (PEEP) and bovine lipid extract surfactant (BLES) attenuates airspace overdistension induced by SD. Methods: 6 healthy male Sprague-Dawley rats (426⫾74 g) were anesthetized, intubated, paralyzed, and ventilated with 10 ml/kg tidal volume. In eachanimal,PEEPwastransientlyincreasedasarampfrom0to9cmH2O.Then,SDwas induced by repeat instillations of 30 ml/kg warmed saline. PEEP was then transiently increased from 0 to 15 cmH2O. Finally, 50 mg/kg of BLES were instilled in the endotrachal tube followed by PEEP increases from 0 to 9 cmH2O (PEEP⫹BLES). At each PEEP level, MRI scans, arterial saturation (SaO2), and dynamic compliance (Cdyn) were obtained. ADC was measured using a diffusion-weighted gradient echo pulse sequence through a 4.7-T MRI scanner. Each image was obtained during an inspiratory hold and after ventilation with 1:4 oxygen in 3He. Mean ADC values were obtained from maps of coronal slices. Results: In the healthy rats before SD, PEEP 9 cmH2O caused 18% ADC increase, due to distension of normal lung parenchyma. SD caused a decrease in Cdyn and a 37% increase in ADC at PEEP 0 cmH2O, likely due to atelectasis. After SD, increasing PEEP induced a significant 9.4% decrease in ADC at PEEP 15 cmH2O, and a non significant 3.5% decrease at 9 cmH2O. BLES alone decreased ADC of 6.4% at PEEP 0 cmH2O. PEEP⫹BLES decreased ADC of 15% compared to SD at PEEP 0 cmH2O. Decreases in ADC were associated with increases in Cdyn and SaO2, supporting the occurrence of alveolar recruitment. Conclusions: Our results suggested that, by inducing alveolar recruitment, PEEP and ESA synergistically decreased airspace overdistension in SD rats. This effect is likely to protect from ventilator induced lung injury in subjects with SD. NIH R01-HL064741 and R01-HL077241.

Bedabrata Sarkar, University of Michigan Hospitals, Suresh Madathilparambil, Bi Yu, Ashwin Ashwin, University of Michigan Hospital, David Machado, University of Michigan, Krishnan Raghavendran, UMHS Introduction: Lung contusion (LC) is common following blunt chest trauma, and is an independent risk factor for ALI/ARDS and increased mortality. Tolllike Receptor-9 (TLR-9) signaling has recently been implicated as a critical component of the inflammatory response after traumatic injury. We sought to evaluate the contribution of TLR-9 signaling to the acute physiologic changes following LC using an established murine model and TLR-9 knock-out (KO) mice. Hypothesis: Activation of TLR-9 signaling is required for LC mediated inflammation and injury. Methods: Using a mouse model of non-lethal unilateral LC, wild-type (WT) and TLR-9 knockout mice were sacrificed at 5, 24, 48, and 72 hours following injury (n ⫽ 6 –9). At sacrifice, animals underwent BAL and the cell-free supernatant was used for cytokine analysis as well as total albumin (permeability injury) levels by ELISA. Alveolar macrophages were isolated from BAL samples and cultured with FITC-labeled pseudomonas bacteria to assess phagocytic activity. Data expressed as mean ⫾ SEM; comparisons with ANOVA, p⬍0.05*. Results: Compared to TLR-9 KO mice, WT mice demonstrated elevated levels of pro-inflammatory IL-1␤ (9.6 ⫾ 2.8 v 5.3 ⫾ 1.8 pg/ml) and MIP-2 (76.2 ⫾ 28.2 v 34.9 ⫾ 13.4 pg/ml) cytokines 48h post LC. In contrast, anti-inflammatory IL-10 levels were higher in TLR-9 KO mice than WT mice (6.2 ⫾ 0.6 v 2.7 ⫾ 0.8 pg/ml). LC resulted in higher levels of BAL albumin in WT than in TLR-9 KO mice at 48h (18163 ⫾ 4964 v 6544 ⫾ 2207 ␮g/ml). Macrophages isolated from TLR-9 KO mice exhibited increased phagocytic activity at 24h post LC compared to WT mice (89% vs 116% relative phagocytic index). Conclusions: TLR-9 signaling mediates the inflammatory process following LC likely by modulating activation of alveolar macrophages.Supported by NIH grant 5R01HL102013– 02.

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ENHANCED PULMONARY RESPONSES TO ALLERGEN IN OBESE MICE IS INDEPENDENT OF GENETIC BACKGROUND

END TIDAL CO2 AND ARTERIAL PCO2 GAP IN RATS DURING VARIOUS TIDAL VOLUMES AND BREATHING RATES

Paul Dahm, Ikram Haque, Richard Johnston, University of Texas Health Science Center At Houston

Alfredo Castellanos, Avi Ronay, Dan Torbati, Andre Raszynski, Balagangadhar Totapally, Miami Children’s Hospital

Introduction: Obesity is a risk factor for asthma, yet the mechanistic basis for this relationship is poorly understood. We previously reported that genetically obese ob/ob, db/db, and Cpefat mice, which are on a C57BL/6 genetic background, have greater airway obstruction and/or pulmonary inflammation when compared to lean, wild-type C57BL/6 mice following sensitization and challenge with allergen (ovalbumin; OVA), an asthma trigger. These aforementioned responses to OVA have not been examined in obese TallyHo mice, which are on an SWR genetic background. Hypothesis: Enhancement of airway obstruction and pulmonary inflammation in obese mice following OVA sensitization and challenge is independent of genetic background. Methods: Obese TallyHo and lean, wildtype SWR mice were sensitized to OVA and then challenged with either aerosolized OVA or phosphate-buffered saline (PBS). Indices of airway obstruction or lung parenchymal mechanics [airway resistance (Raw), lung tissue damping (G), and lung tissue elastance (H)] were determined by the forced oscillation technique. Pulmonary inflammation [bronchoalveolar lavage fluid (BALF) eosinophils, lymphocytes, interleukin (IL)-13, and eotaxin] was assessed via histological and biochemical techniques. Results: TallyHo and SWR mice weighed 36.2⫾0.9 and 23.6⫾0.1 grams, respectively. There were no differences in Raw, G, and H between TallyHo and SWR mice following PBS challenge. OVA challenge increased Raw, G, and H in both genotypes, but these increases were enhanced in TallyHo when compared to SWR mice. In both TallyHo and SWR mice, OVA challenge increased BALF eosinophils, lymphocytes, IL-13, and eotaxin. However, after OVA challenge, TallyHo mice had fewer BALF eosinophils and lymphocytes but higher levels of BALF IL-13 and eotaxin when compared to SWR mice. Conclusions: Obese TallyHo mice exhibit greater airway obstruction following allergen sensitization and challenge, which may be due, in part, to increased IL-13 expression. Furthermore, obese mice manifest greater airway obstruction following allergen sensitization and challenge regardless of their genetic background.

Introduction: End-tidal CO2 (EtCO2) is used to monitor ventilation in clinical setting. Repeated blood gas analysis during experiments involving small animals can lead significant blood loss. This study evaluates EtCO2 and PaCO2 gap during normal range of ventilation, hypoventilation, and hyperventilation in a rat model of critical care. Methods: In a prospective, interventional study seven Sprague Dawley rats were anesthetized, tracheotomized, and catheterized in femoral artery and vein. The animals were subjected to mechanical ventilation at different tidal volumes (Vt) and breathing rates (f) for 15 minutes under maintained anesthesia and normothermia. Ventilation modes were categorized in to three groups: normal, hypoventilation and hyperventilation using various tidal volumes and breathing rates. Ventilation modes were randomly changed. EtCO2 and mean arterial blood pressure (MBP) were continuously recorded. Seventyfive trials in 7 rats were analyzed. Results: The mean (SD) Vt (ml/kg) during normal, hypoventilation, and hyperventilation were, 12.5 (1.1), 6.5 (1.8), and 18 (2), respectively. During the three modes of ventilation, the mean (SD) PaCO2 (mmHg) were 44.8 (8.5), 53.6 (4.7), 41.4 (8.6) and EtCO2 (mmHg) were 33.7 (7.4), 38.5 (6.2), 32.1 (6.8), respectively. PaCO2-EtCO2 bias, as evaluated by the Bland-Altman technique, was 11, 15, and 9 mmHg during normal, hypoventilation and hyperventilation, respectively. Precision, defined as the SD of the bias, was approximately 4 mmHg in all ventilation categories. Bias was significantly lower at ventilation rate of 60/min, compared to 90/min (8.2 versus 13.3 mmHg; p⬍0.001) at comparable PaCO2. Conclusions: EtCO2 is reliable for ventilation monitoring during experiments in rats. However, EtCO2 has large but constant bias at 22 to 28% during various levels of ventilation. This data will help to set target EtCO2 levels as a surrogate for PaCO2 values during various modes of ventilation in rats.


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CARBON DIOXIDE ELIMINATION (VCO2) AND END-TIDAL CARBON DIOXIDE (ETCO2) REFLECT PULMONARY BLOOD FLOW RESPONSE TO ALTERATIONS IN BLOOD VOLUME IN MECHANICALLY VENTILATED JUVENILE SWINE

SURVIVAL AND MORBIDITY IN A PORCINE ADULT ICU MODEL OF PROLONGED MECHANICAL VENTILATION

Steven McSwain, Medical University of South Carolina, Michael Gentile, Phillip Smith, Ira Cheifetz, Duke University Medical Center Introduction: Carbon dioxide elimination (VCO2) and end-tidal carbon dioxide (ETCO2) are principally influenced by pulmonary blood flow (PBF) when minute ventilation and physiologic dead space are stable. The purpose of this study is to quantify this relationship in response to changes in blood volume. Hypothesis: In stably ventilated juvenile swine, changes in VCO2 and ETCO2 in response to changes in blood volume correlate with changes in PBF. Methods: We recorded breath-by-breath measurements of multiple capnographic parameters, including VCO2 and ETCO2, and measurements every three cardiac cycles of hemodynamic parameters including PBF, pulmonary arterial pressure (PAP), and right ventricular pressure (RVP), in seven mechanically ventilated juvenile swine. Volume status was manipulated by removing 10 ml/kg of blood, reinfusing the removed blood, and bolusing 10 ml/kg of normal saline. The correlation of PBF, RVP, and PAP with VCO2 and ETCO2 was calculated by linear regression analysis. Capnographic lag time was determined, and the absolute changes in multiple hemodynamic, capnographic, and laboratory values were calculated for each intervention. Results: The average adjusted r2 value for PBF for all subjects was 0.75 (range 0.61– 0.88) for VCO2 and 0.72 (range 0.38 – 0.94) for ETCO2 during blood removal (698 observations); 0.64 (range 0.39 – 0.90) for VCO2 and 0.79 (range 0.6 – 0.91) for ETCO2 during blood return (536 observations); and 0.71 (range 0.48 – 0.92) for VCO2 and 0.76 (range 0.4 – 0.91) for ETCO2 for the combination of blood removal and return. During the normal saline bolus, the average adjusted r2 value for PBF for all subjects was 0.08 (range ⫺0.02– 0.31) for VCO2 and 0.09 (range ⫺0.02– 0.35) for ETCO2 (397 observations). The correlation of VCO2 and ETCO2 with PAP and RVP was also calculated, showing similar results. The change in capnographic parameters consistently lagged the hemodynamic changes by 2.5 minutes. Conclusions: Measurement of continuous carbon dioxide elimination (VCO2) and ETCO2 by volumetric capnography during changes in volume loading conditions by removing or bolusing whole blood correlates well with changes in pulmonary blood flow in mechanically ventilated juvenile swine.


Sandra K. Hanneman, Rene Flores, University of Texas Health Science Center at Houston, Fred Clubb, Texas A & M University, Katrina Leyden, University of Texas Health Science Center at Houston Introduction: Mechanical ventilation ⱖ4 days in the intensive care unit (ICU) is associated with high morbidity, mortality, and cost. An in vivo preclinical model that comprises the complexity of a clinical ICU patient mechanically ventilated for ⱖ4 days would enhance research to improve outcomes of this growing population. Hypothesis: The objective was to standardize a nurse-managed porcine adult ICU model of prolonged mechanical ventilation. Methods: The planned ICU stay was 40 hr for two pigs to refine study protocols, and 7 days for four pigs to confirm reproducibility of the model. Crossbred pigs (72 ⫾ 9.7 kg) were instrumented with oral endotracheal tube, arterial, central venous, and bladder catheters; transferred to a clinical ICU bed; and admitted to the ICU with continuous mechanical ventilation, sedation, anticoagulation, parenteral nutrition, and cardiopulmonary, hemodynamic, and thermal monitoring. Upon completion of the ICU stay, liver tissue was taken for ultrastructural and histological evaluation. Results: Five of six (83%) pigs survived the planned length of ICU stay; one pig died suddenly after 5 days in the ICU from pulmonary embolus. Five pigs experienced complications: pneumonia (n ⫽ 4), hemorrhagic shock (n ⫽ 3), airway obstruction (n ⫽ 3), arrhythmia (n ⫽ 2), acute respiratory distress syndrome (n ⫽ 1), inadvertent extubation (n ⫽ 1), pulmonary embolus (n ⫽ 1), stroke (n ⫽ 1), and lobar atelectasis (n ⫽ 1). Ultrastructural and histological findings were consistent with the clinical picture and varied from mild, reversible to severe, irreversible cellular changes in organ pathology. Conclusions: The domestic farm pig can survive up to 7 days of mechanical ventilation undergoing care by ICU nurses following clinical ICU protocols, despite the development of complications. Standardized sedation, anticoagulation, parenteral nutrition, fluid administration, mechanical ventilation, airway management, resuscitation, and general ICU care protocols extended ICU survival beyond the ⱕ2-day survival time previously reported. The porcine ICU model is useful for translational research relevant to patients who receive mechanical ventilation ⱖ4 days in the ICU.Funding: NINR, NIH; Vivian L. Smith Foundation; PARTNERS.

Posters: Basic Science: Renal 177

178

ATRIAL NATRIURETIC PEPTIDE PREVENTS ACUTE KIDNEY INJURY IN RENAL ISCHEMIA-REPERFUSION INJURY RAT MODEL

HUMAN ATRIAL NATRIURETIC PEPTIDE IMPROVES RENAL ISCHEMIA/REPERFUSION INJURY VIA ANTIOXIDANT MECHANISM

Miniwan Tulafu, Tokyo Medical and Dental University Graduate School, Chieko Mitaka, Tokyo Medical and Dental University, May Khin Hnin Si, Tokyo Medical and Dental University Graduate School

Hironori Koga, Taichi Nishida, Satoshi Hagiwara, Shigekiyo Matsumoto, Chihiro Shingu, Takayuki Noguchi, Oita University

Introduction: Acute kidney injury (AKI) is common in critically ill patients. AKI produces inflammatory cytokines, which induce injury and inflammation of remote organ such as lungs. Atrial natriuretic peptide (ANP) has natriuretic, diuretic, and anti-inflammatory effects. Hypothesis: ANP prevents AKI and inflammation of kidneys and lungs in renal ischemia- reperfusion injury rat model. Methods: Male Sprague-Dawley rats were anaesthetized with intraperitoneal injection of pentobarbital. Tracheostomy was performed and rats were ventilated at VT 10 ml/kg with 5 cmH2O of PEEP. The right carotid artery was catheterized for blood sampling and continuous blood pressure measurements. The right femoral vein was catheterized for infusion of saline or ANP. Rats were divided into 3 groups; 1) control group (n ⫽ 6), 2) AKI group (n ⫽ 12); left renal pedicle was clamped for 1 hr, 3) ANP⫹AKI group (n ⫽ 12); ANP (0.2 ␮g/kg/min, for 3 hr) was started 5 min before clamp, and then left renal pedicles was clamped for I hr. Hemodynamics, arterial blood gas, and plasma lactate levels were measured at 0, 1, 2 and 3 hrs. The expression of IL-1▫/span⬎ and IL-6 mRNA in kidneys and lungs and wet/dry ratio of the lungs were measured. Results: AKI induced metabolic acidosis, pulmonary edema and expression of IL-1▫/span⬎ and IL-6 mRNA in kidneys and lungs. The pre-treatment with ANP attenuated metabolic acidosis and expression of cytokines mRNA in kidneys and lungs. Conclusions: These findings suggest that ANP prevents AKI and inflammation of kidneys and lungs in renal ischemia-reperfusion injury rat model.

Introduction: Acute kidney injury (AKI) is common in the intensive care unit, and one of its primary causes is renal ischemia-reperfusion (I/R) injury. Human atrial natriuretic peptide (hANP) has been used as a drug for heart failure, on the other hand, some studies have shown that hANP has various pharmacological effects, including renal protection. Hypothesis: In the present study, we evaluated the renal protective effect of hANP in a rat model of renal I/R, and tested hypothesis that the antioxidant effect is involved in the protective mechanism. Methods: Male Wistar rats were divided into three groups that received the following treatments: induction of renal I/R (I/R group); continuous intravenous injection of hANP followed 30 min later by induction of renal I/R (hANP⫹I/R group); and sham treatment (control group). Rats were sacrificed after 60 min of ischemia and 24 hours of reperfusion or sham treatment. To evaluate the renal protective effects of hANP, serum blood urea nitrogen (BUN) and creatinine (Cre) concentrations were determined, kidneys were histologically assessed, and serum biomarkers of oxidative stress were evaluated. In addition, antimycin A (AMA)-stimulated RAW264.7 cells were treated with hANP, and reactive oxygen species (ROS) activity was measured using FACS to assess its antioxidant effects. Results: Serum BUN and Cre levels were elevated in the I/R group; however, these increases were significantly inhibited in the hANP⫹I/R group. Similarly, kidney tissue damage observed in the I/R group was attenuated in the hANP⫹I/R group. In vitro, AMA-stimulated cells treated with hANP showed reduced ROS activity compared to cells treated with AMA alone. Conclusions: Our findings indicate that hANP ameliorates renal I/R by antioxidant effect, and may be effective in the treatment of various types of I/R injuries.

179 E-GABA-GS, A NEW VITAMIN E DERIVATIVE, AMELIORATES RENAL ISCHEMIA-REPERFUSION INJURY IN A RAT MODEL Taichi Nishida, Hironori Koga, Satoshi Hagiwara, Ryota Imatomi, Koji Goto, Takayuki Noguchi, Oita University Introduction: Recent studies have reported that substances in the body such as vitamin E and gulutathione, which play an important role in redox reaction, can improve specific clinical settings caused by inflammation or oxidative stress. We have revealed some vitamin E or glutathione derivatives have curative properties against a kind of ischemia/reperfusion (I/R) injury. It is, however, unknown if E-GABA-GS, a vitamin E derivative consisting of vitamin E, gamma-aminobutyric acid (GABA) and glutathione, can ameliorate renal I/R injury. Hypothesis: The aim of this study was to test hypothesis that E-GABA-GS has renal protective effect against renal I/R injury in a rat model. Methods: Male Wistar Rats were divided into 3 groups, and received intravenous infusion of E-GABA-GS 10 mg/kg (E-group) or saline (vehicle group, sham group) for pretreatment. Under general anesthesia, right kidney was removed, followed by ligation of left kidney hilus with a clamp for renal ischemia. After 60 min ischemia, the clamp was removed. Rats were sacrificed 24 h after reperfusion or sham treatment. Serum blood urea nitrogen (BUN) and creatinine (Cre) concentrations were measured. Kidney tissue histology, myeloperoxidase (MPO) and malondialdehyde (MDA) levels were evaluated. In addition, the expression levels of High Mobility Group Box 1 (HMGB1), inducible nitric oxide synthase (iNOS), and Inter-Cellular Adhesion Molecule 1 (ICAM1) were evaluated using Western Blotting method. Results: E-GABA-GS attenuated renal histological injury, and the elevation of BUN and Cre in vehicle group was drastically reduced by E-GABA-GS treatment. Furthermore, MPO and MDA levels in the renal tissues were lower in Egroup than in vehicle group. The I/R- induced high expression of HMGB1, iNOS, ICAM1 was reduced by E-GABA-GS. Conclusions: E-GABA-GS can reduce renal injury which results from oxidative stress and inflammation induced after reperfusion. Our recent study suggests that E-GABA-GS may have therapeutic potential against a variety of I/R conditions.


Posters: Basic Science: Sepsis 180

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EFFECTS OF NITRIC OXIDE ON HEART RATE VARIABILITY DURING SEPSIS

THE EXPRESSION PATTERN OF TREM-2 IN TISSUE MACROPHAGE OF SEPTIC MICE

Michael Kwiatt, Robert Perez, Joe LaChant, Steven Hollenberg, Sergio ZanottiCavazzoni, Cooper University Hospital

Qixing Chen, Kai Zhang, MeiTing Cai, XiangMing Fang, Zhejiang University

Introduction: Nonlinear hemodynamic variables are abnormal in sepsis. Nitric oxide has a complex role in hemodynamic alterations in sepsis. The role nitric oxide synthase (NOS) in nonlinear hemodynamics in sepsis is unknown. Hypothesis: Selective inhibition of inducible NOS (iNOS) and endothelial NOS (eNOS) will cause distinct alterations in the response of nonlinear hemodynamic parameters in a murine model of sepsis. Methods: Radio-transmitters were implanted into the aorta of C57/BL6 wild type (WT) (n ⫽ 15), C57/BL6 NOS 2 (iNOS knockout) (n ⫽ 8), and C57/BL6 NOS 3 (eNOS knockout) (n ⫽ 7) mice for continuous hemodynamic monitoring. After 72 hours of recovery, baseline heart rate recordings were captured for 24 hours. Sepsis was induced by cecal ligation and puncture and continuous recordings were taken for the next 48 hours. All mice received antibiotics (ceftriaxone and clindamycin) and fluids (35 mg/kg 0.9% NaCl) every 6 hours. Volatility was used as a measurement of variability. Heart rate volatility (HRV) measurements were compared between groups. Results: At baseline both iNOS KO mice and eNOS KO mice had higher mean systolic blood pressures (SBP) and a lower mean heart rate (HR) at baseline compared to WT mice. During sepsis, HR and SBP were similar between KO mice and WT mice. The iNOS KO mice had more frequent normal intervals of HRV than the WT mice (48.9 vs. 33.3%, p⬍0.001). eNOS knockout mice had fewer normal intervals of HRV compared to the WT mice (24.1 vs. 33.3%, p⬍0.001). Survival was significantly higher in the iNOS KO mice compared to wild type mice (75 vs. 26.7%, p ⫽ 0.039). Survival was similar between the eNOS KO and WT mice (28.6% vs. 26.7%, p ⫽ 1.0). Conclusions: NO has a complex role in nonlinear hemodynamic parameters during sepsis. Selective inhibition of iNOS during sepsis resulted in improvement in heart rate variability and correlated with improved survival compared to WT mice. However, selective inhibition of eNOS led to less heart rate variability and no survival difference. Our findings suggest a complex role of NO in nonlinear hemodynamics during sepsis, with inhibition of different NOS isoforms having significantly different effects on nonlinear hemodynamic parameters and survival.

Introduction: Triggering receptor expressed on myeloid cells-2 (TREM-2) is a cell surface receptor mainly expressed on macrophages and a member of the IgG superfamily. Previous studies have shown that TREM-2 functions to inhibit cytokine production by macrophages in response to the TLR ligands LPS, zymosan and CpG, thus attenuates macrophage activation. TREM-2 may regulate host immune response in inflammatory diseases such as sepsis. However, the expression pattern of TREM-2 in the course of sepsis remained unknown. Hypothesis: The expression levels of TREM-2 in tissue macrophage are elevated during sepsis and depend on the course of sepsis. Methods: The sepsis model was conducted by means of cecal ligation and double puncture (2CLP) in mouse. The mouse were sacrificed at 0 h, 6 hrs, 12 hrs, 24 hrs, 72 hrs, 120 hrs and 168 hrs following 2CLP. Tissues of liver, spleen and lung were resected at each time point. The expression levels of TREM-2 in the tissues were measured by means of immunohistochemical analysis. Results: No baseline levels of TREM-2 were detected in mouse immediately after induction of sepsis. With the sepsis developing, the expression levels of TREM-2 in liver, spleen and lung increased, and reached the peak value at 72 hrs after 2CLP, then declined. Double-labelling immunofluorescence assay further confirmed that the distribution of TREM-2 in liver, spleen and lung were located on the macrophages in these tissues. Conclusions: TREM-2 may play an important role in sepsis. Combined with the functional activity of TREM-2, regulation of the expression levels of TREM-2 may provide a new immunomodulatory approach for sepsis.

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CODE SEPSIS: IMPROVING SURVIVAL BY ACTIVATION OF A CRITICAL CARE TEAM

AZD9773, A NOVEL ANTI-TUMOR NECROSIS FACTOR-A IMMUNE FAB IN DEVELOPMENT FOR SEVERE SEPSIS AND SEPTIC SHOCK: ANALYSES OF COMPLEX FORMATION AND BINDING SITES WITH TNF-A

Nicole Kupchik, Valerie Calogero, David Carlbom, Diane Switzer, Richard Utarnatchitt, Harborview Medical Center Introduction: Sepsis is a leading cause of death in the US. Compared to other UHC hospitals, Harborview’s sepsis rate is 37.5 per 1,000 patients; ranking us over the 75th percentile. It is a key driver of inpatient death and produces substantial economic costs. Hypothesis: Using SIRS screening criteria and GoalDirected Therapy, a process was developed for screening ED patients aimed at early identification and activation of “Code Sepsis,” with aggressive sepsis treatment and early critical care team involvement. We hypothesize an organized treatment approach will lead to lower mortality, hospital and ICU LOS, fewer vent days and reduced costs. Methods: In 2009, a Sepsis protocol was developed to guide and standardize therapy in the ED. A mechanism to activate a team of critical care providers was created to respond to patients identified as high risk unresponsive to initial treatment. If patients exhibit low blood pressure or elevated lactate after antibiotics and fluids, ED staff activate “Code Sepsis.” The team is comprised of a Critical Care Physician, ICU nurse and pharmacist. After the program was launched, monthly multi-disciplinary meetings were used to review cases looking for areas which excelled and areas for improvement. A long term, intermittent educational approach was utilized with the ED and ICU teams to improve sepsis care. Compliance with “Code Sepsis” activation improved each time education was offered. Results: We compared “Code Sepsis” activation cases to Sepsis DRG cases without an activation. The mean LOS was almost 25 days in the group without activation compared to 8-day LOS with “Code Sepsis” activation. The average ICU LOS was 13 days in the non-activation group, compared to 4 days in the activation group. The average cost to treat a patient with early intervention was on average $41,966 compared to $97,725 in the group without activation. Conclusions: Early recognition and intervention with activation of a critical care team was the key to success in reducing mortality and costs. Significant overall improvements in our care of patients with Sepsis were identified. The formation of a “Code Sepsis” team was innovative and providers were more intentional with treatment & interventions.


Peter Newham, Melanie Snow, Sonia Eckersley, Gareth Davies, Mark Abbott, AstraZeneca Introduction: TNF-a is thought to play a central role in the pathogenesis of sepsis and septic shock. AZD9773 is an ovine polyclonal anti-human TNF-␣ (rhTNF-␣) immune Fab with modest binding affinity for human TNF-␣ (60 nM); however, the apparent inhibitory constant for TNF-␣ neutralizing potency is ⬃40 pM. Here we explore the mechanism of TNF-␣ inhibition. Hypothesis: Since AZD9773 is a polyclonal rhTNF-␣ immune Fab preparation, it is anticipated to have multiple binding sites on human TNF-␣. Thus, we utilized multiple biochemical approaches to define the AZD9773:TNF-␣ interaction. Methods: AZD9773:TNF-␣ binding mode studies: (i) 2625 chemically linked peptides on scaffolds covering linear, conformational and discontinuous TNF-␣ epitopes were tested for AZD9773 binding (ELISA); (ii) in-solution AZD9773/ TNF-␣ hydrogen/deuterium exchange mass spectrometry was used to detect AZD9773:TNF-␣ contact sites; (iii) surface plasmon resonance studies using murine/human TNF-␣ chimeras (AZD9773 does not bind murine TNF-␣) were used to identify human sequences capable of supporting AZD9773 binding. S200 size-exclusion chromatography of AZD9773, TNF-␣ and AZD9773: TNF-␣ mixtures was used to determine the size of the AZD9773:TNF-␣ complex. Results: Two strong epitopic regions have been identified by these methods. A further four regions show binding by one or two of the approaches and are considered to be tentative or weak epitopes. Size-exclusion chromatography data resolved a ⬃390-kDa AZD9773:TNF-␣ complex. Conclusions: We have identified six key regions within TNF-␣ that engage with AZD9773 Fabs. Chromatography data reveal AZD9773 to comprise 6 –7 AZD9773 Fabs (50 kDa) bound per TNF-␣ trimer (51 kDa). These data indicate the polyclonal nature of AZD9773 and may provide an explanation for its high biological potency. AZD9773 is currently in Phase IIb development for severe sepsis and septic shock.

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THERAPEUTIC HYPOTHERMIA DECREASES LIVER INJURY IN POLYMICROBIAL SEPSIS MODEL OF RATS

ATTENUATION OF INTEGRIN B8 EXPRESSION IS ASSOCIATED WITH MICRORNA DYSREGULATION DURING SEPSIS

Jae Hyuk Lee, Kyuseok Kim, You Hwan Jo, Kwang Pil Rim, Kyeong Won Kang, Tae Ho Song, Min Ji Lee, Hyun Sook Lee, Joong Eui Rhee, Seoul National University Bundang Hospital

Cathy Moore, George Alyateem, Iain McKillop, Toan Huynh, Carolinas Medical Center

Introduction: Therapeutic hypothermia has been proposed to protect organs in the management of cardiac arrest, traumatic brain injury and hemorrhagic shock. The effect of therapeutic hypothermia on liver injury in sepsis was unknown. Hypothesis: We hypothesized that application of therapeutic hypothermia in polymicrobial sepsis would result in decreasing liver injury and apoptosis and would preserve Akt survival pathway. Methods: Male Sprague-Dawley rats underwent cecal ligation and incision (CLI) to induce sepsis. Rats were randomly allocated into one of two groups after 1hour of CLI: hypothermia (HT) group vs. normothermia (NT) group. In the HT group, body temperature was decreased to 32⫾0.5°C using ice packs. Hypothermia was maintained for 4 hours and rewarmed to 37°C for 2 hours. In the NT group, body temperature was maintained at 37⫾0.5°C throughout the experimental periods. After 7 hours post CLI, blood and liver tissues were harvested. Serum alanine aminotransferase (ALT) and liver injury score were measured in serum and H&E stained liver tissue. Immunohistochemistry was performed for cleaved caspase-3 and phosphorylation of Akt, GSK-3 and Bad were evaluated with western blot assay. Results: Serum ALT was significantly lower in the HT group than in the NT group (57.0⫾6.0 IU/L VS. 192.5⫾92.5 IU/L, p ⫽ 0.028). Histological injury score was also significantly lower in the HT group than in the NT group (2.9⫾0.5 VS. 5.4⫾0.6, p ⫽ 0.016). Phosphorylation of Akt, GSK-3 and Bad were significantly increased in the HT group compared with the NT group (p⬍0.001, p ⫽ 0.007, p ⫽ 0.001, respectively). Expression of cleaved caspase-3 was significantly decreased in the HT group compared with the NT group (p ⫽ 0.032). Conclusions: Therapeutic hypothermia decreased liver injury in polymicrobial sepsis model of rats via preserving Akt signaling pathway and decreasing apoptosis concurrently.

Introduction: Sepsis is characterized by a severe immunopathological state in which high levels of the Gram-negative bacterial component, lipopolysaccharide (LPS), perpetuate endothelial cell activation resulting in leukocyte adhesion and generation of reactive oxygen species. This can lead to cellular injury and organ dysfunction. Under physiological conditions, cellular adhesion molecules are regulated to maintain vascular integrity. During sepsis, microRNAs (miRNAs) limit the innate immune response by targeting cellular adhesion mRNA transcripts in endothelial cells and TNF␣ transcripts in macrophages. Hypothesis: We hypothesize that miRNA expression mediates endovascular dysfunction by targeting genes regulating cellular adhesion molecules in sinusoidal endothelial cells following LPS challenge. Methods: Transformed sinusoidal endothelial cells (TSECs) were treated with increasing LPS concentrations (10 and 100 ng/mL). RNA was isolated at 4- and 6-hour time points and focal adhesion gene expression analyzed using RealTime PCR. In parallel experiments, TSECs were treated with LPS (100 ng/mL) and miRNA isolated at 6 hours. Anti-correlated target pairs (mRNA:miRNA) were identified using TargetScan and miRanda to confirm the expression of miRNA and its ligand. Results: Realtime PCR analysis showed that mRNA targets associated with the cellular adhesion pathway (Itg␤8, Map2k1, and Pxn) were modulated by endotoxin challenge. miRNA analysis at 6 hours following 100ng/ml LPS-stimulation was associated with a significant down regulation of miRs -302d, -93, -19a, -23a, -142–5p, -27a (2-⌬Ct ⬍-2.5 foldchange). In silico analysis demonstrated that miRs -302d, -93, and -19a target the cellular adhesion molecule, integrin ␤8. Conclusions: Our data suggest that miRNAs associated with the adhesion pathway may contribute to endothelial cell dysfunction following endotoxin challenge. Restoration of miR-93 may represent a novel mechanism to reduce endothelial cell activation and thus subsequent organ injuries in sepsis.

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NEUTROPHIL GELATINASE-ASSOCIARED LIPOCALIN PREVENTS GUT BACTERIAL GROWTH IN SEPTIC MOUSE

CAPTOPRIL IMPROVES SURVIVAL IN LPS–INDUCED ENDOTOXEMIC MICE

Katsuya Mori, The Japan Society for Promotion of Science, Toru Igarashi, Hiroshi Morisaki, Junzo Takeda, Keio University School of Medicine

Sanghyum Kwak, Dept. of Anesthesiology & Critcal Care Medicine, Chonnam National Medical School

Introduction: Neutrophil gelatinase-associated lipocalin (NGAL) prevents bacterial iron uptake, leading to provide bacteriostatic effects. We previously demonstrated that sepsis evoked the up-regulation of NGAL mRNA in gut tissues. However, it remained unclear whether NGAL was secreted into gut lumen, possibly resulting in modulation of bacterial overgrowth in gut. Hypothesis: We hypothesized that NGAL was secreted into gut lumen. Methods: With our institutional approval, male C57BL/6J mouse (6 –7 weeks) were randomly assigned to two groups: Control or Endotoxin group. The former was administered 1 mL of intra-peritoneal injection of normal saline and the latter endotoxin. Endotoxin group was further divided into 3 subgroups: low (0.125 mg/mL), middle (0.25 mg/mL) or high dose (0.5 mg/mL) group. After 24 hr, intraluminal contents of ileum and colon were collected for detection of NGAL protein. In in vitro study, Escherichia coli collected from fecal was cultured with recombinant NGAL protein and counted after 48 hr. Results: While NGAL was not detected in intraluminal contents in Control group, there was significant level of NGAL found depending on its dose in Endotoxin group (P⬍0.05). Escherichia coli growth was significantly inhibited by NGAL (P⬍0.01), whereas the addition of 1ng NGAL apparently prevented bacterial proliferation. Conclusions: Sepsis evokes a large number of NGAL discharge into gut lumen, possibly contributing to regulation of aberrant microflora in gut.

Introduction: This study was performed to evaluate the effects of the ACE inhibitor captopril on lipopolysaccharide (LPS)-induced neutrophil activation and mortality in LPS-induced endotoxemic mice. Hypothesis: Angiotensin– converting enzyme (ACE) mediates inflammatory response in healthy lungs via angiotensin II and plasminogen activator inhibitor-1. Neutrophils play an important role in the development of acute lung injury associated with severe sepsis. However, the ability of ACE directly participating in LPS-induced neutrophil activation has not been fully examined. Methods: To assess possible interactions between captopril and LPS on neutrophil activation, neutrophils from human blood were incubated with various concentrations of captopril (0, 1, 10, 50 and 100 nM) and LPS (100 ng/ml). The protein levels for interleukin (IL)-6, 8 and tumor necrosis factor (TNF)-␣ were measured using ELISA 4 hr after incubation period. To elucidate the intracellular signaling pathway, We measured the levels of phosphorylation of p38 mitogen activated protein kinases (p38), extracelluar signal-regulated kinase (ERK)1/2 and c-Jun amino-terminal kinases (JNK) with western blot analysis and nuclear levels of nuclear factor (NF)-?)-KB with electrophoretic mobility shift assays 0.5 hr after incubation period. We also examined the effect of captopril (30 mg/kg, IP) on mortality of mice treated with LPS (20 mg/kg, IP) to determine whether these effects of captopril also have in vivo significance. Results: Captopril attenuated LPS-induced neutrophils activation including expression of p38, JNK, NF-?-KB, IL-6, 8 and TNF-␣. Captopril also attenuated mortality in LPS-induced endotoxemic mice. Conclusions: Captopril can attenuate mortality in LPS-induced endotoxemic mice via the attenuation of neutrophil activation caused by LPS.


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REMOVAL PROPERTIES OF INTERLEUKIN-6 AND HMGB1 FROM PATIENT’S PLASMA WITH HEPATIC INSUFFICIENCY: COMPARISON BETWEEN CVVHD AND CVVH USING A POLYMETHYL METHACRYLATE (PMMA) MEMBRANE HEMOFILTER

ENDOTOXIN EVOKES UP-REGULATION OF NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN IN GUT

Shuhei Niiyama, Kurume University Medical Center

Introduction: Neutrophil gelatinase-associated lipocalin (NGAL), a bacteria siderophres-binding protein, possesses bacteriostatic effects, possibly resulting in the improvement of outcome in patients with bacterial infection. While pneumonia leads to evoke the up-regulation of NGAL at pulmonary epithelial cell, it remains unclear whether sepsis, associated with abnormal growth in gut, accelerates NGAL expression in gut. Hypothesis: We therefore tested the hypothesis that sepsis evoked the up-regulation of NGAL mRNA in gut. Methods: With our institutional approval, male C57BL/6J mouse (6 –7 weeks) were randomly assigned to two groups: Control or Endotoxin group. The former was administered 1 mL of intra-peritoneal injection of normal saline and the latter endotoxin (0.5 mg/mL). The animals were euthanized at 0, 6, 12, 24 hr study period. and the tissues of ileum and colon were collected for analysis of the NGAL mRNA level. Results: Endotoxin group showed a marked increase of NGAL mRNA expression in a time-dependent manner in both ileum and colon as compared with Control group. Conclusions: Sepsis evokes the up-regulation of NGAL mRNA in gut, suggesting that NGAL might play a consequential role in regulation of gut flora if needed.

Introduction: It is widely accepted that excess inflammatory cytokines play a pivotal role in severe sepsis and septic shock. Various blood purification techniques used to remove these cytokines have proven to be effective. Hypothesis: The present study was conducted to demonstrate the removal efficacy of high concentrations of IL-6 and HMGB1 from human plasma with CVVHD (HD) and CVVH (H) using a PMMA membrane hemofilter. Methods: The plasma was waste plasma collected after plasmapheresis. The concentrations of IL-6 and HMGB1 were 477,917 pg/ml and 41.8 ng/ml, respectively. Informed consent was obtained from the family. For HD and H, the hemofilter was used under the following operating conditions: plasma flow rate (QP); 80 ml/min, dialysate flow rate (QD); 400 ml/hr, body fluid removal rate; 0 ml/hr in HD and QP; 80 ml/min, filtration rate (QF); 400 ml/hr, body fluid removal rate; 0 ml/ml in H. The plasma samples from the inlet and outlet sides of the hemofilter and the sample of filtrated solution were collected at the start and after 0.5, 1, 3, 6, 12, 18, 24, 30, 36 and 48 hours. Parameters including clearance of plasma (CLp), sieving coefficient (SC), and amount of total removal of IL-6 and HMGB1 were assessed. Results: At 6 hr, the IL-6 was 11,675 and 6,656 pg/ml in HD and H, respectively. At 18 to 48 h, the IL-6 level was about 1,000 pg/ml and 500 pg/ml, in HD and H, respectively. The CLp of IL-6 at 0.5 hr was 31 ml/min and 36 ml/min in HD and H, respectively. The value of SC of IL-6 was 0.05 and 0.15, in HD and H, respectively. In both HD and H, the amount of total removal of IL-6 was almost equal and the value was 400,000,000 pg. At 6 hr, the HMGB1 was 4.8 and 4.4 ng/ml in HD and H, respectively. At 48h, the HMGB1 was 2.8 and 2.9 ng/ml, in HD and H, respectively. The CLp of HMGB1 at 0.5 hr was 30 and 31 ml/min in HD and H, respectively. The value of SC was both 0, in HD and H. Conclusions: These data demonstrate that the mechanisms underlying the removal of IL-6 and HMGB1 in both HD and H using a PMMA membrane hemofilter may be mainly due to adsorption. Regarding the adsorption of IL-6 and HMGB1, there is little difference between HD and H. Furthermore, we demonstrate the limit of adsorption of IL-6 in this hemofilter.

190 THE PROGNOSTIC VALUE OF LOWEST DIASTOLIC BLOOD PRESSURE ON DAY 3 IN SEPTIC SHOCK PATIENTS Fadi Alattar, Nancy Holder, Saad Usmani, Fayez Shamoon, Trinitas Hospital Introduction: Septic shock patients are at high risk of mortality and morbidity. Currently their prognosis is assessed by scores that evaluate the cardiovascular system early on admission and do notcount for the dynamic response to vasopressors. Hypothesis: To study the cardiovascular reactivity during vasopressor therapy in the first 4 days of septic shock as an early predictor of in hospital survival in septic shock patients in comparison to SAPS II and APACHE II scores. Methods: Septic shock patients who were treated for at least 3 days of vasopressors in academic regional medical center were prospectively observed for in hospital mortality. SOFA, APACHE II ,SAPS II were calculated at day 1 of shock while BP was recorded every hour in the first 4 days. Results: f total 62 patients included (age 67⫾11 years, 35 men), 30 died in hospital(group1) and 32 survived (group2).Initially, group 2 had worse organdysfunction (SOFA score 12 (10 –14) vs. 10 (8 –13); p: 0.02). Median length ofstay was 15 days (9 –22).The lowest diastolic blood pressure(LDP) in the first4 days, and the percentage of time MAp⬍65 mmHg was lower in group1(ANOVA p:0.01, p:0.007; respectively). LDP was lower in group 2 startingfrom day 3(40⫾2 mm Hg vs. 46⫾1 ; p:0.025). A cut point of 45 mmHg wasdetermined using ROC analysis. On day 3, patients with LDP ( LDPD3) ⱕ45 mm Hg were at higher risk of death compared to patients with LDPD3 ⬎45 mm Hg (odd ratio: 3.2 (1.1 to 9.0); p:0.04)).LDPD3 inversely correlated withlength of stay in survivors (r:-0.4,p:0.02), and inversely with peak troponins (r:-0.3; p: 0.04). LDPD3, APACHE II, and SAPSII scores performed similarly inpredicting mortality (Area under the curve:0.65, 0.7, 0.8; respectively. p valuefor difference⬎0.05). Conclusions: LDPD3 is a simple and strong prognostic indicator of in- hospital mortality inseptic shock patients.


Katsuya Mori, The Japan Society for Promotion of Science, Toru Igarashi, Hiroshi Morisaki, Junzo Takeda, Keio University School of Medicine

Posters: Burns/Trauma -1 191

192

COMBAT-RELATED TRAUMATIC BRAIN INJURY: A PROSPECTIVE STUDY OF DEMOGRAPHICS AND RISK FOR EARLY MORTALITY

HEPARIN-BINDING EGF-LIKE GROWTH FACTOR (HB-EGF) ATTENUATES ACUTE LUNG INJURY FOLLOWING SCALD BURN IN MICE

Joe Dubose, USAF MC, R Adams Cowley Shock Trauma Center, Manjunath Markandaya, Carolyn Carroll, Lynn Stansbury, R Adams Cowley Shock Trauma Center, Warren Dorlac, University of Cincinnati, Brian Eastridge, Institute of Surgical Research, Thomas Scalea, University of Maryland Medical Center R Adams Cowley Shock Trauma Center, Lorne Blackbourne, Brooke Army Medical Center

Jeffrey Lutmer, Nationwide Children’s Hospital, Chun-Liang Chen, Markus Velten, Hong-Yi Zhang, Gail Besner, The Research Institute at Nationwide Children’s Hospital

Introduction: Combat-related TBI (CRTBI) is known to be associated with significant mortality. The purpose of our present examination was to examine the demographics of CRTBI and determine the early factors associated with intheater death after these injuries. Methods: A prospective sample of 99 consecutive CRTBI patients (GCS ⬍14 on admission or penetrating TBI) was collected from both Coalition casualties and injured Host Nationals presenting to level II or III facilities. Admission variables (demographics, exam, labs, imaging) were documented and correlated with theater mortality. Results: Patients were mostly male (96.0%) and had sustained injury due to explosive mechanisms (78.6%). Penetrating brain injuries occurred in 42.9%. On arrival at a hospital facility, GCS was ⬍ or ⫽ 8 in 47.7%, with abnormal admission pupillary exams in 31.6%, and abnormal motor exams in 41.7%. Hypercarbia (paCO2 ⬎45; 50%) and hypocarbia (paCO2 ⬍36; 20.3%) were common on admission. Head CT results were documented for 74 patients. The most common findings were skull fracture (68.9%), subdural hematoma (54.1%) and cerebral contusion (51.4%). Hypertonic saline (3%) was administered to 69.7%, and Factor VIIa to 11.1%. Overall in-theater mortality was 19.4%. On univariate evaluation, significant increases of in-theater mortality after CRTBI were associated with penetrating brain injury (p ⫽ 0.003), GCS ⬍ ⫽ 8 on admission (p⬍0.001), hypoxia (spO2 ⬍90%) within the first 24 hours of admission (p ⫽ 0.002), massive transfusion (p ⫽ 0.025), GCS ⬍ ⫽ 8 and an abnormal head CT (p ⫽ 0.018), GCS ⬍ ⫽ 8 and any hypotension in the first 72 hours of admission (p ⫽ 0.007), abnormal admission pupillary exam (p⬍0.001), and abnormal admission motor exam (p ⫽ 0.001). Conclusions: CRTBI is associated with significant mortality. Opportunities exist for the potential improvement in the pre-hospital care of CRTBI, particularly optimization of pCO2 levels and avoidance of hypoxia.

Introduction: Acute lung injury (ALI) is a significant component of the multi-organ dysfunction syndrome that accompanies severe burns in children. Impaired gut barrier function has been implicated in the development of ALI following burns. HBEGF has been shown to reduce inflammation and preserve gut barrier function in intestinal ischemia/reperfusion and hemorrhagic shock and resuscitation models. The role of HB-EGF in the prevention of ALI following severe burn injury has yet to be investigated. Hypothesis: HB-EGF will reduce the severity of ALI following scald burn in mice. Methods: Mice were divided into sham, burn, and burn⫹HB-EGF groups. The burn⫹HB-EGF group received HB-EGF (1,200 ␮g/kg) via gavage both 12h and1h prior to burn injury. Anesthetized mice were subjected to either 25% TBSA full-thickness dorsal scald burn or to sham injury, followed by fluid resuscitation with 1 mL LR. Mice were sacrificed 8h after burn or sham and lung tissue harvested for myeloperoxidase (MPO) assay and cleaved caspase-3 immunohistochemistry. Additional animals were subjected to measurements of lung resistance, elasticity, and bronchial reactivity using the SCIREQ Flexivent system. Results: Burn mice (n ⫽ 4) had increased lung MPO activity compared to sham mice (n ⫽ 3), whereas mice subjected to burn⫹HB-EGF (n ⫽ 7) had significantly decreased lung MPO activity compared to burn mice (3.2⫹2.1 vs. 6.7⫹2.0 U/g, p⬍0.02). Burn mice (n ⫽ 6) demonstrated significantly increased pulmonary apoptosis relative to sham mice (n ⫽ 5) (5.3⫹ 0.5 vs 0.1⫹ 0.1 apoptotic bodies/HPF, p⬍0.001), whereas mice subjected to burn⫹HB-EGF (n ⫽ 7) had significantly decreased pulmonary apoptosis compared to burn mice (0.7⫹ 0.5 vs. 5.3⫹1.9 apoptotic bodies/HPF, p⬍0.001). Administration of HB-EGF prevented the elevated airway resistance, decreased tissue elasticity, and increased airway reactivity seen in burned mice (all p⬍0.05). Conclusions: These data suggest that HB-EGF protects mice from ALI following scald burn. Additional studies are needed to elucidate the mechanisms by which HB-EGF exerts these effects, and to assess its potential therapeutic use.

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NEIGHBORHOOD POVERTY RATE AND OUTCOME FOLLOWING BURN INJURY: A MULTICENTER STUDY

MEMANTINE PROVIDES SUPERIOR MOLECULAR NEUROPROTECTION COMPARED TO MK801 AFTER TRAUMATIC BRAIN INJURY IN IMMATURE RATS

Anaeze Offodile, Kenneth Christopher, Brigham and Women’s Hospital Introduction: The incidence of burn is higher in lower socioeconomic (SES) groups. It is not clear if SES alters the mortality in patients with burn injury. Hypothesis: We hypothesized that %TBSA burn would be associated with mortality and that low SES would increase the mortality risk associated with burn injury. Methods: We performed an observational cohort study of 471 burn patients, age ⱖ18 years, admitted between 1997 and 2007 in two hospitals in Boston. Data sources included hospital administrative data, patient records and the US Census. Information on vital status was obtained from hospital records and the Social Security Administration Death Master File. The exposure of interest was %TBSA burn characterized as minor ⬍15%, moderate 15–25% or critical ⬎25%. Neighborhood Poverty rate, a proxy for SES, was categorized as ⱕ10% or ⬎10% of residents below the federal poverty line. The primary end point was all cause mortality 30 days following critical care initiation. The secondary outcome was length of stay for in-hospital survivors. Associations between %TBSA burn and mortality were estimated by logistic regression models. Results: The average patient age was 47.5 years and mean (SD) %TBSA burn was 24.2(23.7)%. The 30-day mortality was 10.6%, with an average LOS of 26.7 days. There was a significant adjusted association between %TBSA and mortality (OR 15–25% was 2.91; 95%CI 0.84 –10.12, p ⫽ 0.093 and OR ⬎25% was 23.70; 95%CI 7.33–76.62, p⬍0.001). The association between %TBSA and mortality were not modified by the presence of Neighborhood Poverty rate ⬎10% (p interaction ⫽ 0.37). There was a non significant adjusted association between Neighborhood Poverty rate and mortality outcomes (Poverty ⬎10% OR 1.58; 95%CI 0.79 –3.15, p ⫽ 0.2). There was a significant adjusted association between %TBSA and length of stay. There was a non significant adjusted association between Neighborhood Poverty rate and length of stay. Associations were adjusted for age, gender, race, inhalational injury and Deyo Charlson comorbidity index. Conclusions: In our primarily urban and suburban cohort, patients with low SES and burn injuries are not at greater risk of mortality and do not require longer durations of total hospitalization.

Delee Har, Los Angeles County-Harbor-University of California Los Angeles Medical Center, Farbod Fazlollahi, Yan Cai, David Hovda, Christopher Giza, UCLA Introduction: Traumatic brain injury (TBI) is a major cause of morbidity in children. N-methyl-D-aspartate receptor (NMDAR)-mediated pathways are activated for both the TBI response and for neuroplasticity. CaMKII and ERK1/2 are important signaling molecules phosphorylated when NMDARs are stimulated. While NMDAR blockers like dizocilpine (MK801) are neuroprotective in adult animal TBI studies, in the immature brain this indiscriminate NMDAR blockade increases neuronal apoptosis. Memantine (MEM), also a non-competitive NMDAR antagonist, has a unique rapid off-rate that blocks excess NMDAR stimulation while preserving normal physiologic activity. Hypothesis: We hypothesized that post-TBI administration of MEM would be superior to MK801 in promoting molecular and cognitive recovery. Methods: Postnatal day 19 Sprague-Dawley rats were randomized to lateral fluid percussion injury (FP, n ⫽ 15) or sham surgery (n ⫽ 17), 5 min after which they received IP injections of either saline, low-dose MK801 (0.1 mg/kg), high-dose MK801 (1 mg/kg) or MEM (20 mg/kg). Novel Object Recognition (NOR), a test of working memory, was done on post-injury day 3 (PID3). Immunoblots from ipsilateral hippocampus were performed on PID4 for CaMKII, pCaMKII, ERK1/2, and pERK1/2. Results: Western analysis showed a significant interaction between injury and drug for pCaMKII (p⬍0.04), and no significant change in total CaMKII. FPsaline rats had lower levels of pCaMKII than sham-saline (73⫾4 vs 100⫾5, p ⫽ 0.005), and FP-MEM had a strong trend towards higher levels than FP-saline (87⫾5 vs 73⫾4, p ⫽ 0.057). There was a main effect of injury for ERK2 (ANOVA, p⬍0.03), with no change in pERK2 levels. Preliminary NOR data showed no significant group effects. Conclusions: These results suggest that post-TBI MEM may preferentially protect molecular pathways downstream from the NMDAR compared to saline or MK801 treatment. While working memory did not improve, selective modulation of the NMDAR system represents a potential way to protect downstream molecular pathways critical for developmental plasticity.Support: UCLA BIRC, NS27544, NS30308, Child Neurology Foundation, Today’s and Tomorrow’s Children Fund.


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USE OF WARMED INTRAVENOUS FLUIDS DURING TRANSPORT OF TRAUMA PATIENTS TO PREVENT ADMISSION HYPOTHERMIA

THE EFFECT OF HELICOPTER EMERGENCY MEDICAL SERVICES ON MORTALITY FOR ADULTS WITH MAJOR TRAUMA: AN ANALYSIS USING PROPENSITY SCORE MATCHING

Brett Waibel, Brody School of Medicine, East Carolina University, Jeffrey Ferguson, Brody School of Medicine at East Carolina University, Mark Newell, Brody School of Medicine at ECU

Samuel Galvagno, University of Maryland, Elliott Haut, The Johns Hopkins Medical Institutions, Stephen Bowman, Susan Baker, Johns Hopkins Bloomberg School of Public Health, George Koenig, Thomas Jefferson University Hospital, Michael Millin, Johns Hopkins University Medical School, David Efron, Johns Hopkins University, Peter Pronovost, John Hopkins University School of Medicine, Adil Haider, Johns Hopkins University Medical School

Introduction: Temperature, an often-overlooked vital sign, can be difficult to control in the rural trauma patient during transport to definitive care. Hypothermia, a known independent predictor of death, is thus common in this patient population. Hypothesis: It was hypothesized that the use of warmed IVF during transport from scene or outlying hospital to the rural regional level 1 trauma center would be associated with a decrease in hypothermia at time of arrival. Methods: The National Trauma Registry of the American College of Surgeons was queried for all admissions to the trauma service from January 2009 to June 2011 transported by the local ambulance service. In January 2010, fluid warmers were added to this service. A prospectively collected cohort of patients receiving warmed IVF’s during transport (July 2010 through June 2011) was compared to a historic cohort of no warmed IVF (2009 admissions). The patients from January 2010 to June 2010 were excluded to allow for compliance with the use of warmed IVF during transport. Admission demographics, vitals, and measurement of injury severity were compared between the cohorts. Results: Of 1,067 patients admitted in the no warmed IVF cohort, 213 (20.0%) patients arriving hypothermic (admission temperature below 36 degrees Celsius). Of the 1,375 patients admitted after receiving warmed IVF, 215 (15.6%) arrived hypothermic (p ⫽ 0.006). This represents a 22% relative risk reduction in admission hypothermia. Patients arriving with moderate to severe hypothermia (temperature below 35 degrees Celsius) had a 53% relative risk reduction with warmed IVF (48 patients4.5% vs. 29 patients-2.1%, p ⫽ 0.001). Age, gender, ethnicity, percent transferred from outlying hospital, mechanism of injury, Glasgow Coma Score, Revised Trauma Score, heart rate, respiratory rate, and systolic blood pressure were statistically similar. Injury Severity Score was statistically, but not clinically, greater in the no warmed IVF cohort (15.1 vs. 13.4, p⬍0.001). Conclusions: Patients who received warmed IVF during transport had a significant lower rate of hypothermia. Further study is needed to determine if prevention of hypothermia in this manner will improve clinical outcomes.

Introduction: The potential association between helicopter emergency medical services (HEMS) and improved outcomes for injured patients remains the subject of debate. This study assessed the effectiveness of HEMS versus ground emergency medical services (GEMS) using national level data. Hypothesis: We hypothesized that transportation of traumatically injured adults by HEMS, compared to GEMS, was associated with improved mortality. Methods: Using the 2007 and 2008 versions of the National Trauma Data Bank, a merged data set was established. Inclusion criteria were: transport from scene by HEMS or GEMS, penetrating or blunt trauma, age⬎15, injury severity score (ISS) ⬎15, and transport to a Level 1 or Level 2 trauma center. The primary outcome was in-hospital mortality. Multiple imputation was performed for missing variables. Three analyses were performed: 1) logistic regression 2) logistic regression using generalized estimating equations to control for clustering by facility with robust variance calculations and 3) logistic regression performed after propensity score matching. The following variables were included in each model: age, gender, ISS, systolic blood pressure, motor component of GCS, respiratory rate, type of trauma, e-code, and type of transport. P values ⱕ0.05 were statistically significant. Results: 108,634 Level 1 patients and 40,206 Level 2 patients were analyzed. Unadjusted mortality for Level 1 patients was 10.8% for GEMS and 12.6% for HEMS; for Level 2 patients, mortality was 10.8% vs. 12.9% for GEMS vs. HEMS. Logistic regression showed higher odds of survival for Level 1 (OR 1.15; 95% CI, 1.09–1.29; p ⫽ .01) and Level 2 patients (OR 1.18; 95% CI, 1.04–1.34; p ⫽ .009) transported by HEMS. After propensity score matching, more conservative benefits for Level 1 patients were observed (OR1.08; 95% CI, 1.03–1.14; p⬍0.0001) and Level 2 patients (OR 1.04; 95% CI, 1.01–1.14; p⬍0.0001). Conclusions: In this retrospective cohort based on national level data, HEMS patients had a mortality benefit compared to GEMS. This study represents a methodologically rigorous analysis using robust statistical methods to study HEMS-related outcomes; we recommend the use of these methods for future work in this area.

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HIGH RATES OF VENTILATOR ASSOCIATED PNEUMONIA IN OBESE TRAUMA PATIENTS ARE SIGNIFICANTLY REDUCED WITH VAP BUNDLE COMPLIANCE

ADVANCED PRACTITIONERS ARE PEERS IN TRAUMA PERFORMANCE IMPROVEMENT PEER REVIEW

Andrea Pakula, Ruby Skinner, Kern Medical Center Introduction: Obesity has been linked to infectious complications in critically ill patients. During 2009 obese trauma patients admitted to our intensive care unit (ICU) were observed to have high rates of ventilator associated pneumonia (VAP). During that time a VAP bundle was also implemented at our institution and closely tracked to ensure its implementation. Hypothesis: The implementation and subsequent compliance with a VAP bundle would result in a reduction of VAP rates in obese trauma patients. Methods: After IRB approval, 355 patients requiring ICU admission were identified from the trauma registry from January 2009 to January 2011. 97 of these patients met criteria for obesity based on a BMIⱖ30. We performed a retrospective analysis comparing outcomes in the obese patients managed at the beginning of the VAP bundle (2009, Group I n ⫽ 47) to those patients managed after the first year (2010, Group II n ⫽ 50). Variables analyzed included demographics, VAP rates, ICU length of stay (LOS), ventilator days and mortality. A p value of ⱕ0.05 was statistically significant. Results: The groups were well matched for age, injury severity score (ISS) and mechanism of injury (Age: I 41⫾17yrs vs II 40⫾13yrs, p ⫽ 0.7; ISS: I 33⫾12 vs II 30⫾18, p ⫽ 0.3; Penetrating: I 17% vs II 28%; Blunt: I 83% vs II 72%, p ⫽ 0.2). The groups were similar for Diabetes Mellitus (DM), Hypertension (HTN), and COPD, (DM: I 15% vs II 20%, p ⫽ 0.5; HTN: I 50% vs II 32%, p ⫽ 0.1; COPD: I 7% vs II 10%, p ⫽ 1.0). Differences in VAP rates were reduced significantly after one year, Group I 40% vs Group II 20%, p ⫽ 0.04 as well as ICU LOS, I 9⫾7 days vs II 6⫾6 days, p ⫽ 0.02. Ventilator days and mortality did not reach statistical significance, (Vent days: I 9⫾6 vs II 9⫾2, p ⫽ 1.0; Mortality: I 10% vs II 20%, p ⫽ 0.1). Conclusions: The implementation and compliance with a VAP bundle correlated with a 50% reduction in VAP rates and a reduced ICU length of stay in obese trauma patients.


Tara Ann Collins, Corinna Sicoutris, Hospital of the University of Pennsylvania, Amanda McNicholas, Abby Eddinger, Forrest Fernandez, Reading Hospital and Medical Center, C. Schwab, University of Pennsylvania Health System/Trauma Center at Penn, Patrick Reilly, Hospital of The University of Pennsylvania, Patrick Kim, University of Pennsylvania/Hospital of The University of Pennsylvania Introduction: Advanced Practitioners (APs, Nurse Practitioners and Physician Assistants) have been successfully integrated into the clinical care of injured patient; however, performance improvement (PI) peer review has been traditionally performed by MDs. Hypothesis: Given the expanding role and experience of APs in trauma care, we hypothesized that APs can perform PI peer review at a comparable level to MDs. Methods: The study centers were an urban Level I and a rural Level II trauma center. At each center, peer review involves completion of a PI form that evaluates appropriateness of care at all phases. Mortality is categorized as preventable, potentially preventable, or nonpreventable. For this study, cases were randomly selected by the PI coordinator and peer reviewed by both a trauma/critical care AP and MD from the same center. APs and MDs used identical PI forms and were blinded to each other’s review. Concordance was defined as agreement of responses on the PI form. Issues relating to intraoperative technique were excluded. Kappa statistic was used to compare agreement between AP and MD. The study protocol was approved by the IRB. Results: Forty-six PI cases were reviewed (total 932 responses, mean 20.3 responses per case), including 22 deaths. APs and MDs had high concordance (96.0%) regarding appropriateness or inappropriateness of care (Kappa ⫽ 0.774). Among disagreements, APs were 3x more likely than MDs to determine care to be inappropriate. MDs and APs had similarly high concordance (95.5%) regarding preventability of mortality (Kappa ⫽ 0.861). Conclusions: AP and MD peer review of trauma PI cases was comparable. Specifically, APs and MDs identified issues in care and evaluated outcomes with high precision. Within the scope of AP practice, APs are effective peers in trauma PI peer review.

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VENOUS THROMBOEMBOLISM SCREENING AND PROPHYLAXIS FOLLOWING PEDIATRIC TRAUMA: SYSTEMATIC LITERATURE REVIEW AND DEVELOPMENT OF A CLINICAL ALGORITHM

IMPACT OF EARLY INITIATION OF METHADONE IN TRAUMA PATIENTS REQUIRING MECHANICAL VENTILATION

A. Jill Thompson, Sally Webb, Steven McSwain, Melanie Stroud, Christian Streck, Medical University Of South Carolina

Introduction: Numerous studies have identified strategies to reduce mechanical ventilation duration by targeting appropriate sedation levels. However, applicability of these strategies to trauma patients has not been established. At our medical center, methadone is commonly used as part of the sedation and analgesia plan for trauma patients admitted to the intensive care unit as a means to treat acute pain and limit the development of opioid tolerance. Hypothesis: We hypothesized that early initiation of methadone therapy in mechanically ventilated trauma patients increases the number of ventilator-free days in a 28-day period by providing an enhanced level of sedation through increased control of background pain. Methods: This retrospective pilot study compared clinical outcomes of trauma patients who received early methadone to patients who did not receive methadone while mechanically ventilated. The primary outcome was the number of ventilator-free days in a 28-day period. Secondary outcomes included length of stay, discharge status, the total number of fentanyl and lorazepam equivalents administered during mechanical ventilation and development of ventilator-associated pneumonia. Patients who received methadone within 4 days of intubation and remained ventilated for 2 days after the first dose were included in the methadone group. Propensity scores were used to match up to three control patients to each methadone patient. Results: One hundred and eighteen patients (30 methadone and 88 matched control patients) were included. Patients in the methadone group had 15.2 ventilator-free days compared to 12.6 in the control group (p ⫽ 0.18). In the burn subgroup, the number of ventilator-free days was significantly higher in the methadone group (16.5 vs. 11.5 days; p ⫽ 0.03). Among all patients, the incidence of ventilator-associated pneumonia was 20.0% in the methadone group and 39.8% in the control group (p ⫽ 0.05). Conclusions: Our results suggest that early methadone may impact the number of ventilator-free days and the incidence of ventilator-associated pneumonia in trauma patients requiring mechanical ventilation. Further research is warranted.

Introduction: Criteria for screening and implementing prophylaxis against venous thromboembolism (VTE) in hospitalized pediatric traumatic injury (PTI) victims are not well-established. Hypothesis: We sought to answer the following questions in the PTI population: 1) Is age (pre-adolescence versus adolescence) associated with higher VTE incidence? 2) Which risk factors are associated with higher VTE incidence? 3) Does mechanical and/or pharmacological VTE prophylaxis impact outcomes (deep venous thrombosis, pulmonary embolism, bleeding or mortality)? Methods: We searched Medline’s Pubmed for Englishlanguage evidence published from 1995 until June 2011 using keywords “deep venous thrombosis,” “pediatric,” and “trauma,” and the MESH database using index terms “venous thrombosis,” “venous thromboembolism,” and “wounds and injuries.” Relevant articles were also identified from bibliographies. Evidence quality was graded as Class I, II, or III according to the Canadian & US Preventive Task Force criteria. Results: Thirty-eight articles were included in the review; most were Class II or III evidence. The incidence of VTE after PTI ranged from 0.03%-4%; all studies reported no or unknown prospective screening for VTE (II, III). By comparison, the incidence of VTE with prospective screening in pediatric non-trauma patients was 0.05% (general population, II) to 13.3% (with central venous catheters, I). In PTI, age 13 years or greater was associated with higher VTE risk (III). Vascular injury, pelvic or lower extremity fracture, head or spinal injury, and central venous catheter placement were among the additional risk factors identified (II, III). Low molecular weight heparin prophylaxis appeared effective for preventing symptomatic VTE in one pediatric trial (III), supported by another trial that included adults (II). Adverse outcomes including bleeding were uncommon (II, III). Conclusions: Based on this systematic review, we created an algorithm to prospectively risk-stratify all pediatric trauma victims. Pharmacologic VTE prophylaxis is recommended only in adolescents with significant VTE risk factors and no contraindications to anticoagulation. Criteria for screening ultrasounds and mechanical prophylaxis are also included.

G. Morgan Jones, Rebecca Coffey, Sidney Miller, Claire Murphy, Kyle Porter, Melissa Whitmill, The Ohio State University Medical Center

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YOU WANT TO DO WHAT?? WHY DECOMPRESSIVE SURGERY IN ANTICOAGULATED PATIENTS WITH TRAUMATIC INTRACRANIAL HEMORRHAGE MAY NOT BE A BAD IDEA

THE ROLE OF PLATELET FUNCTION ASSAYS AS A GUIDE FOR PLATELET TRANSFUSION IN PATIENTS WITH TRAUMATIC BRAIN INJURY

Amanda McNicholas, Reading Hospital and Medical Center, Tara Collins, Eugene Reilly, The Reading Hospital and Medical Center, Jared Zavilla, Reading Hospital and Medical Center, Forrest Fernandez, The Reading Hospital and Medical Center

Brandon Hobbs, Xi Liu-DeRyke, Kara Birrer, Kimberly Berger, Rodrigo Alban, Orlando Regional Medical Center

Introduction: Traumatic intracranial hemorrhage (ICH) in anticoagulated patients presents a clinical challenge, and associated, in multiple previous studies, with increased mortality. Decompressive craniotomy and/or craniectomy (DC/C) are frequently performed in traumatic ICH to relieve shift, mass effect, and refractory intracranial hypertension. The benefit of DC/C in anticoagulated patients, however, is unclear. Hypothesis: Pre-injury anticoagulation and antiplatelet (AC/AP) therapies (i.e. aspirin, clopidogrel, and warfarin) do not predict mortality in patients with traumatic brain injury requiring surgical decompression. Methods: A retrospective review of prospectively collected data was performed for all patients evaluated between January 2005 and January 2010. 117 patients were identified with DC/C following blunt traumatic brain injury. Mortality was tested against combinations of AC/AP therapies using Chi-squared and Fisher’s Exact tests, with analyses restricted to the 73 patients greater than 45 years old to match the age range of anticoagulated patients. The discharge destination of survivors was studied as well. Results: Overall mortality in all patients undergoing DC/C was 38% (45 of 117). Of 73 patients older than 45, 27 (37%) were prescribed pre-injury AC/AP therapy with a mortality of 41%, versus 46% in the non-AC/AP group (p ⫽ 0.8697). AC/AP therapy included aspirin (n ⫽ 17), clopidogrel (n ⫽ 4), and warfarin (n ⫽ 14), and carried mortalities of 18% (p ⫽ 0.0237), 50% (p ⫽ 1.0), and 57% (p ⫽ 0.4141), respectively. Five patients were on the combination of warfarin and aspirin, with only 1 death (20%, p ⫽ 0.377). Moreover, 80% of the 41 survivors in the age-matched group were discharged to an acute rehab center or home. Conclusions: Pre-injury anticoagulant and antiplatelet therapies in patients with traumatic intracranial hemorrhage requiring decompressive craniotomy or craniectomy does not preclude a satisfactory outcome and should remain in the armamentarium of providers caring for this clinically challenging and ever-growing population.

Introduction: The use of anti platelet drugs (APD) continues to increase as our population ages. Their therapeutic effect can have significant hemorrhagic consequences in patients with traumatic brain injury (TBI). Platelet transfusion (PT) in patients with a documented history of APD use and TBI has shown controversial results. The role of platelet function assays (PFA) as a guide for PT in this high risk population is unknown. Hypothesis: The objective of this study is to evaluate the utility of PFA as a guide for PT in patients with TBI. Methods: This is a retrospective review of prospectively collected data in an urban level 1 trauma center. Data was collected for all TBI admissions between January 2010 and April 2011. Adult patients with documented TBI on CT and a PFA test ordered on admission were included for analysis. Data collected included demographics, severity scores, PFA results and type of TBI. Outcome variables were PT, worsening of head CT, need for operative intervention and mortality. Results: From a total of 127 patients, 82 (65%) had a positive PFA test. This group was significantly older than the PFA negative group (74⫾12 vs. 60⫾19 years old respectively, p⬍0.001). Analysis of admission head CT revealed no significant differences in type of TBI (subarachnoid, subdural or epidural), however intracranial hemorrhage was more frequent in the PFA negative group (49% vs. 24%, p ⫽ 0.006). There were no differences in GCS, ISS, and AIS-head scores between groups. Patients with a positive PFA were more likely to receive PT (67% vs. 38%, p ⫽ 0.003) however there was no difference in the total number of platelet packs given (1.6⫾1 vs. 1.4⫾1.3, p ⫽ 0.68). Logistic regression revealed that PFA positivity was not predictive of worsening of head CT, operative intervention or mortality. Nevertheless, a positive PFA was significantly associated with PT (OR 3.2; 95% CI 1.4 –7.4, p ⫽ 0.008). Conclusions: In our study, older patients were more likely to have a positive PFA result. Type of TBI was similar between PFA positive and negative patients with the exception of ICH. In addition, PFA positivity was not predictive of worse outcomes; however it was strongly associated with increased likelihood for platelet transfusion.


203 ESTIMATING SEVERITY OF INJURY AFTER BURNS IN CHILDREN: PRISM VERSUS ABSI SCORE Allison Berndtson, University of California-Davis, Soman Sen, David Greenhalgh, Tina Palmieri, Shriners Hospital for Children Northern California Introduction: The Pediatric Risk of Mortality (PRISM) Score is commonly used to estimate severity of disease in critically ill children, but does not account for cutaneous injury and has not been validated in burns. The purpose of this study is to validate PRISM scoring after burn injury and to compare PRISM-predicted outcomes to the easier to calculate but potentially less sensitive Abbreviated Burn Severity Index (ABSI) score. Hypothesis: PRISM scores will be more accurate in predicting mortality than the ABSI score in children with severe burns. Methods: We retrospectively reviewed children ⬍18 years of age with a ⱖ20% TBSA burn admitted to a regional pediatric burn center over a 2.5 year period. Exclusion criteria were admission ⱖ7 days after injury or initiation of comfort care within 24 hours. Parameters measured included demographics, burn characteristics, PRISM and ABSI scores at admission and outcomes (mortality, hospital length of stay, ventilator days and cause of death). Results: 83 patients were included, with mean ⫾ SEM age 8.0 ⫾ 0.6 years and TBSA 49.9 ⫾ 2.1%. 62.7% were male, and 45.8% had a documented inhalation injury. Hospital LOS was 74.4 ⫾ 7.9 days, with 31.5 ⫾ 4.9 vent days. Mean PRISM score ranged from 14.2–16.0, with ABSI scores 7.9 – 8.5. Overall mortality was 18.1% compared to a PRISM predicted mortality of 19.8 ⫾ 2.5% (p⬍0.001, r ⫽ 0.570). ABSI predicted mortality varied from 10 –20% for a score of 7.9 to 30 –50% for a score of 8.5. Both PRISM (p⬍0.001) and ABSI (p⬍0.001) predicted mortality via logistic regression. The addition of TBSA to PRISM score did not improve results. ABSI was more predictive than PRISM of hospital LOS (p⬍0.001 vs. p ⫽ 0.50) and vent days (p⬍0.001 vs. p ⫽ 0.06). Conclusions: Both PRISM and ABSI scores predict mortality in severely burned children, while only ABSI correlates with hospital LOS and vent days. PRISM is useful in that it provides a more specific prediction of expected mortality whereas ABSI provides a wide range; however, ABSI can be immediately calculated at the bedside with no laboratory work or vital signs required. Hence, in settings with limited time and resources, the ABSI may have greater utility in predicting outcomes after major burn injury in children.


Posters:Burns/Trauma -2 204

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PRIMARY FASCIAL CLOSURE AFTER DAMAGE CONTROL LAPAROTOMY: SEPSIS VS HEMORRHAGE

CRITICAL CARE IN SUB-SAHARAN AFRICA: OUTCOMES IN THE MIDST OF AUSTERITY

Naeem Goussous, Donald Jenkins, Martin Zielinski, Mayo Clinic

Jared Tomlinson, Bryce Haac, University of North Carolina, Clement Kadyaudzu, Kamuzu Central Hospital, Clara Lee, University of North Carolina, Arturo Muyco, Kamuzu Central Hospital, Anthony Charles, University of North Carolina

Introduction: Damage control laparotomy (DCL) can improve the survival of critically ill patients undergoing celiotomy, however, rates of primary fascial closure remain low. Septic wound complications limit the ability to perform primary fascial closure. Hypothesis: We hypothesize that patients undergoing DCL for intra-abdominal sepsis will have a higher rate of septic complications and, therefore, a lower rate of primary fascial closure. Methods: IRB approval was obtained to retrospectively study patients undergoing DCL for sepsis and hemorrhage from December 2006 to November 2009. Significance was considered at p⬍0.05. Results: 126 patients were identified (64 men), 92 with sepsis and 34 with hemorrhage. There was no difference in age (62 vs 59 years), body mass index (BMI, 29 vs 30), diabetes mellitus (13% vs 9%), or duration of initial operation (148 vs 176 minutes). Patients with sepsis presented with a higher systolic blood pressure (122 vs 108, p ⫽ 0.023) but lower serum lactate (2.8 vs 4.6 mmol/L, p⬍0.001), base deficit (4.9 vs 8.0, p ⫽ 0.002) and ASA score (3.2 vs 3.7, p⬍0.001). There was equivalent overall morbidity (83% vs 71%), ventilator days (8 vs 11), intra-abdominal abscess (18% vs 17%), deep wound infection (9% vs 8%), enterocutaneous fistula (7% vs 3%) and mortality (22% vs 21%). There was no difference in primary fascial (59% vs 58%), partial fascial (13% vs 9%) and planned ventral hernia closure rates (21% vs 26%). Multivariate analysis demonstrated that intra-abdominal abscess (OR 0.18, 95% CI 0.04 – 0.72), higher base deficit (OR 1.13, 95% CI 1.00 –1.30) and more abdominal explorations (OR 1.50, 95% CI 1.20 –1.98) were associated with lack of primary fascial closure, but BMI (OR 1.02, 95% CI 0.31–3.68), age (OR 1.01, 95% CI 0.99 – 1.04), deep wound infection (OR 1.06, 95% CI 0.19 – 6.58) and intra-abdominal hemorrhage (OR 0.84, 95% CI 0.24 –2.78) were not. Conclusions: There was an equivalent rate of septic complications and primary fascial closure rates regardless of cause for DCL. Intra-abdominal abscess, worse base deficit and higher number of abdominal explorations, regardless of the inciting cause for DCL, were independently associated with the lack of primary fascial closure.

Introduction: There is limited data on current critical care resources and practices in sub-Saharan Africa. The pre-morbid conditions and late presentation of patients, patterns of disease, poor hospital infrastructure, and shortage of qualified healthcare workers makes the delivery of critical care challenging. Hypothesis: Our objective was to describe the presenting illnesses and outcomes in an ICU in sub-Saharan Africa. Methods: We conducted a retrospective review of ICU admission records for all patients admitted to Kamuzu Central Hospital (KCH) in 2010. KCH serves a catchment population of 4.8 million. We gathered data on length of stay (LOS), admitting service, demographics and outcomes. Results: There were 234 admissions with a median age of 26.5 yrs. (range 4 – 88 yrs.). The LOS was 3 days (range 1–31 days). There was no significant difference in LOS based on service or outcome. 191 (82%) surgical and 36 (15%) surgical medical patients were admitted. For 7 patients (3%) the admitting service could not be determined. Of the 191 patients admitted from a surgical service, 64 (33%) were admitted for trauma, 57 (30%) were from Ob/Gyn and 70 (37%) were from general surgery. The overall mortality rate for ICU admissions was 45%. The mortality rate for medical admissions was significantly higher than for surgical admissions, 61% vs. 43% (p ⫽ 0.04). Within surgery patients, the mortality rate for trauma was significantly higher (61%) than general surgery (40%) or OB/Gyn admissions (24%) (p⬍0.001). The top causes of death in surgery admissions were septic shock, head injury, hemorrhagic shock and polytrauma. The top causes of death in medical admissions were pulmonary disease, renal failure and septic shock. Conclusions: Overall mortality was extremely high for reasons that are not clear from our current data. Trauma patients had significantly higher mortality rates and should have better triage to exclude unsalvageable patients from admission to the ICU. The challenge in sub-Saharan Africa is one of immense critical care needs in the face of extreme limitations. Research for the development of appropriate mortality prediction tools to optimize allocation of scarce critical care resources is ongoing at KCH.

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PERI-PROCEDURAL COAGULATION MANAGEMENT AROUND BEDSIDE PEGS AND PDTS: REVIEW OF CURRENT PRACTICES AT A LEVEL 1 TRAUMA CENTER

AGE DOES NOT AFFECT MORTALITY OF BLUNT TRAUMATIC BRAIN INJURY

Cassie Barton, Wesley McMillian, Fletcher Allen Health Care, Turner Osler, University of Vermont, William Charash, Nicholas Brenny, Peter Igneri, John Fortune, Fletcher Allen Health Care Introduction: The aim of this study is to evaluate practice patterns regarding management of anticoagulant (AC) and antiplatelet (AP) therapies around the time of percutaneous endoscopic gastrostomy (PEG) and percutaneous dilatational tracheostomy (PDT), assess peri-procedural bleeding complications, and identify risk factors associated with bleeding. Hypothesis: There would be no peri-procedural hemorrhagic events in patients prophylactically or therapeutically anticoagulated at the time of PEG/PDT. Methods: A retrospective, observational study of all patients admitted to a rural, academic level I trauma center from 01/2005 to 12/2009 who received bedside PEG or PDT was conducted. Patients were identified by procedure codes via an in-hospital database. Exclusion criteria included unobtainable timing of AC/AP agent administration, procedure performed in open or surgical manner, or documented premorbid bleeding disorder. A medical record review was performed for each included patient. Results: 415 patients were included, with 187 PEGs and 352 PDTs performed. ACs for venous thromboembolism prevention was held for an average of 1 dose prior to and 2 doses or less after the procedure. There was wide variation in patterns of holding therapy in patients receiving ACs via continuous infusion. There were 19 recorded bleeding events, 1 (0.5%) was associated with PEG and 18 (5.1%) with PDT, with no documented hemorrhagic events. Fourteen (73.7%) of these patients were considered unanticoagulated, 4 (21.1%) were prophylactically anticoagulated, and 1 (5.3%) was therapeutically anticoagulated. No association was found between INR (p ⫽ 0.853), PT (p ⫽ 0.689) or aPTT (p ⫽ 0.440) values obtained the day of procedure and bleed risk. Platelet count was significantly lower in patients who bled (p ⫽ 0.006). Neither the use of any specific AP agent (p ⫽ 0.360), nor level of anticoagulation the day of procedure was associated with bleed risk. Conclusions: We found practice patterns were quite consistent regarding the management of prophylactically dosed ACs, but varied widely in patients receiving therapeutically dosed ACs. Further investigations should be completed to identify the optimal peri-procedural management of AC and AP therapies.

Bao-Thuy Hoang, Donald Johnson, University of Florida College of Medicine, Jacksonville, Indermeet Bhullar, Orlando Regional Healthcare System Introduction: Worldwide, traumatic brain injury (TBI) is a leading cause of death and permanent disability. The elderly are a rapidly growing population in the United States. Knowledge of their hospital mortality may help improve clinical decision making protocols and resource utilization. Hypothesis: This retrospective review tests the hypothesis that protocol based management techniques started at our institution in 2005 have significantly decreased mortality for blunt TBI in the elderly (ageⱖ55) population over the last five years and that there is no longer a significant difference in mortality for the elderly (ageⱖ55) as compared to adult (age 17–55) population. Methods: The records of adult patients with computed tomography (CT) scan positive TBI after blunt trauma from January 2005 to January 2009 at a Level I trauma center were retrospectively reviewed using NTRACS. Mechanism of injury, admission Glasgow Coma Score (GCS), age, injury severity score (ISS), and disposition were reviewed. Statistical analysis was performed with mean, and Chi-square test. Results: A total of 1884 adult patients with CT scan positive blunt TBI were identified. The patients were then divided in two groups based on age: 1385 in the Adult Group (AG) (age 17–55) and 499 in the Elderly Group (EG) (age⬎55). There was a significant decrease in mortality from 2005 to 2009 for both age groups: AG (22% vs. 10%, p ⫽ 0.002) and EG (31% vs. 14%, p ⫽ 0.02). When comparing the mortality for the AG vs. EG no significant difference in mortality was found for each respective year: 2005 (22% vs. 31%, p ⫽ 0.21), 2006 (17% vs. 23%, p ⫽ 0.26), 2007 (15% vs. 23%, p ⫽ 0.16), 2008 (11% vs. 19%, p ⫽ 0.09), and 2009 (10% vs. 14%, p ⫽ 0.25). Conclusions: The application of protocol based management techniques for blunt TBI have resulted in a significant decrease in mortality for blunt TBI in the AG and EG over the last five years. Furthermore, contrary to previous reports, no significant difference in mortality was noted between the two age groups; age should not be a limiting factor for resource utilization in the management of blunt TBI.


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ROLE OF PRE-INJURY ANTIPLATELET AND ANTICOAGULANTION THERAPY ON TRAUMATIC BRAIN INJURY INTERVENTIONS AND OUTCOMES

REGISTERED DIETICIAN CALCULATIONS USING ASPEN GUIDELINES UNDERESTIMATE NUTRITION REQUIREMENTS OF ADULT TRAUMA AND BURN PATIENTS: A COMPARISON WITH INDIRECT CALORIMETRY

Robert Andres, Maleeha Hassan, Jane Channel, Alison Wilson, West Virginia University Introduction: Traumatic brain injury (TBI) is a significant cause of morbidity and mortality. How pre-injury anticoagulation and antiplatelet medications affects outcomes and the efficacy of therapeutic interventions continues to be a controversy. Hypothesis: Our study evaluated the impact of pre-injury use of aspirin (ASA), clopidogrel or warfarin on the outcomes and interventions in TBI patients (pts). Methods: A retrospective analysis of our Level 1 trauma center was performed between 2007–2009. Results: 513 TBI patients as defined by evidence of acute traumatic bleed by CT scan were evaluated [(289 (56%) men; 224 (43%)]. 50 pts were on warfarin, 66 were on clopidogrel and 141 were on aspirin pre-injury. 117 (57%) of pts on ASA or clopidogrel received platelets. 46/50 (94%) pts on warfarin received FFP and 22/50 (44%) received Factor IX. Overall mortality rate for all patients was 10.9% (56/513). For pts on pre-injury anticoagulant/-platelet medications mortality was the following: ASA 7.8% (p ⫽ .14), clopidogrel 16.6% (p ⫽ .12) and warfarin 22% (p ⫽ .009). The Odds Ratio for mortality when on clopidogrel was 1.74 (CI 95%) and warfarin was 2.5 (CI 95%). The increase in mortality of warfarin was present even when the INR was subtheraputic. Those on ASA were not more likely to require EVD (p ⫽ .88), craniotomy (p ⫽ .75) or treatment with mannitol or hypertonic saline (HTS) (p ⫽ .27). Pts on clopidogrel showed a trend toward requiring an EVD (p ⫽ .06), but not craniotomy (p ⫽ .36). Those on warfarin showed a trend toward craniotomy (p ⫽ .05). Pts on warfarin more often received HTS or mannitol (p ⫽ .004). Warfarin pts had an Odds Ratio of 3.05 (CI 95%) for requiring an intervention of either HTS or mannitol to control ICP. Pts on warfarin received more follow up imaging (mean number follow up CT brain 2 vs 1.6 p ⫽ .04). Conclusions: As previously described, warfarin was associated with a higher risk of death and need for interventions. These effects were independent of INR, which is contrary to previously published data. Interestingly, our data demonstrates that clopidogrel also significantly increases the risk of death after TBI and that ASA does not seem to incur a higher risk of mortality, interventions or necessitate additional therapies.

Krystle Tuano, Charleston Chua, University of Nevada School of Medicine, Paula Dyer, James Muterspaw, University Medical Center of Southern Nevada, Timothy Browder, University of Nevada, John Fildes, Deborah Kuhls, University of Nevada School of Medicine Introduction: Metabolic carts are considered to be the gold standard in indirect calorimetric assessment. The purpose of this study is to compare registered dietician (RD) calculated resting energy expenditure (REE) using ASPEN 2009 guidelines with measured REE utilizing metabolic cart (MC) data. Hypothesis: The RD-REE will underestimate nutritional needs of trauma and burn patients compared to REE as determined by the MC. Methods: A retrospective analysis of trauma and burn patients at our Level I Trauma Center who received a MC reaching steady state from 5/1/10 to 5/31/11 was performed. Patients were divided into two groups: adult trauma and burns. MC results were compared with the average RD-REE for each patient. Trauma patient REE data was also analyzed by presence or absence of obesity (BMI⬎30). The student’s t-test was utilized with statistical significance at p⬍ ⫽ 0.05(*). Results: 18 adult patients (16 trauma, 2 burn), aged 22– 86, and 27 metabolic cart results were analyzed. Twenty-five percent of the adult trauma patients were obese. Average BMI for all trauma patients was 28.0, with an average BMI of 35.1 for obese trauma patients and 25.7 for non-obese trauma patients. Average ISS for all subsets of trauma patients was similar (28.3–28.5), with burn patients having an average TBSA of 42.5%. Metabolic Cart REE values were statistically higher than RD-REE in all groups. RD-REE was more under-estimated in obese trauma and burn patients, which had an average actual difference of 847.2 and 530.1, and percent differences of 26.0% and 15.3%, respectively. All trauma patients had an average actual difference of 289.7, with a percent difference of 8.9%. Non-Obese trauma patients presented with the least average actual difference (103.9) and percent difference (3.3%). Conclusions: Registered Dietician REE using 2009 ASPEN guidelines significantly underestimates the REE for adult trauma and burn patients when compared with Metabolic Cart REE. This difference was greatest in obese trauma patients and burn patients. The impact of nutritional support for trauma patients at the RD calculated versus metabolic cart REE warrants investigation.

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HIGH-DOSE BARBITURATES FOR REFRACTORY INTRACRANIAL HYPERTENSION IN CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY

TIME-DEPENDENT EVALUATION OF RESPIRATORY CULTURE SUSCEPTIBILITIES IN THE INTENSIVE CARE TRAUMA POPULATION

German Ellsworth, University of Utah School of Medicine, Kimberly Bennett, Sarah Mellion, University of Utah, Kevin Moore, Primary Children’s Medical Center, Jay Riva-Cambrin, Ryan Metzger, Susan Bratton, University of Utah

Jessica Brown, Kimberly Clark, Benjamin Manning, Fady Nassif, Anna Cass, Greenville Hospital System

Introduction: Current traumatic brain injury (TBI) treatment guidelines recommend barbiturates as a second-tier therapy for refractory intracranial hypertension (RICH). However, efficacy has not been recently evaluated in children. Hypothesis: We determined if high-dose barbiturates control RICH with maintenance of targeted cerebral perfusion pressure (CPP) in children. We also evaluated functional hospital discharge and ⬎3 month post discharge outcomes associated with RICH control. Methods: All infants and children admitted to a single center from 2001 to 2010 receiving high-dose barbiturate therapy for RICH complicating TBI were evaluated. Uncontrolled RICH was defined as two consecutive hourly intracranial pressure (ICP) measurements ⬎20 mm Hg after the initial 6 hours of barbiturate infusion. Demographic, clinical, radiographic features and complications, as well as patient outcome (discharge and long-term pediatric cerebral performance category (PCPC)), were compared between patients with sustained control and persistent RICH using nonparametric statistics and relative risk ratios (RR). Results: Ten (28%) of 36 patients had control of RICH. No significant differences in demographic or injury characteristics were associated with control of RICH. Children who responded received barbiturates significantly later after time of injury (76 vs. 29 median hours). Overall, 14 children died, 13 with RICH. There was a non-significant trend of death occurring less commonly in those with ICP control [RR 0.2; 95% CI; (0.03–1.3)]. Eighty-one percent experienced at least one episode of low CPP. However, a strict maintenance of goal CPP was not independently associated with long-term outcome. Eighteen of 22 survivors had an acceptable survival (PCPC⬍3) at 3 months or longer after injury; however only 3 returned to normal function. Control of ICP was associated with a greater than two-fold increased rate of acceptable long-term outcome [RR 2.3; 95% CI, (1.4 – 4.0)] compared to persistent RICH. Conclusions: Almost 30% of treated children had control of RICH. Hemodynamic instability was common. Control of ICP was associated with increased risk of an acceptable long term outcome.


Introduction: Appropriate empiric antibiotic therapy for pneumonia is critical for successful patient outcomes and should target the most likely pathogens without inducing resistance. The trauma population has unique characteristics that influence the time of onset and likely pathogens. Hypothesis: This study was designed to evaluate susceptibilities of pathogens in the critically ill trauma population related to time of infection. Methods: Patients ⱖ18 years of age, admitted to the intensive care unit for trauma, with a positive respiratory culture were included in this IRB-approved, retrospective cohort. Exclusion criteria included recent hospitalization within the last 6 months, death within 48 hours, or initial admission to an outside hospital. The primary outcome was the percent of respiratory cultures susceptible to community acquired pneumonia (CAP) empiric coverage (beta-lactam plus respiratory fluoroquinolone) at ⬍3 days, 3– 6 days, and ⬎6 days. Descriptive statistics were used to analyze patient demographics and outcomes. A multivariate logistic regression analysis was performed to assess the influence of risk factors on the outcome of susceptibility to CAP empiric coverage. Results: Of the 200 patients included in the study, 83% were Caucasian males and the mean age was 45 years (range 18 –90). The mean Glasgow Coma Score was 8 (range 3–15) and 22% had a history of recent antibiotic exposure not including surgical prophylaxis. Seventy-one percent of cultures were susceptible to CAP empiric coverage (95% CI 64 –77). Eighty-eight percent of cultures were susceptible to CAP empiric coverage at ⬍3 days, 72% at 3– 6 days, and 58% at ⬎6 days. Time to positive culture correlated with susceptibility to CAP empiric coverage. Conclusions: The time period of ⬍3 days was associated with high susceptibility to CAP empiric coverage. Recent antibiotic exposure was related to increased resistance to CAP empiric therapy. Only time to positive culture correlated with CAP empiric coverage susceptibility.

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UTILITY OF MICROHEMATURIA AS INDICATION FOR CT CYSTOGRAM TO DIAGNOSE TRAUMATIC BLADDER INJURY

SURVIVAL IN BURN PATIENTS FOLLOWING DROTRECOGIN ALFA ACTIVATED USE

Cristobal Barrios, University of California Irvine Medical Center, Ramandeep Dhillon, University of California, Irvine, Matthew Dolich, UCIMC Deot of Surgery, Nicole Bernal, Univrsity of California, Irvine, Allen Kong, Stephanie Lush, University of California, Irvine, Michael Lekawa, University of California Irvine Medical Center Introduction: Current standards for diagnosing lower genitourinary (LGU) injuries secondary to blunt trauma involve a cystogram by computed tomography(1). At our institution, the protocol requires a CT cystogram if a patient had at least 50 red blood cells in a urine sample. The purpose is to review the data on patients that met these guidelines compared with patients with LGU injuries and to determine the effectiveness of our protocol. Hypothesis: Old criteria using microhematuria defined as 50 red bloods in a urine sample will result in too many patients receiving CT cystograms. Methods: The study is a retrospective review of patients from 2005 to 2010 performed at our Level-1 Trauma Center. A total of 355 patients received cystograms. Results: A total of 11 bladder injuries (3.1%) and 14 urethral injuries (3.9%) were diagnosed. The average number of RBCs in the UA of patients who had suffered a LGU injury was 2745 compared to non-LGU injury, 414. Other parameters that were investigated include the patients’ Injury Severity Scale (ISS), presence of pelvic fracture(s), blood at the urethral meatus, and renal injury(s). Patients who suffered a LGU injury had an average ISS of 22, while patients without a LGU injury had an mean ISS of 15. The correlation between bladder injury and number of RBCs in UA was 0.311 (p⬍0.01). Correlation between bladder injury and pelvic fracture(s) was 0.170 (p⬍0.01). Of the total patients who had confirmed LGU injuries (37), 20 were diagnosed via pelvic CT, 6 diagnosed by exploratory laparotomy, and 4 diagnosed by CT cystogram. LGU injuries diagnosed via CT cystogram had an average RBC count of 1600. Conclusions: Approximately 96% of patients who did receive CT cystograms were false positives for LGU injury. We suggest that our protocol of 50 RBCs per UA be revised, such that a large number of patients will avoid urinary tract infections, excessive radiation, and urethral and/or bladder injuries from urinary catheterization required for UA.

Aimee LeClaire, Shands at the University Of Florida, Kristi Beerman, Nicholas Ladikos, David Mozingo, University of Florida Introduction: Burn patients are at increased risk of sepsis given their soft tissue injury and invasive therapies often needed to manage their care. Drotrecogin alfa activated (DAA) has demonstrated mortality benefit in patients with severe sepsis and multi-organ failure; however, burn patients were not included in the major clinical trials evaluating DAA. The frequent surgical interventions often necessary to manage infection source control in the burn patient pose a clinical problem when attempting to use DAA as well given the drug must be held around procedures due to bleeding risk. Hypothesis: The purpose of this study was to determine 28-day survival after DAA use in burn patients. Methods: A retrospective study evaluating the use of DAA in adult burn patients between January 1, 2003 and April 30, 2011 was conducted. Patients were eligible for inclusion if above 18 years of age, had a diagnosis of burn, and received DAA. The primary outcome was mortality at 28 days following DAA. Number and duration of DAA therapy interruptions, total DAA dose received, and hospital survival were among the secondary measures. Results: Eighteen patients with an average 46% TBSA burn and APACHE II score of 21 were included. At 28 days following DAA initiation, overall survival was 61%. Hospital survival was 33% for all study patients. Most (72%) patients experienced an interruption of DAA therapy with the average duration of the interruption around 17 hours (range 1–56). Only one-third of patients received a full 96-hour treatment course; of those completing DAA therapy, 28-day and hospital survival was 83% and 50%, respectively. Conclusions: Survival in burn patients receiving DAA is lower than reported in the initial clinical trial of DAA in severe sepsis. Therapy interruptions and incompletion may contribute to the lower survival and a full treatment course may be necessary to derive survival benefit.

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COMPARING THE SAFETY AND EFFICACY OF DALTEPARIN AND ENOXAPARIN IN TRAUMA PATIENTS REQUIRING THROMBOPROPHYLAXIS

RELATIONSHIP OF AN INDWELLING BOWEL CATHETER SYSTEM TO SEPSIS/PNEUMONIA IN BURNS AND SKIN&SOFT TISSUE INFECTIONS

Paul Huiras, Beth Israel Deaconess Medical Center, Lindsay Arnold, Stella Papadopoulos, Boston Medical Center

Stathis Poulakidas, Areta Kowal-Vern, Stroger Cook County Hospital, Michael Riemer, Malford Cullum, Hollister Incorporated

Introduction: National guidelines recommend using low molecular weight heparins (LMWHs) for thromboprophylaxis in trauma patients. Comparative trials between dalteparin and enoxaparin in this high risk population are lacking. A change in the formulary LMWH at Boston Medical Center provided two cohorts for comparison. Hypothesis: Multisystem trauma patients receiving either dalteparin or enoxaparin for chemoprophylaxis of venous thromboembolism (VTE) will have no difference in incidence of VTE or major bleeding. Methods: This was a retrospective chart review of multisystem trauma patients on dalteparin or enoxaparin for VTE prophylaxis from March 2008 to February 2010 at an urban, academic medical center. The primary outcome of this study was venous thromboembolic events within 30 days of inclusive admission. Secondary outcomes included major bleeding and time to initiation of LMWH. Results: Among 200 patients (100 patients in each group), the incidence of VTE was 6% with dalteparin and 3% with enoxaparin (p ⫽ 0.306). The incidence of major bleeding was higher in those receiving dalteparin (20% versus 10%, p ⫽ 0.048). Dalteparin was started earlier compared to the enoxaparin treated group (1.61 versus 4.83 days after admission, p⬍0.001). More patients received unfractionated heparin (UFH) for thromboprophylaxis prior to initiating a LMWH in the enoxaparin group than in the dalteparin group (75% versus 17%, p⬍0.001). The majority (78%) of enoxaparin patients received a dosing regimen of 40 mg daily. Conclusions: Dalteparin 5000 units daily was no more efficacious than enoxaparin 40 mg daily, preceded by 3 days of UFH usage, in preventing VTE in multisystem trauma patients. Further prospective analysis to delineate differences between dalteparin and enoxaparin for thromboprophylaxis in trauma patients is warranted.

Introduction: Gut bacterial translocations may contribute to sepsis in immunocompromised burn patients. Hypothesis: Our purpose was to determine if fecal elimination through a bowel catheter placed in the first 5 days after admission decreased sepsis/pneumonia episodes in Burn/TENS patients during their hospital stay. Methods: This was a 35 month retrospective study of 60 patients: 44 Burn/TENS and 16 Skin & Soft Tissue Infections (SSTI). ActiFlo™ (Hollister Incorporated, Libertyville, IL) bowel catheter was used. Statistical analysis was implemented using SAS v.9.2 (SAS Institute Inc., Cary, NC) for chi-square and descriptive statistics. There were no complications with the bowel catheters used during this study. Results: The bowel catheter was utilized for a mean of 68% of the hospital stay in the Burn/TENS group versus 62 % in the SSTI group. Catheter placement timing had no significant impact on the development of pneumonia or sepsis in the SSTI group. The mean age of the Burn/TENS group was 45 years with a mean length of stay of 43 days, and 47 % total body surface area (TBSA). Of the 21 Burn/TENS patients with bowel catheter placement in the first five days after admission, 9 (43%) developed pneumonia within 14 days of admission compared to 17 of 23 (74%) who had their bowel catheter placed after the fifth day post admission, ?2 ⫽ 4.38, df ⫽ 1, p ⫽ .0364. Similar proportions of patients with early (12 of 21, 57%) and later (18 of 23, 78%) catheter placement developed sepsis within 14 days of admission ?2 ⫽ 2.26, df ⫽ 1, p ⫽ .1330. Fewer patients with early catheter placement (12 of 21, 57%), than patients who had their catheter placed later (20 of 23, 87%), developed pneumonia during their hospital stay ?2 ⫽ 4.92, df ⫽ 1, p ⫽ .0266. Similarly, fewer patients with early catheter placement (8 of 21, 38%), than patients who had their catheter placed later (16 of 23, 70%), developed sepsis during their hospital stay ?2 ⫽ 4.38, df ⫽ 1, p ⫽ .0363. Conclusions: Early bowel catheter placement with removal of gut contents (as a source of bacterial translocation) may decrease pneumonia/sepsis episodes in Burn/TENS patients during hospitalization.


Posters: Cardiovascular–Diagnostics 216

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THE ROLE OF HEAD CT IMAGING IN EVALUATION OF POSTOPERATIVE NEUROLOGIC DEFICITS IN CARDIAC SURGERY PATIENTS

COMPARISON OF BLOOD VOLUME MEASUREMENTS IN A PEDIATRIC ANIMAL MODEL

Timothy George, George Arnaoutakis, Maura Grega, Chase Robinson, Jennifer Alejo, William Baumgartner, Rebecca Gottesman, Guy McKhann, Duke Cameron, Glenn Whitman, The Johns Hopkins Medical Institutions Introduction: Computed tomography (CT) scans of the head are routinely obtained to evaluate neurologic deficits after cardiac surgery, but their utility is unknown. Experience with these scans in a large academic medical institution was reviewed to determine their value. Hypothesis: In cardiac surgery patients with non-focal deficits, early head CT scans rarely yield positive findings. Methods: A computerized database of cardiac surgical patients was used to identify patients with new postoperative neurologic deficits between 1/2000 and 12/2009. Hospital charts were reviewed and patients classified as having stroke (S) if focal neurologic deficits were present, or non-focal deficits (NFD) for seizure, delirium, or cognitive impairment. Early head CT was defined as ⬍7 days post-op. Reports of all non-contrast head CT scans were independently reviewed. Outcomes included length of stay (LOS) and in-hospital mortality. Multivariable logistic regression analysis was performed to identify clinical variables predictive of positive findings on the first postoperative head CT scan. Results: Among 675 patients who had a non-contrast head CT in the post-operative period, 451(67%) had their head CT within the first 7 days post-op. 202 (44.7%) were S and 249 (55.2%) were NFD. Among S patients, 40/202 (20%) showed acute infarction, 17/202 (9%) showed subacute infarction, and 5/202 (3%) showed hemorrhage. Among NFD patients, only 1/248 (0.4%) showed an acute infarction, 4/248 (1.6%) showed subacute infarction, and 1/248 (0.4%) had hemorrhage. There was no difference in LOS (NFD: 22d versus S: 24d, p ⫽ 0.5) or in-hospital mortality (NFD: 41/248 (16%) versus S: 42/201(21%), p ⫽ 0.2). On multivariable logistic regression, only the presence of focal deficit predicted new findings on head CT scan (OR: 22.04 95%CI[9.03–53.78], p⬍0.001). Conclusions: Despite common use of early head CT, to our knowledge this is the only modern study to review its utility in cardiac surgery patients. Head CT imaging for neurologic deficits after cardiac surgery shows positive findings in approximately one third of patients with focal deficits, but is rarely positive in patients with non-focal deficits.

Carsten Bandt, University of Florida, Naveen Thuramalla, Transonic Systems Inc, Gareth Buckley, University of Florida, Andre Shih, University of Florida College of Medicine Introduction: Accurate assessment of intravascular blood volume status is crucial in the management of critically ill patients. Recently introduced COstatus® System (Transonic Systems Inc, NY, USA) allows for routine bedside measurement of cardiac output (CO), and volumetric variables such as active circulation volume (ACV). Radioisotope dilution technique is the clinical gold standard to determine the patients total blood volume (TBV). Hypothesis: The hypothesis was that ACV would have good agreement with TBV in pediatric septic porcine model. Methods: 13 anaesthetized piglets (1 month old, 8 –12.3 kg) were instrumented with central venous and femoral artery catheters. Animals were studied at baseline (base) and after LPS induced sepsis (sepsis). For COstatus, an extracorporeal AV loop tubing is connected between the arterial and venous catheters with two ultrasound sensors clamped on the AV loop. ACV was determined using COstatus ultrasound dilution technology by injecting 1 ml/kg saline into the venous limb of the AV loop. TBV was determined by I-131 labeled albumin using Blood volume analyzer (BVA100, Daxor, NY, USA). Agreement between ACV and TBV was determined using regression analysis and with Bland Altman analysis. Results: A total of 13 base and 6 sepsis measurement points were obtained. CO ranged between 0.9 –2.7 L/min/m2 (1.5 ⫾ 0.52); TBV ranged between 571–989 ml (769 ⫾ 140); and ACV ranged between 320 – 664 ml (506 ⫾ 86). Limits of agreement between TBV and ACV were 474 ml and 52 ml. Mean difference between the two volumes was 26 ⫾ 10 ml/kg. Correlation between TBV and ACV was r ⫽ 0.61 (p⬍0.005). Conclusions: This first study in a pediatric animal model showed a significant correlation between TBV and ACV, especially considering the small range of measurements. Thus, COstatus measured active circulation volume could potentially be used to assess fluid status in neonatal & pediatric animal models. Further studies to test this relation under different clinical conditions are required.Supported by: NIH SBIR Grant# R44HL061994.

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ACCURACY OF FOCUSED CARDIAC TRANSTHORACIC ECHOCARDIOGRAPHY BY CRITICAL CARE FELLOWS USING A HAND-HELD ULTRASONOGRAPHIC DEVICE

MULTICENTER EVALUATION OF A FIRST GENERATION AUTOMATED BLOOD GLUCOSE MONITOR IN THE OR/ICU

Sukhvinder Nagi, Jeremy Gonda, David Liang, Ronald Pearl, Norman Rizk, Anne-Sophie Beraud, Stanford University Hospital Introduction: Focused transthoracic echocardiography (F-TTE) is increasingly used in emergent settings. F-TTE is performed and interpreted by non-cardiologists at the patient’s bedside to provide immediate results and guide management. It is aimed at improvement of the clinical examination rather than the performance of a comprehensive echocardiographic examination. Hypothesis: We hypothesized that F-TTE performed by critical care fellows with limited training in echocardiography, with the smallest pocket-size devices, would provide reliable estimation of left and right ventricular size and function and detection of pericardial and pleural effusions. Methods: In 45 critically ill patients, F-TTE and formal echocardiography were blindly performed within 24 hours. F-TTE were performed and interpreted by critical care fellows using a pocket-size echocardiography device (Vscan, GE). F-TTE interpretation was visual and semiquantitative. The formal examination was performed by cardiac sonographers with a high-end echocardiography device (ie33, Philips) and interpreted by cardiologists board-certified in echocardiography. Images and written reports from both examinations were collected and compared. The parameters assessed were left ventricular (LV) size: normal or dilated; LV function: EF ⬎ or ⬍45%; right ventricular (RV) size: normal or dilated (RV⬎LV size); RV function: normal or impaired. Statistical analysis was performed to compare the accuracy of F-TTE to the formal examination. Results: Compared to formal examination, LV function was accurately assessed by F-TTE in 87% of patients, LV size in 78% of patients, RV size in 77% of patients, RV function in 80% of patients. F-TTE tended to underestimate LV but overestimate RV function. All misinterpretations were discrepancies between mild and normal size or function, which would not have changed management. In one patient, the RV could not be assessed by F-TTE. Clinically significant pericardial and pleural effusions were detected or ruled out in 100% of the patients. Conclusions: F-TTE provided immediate and reliable assessment of overall cardiac function as well as detection of pericardial and pleural effusions in most critically ill patients.


Grant Bochicchio, Washington University in St. Louis, Jeffrey Joseph, Jefferson Medical College of Thomas Jefferson University, Michelle Magee, Washington Hospital Center, Angela Gulino, Michael Higgins, Edwards Lifesciences, Thomas Peyser, Peter Simpson, Jacob Leach, Apurv Kamath, Dexcom Inc Introduction: Evaluation of performance and safety of the first generation GlucoClear intravenous blood glucose monitoring system (IVBG) in critically-ill patients and healthy volunteers with diabetes. Hypothesis: IVBG meets specified accuracy in a Clinical Research Center (CRC) (Study A), demonstrates noninferiority to a point of care glucose meter (POC) in the hospital, and meets comparable accuracy and safety metrics in OR and post-surgical ICU patients (Study B). Methods: IVBG contains a glucose-oxidase sensor, bedside monitor, IV catheter, calibration IV bag, and IV tubing. It measures blood glucose (BG) every 7.5 minutes and displays trending data over 72 hours. IVBG values were blinded. Study A: 50 healthy volunteers with diabetes were monitored up to 72 hours. Comparative samples were drawn every 15 minutes including venous blood for YSI 2300, POC using blood drop from YSI sample, and POC using fingerstick. Over 2800 samples were compared. Carbohydrate consumption and insulin dosing were manipulated across the full BG range of IVBG. Study B: 100 hospitalized, elective or non-emergent surgery and medical/surgical ICU subjects in a 6 center study were monitored up to 72 hours. Comparative samples were drawn every 4 hours from various blood sources and measured on YSI and POC. 996 values were compared. Results: Study A: IVBG accuracy met ISO 15197 acceptance criteria: 95% of IVBG values were within 15 mg/dL at BG ⬍75 mg/dL and within 20% at BG ⱖ75 mg/dL of YSI. IVBG had a Mean Absolute Relative Difference (MARD) of 6.6% compared to YSI. Study B: 93.3% of IVBG while 91.5% of POC (p⬍0.001) were within ISO 15197 compared to YSI. IVBG had a MARD of 8.23%, whereas POC had a MARD of 12.54% compared to YSI. Patients in Study B were exposed to over 200 medications with no signs of interference. Conclusions: IVBG demonstrated a comparable level of accuracy and safety in the hospital as in a CRC. An accurate and reliable IVBG that blocks potential interferents may help to solve controversies over safe implementation of glycemic control and may allow safe implementation of protocols. These data are encouraging and strongly support the need for additional studies using nearcontinuous glucose monitors in the ICU.

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ASSESSMENT OF AORTIC AUGMENTATION INDEX IN CRITICALLY ILL PATIENTS: COMPARISON BETWEEN NONINVASIVE AND INVASIVE PULSE WAVE ANALYSIS.

FEASIBILITY OF TRANSTHORACIC ECHOCARDIOGRAPHY IN SEPTIC SHOCK

Sabino Scolletta, Department of Intensive Care, Erasme Hospital, Beatrice Benedetti, Cecilia Covajes, Katia Donadello, Antoine Herpain, Erasme Hospital, Salvatore Mario Romano, Universit␮i Siena, Fabio Silvio Taccone, Philippe Van de Borne, Erasme Hospital, Jean-Louis Vincent, Daniel De Backer, Erasme University Hospital Introduction: Arterial pressure measurements are often used as an indicator of left ventricular afterload. However, ascending aortic pressure differs from peripheral arterial pressure, due to the presence of reflected waves. The aortic augmentation index (Aix) reflects the difference between peripheral and central pressure measurements. Aix is usually measured with applanation tonometry but new cardiac output monitors based on pulse wave analysis can also derive Aix. Hypothesis: We compared the performance of a PWA monitor and applanation tonometry in critically ill patients. Methods: We simultaneously measured in 24 patients (age 57 ⫾ 17, APACHE II 20 ⫾ 7, SOFA 5.5 ⫾ 2, 14 surgical, 10 medical, 1 dobutamine, 4 norepinephrine, 5 vasodilators, 7 mechanically ventilated) equipped with a radial arterial line and under stable hemodynamic conditions, Aix with applanation tonometry (SphygmoCor, AtCor Medical, West Ryde, Australia) (S-Aix) and PRAM (Pressure Recording Analytical Method; Vygon, Padua, Italy) (P-Aix). All measurements were obtained in triplicate (T1, T2, and T3) with 2 minutes intervals. Results: Mean arterial pressure ranged from 53–107 mmHg (average 85 ⫾ 15), and pulse pressure ranged from 19 – 82 mmHg (average 42 ⫾ 18). S-Aix ranged from -21 to 60% (mean15.4 ⫾ 17), P-Aix ranged from -8 to 39% (mean 7.3 ⫾ 13). S-Aix and P-Aix correlated (R2 ⫽ 0.65, p⬍0.0001) with satisfactory bias (⫹8.1 %, LoA -12.7 to 28.8). P-Aix showed better repeatability (R2 ⫽ 0.97, bias -0.13, LoA -4.90 to 4.67; P⬍0.0001) than S-Aix (R2 ⫽ 0.88, bias -1.5, LoA -14.0 to 11.0; P⬍0.0001). Conclusions: Pulse wave analysis reliably estimated Aix in critically ill patients and offers the advantage of tracking ventricular-vascular interactions continuously.

Jessie Hammes, Stanford University, Anne-Sophie Beraud, Maria Cristina Vazquez Guillamet, Lina Meng, Joe Hsu, Stanford University Hospital Introduction: Although transthoracic echocardiography (TTE) is an important non-invasive diagnostic tool in patients with cardiovascular disease, its efficacy to diagnose cardiac dysfunction in patients with septic shock has not been investigated. Hypothesis: We hypothesized that the feasibility of TTE for the evaluation of cardiac function would be high, independent from mechanical ventilation status, body mass index (BMI), age, and severity of illness. Methods: We identified patients admitted to the intensive care unit (ICU) between May 2009 and July 2011 with septic shock who had a TTE within 72 hours of admission. TTEs were obtained by experienced sonographers and reviewed by a single cardiologist blinded to clinical outcomes. Systolic dysfunction was defined as an ejection fraction (EF) ⬍50% by Simpson method. Diastolic function was determined following the American Society of Echocardiography guidelines. Left atrial (LA) dilatation (area ⬎20 cm2) was used to assess chronicity of diastolic dysfunction. A detailed chart review was performed to collect patient information including demographics, clinical course, and laboratory values from the day of the TTE. Results: 76 patients met the study’s inclusion criteria. Mean age was 70 years and 53% of patients were mechanically ventilated. Median APACHE II score on admission was 22. EF was determined in 83% of patients. The feasibility of TTE to assess diastolic function was 73%. Significant mitral regurgitation or aortic stenosis were the most frequent impediments for the assessment of diastolic function (10/13 patients). The LA was dilated in 42% of patients with diastolic dysfunction. 79% of all patients showed some type of cardiac dysfunction (left ventricular (33%)/right ventricular (29%) dysfunction and/or diastolic dysfunction (50%)). In regression analyses, TTE feasibility was not impacted by BMI ⱖ25, mechanical ventilation, age ⱖ65 or severity of illness (APACHE II ⱖ22). No association was found between cardiac dysfunction and mortality. Conclusions: TTE showed high feasibility for assessment of systolic (83%) and diastolic function (73%). Cardiac dysfunction was detected in 79% of patients with septic shock.

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VALIDATION OF MINIATURE ULTRASOUND DEVICE: ESTIMATION OF LEFT VENTRICULAR FUNCTION

POSTOPERATIVE SERUM CORTISOL CONCENTRATION AND ADRENAL INSUFFICIENCY IN NEONATES UNDERGOING OPEN-HEART SURGERY

Steven Trottier, Saint John’s Mercy Medical Center Introduction: Timely evaluation of cardiac function in critically ill or injured patients presents challenges for the intensivist and health care systems. The decline in pulmonary artery catheter use has paralleled the development of bedside ultrasound equipment. Hypothesis: The purpose of this study is to validate the results of a low cost miniature ultrasound device (VScan GE, Fairfield, CT) to that of transthoracic echocardiogram (TTE) results. Methods: Consecutive ICU patients that had undergone TTE were evaluated with the miniature ultrasound device (3 x 5 inches). An intesivist with Level III status (Crit Care Med 2007 Vol. 35, No. 5 (Suppl.) performed and interpreted the study echocardiograms. The quality of the images, number of echocardiographic views (parasternal long axis, parasternal short axis, apical four-chamber), and demographics were recorded. The left ventricular ejection fraction (EF) was categorized into three groups: I normal (⬎50%), II mild to moderate (30 –50%), and III severe (⬍30%). Results: Fifty-nine (87%) of 68 study patients had ultrasound images that could be interpreted. There were 24 females and 35 males with an average age of 65 ⫹/⫺ 16 years and BMI of 30 ⫹/⫺ 9. The results were categorized as follows: group I: 39, group II: 16, group III: 4. Fifty-three (89%) of the intensivist results correlated correctly with the formal TTE results. Six patients were incorrectly categorized between group I and II and the EF differences were between 5 to 10%. All group III results correctly correlated with the TTE results. Study patients had the following views: 38 had 3 views, 18 had 2 views, and 3 had 1 view. The quality of the study images were recorded as 21 excellent, 18 good, 15 fair, and 5 poor. There was no difference in the results comparing mechanical ventilation or BMI. Conclusions: The results of this study validate the low cost miniature ultrasound device assessing LV function by a Level III trained intensivist. Further data corroborating the results of this study are necessary. Following the corroboration, future studies should be designed to determine whether real time bedside echocardiogram results impact patient care decisions and outcome.

Santiago Borasino, William Sasser, Ashley Moellinger, Krissie Hock, Robert Dabal, Jeffrey Alten, University of Alabama at Birmingham Introduction: We sought to determine whether immediate postoperative serum cortisol concentration predicts adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass. Hypothesis: We hypothesized that cortisol ⬍10 ␮g/dL would be associated with increased catecholamine requirements and fluid resuscitation, and would predict hemodynamic responsiveness to exogenous steroids. Methods: Retrospective study of 41 neonates with cortisol levels in the immediate postoperative period, 15 of which received steroids due to high levels of inotropic support. Surrogates of oxygen transport, hemodynamic parameters, and clinical outcomes were collected. Results: Median cortisol was 12 ␮g/dL (IQR 5.2, 27.4). Serum cortisol level ⱖ10 ␮g/dL was associated with higher peak lactate (11.8 mMol/L vs. 9.1 mMol/L, p ⫽ .04) and maximum arteriovenous saturation difference (32% vs. 28%, p ⫽ .05). Cortisol level was positively correlated with maximum lactate (p⬍.001), maximum arteriovenous saturation difference (p⬍.001), maximum inotrope score (p ⫽ .014), initial 24-hour fluid intake (p ⫽ .012), and time to negative fluid balance (p ⫽ .008) and was negatively correlated with initial 24-hour urine output (p⬍.001). Six (40%) patients had a significant hemodynamic improvement within 24 hours after receiving steroids (responders). There was no statistical difference between cortisol levels in responders vs. non-responders. Conclusions: Low serum cortisol obtained in the immediate postoperative period is not associated with worse postoperative outcomes or predictive of steroid responsiveness. In contrast, elevated cortisol levels are positively correlated with severity of illness. The use of an absolute cortisol threshold to identify adrenal insufficiency and/or guide steroid therapy in neonates after cardiac surgery is unjustified.


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COMPARING LEFT VENTRICULAR STROKE WORK INDEX (LVSWI) WITH WEDGE PRESSURE (PAWP) AND CENTRAL BLOOD VOLUME (CBV) IN PEDIATRIC PATIENTS

EARLY DETECTION AND DIAGNOSIS OF PULMONARY HYPERTENSION: TRANSTHORACIC ECHOCARDIOGRAPHY VERSUS RIGHT-SIDED HEART CATHETERIZATION

Ivory Crittendon, Texas Children’s Hospital, Naveen Thuramalla, Transonic Systems Inc, Jeffrey Kim, Texas Children’s Hospital

Elvira Umyarova, Chok Limsuwat, Aliakbar Arvandi, TTUHSC

Introduction: Frank Sterling curve between thermodilution measured PCWP (preload) and LVSWI (contraction force) could assess the volume status in the patient [1]. However, routine assessment of these parameters in pediatric patients is difficult due to the risks associated with pulmonary artery catheters (PAC). Recently introduced COstatus system (Transonic Systems Inc, NY, USA) works off standard insitu arterial and central venous lines to routinely measure cardiac index (CI), CBV (blood volume in the heart, lungs and major vessels) and other hemodynamic parameters in pediatric patients. Hypothesis: Purpose of this study was to investigate if CBV could assess volume status in pediatric patients. Methods: Twenty two patients (9.4 –78 kg; aged between 1–17 years) with a structurally normal heart undergoing hemodynamic assessment in the cardiac catheterization laboratory were studied. For COstatus measurements, 1 ml/kg (up to 30 ml) body temperature isotonic saline was injected into the venous side of an extracorporeal AV loop, which was connected between the existing femoral arterial line and sheath of the right heart catheter. Two flow-dilution sensors were clamped on the AV loop. 10 ml room temperature injections were performed for PAC measurements. 2–3 injections were performed and averaged for comparison. Results: LVSWI range: 4.3–11.9 gm-m/m2/beat; PAWP range: 6 –26 mm Hg; and CBVI range: 5.8 –17.3 ml/kg. Lower limits of 40 gm-m/m2/beat, 15 mm Hg and 18 ml/kg were used for LVSWI, PAWP and CBVI, respectively to indicate hypovolemic status. Plotting LVSWI vs. PAWP showed that 21 out of 22 patients were in the hypovolemic quadrant while plotting LVSWI vs. CBVI showed that 19 out of the 22 patients were hypovolemic. These findings were in agreement with clinical assessment of the patients. Conclusions: Preliminary study in pediatric post heart transplant patients showed that COstatus measured central blood volume could be used to assess volume status in patients. Further studies to investigate if this relation holds under different therapies and loading conditions are required.NIH SBIR Grant# R44HL061994. References: [1] Respiratory care calcualtions. David W Chang, pg 228; [2] Crittendon I et al, Ped Crit Care Med, 2011.


Introduction: Pulmonary hypertension (PHTN) is a syndrome characterized by increased pulmonary vascular resistance. Currently, pulmonary hypertension is established through right heart catheterization (RHC), but transthoracic echocardiography (TTE) with Doppler interrogation has been recommended as an initial noninvasive modality. Hypothesis: The goal of this study was to determine the correlation between pulmonary artery systolic pressures (PASP) estimated by TTE and RHC in patients with PHTN. Methods: Retrospective review of medical charts of the patients with PHTN. TTE estimates of PASP were compared to PASP measured during RHC. TTE was performed within 3 months before or after RHC. Accuracy was predefined as ⫹/⫺ 5 mm Hg for PASP estimates. Results: 96 patients were assessed. Mean PASP was 60.93 mm Hg and 55.3 mm Hg determined by TTE and RHC respectively. We found that TTE was inaccurate in 71% of the cases (69/96): overestimated PASP ⬎5 mm Hg in 66% (46/69) and underestimated in 33% (23/69). There was a moderate correlation between PASP measurements obtained by TTE and RHC (r ⫽ 0.52), with T test p values ⬍0.001. Conclusions: TTE estimates of PASP are inaccurate in patients with PHTN and should not be used to make a diagnosis. There is a moderate correlation between PASP measurements obtained by TTE and RHC, but TTE is inaccurate in 71%. Overestimations of PASP are more common while using TTE. TTE still remains an important tool in patients with PHTN by assessing right ventricular size, systolic function and wall motion, most of those are independent predictors of PHTN. Because of the moderate correlation between PASP measurements, TTE should be considered as an additional tool assisting RHC in assessment of patients with PHTN.

Posters: Cardiovascular–Monitoring-1 226

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CHANGES IN CEREBRAL OXYGEN EXTRACTION CORRELATE WITH S100B IN INFANTS FOLLOWING CARDIOPULMONARY BYPASS (CPB)

EFFECTS OF BALLOON-INDUCED PULSATILE PERFUSION ON POSTOPERATIVE SHORT- AND LONG-TERM COGNITIVE DYSFUNCTION IN DIABETIC PATIENTS WITH IMPAIRED CEREBROVASCULAR CARBON DIOXIDE REACTIVITY

Samer Abu-Sultaneh, David Hehir, Nancy Ghanayem, Jennifer Liedel, Raymond Hoffmann, Yumei Cao, Michael Mitchell, Medical College of Wisconsin, Andreas Jeromin, Banyan Biomarkers, Inc., James Tweddell, George Hoffman, Medical College of Wisconsin Introduction: Monitoring regional cerebral oxyhemoglobin saturation (rSO2C) with near-infrared spectroscopy (NIRS) in infants with congenital heart disease has revealed periods of vulnerability for cerebral hypoxia both during and after CPB. Elevation of S100B correlates with adverse neurologic outcome in pediatrics after cardiac arrest and traumatic brain injury (TBI) and in adults following surgery with CPB. By examining the relationship of cerebral hypoxia to early biomarkers of injury, we sought to clarify the clinical importance of NIRS in infants undergoing CPB. Hypothesis: We hypothesized that cerebral desaturation measured by low rSO2C or increased arterial-cerebral oxygen saturation difference (?a-rSO2C) is related to biochemical evidence of cerebral injury as measured by elevation of S100B. Methods: Patients 1–12 months of age scheduled for surgery with CPB were enrolled. Serum S100B was measured after 8 epochs (pre and post CPB, 3 early postoperative times, and each AM for 3 post-operative days). Arterial saturation (SpO2) and rSO2C were and recorded each minute from anesthesia induction until 72 hours postoperatively. The relationship between rSO2C and ?a-rSO2C to serum S100B levels after each epoch was assessed by direct and lagged linear correlation using Pearson or Spearman correlation and by time-series generalized least squares regression techniques. Results: 9 infants (5.4 ⫾ 2.6 months) underwent surgery with CPB. In all patients, S100B increased during CPB, peaking either immediately post-CPB (7/8) or on ICU admission. Baseline and peak S100B levels varied greatly (125⫾206 and 437⫾356 pg/mL, respectively), for a mean change of 312⫾197 pg/mL. Increased ?a-rSO2C was associated with elevated S100B levels at later time points, with a delay of 3 epochs (p ⫽ 0.030) and 4 epochs (p ⫽ 0.032). Conclusions: Changes in cerebral oxygenation were associatedwithanincreaseinS100BintheperioperativeperiodfollowingCPB.Thisstudy further validates the use of NIRS as a noninvasive monitor of brain injury in cardiac surgery and facilitates the evaluation of neuroprotective strategies in this population.

Yuji Kadoi, Gunma University Introduction: The purpose of this study was to identify whether reduced jugular venous oxygen saturation (SjvO2) in diabetic patients with impaired cerebrovascular CO2 reactivity could be improved by pulsatile perfusion during cardiopulmonary bypass (CPB) and whether improved SjvO2 could improve postoperative cognitive dysfunction after coronary artery bypass graft surgery. Hypothesis: We hypothesized that the frequently observed reduction of SjvO2 in diabetic patients could be improved by pulsatile perfusion during hypothermic CPB. In addition, improved reduction of SjvO2 by pulsatile perfusion may in turn improve postoperative short-term cognitive dysfunction in diabetic patients. Methods: Subjects comprised 99 diabetic patients with impaired CO2 reactivity (⬍3%/ mmHg) randomly divided into two groups: Group 1, which received intra-aortic balloon pumping (IABP) before induction of anesthesia; and Group 2, which did not. Group 1 received nonpulsatile perfusion during CPB, and Group 2 received pulsatile perfusion during CPB. Hemodynamic data (arterial and jugular venous gas values) were measured during CPB. All patients underwent neurological and neuropsychological tests the day before surgery, and 7 days and 6 months after surgery. Results: Duration of SjvO2 ⱕ50% during CPB was shorter in Group 2 (13⫾5 min) than in Group 1 (20⫾6 min; p⬍0.01). No significant differences in rate of cognitive dysfunction were seen between groups at 7 days and 6 months postoperatively. Conclusions: Pulsatile perfusion flow generated by IABP could reduce the decrease in SjvO2 values during CPB, but amelioration of SjvO2 values was not associated with short- or long-term postoperative cognitive dysfunction in diabetic patients with impaired CO2 reactivity.

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COMPARISON OF BLOOD VOLUME ANALYSIS MEASURED BY ULTRASOUND DILUTION METHOD AND RADIOISOTOPE DILUTION TECHNIQUE.

ESTIMATION OF EJECTION FRACTION FROM MITRAL ANNULAR DISPLACEMENT USING PERIOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Sho Furuta, Erin Suydam, Uy Vu, Keilla Schmidt, Michael Hayashi, David Inouye, Maimona Ghows, Danny Takanishi, University of Hawaii, Mihae Yu, University of Hawaii School of Medicine and the Queen’s Medical Center

Timothy Ball, Jonathan Mock, Nicholas Shelburne, Darius Tolbert, Chirstopher Chiles, William Culp, Texas A&M University College of Medicine, Scott & White Hosptial

Introduction: Assessment of circulating blood volume (BV) has been challenging for clinicians. The gold standard is using the radioisotope dilution technique (BVRD). Our prospective randomized trial demonstrated improved mortality utilizing information from BVRD (1). The technique of BVRD determination remains cumbersome, thus we evaluated an ultrasound dilution method for blood volume analysis (BVUD) which may be more clinically useful in the intensive care setting. Hypothesis: Circulating BV values obtained by BVUD is equivalent to measurements utilizing BVRD. Methods: Critically ill surgical patients had simultaneous measurements of circulating BV using BVUD (COstatus system, Transonic, Ithaca, NY) and BVRD (BVA-100, Daxor, NY, NY). The COstatus system utilizes ultrasound sensors attached to an extracorporeal arterial-venous loop that bridges arterial and central venous catheters. After 60 ml isotonic saline injections, the sensors recorded the change in velocity of the blood within 90 seconds to calculate circulating BV. The BVA-100 utilizes I-131 albumin as an indicator which is injected followed by serial measurements using 5 ml aliquots of blood collected at 12, 18, 24, 30, and 36 minutes and extrapolated to time zero to compensate for albumin transudation. Results: Fourteen patients contributed 32 data points with the following demographics: age 68⫾11 years, Female:Male 6:8, APACHE II ⫽ 22⫾7.0. Diagnoses included: severe sepsis/septic shock (n ⫽ 11), ALI/ARDS (n ⫽ 3). Regression analysis demonstrated significant correlation between circulating BV measured by BVUD and BVRD (r ⫽ 0.66, R2 ⫽ 0.35, p⬍0.01). The mean circulating BV was 5071⫾897 ml using BVUD and 5078⫾883 ml using BVRD. Bias was -6.7 ml with limits of agreement as -1574 to 1560 ml. Conclusions: This preliminary investigation shows that there is significant correlation between measurements of circulating BV using the BVUD and BVRD methodologies. The COstatus system allows for frequent bedside measurement of circulating BV and if validated in larger patients cohorts, has the potential to be less cumbersome and more clinically efficacious to perform rather than the radioisotope methods in current use. Reference: (1)Yu M et al, Shock 2011, 35, 220.

Introduction: Assessing systolic function in critically ill patients is clinically important, yet often technically challenging; thus we sought to study the relationship of mitral annular displacement (MAD) with ejection fraction (EF) from perioperative transesophageal echocardiograms (TEE) to develop a fast, easily teachable method of measuring systolic function. Hypothesis: Recent studies have validated MAD as a surrogate for EF using transthoracic echocardiography (TTE), but this relationship has not been validated with perioperative TEE. We hypothesize that TEE derived MAD correlates with EF. Methods: After IRB approval, fifty archived and de-identified perioperative TEE exams with midesophageal four chamber, mitral commissural, and two chamber views were selected for analysis. Digital tracking software (ProAnalyst, Xcitex, Cambridge, MA) measured absolute vertical motion with regards to the LV apex along six distinct mitral annular points. Two blinded echocardiographers measured EF using the same TEE views. Quadratic correlation was used to identify a relationship between TEE MAD and EF. We also analyzed MAD in regards to EF to identify specific ranges for poor, moderate and normal LV function as a potential screening tool. Results: There were fifty separate TEE exams studied with a total of 6 points along the mitral annulus in the three separate views previously mentioned. The septal, lateral, posterior-medial, anterior-lateral, posterior, and anterior points showed R values of 0.54, 0.47, 0.36, 0.48, 0.46, and 0.37 respectively. We then stratified MAD by grouping them into EF categories of normal (⬎49%), moderately reduced (30 – 49%), and poor (⬍30%) with a mean (SD) MAD of 0.95 (0.24), 0.80 (0.32), and 0.53 (0.16) in centimeters respectively. Conclusions: There is a correlation between TEE MAD and EF. This technique has potential to stratify EF classes and ranges in the critical care setting, though the relatively large standard deviations make additional refinements necessary. Speckle tracking may improve TEE MAD measurements. Future studies with three-dimensional tracking of the mitral annulus may show more discrete stratification among these functional groups.


232 HEMOGLOBIN DRIFT AFTER CARDIAC SURGERY Timothy George, Claude Beaty, Kara Haggerty, Steve Frank, William Savage, Glenn Whitman, The Johns Hopkins Medical Institutions Introduction: In cardiac surgery (CS), a restrictive approach to red blood cell transfusions (Tx) is associated with improved outcomes. Understanding the postop pattern of hemoglobin (Hgb) levels in CS patients may enable better evaluation of the need for postop Tx. Hypothesis: We hypothesized that postop Hgb initially drifts downward and then recovers prior to discharge. Methods: From 10/1/2010 –3/31/2011 in CS patients not receiving a postop Tx, we evaluated postop Hgb levels. To account for postop Tx of cellsaver blood, the initial Hgb was defined as the first Hgb ⱖ6 hours postop. Maximal drift was defined as the initial minus the minimum postop Hgb. End drift was defined as the difference between initial and discharge Hgb. The multivariable model of predictors of maximal drift included age, weight, intraoperative Tx, and CPB time. Results: Of 199 patients in our study, 71 (36%) were transfused intraoperatively. The mean initial postop Hb was 11.0 ⫾ 1.4 gm/dL, the mean discharge Hgb was 9.9 ⫾ 1.3 gm/dL, yielding a mean end drift of 1.1 ⫾ 1.4 gm/dL. The maximal drift was 1.8 ⫾ 1.1 gm/dL and was similar regardless of intraoperative transfusion status (1.8 ⫾ 1.0 gm/dL vs. 1.8 ⫾ 1.2 gm/dL, p ⫽ 0.99). Regarding downward drift, 19% of patients drifted ⫾ 0.7 gm/dL by discharge. As with maximal drift, Hgb recovery was similar regardless of intraoperative Tx status (0.7 ⫾ 0.7 vs. 0.8 ⫾ 0.6, p ⫽ 0.60). On multivariable linear regression analysis, CPB time was strongly associated with maximal drift (-0.26 gm/dL/per hour [0.04 – 0.47], p ⫽ 0.02). Conclusions: In this, the first description of Hgb drift following CS, although all postop CS patients experience downward Hgb drift, 80% of patients experience an increase in discharge Hgb from their nadir. On average, this recovery represents 50% of the maximal drift. CPB time is predictive of drift in patients not transfused postop. Knowledge of the pattern of postop Hgb drift should allow physicians to better adhere to restrictive blood transfusion protocols.

233 PERIPHERAL MICROVASCULAR OXYGENATION ABNORMALITIES PERSIST AFTER HOSPITALIZATION FOR ACUTE DECOMPENSATED HEART FAILURE Christopher Hogan, Virginia Commonwealth University Medical Center, Kevin Ward, Virginia Commonwealth University, Roland Pittman, Medical College of Virginia Introduction: Recent work has demonstrated that significantly increased peripheral tissue oxygen extraction occurs in the acute phase of decompensated heart failure (ADHF) and persists through hospital discharge. However, there is limited data on how these abnormalities behave after discharge. Hypothesis: We hypothesized that patients who are readmitted or die within 6 months of an ADHF hospitalization will fail to improve peripheral tissue oxygen saturation (StO2) within 1 month of discharge, while those who do not die or need rehospitalization will improve StO2. Methods: This prospective, observational pilot study enrolled patients admitted with preserved ejection fraction ADHF and non-invasively measured StO2 on the palmar surface of the hand using near infrared spectroscopy. Measurements were made just prior to, then 1 and 4 weeks after an ADHF inpatient discharge. The StO2 15-minute averages were analyzed with a repeated measures ANOVA test (p⬍0.05 significance level). Mean arterial pressure and arterial oxygen saturation were measured and analyzed in similar fashion. Results: Of the 28 patients enrolled, 23 completed outpatient follow-up. Fourteen either died (n ⫽ 1) or required a ADHF hospital readmission (n ⫽ 13) within 6 months. For those who were readmitted or died, the discharge, 1-week and 4-week StO2 values (⫹/⫺ standard deviation), respectively, were 66.5% (10.8), 64.5% (6.1) and 65.6% (8.4), while those who survives and were not readmitted had values of 69.9% (8.1), 67.5% (9.8) and 67.7% (8.3), respectively. ANOVA failed to demonstrate a significant change in St02 for either the readmitted/died group (F(2,27) ⫽ 0.47, p ⫽ 0.63) or in the stable group (F(2, 13) ⫽ 0.50, p ⫽ 0.59). There were no significant changes in MAP or pulse oximetry saturation over this period. Conclusions: The enhanced peripheral tissue oxygen extraction known to occur in ADHF during the acute phase does not appear to decrease after discharge. Improved ADHF mortality and readmission rates may be possible if inpatient treatment was guided by microvascular tissue oxygenation parameters that were optimized prior to hospital discharge.

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COMPARISON OF CARDIAC OUTPUT BY PULMONARY ARTERY THERMODILUTION, ULTRASOUND DILUTION AND ARTERIAL PULSE PRESSURE METHODS

ACTIVE CIRCULATION VOLUME AS A VOLUMETRIC MARKER FOR ROUTINE BEDSIDE USE WITH PEDIATRIC ICU PATIENTS

Uy Vu, Sho Furuta, Erin Suydam, Keilla Schmidt, University of Hawaii, Maimona Ghows, University of Hawaii at Manoa, Michael Hayashi, David Inouye, Danny Takanishi, University of Hawaii At Manoa John A Burns School of Medicine, Mihae Yu, University of Hawaii School of Medicine

Patricia Bastero-Minon, Texas Children’s Hospital, Alejandro Floh, Tilman Humpl, The Hospital for Sick Children

Introduction: Cardiac output (CO) is an important hemodynamic variable in the management of critically ill patients. The pulmonary artery (PA) catheter requires invasive techniques with potential complications and there is increasing interest in less invasive methods of measuring CO. This study was designed to compare CO values from PA thermodilution, ultrasound dilution (UD) and pulse pressure (PP) methods. Hypothesis: PA catheters, COstatus and FloTrac provide similar measurements of CO. Methods: Critically ill surgical patients with PA catheters (Edward Lifesciences, Irvine, CA) had ultrasound sensors attached to an extracorporeal arterial-venous loop connected between an arterial and central venous line (COstatus system, Transonic, Ithaca, NY). PAC CO was generated using thermodilution principles. For COstatus, 2 to 3 injections of 30 ml isotonic saline decreased the blood ultrasound velocity and produced dilution curves to generate CO values. The FloTrac, version 3.02, (Edward Lifesciences, Irvine, CA) was attached to the arterial line and used the PP method to calculate the stroke volume (SV) by analyzing the waveform (Khi) morphology, multiplied by the standard deviation of the arterial pressure. SV*heart rate determined CO. Results: Eleven patients provided 24 data points with the following demographics: age 68 ⫾ 12 years, female:male 4:7, APACHE II ⫽ 23.2 ⫾ 7.6. Diagnoses included: severe sepsis/septic shock (n ⫽ 9), ALI/ARDS (n ⫽ 2). Regression analysis showed significant correlation between PAC and COstatus (r ⫽ .646, r2 ⫽ .367, p⬍.001). CO values were 5.93 ⫾ 1.13 L/min (PAC) and 6.09 ⫾ 1.40 L/min (COstatus). Using the Bland-Altman approach the bias was 0.152 L/min with limits of agreement as -2.08 to 2.38 L/min. The percentage error was 38%. There was no significant correlation with PAC and FloTrac CO (r ⫽ .455, p ⫽ .257), or with COstatus and FloTrac CO (r ⫽ -.191, p ⫽ .512). Conclusions: Although there is no gold standard for bedside measurement of CO, the PAC has been studied with numerous outcome studies with varying results. The ability to measure the cardiac function still remains a valuable tool. The PAC and COstatus system demonstrated adequate agreement while CO values from the FloTrac deviated significantly.


Introduction: The COstatus® system (Transonic Systems Inc, NY, USA) based on ultrasound dilution technology allows for routine measurement of active circulation volume index (ACVI), cardiac index (CI) and other circulatory blood volumes. ACV is defined as the amount of blood volumes in which the indicator (isotonic saline) mixes within one minute and quickly returns to support the heart. The purpose of this study was to determine if ACVI is influenced by a patient’s pre- or after-load status. Hypothesis: We hypothesize that an association exists between ACVI, CI and systemic vascular resistance index (SVRI) in pediatric ICU (PICU) patients. Methods: Children following biventricular repair of congenital heart disease, in absence of significant intracardiac shunts, were prospectively identified. CI, SVRI and ACVI were measured by ultrasound dilution. An extracorporeal arteriovenous (AV) loop was connected between in-situ arterial and central venous catheters with two flow-dilution sensors attached on the arterial and venous ends of the AV loop. Blood was circulated at 10 –12 ml/min through the loop from artery to vein using a small roller pump. Body temperature isotonic saline (0.5–1 ml/kg, up to 30 ml) was injected into the venous side to obtain all measurements. Results: Twenty one patients (aged: 6 days-14.5 years; weight: 2.7– 80 kg) were recruited, with a total of 107 data sets obtained. CI range: 0.8 -5.5 ml/m2 (2.3 ⫾ 0.2); ACVI range: 27–100 ml/kg (51.52 ⫾ 4.69) and SVRI range: 500 – 6070 dynes/s/cm5/m2 (1914 ⫾ 162). The relationship between SVRI and CI was logarithmic in nature with a strong positive association at CI less than 2 L/min/m2. A positive linear correlation of r ⫽ 0.72 (p ⫽ ⬍0.005) was observed between CI and ACVI while an inverse correlation of r ⫽ 0.53 (p ⫽ ⬍0.005) was observed between ACVI and SVRI. Conclusions: This is the first study in pediatric ICU patients demonstrating the relationship between SVRI, CI and measured ACVI. We believe that ACV may reflect the balance between preload and afterload and hence may be a good marker of optimal loading conditions. To better understand the underlying physiology, further studies investigating the effect of volume loading on these relations are required.

236 LOW STO2 MEASUREMENTS IN ICU PATIENTS PREDICTS INCREASED HOSPITAL AND ICU LENGTH OF STAY Tyler Conway, Javariah Asghar, Patei Iyegha, Duncan Nyangau, Kristine Mulier, Gregory Beilman, University of Minnesota Introduction: Near-infrared (NIR) spectroscopy derived tissue hemoglobin saturation (StO2), reflects changes in microcirculatory tissue perfusion. Previous studies in trauma patients have shown a correlation between low StO2 levels and mortality, organ failure, and severity of injury. Hypothesis: We hypothesized that low StO2 levels during a patients’ ICU course predict poor outcomes in critically ill patients. Methods: We conducted a prospective cohort study at the University of Minnesota Medical Center. We identified 620 patients from all adult patients admitted to the Surgical Intensive Care Unit (SICU) between July 2010 and July 2011. Of these patients, 502 met enrollment criteria. StO2 measurements were taken from the thenar eminence within 24-hours of admission and twice daily for the length of a patient’s stay in the ICU, (up to 14 days). Outcome data were collected including mortality, ICU and hospital length-ofstay (LOS), and time on the ventilator. In addition, the need for life saving intervention within 48 hours of ICU admission was recorded. Results: Of 502 patients enrolled, 226 were female (45%) and 276 were male (55%), with a mean age of 56 years (range 19 –93 years). The most frequent admission diagnoses were post-operative monitoring, neurovascular care and respiratory failure. Patients with any StO2 measurement less than 70% (N ⫽ 165, 32.9%) during their ICU stay experienced a statistically significant greater ICU LOS (4.5 vs. 6.4 days, p ⫽ 0.0002) and hospital LOS (10.8 vs. 13.5 days, p ⫽ 0.0004). There were no statistically significant differences in 28-day mortality, ventilator days or need for life saving intervention in patients with StO2 levels less than 70% compared to those with levels greater than 70%. Conclusions: Low NIR-derived StO2 levels during ICU stay are associated with a greater hospital and ICU length of stay in critically ill patients.Source of funding: Hutchinson Technology, Inc., Hutchinson, MN.


Posters: Cardiovascular–Monitoring-2 237

238

ULTRASOUND DILUTION TECHNIQUE AS A MINIMALLY INVASIVE WAY TO DETECT INTRA-CARDIAC SHUNTING IN AN ATRIAL SEPTAL DEFECT MODEL

BEAT-TO-BEAT QTC MONITORING DETECTS QTC PROLONGATION IN 50 CONSECUTIVE TELEMETRY MONITORED PATIENTS

Andre Shih, Amara Estrada, Herbert Maisenbacher, U of Florida, Joseph Paolillo, Sanger Heart and Vascular Institute, Aline Ambrosio, University Sao Paulo, Brandon Pogue, U of Florida, Naveen Thuramalla, Transonic Inc, Hunter Schrank, Carsten Bandt, U of Florida

Judy Davidson, Donna Agan, Scripps Mercy Hospital, Dan Ballard, Welch Allyn Monitoring, Huu Truong, Christine Bridgen, Harminder Sikand, Steven Rubino, Joseph Stein, Scripps Mercy Hospital

Introduction: Ultrasound dilution (UD) technique is a minimally invasive method used to determine cardiac output (CO) and volumetric variables of preload such as total end diastolic volume (TEDV) for critical care patients. This novel technique may also be useful in detecting intra-cardiac shunting. Hypothesis: UD is a good method to detect right to left (R-L) shunting in a porcine atrial septal defect (ASD) model. Methods: 11 anesthetized piglets (1 mo, 10kg) were studied at baseline (base) and after atrial septostomy with partial pulmonary artery occlusion (ASD-RL). Pulmonary artery blood flow (Qp) and aortic blood flow (Qs) were measured by implanted ultrasound flow probes. Shunt fraction was calculated as Qp/Qs. The ASD was created after transeptal puncture by serial dilation with 8 and 16 mm ballon dilation catheters via the right external jugular vein. Shunting accross ASD was confirmed by angiography in all animals. Shunt presence and CO were measured by UD technology with COstatus device. Data was analyzed using K Wallis and CO agreement to Qp was determined by Bant Altman. Results: Total of 96 paired measurements were made. COstatus UD had good agreement with Qp with relative bias of 13.2% Limits of agreement (LOA) 26 and -30%. Success rate of UD in detecting RL shunt was 95.8% when Qp/Qs was ⬍0.85 and 98% when Qp/Qs was ⬎0.85. Percentage of false positives and negatives were 3% and 5.2% respectivelly. Conclusions: UD was successful in identifying shunt in ASD model.

Introduction: AHA/ACCF recommends monitoring patients for QTc prolongation. Although the risk of QTc prolongation is recognized, the incidence in hospitalized telemetry patients (pts) is unknown. Hypothesis: Beat-to-beat QTc monitoring will detect a greater incidence of QTc prolongation than standard monitoring procedures. Methods: After IRB approval, waveforms of telemetery monitored pts were downloaded and analyzed consecutively until 50 abnormals (any episode of QTc prolongation) were identified (QTc⬎470 msec in males, ⬎480 msec in females using Bazette’s formula per hospital standard and ⬎500 msec in bundle branch block). Incidence was calculated by the number of pts screened to identify 50 abnormals. Closed medical records were abstracted for clinical risk factors and the outcomes of TdP or sudden death. Home and hospital medications administered prior to the QTc prolongation were evaluated. Results: In fifty consecutive patients, 100% had at least one documented episode of QTc prolongation. Home medications that could result in QTc prolongation were identified in 9 pts (18%). Hospital medications with risk of QTc prolongation were administered to 31pts (62%). No high-risk medications were taken by 16 pts (32%). Risk factors identified in the history 2 pts (4%), hypomagnesemia or hypokalemia was seen in 6 pts (12%). In 45 pts with 12 lead EKGs in the medical record, 12 lead EKG detected prolonged QTc in 13 pts (26%). Prolongation of QTc was detected by manual analysis in 4 pts (8%). No pt experienced TdP or sudden death. Conclusions: With beat-to-beat analysis QTc prolongation was detected in 50 consecutive pts where standard of care (nursing manual analysis or 12 lead EKG) would have detected prolongation in 14 pts. In this pilot, hospital medications were more likely to contribute to QTc prolongation than home medications. Sample size of this pilot is too small to determine clinical significance of QTc prolongation. Better definitions for determining risk are needed as automated technology improves the capture rate of QTc prolongation events. Significance of intermittent QTc prolongation warrants further exploration.

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NONINVASIVE ASSESSMENT OF PLASMA LEAKAGE IN DENGUE WITH NEAR INFRARED SPECTROSCOPY (NIRS)–PRELIMINARY RESULTS

MEASUREMENT OF CARDIAC OUTPUT BY NON-INVASIVE ARTERIAL PULSE CONTOUR TECHNIQUE COMPARED TO ECHOCARDIOGRAPHY IN THE ICU.

Babs Soller, Reflectance Medical Inc., Sharone Green, University of Massachusetts Medical School, Anon Srikiatkhachorn, USARMC-AFRIMS, Fengmei Zou, Reflectance Medical Inc., Alan Rothman, University of Rhode Island, Siripen Kalayanarooj, Queen Sirikit National Institute of Child Health, Children’s Hospital, Stephen Thomas, Walter Reed Army Institute of Research

David Fagnoul, olivier tatonOlivier Taton, Daniel De Backer, Jean-Louis Vincent, Erasme University Hospital

Introduction: An estimated 50 –100 million dengue infections occur annually, worldwide, with over 500,000 hospitalizations and 25,000 deaths, primarily in children. Infected patients are at risk for severe disease (dengue hemorrhagic fever (DHF)) and death due to plasma leakage, decreased intravascular volume, and shock. The period surrounding defervescence is the highest risk period for plasma leakage. Early recognition and proper intravascular volume resuscitation improve morbidity and mortality. NIRS can be used to determine muscle oxygen saturation (SmO2) along with an index of blood (HbT) and water (wat) volume in a tissue region [1]. Hypothesis: NIRS can be used to alert for plasma leakage in patients with severe dengue. Methods: A prototype NIRS sensor was placed on the upper arm or thigh of dengue patients in Bangkok, Thailand. NIRS data were recorded over a 2– 4 day period; only data collected in the 24 hr period before defervescence were analyzed. SmO2, HbT and wat were calculated from each spectrum and the ratio wat/HbT was computed; data were averaged over 30 min. One day after deferevescence the pleural effusion index (PEI) was determined from a chest x-ray. PEIⱖ5% was used to define significant plasma leakage. A Mann-Whitney test was used to assess differences in the NIRS parameters between the two PEI groups. Results: 255 data points were analyzed from 13 subjects, 7 with PEIⱖ5%. There were ⬃10 hrs of discontinuous data collected per patient. Both SmO2 and wat/HbT distinguished patients with PEIⱖ5% (p⬍0.0001). Median SmO2 was 63% (IQR:59 – 67%) for PEI⬍5% and 55% (IQR:49 – 60%) for PEIⱖ5%. Median wat/Hb index was 0.067 (IQR:0.048 – 0.094) for PEI⬍5% and 0.138 (IQR:0.103– 0.171) for PEIⱖ5%. Conclusions: In this small study two NIRS indices successfully detected changes prior to defervescence in patients who later exhibited signs of plasma leakage. The increased water to blood ratio and reduction in SmO2 in tissues likely reflect a combination of fluid leakage and vasoconstriction in response to hypovolemia.[ Reference: [1] Zou et al Biomed Opt Exp, 1, 748 (2010)Funded by USARMC, TATRC and NIH.


Introduction: Cardiac output monitoring can be useful in critically ill patients it can be estimated from non-invasive measurement of blood pressure (COnibp) but the ability of this device to track changes in cardiac output in critically ill patients is not well defined. Hypothesis: COnibp can reliably track changes in cardiac output during fluid challenge in the critically ill patient. Methods: We studied 34 patients requiring fluid challenge. COnibp was measured by the Nexfin CO-trek device (BMEYE, Amsterdam, The Netherlands) and with echocardiography (velocity-time integral (VTI) of aortic flow obtained in apical five chambers view) just before and after a fluid challenge (27 (90%) with 500 –1000 mL of crystalloids, 3 (10%) with 300 –500 mL of colloids) over 30 min. We evaluated the ability of COnibp to detect significant changes in VTI (defined as a 10% increase in cardiac output). Results: The primary diagnoses were postsurgery care (39%), sepsis (36%), respiratory failure (24%), hypovolemia (18%) or cardiac failure (15%). Ten patients (30%) were treated with norepinephrine (mean dose 10⫾6 mcg/min) and 4 (12 %) with dobutamine (10⫾5 mcg/kg/ min).The Nexfin CO-trek device failed to calibrate the pulse wave in 4 patients (12%), leaving 30 patients for analysis.COnibp follows the evolution of the VTI (increase, decrease or no change) in 15 (50%) patients in the entire population. COnibp adequately follows the VTI in 13 (68%) of 19 patients with normal lactate levels (⬍2 mEq/L) but in only 2 (18%) of 11 patients with increased lactate levels (p⬍0.01). Conclusions: CO measurements derived from peripheral non-invasive blood pressure techniques can track changes in cardiac output to some extent, but the technique is unreliable in the more severely ill patients.

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ACCURACY OF AUTOMATED OSCILLOMETRIC NON-INVASIVE BLOOD PRESSURE MEASUREMENT IN THE LEGS OF CHILDREN

SOMATIC REGIONAL OXYGEN SATURATION DURING CARDIOPULMONARY BYPASS IS ASSOCIATED WITH BLOOD LACTATE CONCENTRATION AND IS A GOOD INDEX OF SYSTEMIC PERFUSION

Tiong The, Jessica Butrico, Consolacion Solema, St. Peter’s Univ. Hospital Introduction: It is standard practice to take blood pressure measurements on the calf using an automated Oscillometric Blood Pressure machine with the assumption that this reading corresponds with the right arm reading. The scientific basis of this practice is however, controversial. Hypothesis: Calf blood pressure measurement are not comparable to arm blood pressure measurement. Methods: Repeated simultaneous blood pressure measurements at the right arm and calf were taken on healthy children age 3–7 lying horizontally supine in bed using two calibrated automated oscillometric machines. Bland–Altman plots and conversion equations between calf versus arm measurements were obtained using the MethComp R statistical package. Results: 166 pairs of right arm– calf blood pressure measurements were made with up to 7 measurements per child. The mean calf-arm difference in systolic(SBP),diastolic(DBP), and mean(MAP) blood pressures were 9.5, -6.6, -3.6 with a limits of agreement of -15 to 34, -21 to 8, -15 to 8 respectively. Only the SBP showed a significant positive correlation between the calf-arm pressure difference and the average. The conversion equations for arm blood pressures from calf readings are: (1) SBP–arm ⫽ 21.5⫹0.7calf (95% p.i.: ⫹/⫺ 20), (2) DBP–arm ⫽ 8.4⫹0.96 calf (⫹/⫺ 14), and (3) MAP–arm ⫽ 7.3⫹0.94 calf (⫹/⫺ 11). The SBP, DBP, MAP standard deviation of the method x patient effect, the residual standard deviations for the arm versus the calf readings were 5, 5, and 8, and 3, 4, 4 and 2,3,3 respectively. The coefficient of repeatability for the SBP, DBP, and MAP for arm/calf measurements were: 15/22, 15/13, and 10/11 respectively. Conclusions: Calf SBP are higher than arm, while DBP and MAP slightly lower. The rather large range of possible arm readings given a calf reading makes clinical use of calf blood pressure monitoring unacceptable. This discrepancy between the arm versus the calf reading may be largely attributable to the rather poor repeatability of the measurements. Furthermore, trending the calf readings may not reveal the true trend. Clinical judgement as to the true state of tissue perfusion is advised.

Jun Maki, Junko Kaji, Our Lady of the Snow Social Medical Corporation, St. Mary’s Hospital, Reiko Makizono, Our Lady of the Snow Social Medical Corporation, St. Mary’s Hospital, Keisuke Matsumoto, Mariko Tanaka, Yumi Hatano, Our Lady of the Snow Social Medical Corporation, St. Mary’s Hospital, Yoshimitsu Tsutsumi, Our Lady of the Snow Social Medical Corporation, St. Mary’s Hospital Introduction: In pediatric cardiac surgery, regional oxygen saturation (rSO2) by means of near-infrared spectroscopy has been used as a index of cerebral perfusion during Cardiopulmonary bypass (CPB), but the usefulness of somatic rSO2 remains to be elucidated. Although blood lactate concentration is a good index of balance between oxygen supply and demand, the relationship between lactate concentration and somatic rSO2 has not yet been clear. Hypothesis: Somatic rSO2 is associated with blood lactate concentration, and a good index of balance between oxygen supply and demand in somatic organ. Methods: We conducted retrospective analysis of 14 pediatric patients younger than 2 years undergoing cardiac surgery using cardiopulmonary bypass. Patients with cyanotic heart diseases were excluded. We monitored rSO2 of left (S1) and right (S2) forehead, left kidney (S3) and right thigh (S4) continuously by INVOS 5100.® We also performed serial blood gas analysis including blood lactate concentration. Data are shown as the mean ⫾ SEM, and p⬍0.01 was considered to be significantly different. Results: We divided 14 patients in two groups according to maximum lactate concentration after CPB. The mean lactate concentration of 7 patients in “high” and “low lactate group” were 1.9 ⫾ 0.1 and 1.2 ⫾ 0.1 mmol/L (p⬍0.01), respectively. The delta rSO2 (preoperative valueminimum value during CPB) at S4 in patients divided into high lactate group was significantly large compared to patients divided into low lactate group (10.1 ⫾ 3.8 vs 0.0 ⫾ 3.8 %; p⬍0.01). The delta rSO2 at S1, S2 and S3 were larger in high lactate group, however there was no significance. If the patients were divided in 2 groups according to lactate concentration just before operations were finished, delta rSO2 (preoperative control-the value just before operations were finished) were not different between 2 group (p ⫽ 0.75). Conclusions: In patients with high blood lactate concentration after CPB, the delta rSO2 value measured at thigh during CPB were significantly low. Thus, somatic rSO2 during CPB may be a good index of systemic perfusion in pediatric patients undergoing cardiac surgery.

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THE USE OF PEWS TO PREDICT PROVIDER INTERVENTION AND ADVERSE EVENTS DURING AIR TRANSPORT OF CRITICALLY ILL CHILDREN WITH CONGENITAL HEART DISEASE

INCIDENCE OF ABNORMAL TISSUE OXYGEN SATURATION IN CRITICALLY ILL PATIENTS IN THE NETHERLANDS

Michael Wolf, Children’s Healthcare of Atlanta, Eric Hoar, Chidlren’s Healthcare of Atlanta, Manisha Patel, Toni Petrillo-Albarano, Children’s Healthcare of Atlanta, Janet Simsic, Emory University, Children’s Healthcare of Atlanta At Egleston Introduction: Children with congenital heart disease (CHD) are often transferred from referring hospitals to tertiary care centers via air transport for management. Hypothesis: The purpose of this study was to examine (1) medical interventions or adverse events during air transports and (2) utility of PEWS in predicting need for intervention or adverse events during air transport. Methods: Retrospective review from January 2006-August 2008 of all children with CHD air transported to the cardiac intensive care unit. N ⫽ 79. Transport assessment and events during transport were reviewed. Medical interventions were defined as intubation, volume administration, acidosis management, sedation, and need for IV access. Adverse events were intubation/extubation, addition of inotrope, and CPR. Results: Mean age at transport 12 ⫾ 36 months; median 7.5 days (0 days–16 yrs). 54 (68%) were ⬍1 mos. Most common diagnoses were transposition of great arteries (19%); coarctation of aorta (14%); hypoplastic left heart syndrome (7%). Mean initial PEWS score 4.9 ⫾ 2.7; median 5 (0 –9). 36 (46%) PEWS ⬍4 and 43 (54%) PEWS ⱖ5. Medical interventions occurred in 62% of transports. Adverse events occurred in 3 (3.8%). Medical interventions were more frequent in patients with PEWS ⱖ5 vs PEWS ⬍4 (88(90%) vs 10(10%); p ⫽ 0.001); and in intubated vs non-intubated patients (89(91%) vs 8(8%); p ⫽ 0.001). Of 36 patients on PGE, 24 (67%) were intubated. Medical interventions were more frequent in neonates on PGE vs not on PGE (59 (60%) vs 20 (20%); p ⫽ 0.06). Conclusions: Adverse events were uncommon during the air transport of children with CHD. PEWS ⱖ5, intubation, and PGE were predictive of medical interventions by the transport team. PGE infusion does not appear to be a risk for intubation prior to or during transport. Frequent need for medical interventions, especially with PEWS ⱖ5 supports the importance of a pediatric transport team, and the use of PEWS as a triage tool in patients with CHD transported by air.

Annette Veening, Erasmus MC University Medical Center, Steven Sleeswijk Visser, Reinier de Graaf Gasthuis, Alexandre Lima, Jose Calvache, Jan Bakker, Erasmus MC University Medical Center Introduction: Tissue Oxygen Saturation (StO2) measured with Near Infrared Spectroscopy has been associated with severity of disease and morbidity in critically ill patients (1,2). The incidence of an abnormal StO2 in clinically stable ICU patients is unknown. Hypothesis: Investigate the incidence of an abnormal StO2 in hemodynamically stable patients and relate this to morbidity. Methods: StO2 was measured on the thenar eminence (InSpectra™, Model 650, Hutchinson Technology Inc.) in all patients present at the ICU of 12 hospitals (1 University and 11 teaching hospitals) at one day. All patients were hemodynamically stable. Abnormal StO2 was defined as ⬍71% (abnormal low) or ⬎91% (abnormal high). Data are presented as median (IQR) unless otherwise specified. MannWhitney test was used to analyze differences between groups. A p-value ⬍0.05 was statistically significant. Results: 151 patients (66% male) were included with an age of 60 yrs (60 –77). StO2 was 81% (75– 87)(min:36% max:97%) and skewed to the lower values (Kurtosis 2.65; Skewness -1.30). No relationship was found between StO2 and the duration patients were already admitted to the ICU on the study day. Forty-one patients (27%) had an abnormal StO2 (67 (62– 94))of which 26 (63%) had an abnormal low value (65(58 – 67)). Patients with an abnormal StO2 had higher APACHE II and SOFA scores when compared to patients with a normal StO2 (23(17–31) vs 21(15–27), p⬍0.05 and 9(7–10) vs 7(4 –9), p⬍0.01 respectively). Global hemodynamics were similar in both groups although Dobutamine was used more frequently in patients with an abnormal StO2 (17% vs 5%, p⬍0.05). The difference in length of ICU-stay and ICUmortality was not statistically different. Conclusions: Abnormal tissue oxygen saturation is frequently present in hemodynamically stable ICU patients. Patients with an abnormal StO2 have higher severity of disease and increased morbidity than patients with normal StO2.References1. References: 1. Lima A et al. Crit Care. 2009; 13 Suppl 5: S132. Crookes BA et al. J Trauma. 2005 Apr; 58(4): 806 –13.


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COMPARISON OF PULSE PRESSURE VARIATION DERIVED FROM ARTERIAL PRESSURE WAVEFORM AND PULSE OXIMETRY PLETHYSMOGRAPHY IN A CRITICALLY ILL CHILD.

TEE-GUIDED HEMODYNAMIC MANAGEMENT OF A SERIES OF PATIENTS WITH MECHANICAL HEMODYNAMIC SUPPORT

Stephanie Cruz, Miami Children’s Hospital, Wei-Chiang Lin, Florida International University, Andre Raszynski, Balagangadhar Totapally, Miami Children’s Hospital

Nicholas Cavarocchi, Christopher Kang, Hitochi Hirose, Thomas Jefferson University, Harrison Pitcher, Christiana Care Health Services, Harold Hastings, ImaCor Inc

Introduction: Pulse pressure variation (PPV) derived from an arterial pressure waveform (ABP) is known to be a valid indicator of preload status; however, APB is not routinely monitored in all patients. PPV obtained non-invasively from pulse oximetry plethysmography (PLETH) could be useful if shown to be valid and reliable. This study compares PPV data obtained invasively (ABP) and noninvasively (PLETH). Methods: Recordings of ABP and PLETH were obtained from a central monitor through a custom-made data acquisition system. Five minute recordings were made from a critically ill patient during eight clinical scenarios: before and after initiation of inotropic support, increase and decrease in vasoactive medication, and change in sedation level. PPV was calculated as a percent of difference of maximum and minimum pulse pressure to the average of these two obtained during a 10-sec recording. Thirty consecutive PPV values were obtained during each 5 minute period. The data were screened for artifacts. Any value deviating by more than 3 SD from the mean in each 5 minute period was removed from the analysis. Data from all clinical scenarios were analyzed using ANOVA followed by multiple comparison tests. Paired data (ABP and PLETH) from pooled as well as from each clinical scenario were compared using the Bland-Altman method. Results: The mean PPV values varied significantly from others during some of the clinical scenarios. This change was seen in PPV obtained from ABP as well as PLETH. The mean (SD) of pooled (n ⫽ 226) PPV values from ABP and PLETH were 19.5 (7.8) and 19.1 (7.6), respectively. The bias between two methods was 0.45. However, the precision as measured by the SD of mean difference was 7.6. Largest bias (9.7) and lowest precision (13.8) was before and after starting the inotropic medication, respectively. Low bias and high precision were seen during periods of hemodynamic stability. Conclusions: PPV varies under various clinical conditions. PPV can be easily derived non-invasively from PLETH. PPV obtained from PLETH has high accuracy but low precision compared to that obtained from ABP. Further studies using PPV derived from PLETH are needed to establish its role in various clinical conditions.

Introduction: The purpose of this study was to determine the utility of a miniaturized TEE probe (the ImaCor ClariTEE(TM), approx. NG tube size) for managing patients with VAD or VA-ECMO support. TEE has been cited as especially appropriate for hemodynamic management in these patients because it can provide direct visualization of cardiac function and detailed insight into mechanical support performance. Hypothesis: TEE-guided hemodynamic assessment (hTEE) can impact management of patients with mechanical support. Methods: IRB approved retrospective review of 3 patients on mechanical circulatory support. Results: Case 1. A 55 y/o b female presented for evaluation and management of decompensated heart failure. Further decompensation into multiple organ failure resulted in ECMO; hTEE confirmed right atrial (RA) cannula position and LV decompression. hTEE was also used to wean ECMO while assessing RV and LV function. Patient was successfully weaned from ECMO to LVAD without right heart failure. Case 2: A 47 y/o male had redo sternotomy, HeartMateII II LVAD explant, and orthotropic heart transplantation. Postoperatively, he developed vasoparesis requiring escalated Vasopressors despite good cardiac function. At ⬃ 48 hrs, real time hTEE showed decreased RV and LV function despite adequate hemodynamics with myocardial edema, leading to ECMO support. ECMO temporized circulation. Case 3: A 58 y/o female with multiple morbidities was supported with IABP, switched to Abiomed Impella, then VA ECMO. VA ECMO Flow was at 4 – 4.5 l/min; in 6 hrs flow suddenly dropped to 2 l/m. hTEE disclosed RA thrombus partially blocking venous catheter. Rapid decrease of ECMO RPM, followed by slow increase stabilized flow. Thrombus reabsorbed after heparinization. ECMO weaned and removed successfully after 7 days. Conclusions: Although more study is needed, hTEE can impact management of patients on mechanical support and lead to point of care management.


Posters: Cardiovascular–Therapeutics-1 247

248

SHORT-TERM AND LONG-TERM CARDIAC ELECTROPHYSIOLOGICAL EFFECTS IN RATS WITH MYOCARDIAL INFARCTION TREATED WITH MESENCHYMAL STEM CELLS

RISK FACTORS FOR IN-HOSPITAL MORTALITY AFTER PEDIATRIC HEART TRANSPLANTATION

Tong Wang, Shaoxin Zheng, Changqing Zhou, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Jian Chen, Suihua Huang, The Fifth Affiliated Hospital of Sun Yat-sen University, Yinlun Weng, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; Weil Institute of Critical Care Medicine, Hui Huang, Wei Wu, Jingfeng Wang, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University Introduction: Arrhythmia is of concern after mesenchymal stem cells (MSCs) transplantation in repairing infarcted myocardium. However, the short-term and long-term cardiac electrophysiological effects in rats with myocardial infarction treated with MSCs are still unclear. Hypothesis: MSCs transplantation in the myocardial infarction rats would have positive effects on cardiac electrophysiology in the short-term and long-term period. Methods: Myocardial infarction was induced by ligation of the left anterior descending artery in 40 rats. Two weeks later, animals were randomized to receive of 5⫻106 MSCs labeled with PKH26 in phosphate buffer solution (PBS) or PBS alone injection into the infarction zone in the anterior ventricular free wall. Two weeks (short-term) and 12 weeks (longterm) after MSCs or PBS injection, Ventricular fibrillation threshold (VFT) was measured on the infarct area, the infarct marginal zone and the non-infarct zone. Labeled MSCs were observed in 5 ␮m cryostat sections from each harvested heart. Results: In the short-term (4.9 ⫾2.2 vs. 2.3 ⫾0.7, p⬍0.001) and long-term (5.0 ⫾1.5 vs. 3.5⫾1.4) period, MSCs can improve the VFT on the non-infarct zone, however, no improvements were validated on the infarct area (two weeks: 3.1 ⫾0.9 vs. 3.7 ⫾0.9, p ⫽ 0.16; six weeks: 3.9 ⫾1.3 vs. 4.5 ⫾1.7, p ⫽ 0.39) and infarct marginal zone (two weeks: 3.0 ⫾0.9 vs. 3.6 ⫾1.6, p ⫽ 0.32; six weeks: 5.2⫾2.4 vs. 3.5⫾1.2, p ⫽ 0.06). Labeled MSCs were identified in the infarct zone and infarct marginal zone and expressed von Willebrand factor, ␣-smooth muscle actin and ␣-sarcomeric actin. Conclusions: The myocardial infarction rats were treated with allogenic MSCs, VFT can be improved on the non-infarct zone in the short-term and long-term period.

Boban Abraham, Patrick Selakovich, W Morrow, Elizabeth Frazier, Xiomara Garcia, Michiaki Imamura, Adnan Bhutta, Parthak Prodhan, Arkansas Children’S Hospital, University of Arkansas for Medical Sciences Introduction: Long term and 30 day survival data after pediatric orthotopic heart transplantation (POHT) is known. But there is scant literature on immediate post POHT in-hospital mortality. Hypothesis: Specific risk factors can be identified for in-hospital mortality after POHT. Methods: Retrospective analysis of POHT at our institution from 2000 through 2010 was done. Fisher exact test, t test, ANOVA and Chi-square were used for univariate analysis. Step wise logistic regression was used for multivariate analysis and Fine-Gray method was used for competing risk regression analysis. Results: There were 155 patients and162 POHT during the study period. Average age of the cohort was 7 yrs (18 days-37 yrs, 10 patients ⬎21 yrs of age). Infants constituted 32 % and males constituted 59 % of the cohort. Congenital heart disease (CHD) was the pre-transplant diagnosis in 57 %. There were 16 in-hospital deaths (10 %). The cause of death was primary graft failure without rejection in 3 patients, acute rejection in 1, infection in 7, cerebrovascular event in 2 and multifactorial in 3 patients. By univariate analysis, in-hospital mortality was associated with pre-transplant diagnosis of CHD (84 % among died vs 53 % among survived, p ⫽ 0.012), need for dialysis in the first post operative week (41 % vs 8 %, p ⫽ 0.001), positive donor specific cross match (38 % vs 13 %, p ⫽ 0.003), duration of mechanical ventilation (34 days ⫾ 10 vs 9 ⫾ 1.5, p ⫽ 0.001) and duration of intensive care stay (50 days ⫾ 10 vs 20 ⫾ 3, p ⫽ 0.001). On multivariate analysis, the need for postoperative dialysis was a significant risk factor (odd ratio 7.1, CI 1.3- 40, p ⫽ 0.03, area under the ROC-0.79, p value for the goodness of fit-0.18). The competing risk regression analysis confirmed that the hazard for in-hospital mortality was significantly increased for patients with postoperative dialysis (p ⫽ 0.008). Conclusions: In conclusion, dialysis in the first postoperative week is a significant risk factor for in-hospital death. Evaluation of 30 day mortality after POHT would underestimate the immediate postoperative mortality as the mean duration of ICU stay for those who died in our cohort was 50 days.

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PROPHYLACTIC PERITONEAL DIALYSIS IMPROVES CLINICAL OUTCOMES IN CHILDREN FOLLOWING OPEN-HEART SURGERY WITH CARDIOPULMONARY BYPASS

NEUROHORMONAL BLOCKADE DRUG THERAPY PROMOTES REVERSE CARDIAC REMODELING AND SURVIVAL IN PATIENTS WITH AXIAL-FLOW LEFT VENTRICULAR ASSIST DEVICE

William Sasser, Santiago Borasino, Ashley Moellinger, Krissie Hock, Robert Dabal, James Kirklin, Jeffrey Alten, University of Alabama at Birmingham Introduction: The purpose of this study is to investigate the impact of prophylactic peritoneal dialysis (PD) on clinical outcomes after open-heart surgery in children with complex congenital heart disease. Hypothesis: When compared to passive peritoneal drainage and diuretic therapy, prophylactic PD will lead to improved clinical outcomes including duration of mechanical ventilation (primary endpoint). Methods: 46 consecutive children considered high risk for postcardiopulmonary bypass fluid overload were enrolled in this prospective observational study. Patients received either diuretic therapy and passive peritoneal drainage (PD-) (before Jan 2011) or prophylactic PD without diuretics (PD⫹) (after Jan 2011). Prophylactic PD was initiated in the first 6 hrs of admission as part of a new CICU protocol. Fluid balance, hemodynamic, and clinical outcome data were prospectively collected. Results: In the first 24 hrs of CICU admission, PD⫹ had 160% less positive fluid balance than PD- [-24.2 mL/kg (IQR -66.6,12.2) vs. 37.5 mL/kg (IQR -11.2,78.6) p ⫽ .001, respectively]. At 48 hrs, net fluid balance was -86 mL/kg (IQR -47, -119.8) PD⫹ vs. -30.8 mL/kg (IQR -62.1,6.8) PD-, p ⫽ .01. Urine output was identical for the first 24 hrs (PD⫹ 45.2 mL/kg/day ⫾ 19.9 vs. PD- 45.2 mL/kg/day ⫾ 30.6, p ⫽ 1). Incidence of acute kidney injury, as measured by doubling of baseline serum creatinine, was 33% PD⫹ vs. 26% PD- (p ⫽ .65). PD⫹ had shorter time to chest closure [24 hrs (IQR 19,39) vs. 63 hrs (IQR 44,72) p ⫽ ⬍.0001]. Duration of mechanical ventilation in PD⫹ was non-significantly shorter [93 hrs (IQR 62,149) vs. 131 hrs (IQR 70,208) p ⫽ .5]. PD⫹ demonstrated a trend towards lower inotrope scores at 24 hrs (12 ⫾ 6 vs. 14 ⫾ 6, p ⫽ .18) and 48 hrs (9 ⫾ 5 vs. 11 ⫾ 8, p ⫽ .37). Peak lactate and length of CICU stay did not differ between groups. The incidence of hyperglycemia was similar between groups (47% PD⫹ vs. 44% PD-, p ⫽ .86). There were no episodes of peritonitis. Conclusions: Prophylactic PD significantly improves fluid balance in children following CPB, safely facilitating improved outcomes such as earlier chest closure. Prophylactic PD may not be associated with shorter duration of mechanical ventilation.

Yanjun Zhao, Yan Topilsky, Simon Maltais, Tal Hasin, Lyle Joyce, Soon Park, Tomoko Ichiki, John Burnett, John Schirger, Mayo Clinic Introduction: Neurohormonal blockade drug therapy (NHBDT) is the cornerstone therapy in heart failure (HF) management for promoting reverse cardiac remodeling and improving clinical outcomes. Its utility in LVAD supported patients remains undefined. Hypothesis: Optimizing medical management with NHBDT targeting cardiac fibrosis after ventricular unloading with LVADs may further reverse cardiac remodeling and improve clinical outcomes. Methods: Sixty-four patients who received continuous axial-flow LVADs from January 2007 through June 2010 at our institution were retrospectively reviewed and divided into two groups. Patients in the no-NHBDT group (n ⫽ 33) received LVAD support only. Patients in the NHBDT group (n ⫽ 31) received concurrent NHBDT. Cardiac remodeling (echocardiographic parameters and biochemical markers) and clinical outcome (functional status, HF related hospital readmissions, and mortality) data were collected. Results: A statistically significant increase in ejection fraction (p ⫽ 0.025), decrease in left ventricular end diastolic diameter index (p ⫽ 0.017) and left ventricular mass index (p ⫽ 0.031), and a sustained reduction in N-terminal pro B-type natriuretic peptide (NT-proBNP) (p ⫽ 0.011) were observed in the NHBDT group at month 6 post-implant. NHBDT treated patients experienced significantly greater improvement in New York Heart Association functional classification and 6-minute-walk distance throughout the study. The combined end point of cardiovascular death or hospitalization for HF was significantly reduced among patients receiving NHBDT (p ⫽ 0.013) with the predominant benefit being a 12.1% absolute reduction in HF related hospitalizations (p ⫽ 0.046). Conclusions: NHBDT in LVAD supported patients correlated with a significant reversal in adverse cardiac remodeling and a significant reduction in morbidity and mortality versus LVAD support alone.


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PARACRINE EFFECTS OF MESENCHYMAL STEM CELLS ENHANCED SYMPATHETIC REMODELING AFTER MYOCARDIAL INFARCTION IN RATS

HYPERKALEMIA IN PATIENTS RECEIVING POTASSIUM REPLACEMENT DURING THERAPEUTIC HYPOTHERMIA

Tong Wang, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Jian Chen, The Fifth Affiliated Hospital of Sun Yat-sen University, Shaoxin Zheng, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Suihua Huang, The Fifth Affiliated Hospital of Sun Yat-sen University, Changqing Zhou, Zhuzhi Wen, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Yinlun Weng, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; Weil Institute of Critical Care Medicine, Hui Huang, Wei Wu, Jingfeng Wang, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University

Introduction: Therapeutic hypothermia is associated with shifts of extracellular potassium into intracellular spaces, but limited human data is available to describe the rates of hyperkalemia during the re-warming phase after hypothermia hypokalemia replacement. Hypothesis: Aggressive replacement of potassium and impaired renal function during the cooling period will lead to increased rates of hyperkalemia during the re-warming period. Methods: This was a retrospective study enrolling 80 consecutive patients who received therapeutic hypothermia following cardiac arrest betweem January 1, 2004 and August 20, 2010. Serum potassium levels, replacement doses, and renal fucntion were collected for the 72 hour time period of our hypothermia protocol. Patients were stratified into groups based on potassium received during the cooling period, potassium level at replacement, and renal function. Results: Hypokalemia (⬍3.6 mEq/L) occurred frequently during the cooling period, with 75% of patients receiving replacement, and approximately 84% of all replacement doses given during cooling. The overal rate of hyperkalemia (⬎5.4 mEq/L) was 40%, with 16.3% of patients receiving treatment for reversal. Potential risk factors identified for hyperkalemia included creatinine clearance less than 60 mL/min (55.1% vs. 4%, p⬍0.001), and initiation of replacement for levels ⬍3 mEq/L compared to between 3 and 3.6 mEq/L (60% vs. 27.9%, p ⫽ 0.026). Patients with hyperkalemia who received ⬎50 mEq of replacement had a significantly lower creatinine clearance than patients with no hyperkalema at the same replacement doses (p⬍0.05). Conclusions: Hypokalemia was identified as a common occurrence during therapeutic hypothermia, and may increase the risk for ventricular arrhythmias. Potassium replacement is frequently required, but several factors may increase the risk for hyperkalemia. These factors can be used to help guide replacement therapy, and may decrease rates of hyperkalemia.

Introduction: Mesenchymal Stem Cells (MSCs) transplantation impacts on the electrophysiological characteristics of the rats with myocardial infarction (MI). However, whether MSCs transplantation enhances secreting of nerve growth factor (NGF) and sympathetic remodeling in infarct marginal zone and the underlying mechanisms are still unclear. Hypothesis: NGF secretion increasing in the coexistence of cardiomyocytes and MSCs would be associated with sympathetic remodeling after MI treated with MSCs, which may affect the electrophysiological properties. Methods: MI was induced in 20 male Sprague-Dawley rats. Two weeks later, animals were randomized to receive 1⫻107 MSCs or phosphate buffer solution (PBS) alone as a placebo injection into the infarcted anterior ventricular free wall. Four weeks after the MSCs or PBS injection, NGF, growth associated protein-43 (GAP-43) and tyrosine hydroxylase (TH) in infarct marginal zone were measured. Density of TH positive nerve fibers was calculated. On the other hand, NGF levels (pg/ml) in the different culture systems with neonatal rat ventricular myocytes (NRVMs, 1⫻105/ml L-DMEM) and MSCs (1⫻105/ml L-DMEM) were determined. Results: The expression of mRNA of NGF (2.472 ⫾0.926 vs. 1⫾0.809, p⬍0.001), GAP-43 (2.060⫾0.471 vs. 1⫾0.337, p⬍0.001) and TH (1.699⫾0.749 vs. 1⫾0.524) and protein level of NGF (0.265⫾0.076 vs. 0.143⫾0.055, p⬍0.001), GAP-43 (0.192⫾0.093 vs. 0.122⫾0.031, p ⫽ 0.045) significantly increased in MSCs group compared with PBS group. The two groups had similar densities of TH positive nerves (␮m2/mm2, 3197.346⫾3120.549 vs. 1900.178⫾1479.653, p ⫽ 0.25). Mono-cultured NRVMs secrete more NGF, as compared with mono-cultured MSCs (50.41⫾5.29 vs. 5.25⫾3.27, p⬍0.01). MSCs-conditioned medium (CM) (102.31⫾10.30 vs. 37.88⫾6.65, p⬍0.01) and NRVMs-CM (26.50⫾5.42 vs. 9.91⫾2.33, p⬍0.01) enhance NRVMs and BMSCs to secrete NGF. The effect of NRVMs promoted by MSCs-CM is higher than MSCs promoted by NRVMs-CM (102.31⫾10.30 vs. 26.50⫾5.42, p⬍0.01). Conclusions: NGF secretion of cardiomyocytes significantly enhanced by paracrine factors in MSCs-CM, may promote sympathetic remodeling and affect the electrophysiological properties after MI treated with MSCs.

Kevin Donahue, David Putney, Craig Pratt, The Methodist Hospital

253 MULTISITE VENTRICULAR PACING IN POSTOPERATIVE SINGLE VENTRICLE PATIENTS Vinod Havalad, Linda Aponte-Patel, Santos Cabreriza, Alexandra Murata, Alice Wang, Emile Bacha, Henry Spotnitz, Morgan Stanley Children’s Hospital-Columbia University Medical Center Introduction: Biventricular pacing benefits individuals with heart failure by increasing stroke volume and cardiac output through a mechanism of reversal of ventricular dyssynchrony. Ventricular dysfunction has been correlated with patient morbidity and mortality following single ventricle (SV) palliation. Temporary multisite ventricular pacing (MSVP) may improve hemodynamics in these children. Our objective is to determine the efficacy of MSVP after RV– dominant single ventricle palliation. Hypothesis: Optimized MSVP increases postoperative mean arterial pressure (MAP) with no increase in inotropes, afterload reduction, or volume infusion. Methods: This is a clinical trial of MSVP in the first 24 hours after open-heart surgery for SV palliation. The study was approved by the Columbia University Institutional Review Board. Two unipolar pacing leads were placed on the right atrium and four bipolar pacing leads were placed on the SV during surgery. Pacing was optimized using a protocol which tests: 1) 11 different combinations of the four pacing sites, 2) 6 atrioventricular delays (50 to 150 msec) and 3) 14 intraventricular delays (⫹60 to -60 msec) in a random sequence. In a final comparison, MAP is then measured during: 1) the optimized pacing protocol, 2) the patient’s intrinsic rhythm and 3) single-site ventricular pacing, in random order. Statistical differences were determined by repeated measures ANOVA. Results: To date, 6 patients were studied. MSVP did not result in a change in MAP when compared with the non-paced intrinsic state. However, 2 out of 6 patients had an increase in MAP of ⬎5% with pacing, deemed possibly clinically important. Conclusions: Though there was no change observed when the group was taken as a whole, individual children did show a response to pacing. A larger study is necessary to determine which factors may predict a positive response to MSVP. These results demonstrate feasibility of an optimization protocol performed at the bedside and provide preliminary data for further clinical trials utilizing MSVP to improve the care of children after single ventricle palliation.* Supported by NIH R01 Grant 5R01HL80152–2 and Columbia University Dept of Surgery Startup Grant.


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PREOPERATIVE STATINS DO NOT REDUCE THE INFLAMMATORY RESPONSE AFTER CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS

INTRAVENOUS LABETALOL COMPARED TO INTRAVENOUS NICARDIPINE IN THE MANAGEMENT OF HYPERTENSION IN CRITICALLY ILL PATIENTS

Isabelle De Loecker, Cristina Santonocito, Katia Donadello, Mouhamed Moussa, Jean-Louis Vincent, Erasme University Hospital

Mark Malesker, Creighton University Medical Center, Daniel Hilleman, Creighton University

Introduction: Statins which lower cholesterol levels by inhibiting HMG CoA reductase, also have anti-inflammatory and immunomodulatory effects. Cardiopulmonary bypass (CPB) induces a significant inflammatory process. C-reactive protein (CRP) is the commonly inflammatory marker measured. Hypothesis: Patients preoperatively treated with statins (group 1) have lower inflammatory response (as reflected by CRP levels) than the other patients (group 2) after cardiac surgery with CPB. Methods: Over a 4 months period (May-August 2011), we prospectively studied all postoperative patients who underwent CPB for (elective or emergency) cardiac surgery; APACHE II score on admission, SOFA score, biological and microbiological data were collected daily. CRP and leucocytes values were recorded up to one week after the intervention, during hospital stay. Results: We included 45 patients (age 65⫾14 years, APACHE II 10⫾4, SOFA 4⫾2) of which 24 (53%) were treated with statins. There were 3 postoperative infections (12%) in group 1 and 5 (24%) in group 2 (p ⫽ 0.443). CRP values, which were at admission 1.1 ⫾ 1.7 mg/dl in group1 and 0.9 ⫾ 1.4 mg/dl in group 2 (p ⫽ 0.229), rose on day 1, to 6.7 ⫾ 2.8 mg/dl in group 1 and 7.1 ⫾ 3.7 mg/dl in group 2 (p⬍0.001 compared to admission; p ⫽ 0.128 between groups). Peak value, observed at day 3, was 10.9 ⫾ 6 mg/dl vs.11.7 ⫾ 7.8 mg/dl, for group 1 and group 2, respectively (p ⫽ 0.637). Thereafter, CRP levels decreased progressively in both groups until day 7 (6.5 ⫾ 5.3 mg/dl vs. 8.3 ⫾ 6.3 mg/dl, for group 1 and group 2, respectively; p ⫽ 0.970). Excluding infected patients did not influence the results. Conclusions: The inflammatory response to CPB (as reflected by CRP levels) does not seem to be influenced by preoperative treatment with statins.

Introduction: Critically ill patients with hypertension often require titratable rapid blood pressure (BP) reductions utilizing parenteral administration of medications. There are few comparative studies available to make informed drug product selection decisions. Hypothesis: To determine the short-term clinical outcomes and costs of patients receiving intraventous labetalol or intravenous nicardipine in the management of hypertension in acutely ill patients. Methods: Consecutive patients receiving labetalol or nicardipine in the intensive care unit (ICU) with acute elevations in either systolic (⬎160 mmHg) or diastolic (⬎90 mmHg) BP were included in this analysis. Patient demographic and clinical characteristics were abstracted from the medical record. Hospital costs were derived from hospital billing forms. Results: 189 labetalol patients and 193 nicardipine patients were included in the analysis. The average hourly dose was 13.7 ⫾ 6.2 mg/hr for labetalol compared to 7.1 ⫾ 5.6 mg/hr for nicardipine. The duration of therapy was significantly shorter for labetalol (8.2 ⫾ 6.2 hrs) compared to nicardipine (15.8 ⫾ 4.4 hrs) (p ⫽ 0.03). The proportion of patients achieving their BP targets was significantly greater with nicardipine (83%) than with labetalol (67%) (p ⫽ 0.04). The proportion of patients requiring an alternate antihypertensive agent was significantly greater with labetalol than with nicardipine (31% vs 17%; p ⫽ 0.02). The total number of all-cause adverse events was significantly greater with labetalol (61%) than with nicardipine (48%) (p ⫽ 0.04). Labetalol was associated with a significantly greater incidence of hypotension, bradycardia, and AV block compared to nicardipine.. Median hospital costs were not significantly different between patients receiving labetalol or nicardipine. Conclusions: This data suggests that nicardipine is a more effective antihypertensive agent than labetalol in an unselected group of patients who develop hypertension in the ICU setting. A major advantage of nicardipine compared to labetalol was fewer adverse effects.


Posters: Cardiovascular–Therapeutics-2 256

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VASOACTIVE MEDICATIONS ARE ASSOCIATED WITH INCREASED IN-HOSPITAL MORTALITY IN CHILDREN WITH CARDIOMYOPATHY AND HEART FAILURE

DEGREE OF EXPOSURE TO VASOPRESSORS IS ASSOCIATED WITH POOR OUTCOME IN PATIENTS WITH SHOCK

Pirouz Shamszad, Baylor College of Medicine, Joseph Rossano, University of Pennsylvania, Daniel Graves, Baylor College of Medicine, Brady Moffett, Texas Children’s Hospital, Susan Denfield, Daniel Penny, Antonio Cabrera, Baylor College of Medicine Introduction: Vasoactive medications (VM) are commonly used in children with cardiomyopathy and decompensated heart failure. Few data exist on the safety of these medications in children with heart failure. Hypothesis: The use of VM in pediatric patients with cardiomyopathy and decompensated heart failure will be associated with increased mortality compared to those not treated with VM. Methods: A retrospective review using the Pediatric Health Information System database identified children 18 years or younger with cardiomyopathy and heart failure related intensive care unit (ICU) admission between 2005 and 2010. Factors associated with the use of VM were entered into a multivariable logistic regression model to calculate propensity score-adjusted odd ratios for in-hospital mortality. Results: There were 2932 ICU admissions accounted by 2418 patients from 41 U.S. tertiary children’s hospitals (52.8% male, median age 4.6 [IQR 0.6 –14.1] years). VM were used in 87.9% of admissions with 79.3% of admissions receiving more than one VM. Milrinone was the most commonly used agent (80.3%), followed by epinephrine (51.8%), dopamine (47.9%), and dobutamine (25.6%). Mechanical ventilation (OR 3.5 95% CI 2.8 – 4.4), sepsis (3.3, 2.2– 5.2), renal failure (3.8, 2.2– 6.4), and pulmonary hypertension (2.4, 1.5–3.6) were significantly associated with the use of VM. Propensity score matching yielded a total of 712 admissions split into two equal groups. After adjusting for possible confounders of mortality, VM were significantly associated with increased mortality (6.8% vs. 3.3%, p ⫽ 0.028), length of stay (LOS) (12 vs. 8 days, p⬍0.001), ICULOS (6 vs. 3 days, p⬍0.001), and hospital charges ($90,874 vs. $58,064, p⬍0.001). No single VM conferred a survival benefit. Mechanical circulatory support (9.3, 1.9 – 44.3), renal failure (5.9, 2.2–16.5), respiratory failure (4.1, 1.6 –10.4), and VM (OR 2.2, 95% CI 1.1– 4.6) were independently associated with mortality. Conclusions: VM are commonly used in children with cardiomyopathy admitted to the ICU with decompsenated heart failure and are associated with decreased survival and increased morbidity.

Daniel De Backer, Erasme University Hospital, Patrick Biston, Chu Charleroi, Jacques Devriendt, Brugmann University Hospital, Christian Madl, Medical University of Vienna, Didier Chochrad, Hospital Ixelles, Cesar Aldecoa, Rio hortega University Hospital, Jean-Louis Vincent, Erasme University Hospital Introduction: Adrenergic agents are needed to correct hypotension in shock states, but these agents have unwanted effects that may affect outcomes. Hypothesis: Exposure to vasopressor agents may be associated with poor outcome. Methods: This is a secondary analysis of a prospective, randomized study that included 1679 patients with shock who received dopamine or norepinephrine as the initial vasopressor agent (NEJM 362:779 –789;2010). The cumulative doses of vasopressor (dopamine, norepinephrine or epinephrine) and inotropic (dobutamine) agents for the first 24h after randomization were recorded (computed for each agent as sum of each dose x time spent at that dose). We also computed the area under the curve of mean arterial pressure (MAP) less than 65 mmHg (as time spent with MAP less than 65 x (MAP-65)) and between 65 and 75 mmHg (as the difference between AUC less than 75 and AUC less than 65). We determined which factors were associated with an increased risk of death at day 28 by univariable analysis and multivariable logistic regression. Odds ratios of 28-day survival and 95% confidence intervals are presented. Results: Multivariable analysis identified total exposure to vasopressors (dopamine OR 1.001 [1.000 –1.002], P ⫽ 0.01 and norepinephrine OR 1.045 [1.015–1.076], P ⫽ 0.003), but not inotropic load (dobutamine OR 1.001 [1.000 –1.003], P ⫽ 0.12), as factors independently associated with increased 28-day mortality rate. The AUC of MAP less than 65 mmHg was also associated with higher mortality rates (OR 1.006 [1.003–1.010], P⬍0.001), whereas the AUC of MAP between 65 and 75 mmHg appeared to be protective (OR 0.998 [0.996 –1.000], P ⫽ 0.056). Conclusions: Degree of exposure to vasopressor, but not inotropic, agents is associated with poor outcome. However, limiting doses is not a straightforward solution as a MAP less than 65 mmHg seems to be associated with increased mortality rates.

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A PROTOCOL OF BOLUS-DOSE NITROGLYCERIN AND NON-INVASIVE VENTILATION TO AVERT INTUBATION IN EMERGENCY DEPARTMENT ACUTE PULMONARY EDEMA

ANTIMICROBIAL PROPHYLAXIS AND INFECTION FOLLOWING TOTAL ARTIFICIAL HEART IMPLANTATION

Piyush Mallick, Surjya Upadhyay, TS Senthilnathan, El Matit Waleed, Al Jahra Hospital, Scott Weingart, Mount Sinai School of Medicine Introduction: Severe acute pulmonary edema is a common presentation in adult emergency departments (ED). Patients suffering from this condition often need emergent intubation with the consequent morbidity of mechanical ventilation and intensive care. There is a scarcity of research on the immediate management of the sickest cohort of acute pulmonary edema patients. Hypothesis: We hypothesized that a treatment protocol using and vasodilators and non-invasive ventilation could be used to avert intubation in these patients. Methods: This was a prospective cohort study of patients with sympathetic-surge crashing acute pulmonary edema patients in whom the ED called the anesthesia service for emergent intubation. Rather than immediately perform intubation, the anesthesia service placed these patients on non-invasive positive pressure ventilation (NPPV) and then administered repeated boluses of nitroglycerin. The primary outcome was the need for intubation. Secondary outcomes included improvement in respiratory parameters (SpO2 and respiratory rate), hemodynamic stability, and the need for diuretics. Results: 41 patients were consecutively enrolled. All patients received NPPV, with initial settings of IPAP 14/EPAP 8. The mean number of nitroglycerin boluses required was 4, which corresponded to a mean dose of 1588 mcg (range 800 –28,000 mcg). None (0%) of the patients required intubation (95% CI 0 –7.3%). Patients had marked improvements in their respiratory parameters. Two patients had transitory dips in SBp⬍100, which resolved spontaneously; both of these patients received additional nitroglycerin boluses. No patients required additional drugs or fluids for hypotension. Conclusions: In this small, single center cohort study of hypertensive crashing acute pulmonary edema patients who were initially deemed to require immediate invasive airway management, intubation was avoided using a protocol combining NPPV and boluses of the vasodilator nitroglycerin. Adverse events were not seen with this protocol.


Kristen Bunnell, Rhode Island Hospital, Stacy Voils, Kimberly Lee, Virginia Commonwealth University Health System Introduction: Mechanical assist devices, including the total artificial heart (TAH), are an important treatment modality in the management of end-stage heart failure. Prevention of device-related infection may decrease mortality and improve the risk-to-benefit ratio of artificial support. The optimal use of antimicrobial prophylaxis for device implantation, including selection of agents and duration of therapy, is not clear based upon currently available literature. Hypothesis: It was expected that there would be a high degree of heterogeneity in antimicrobial prophylaxis regimens for TAH implantation at a single urban academic medical center. Methods: This retrospective review included patients who have received a TAH as bridge to transplantation at Virginia Commonwealth University Health System. Patient demographic information, duration of TAH support, antimicrobials prescribed within 48 hours of implantation, and infections contracted during TAH support were extracted from medical records. Results: 45 patients who received a TAH from April 2006 through April 2011 were included. The population was primarily males (91%) with a nonischemic cardiomyopathy (82%). The most commonly prescribed prophylactic regimen, comprising 60% of TAH patients, consisted of vancomycin, piperacillin-tazobactam, and fluconazole. A temporal relationship was noted, such that 41.6% of patients implanted before 2009 and 87.8% of patients implanted post-2009 received fluconazole. The median total duration of prophylaxis was 5 days (IQR 4 –7) and the median duration following sternal closure was 4 days (IQR 2.5–5.5). Among the entire cohort there were 10.9 infections per 1000 TAH days. Device-related infections, including pocket infections and pump endocarditis, presented at a rate of 0.99 infections per 1000 TAH days. Conclusions: A five-day prophylactic course of vancomycin, piperacillin-tazobactam, and fluconazole for TAH implantation was associated with a similar rate of overall infection as has been previously reported among TAH recipients. There was a narrow interquartile range in the duration of prophylaxis and minimal deviation at a single center from combination therapy with broad-spectrum antimicrobials and azoles.

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THE POSSIBLE USE OF INITIAL SERUM B-TYPE NATRIURETIC PEPTIDE (BNP) LEVELS FOR OPTIMAL INITIAL DOSE ADJUSTMENT OF CARPERITIDE (RECOMBINANT HUMAN ATRIAL NATRIURETIC PEPTIDE)

EVALUATING OPTIMAL VASOPRESSOR USE IN NEUROGENIC SHOCK

Mika Iwano, Hyogo College of Medicine, Joji Kotani, Hyogo College of Medicine, Department of Emergency & Critical Care Medicine, Takahiro Ueda, Atsunori Hashimoto, Takaaki Osako, Yuka Nakajima, Taihei Yamada, Hyogo College of Medicine Introduction: In Japan, Carperitide has been on the market since 1995 and applied clinically for the management of acute heart failure syndrome for its unique and to-be-known pharmacological actions. Since it is a relatively new drug, mainly used within Japan and not many RCT results are currently available, its optimal initial dosage has not been investigated and universal dosing algorithms do not exist yet. Hypothesis: Serum BNP levels are one of the reliable factors for optimal initial dose adjustment of Carperitide.(recombinant Human Atrial Natriuretic Peptide). Methods: From April, 2004 to March, 2005, Carperitide was infused continuously with the initial rate of administration of 0.025␮g/ kg/min to total 26 eligible patients(12 male and 14 female, average age, 68) with non-ischemic acute heart failure who presented with dyspnea and required oxygen on admission. The rate of administration was adjusted within 24 hours until the urine volume reached to 1 ml/kg/ml, when the rate was determined as optimal dose of Carperitide. Results: We investigated the correlation between and the maintenance dose of Carperitide and the serum BNP levels on admission as a possible indicator of the appropriate initial dose of the drug. Retrospectively, in the group of patients who received 0.05 ␮g/?/min to achieve the arranged goal of the urine volume, the number of the patients with the initial serum BNP level of over 1000 pg/ml was significantly large. (p⬍0.0001). Conclusions: Serum BNP levels are one of the reliable factors for optimal initial dose adjustment of Carperitide.(recombinant Human Atrial Natriuretic Peptide) Patients with serum BNP levels of over 1000pg/ml should receive Carperitide with the rate of administration of 0.05␮g/kg/ml from the beginning and 0.025␮g/kg/min is acceptable for patients with BNP level of less than 1000pg/ml. In our study, Ejection Fraction did not negatively correlate with the serum BNP levels on admission. Combined with age and serum BNP levels, however, it is considered to be possible to propose an algorithm to decide on the optimal initial dose of Carperitide.

April Miller, South Carolina College of Pharmacy-USC Campus, Maryjoy Lepak, South Carolina College of Pharmacy-USC Campus, Kimberly Clark, Greenville Hospital System Introduction: Hemodynamic management in patients with acute spinal cord injury (SCI) and neurogenic shock can improve outcomes. The unique physiologic aspects of neurogenic shock make optimal vasopressor use difficult, and there are little data to support the use of a specific agent. The purpose of this study is to determine if specific vasopressors are more effective at maintaining blood pressure in patients with neurogenic shock. Hypothesis: Outcomes with phenylephrine (PE) and dopamine (DA) are similar with a greater incidence of tachycardia in patients receiving DA. Methods: A multicenter, retrospective cohort study of adult patients with cervical or thoracic SCI and neurogenic shock between 2003 and 2010 was conducted. Patients were identified via billing records and those receiving DA or PE were included. Data on dosage, dose changes, duration of therapy, mean arterial pressure (MAP), and heart rate were collected. Outcomes based on the American Spinal Injury Association (ASIA) scale were compared between agents. Continuous data were compared using the student’s t-test. Results: Mean dose of PE was 0.83 mcg/kg/min (range 0.06 –3.37) (n ⫽ 8). Mean dose of DA was 4.9 mcg/kg/min (range 1–15) (n ⫽ 11). Seven patients received combination therapy. Average number of dose adjustments per hour was similar, with 0.47 per hour with PE and 0.28 per hour with DA (p ⫽ 0.16). Average duration of therapy for PE was 44 hours vs 53 hours for DA (p ⫽ 0.59). Average MAP for PE was 80 mmHg (51–125 mmHg) versus 78 mmHg (47–120 mmHg) for DA (p ⫽ 0.56). There were a similar percentage of systolic blood pressure readings ⬎90 mmHg (82% of PE vs 79% of DA). There were 50 episodes of tachycardia (HR⬎100) patients receiving PE relative to 20 episodes in patients receiving DA. There were no differences in outcome among patients with recorded ASIA scores. ASIA score A was observed in 2 PE, 2 DA, and 2 combo patients, ASIA score B was observed in 1 PE, 1 DA patient, and 2 combo patients, and ASIA score D was observed in 1 PE and 2 combo patients. Conclusions: Phenylephrine was associated with more tachycardia than DA, but maintained similar MAP in patients with neurogenic shock. In this small study, ASIA outcomes appear similar between groups.

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EFFECT OF SODIUM NITROPRUSSIDE ON THE OCCURRENCE OF ATRIAL FIBRILLATION AFTER CARDIOTHORACIC SURGERY

ARRHYTHMIA FOLLOWING CARDIAC SURGERY IN CHILDREN

Scott Bolesta, Fanhui Kong, Wilkes University, Timothy Aungst, St. Luke’s Hospital and Health Network Introduction: Post-operative atrial fibrillation (POAF) is a frequent complication following cardiothoracic surgery and is associated with an increase in morbidity, mortality and cost. One small prospective study of patients undergoing isolated coronary artery bypass graft surgery has demonstrated a decrease in the risk of POAF with the use of sodium nitroprusside. Hypothesis: Utilization of sodium nitroprusside during cardiothoracic surgery is associated with a decrease in POAF. Methods: All patients 18 years of age or older who underwent any cardiac surgery between April 2007 and July 2010 at Regional Hospital of Scranton were included in this retrospective cohort study. Patients with a history of atrial fibrillation, those who had undergone prior cardiothoracic surgery, or those undergoing surgical treatment for atrial fibrillation were excluded. Utilization of intraoperative sodium nitroprusside was obtained from the pharmacy department’s billing database. Multivariable logistic regression was used to determine the association of intraoperative sodium nitroprusside with POAF. A propensity score-matched analysis was also performed to adjust for potential selection bias of receiving intraoperative sodium nitroprusside. Results: The final analysis included 699 patients; 473 in the sodium nitroprusside group and 226 in the control group. More patients in the sodium nitroprusside group had a history of heart failure and were placed on cardiopulmonary bypass during surgery. Patients in the control group had more mitral valve disease and intraaortic balloon pump utilization, and longer perfusion and cross-clamp times. The incidence of POAF was 25.4% in the sodium nitroprusside group and 27.9% in the control group. Univariate analysis demonstrated no association of sodium nitroprusside with POAF (OR 0.880; 95% CI 0.615–1.257). Multivariable analysis also showed no difference in the odds of POAF with sodium nitroprusside (OR 0.903; 95% CI 0.597–1.366). Repeating the analysis in 276 propensity score-matched patients also failed to demonstrate any association (OR 0.754; 95% CI 0.431–1.318). Conclusions: Utilization of sodium nitroprusside during cardiothoracic surgery is not associated with a decrease in POAF.

Noriko Ishii, Okayama University Hospital, Yuichiro Toda, Dept of Anesthesiology and intensive care Okayama University Medical School, Tatsuo Iwasaki, Kazuyoshi Shimizu, Tomoyuki Kanazawa, Kentaro Sugimoto, Hirokazu Kawase, Kiyoshi Morita, Okayama University Hospital Introduction: Postoperative arrhythmias are a known complication of cardiac surgery. However, little is known about the arrhythmias in children with congenital heart disease. The aims of this study were to investigate incidence of arrhythmia (supraventricular tachycardia, ventricular tachycardia, flutter, fibrillation, premature contraction, atrioventricular conduction disturbance) and related factors of this complication in children following cardiac surgery. Methods: A retrospective cohort study using the prospectively collected electronic database. Children younger than 20 years old admitted to cardiac care unit (CCU) during 2009 were included. Then patients were categorized into group with arrhythmia (A) and without (N). Results: Our data identified 267 children younger than 20 years old. There were 28 children (10.5 %) with arrhythmia during their stay in CCU. Contributing factors were CPB time (A vs N, 128 vs 94 minutes, p ⫽ 0.0003), Cross clump time (78 vs 59 minutes, p ⫽ 0.0142), PIM2(-3.353 vs -4.106 p ⫽ 0.002), preadmission inotropic supports (p ⫽ 0.0413), Fontan operation (p ⫽ 0.0037), epinephrine administration(p ⫽ 0.0017), dopamine(p ⫽ 0.0288), olprinone(p ⫽ 0.044). And Children with arrhythmia more frequently received amiodarone(p ⫽ 0.0039) or magnesium(p⬍0.0001). Children with arrhythmia had higher incidence of reintubation and peritoneal dialysis, higher frequency in use of postoperative steroids, nitric oxide. Moreover, children with arrhythmia received longer duration of mechanical ventilation and stayed longer in CCU compared with children without arrhythmia. Conclusions: 10.5% of children under 20 years of age following cardiac surgery had arrhythmia during intensive care unit stay. Various factors contributed the incidence of arrhythmia. It was suggested that children with arrhythmia might have higher morbidity.


Posters: Endocrine 264

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CLINICAL VARIABLES AFFECTING CEREBRAL OXYGENATION IN CHILDREN WITH DIABETIC KETOACIDOSIS

“POINT OF CARE” GLUCOSE MONITORING MAY BE UNRELIABLE IN CRITICALLY ILL BURN PATIENTS WITH LOW HEMOGLOBIN

Almas Syed, Loma Linda University, Mudit Mathur, Loma Linda University Children’s Hospital, Douglas Deming, Loma Linda Children’s University Hospital, Shamel Abd-Allah, Loma Linda University Children’s Hospital Introduction: Cerebral edema causes significant neurologic morbidity or death in children with diabetic ketoacidosis (DKA) but its recognition is often delayed. Hypothesis: Cerebral oxygenation reading (rSO2 ) can predict cerebral edema. Methods: Prospective, observational study involving patients ⬍18 yrs of age with DKA. Continuous monitoring of cerebral oxygenation with Near Infrared Spectroscopy (NIRS) was done throughout their PICU stay. Cerebral oxygenation was correlated to clinical status, laboratory values and interventions. Patients were divided into 2 groups- normal mental status and altered mental status for analysis. Statistical methods included paired student t-tests, 2 way ANOVA and Pearson correlation. Results: Fifty nine patients were enrolled. Patients with normal mental status (N ⫽ 43) had a median Glasgow coma scale(GCS) of 15(14 –15) and those with altered mental status (N ⫽ 16) had a median GCS of 11(3–14). Baseline glucose and pCO2 were similar between both groups but there was a statistical difference between pH (7.14 vs 6.9/p⬍0.0001), Serum bicarbonate (8 vs 5/p⬍0.005) and total fluids(lit/m2) received (2.6 vs 4/p⬍0.0004). Initial rSO2 was inversely correlated with severity of metabolic acidosis (r -0.433/p⬍ ⫽ 0.002) and pCO2 (r-0.590/p ⫽ 0.002) and directly correlated to more fluid administration (r 0.282/p ⫽ 0.047). Final rSO2 reading after resolution of DKA was lower and statistically significant (r 0.316/p⬍0.025) in all patients. Sixteen patients were treated with hypertonic saline for clinical cerebral edema but no statistically significant change was noted in the cerebral oxygenation readings Conclusions: Cerebral oxygenation correlates with severity of acidosis and excessive fluid administration. In all patients, initial cerebral oxygenation reading was higher probably representing cerebral hyperemia or decreased oxygen extraction, even in the setting of hypocapnia. Both of which may have implications of neurological consequences in DKA. Upon resolution of acidosis, the final rSO2 reading is significantly lower in both groups. In our data, rSO2 values remained unchanged following treatment of suspected cerebral edema. This study was supported in part by a grant from the Smiderle Endowment Fund.

Wil Santavasi, Ohio State University, Ruth Fitzpatrick, Crozer-Chester Medical Center, Robert Guilday, The Nathan Speare Regional Burn Treatment Center, Crozer-Chester Medical Center, Linwood Haith, Crozer-Chester Medical Center, Bruce Ackerman, The Nathan Speare Regional Burn Treatment Center, Diane Herder, Megan Stair-Buchmann, Cynthia Reigart, The Nathan Speare Regional Burn Treatment Center, CrozerChester Medical Center, Mary Lou Patton, Crozer-Chester Medical Center Introduction: To improve blood glucose control in critically ill patients, an insulin infusion protocol was initiated for all critical care patients. In contrast to other critical care units, use of this protocol in the burn center resulted in multiple episodes of hypoglycemia and hyperglycemia. The only difference between our patients and patients in the other critical care units was lower hemoglobin levels. This lead to investigation of the protocol. Hypothesis: Low hemoglobin (HGB) resulted in inaccurate point of care (POC) glucose determinations. Methods: A prospective study with two POC monitors was developed to determine if the monitor itself had an effect on the blood glucose results in patients (N ⫽ 9) managed in the burn center. Paired sampling of POC was initiated using both the Accu-Chek (AC) and Contour (CN) bedside glucose-monitoring devices. Blood glucose determinations (N ⫽ 1060) were obtained as per protocol. Laboratory blood glucose determinations (N ⫽ 69) and hemoglobins were also collected and recorded. Resulting data was subjected to linear regression analysis with calculation of confidence intervals (see below). POC determinations were stratified as greater than or less than 8 g/dL (Range 5.6–11.1 HGB) and analyzed by a 2-way ANOVA. Results: Linear regression of the AC versus the CN POC demonstrated a wide scatter of points outside the confidence intervals for two POC devices. The resulting equation was y ⫽ 0.9905x⫹19.003; r2 ⫽ 0.8424. The AC overestimated the CN reading by 19 mg of glucose. ANOVA comparison of lab glucose, CN glucose, AC glucose as triplicates demonstrated the most variance in the AC POC (F ⫽ 9.987; p⬍⬍0.05). Stratification by HGB (⬍8 g/dL N ⫽ 27; ⱖ8 g/dL N ⫽ 32) also noted greater variance with the AC POC associated with HGB ⬍8 g/dL (F ⫽ 567.5; p⬍00.5). Looking at the triplicate values and hemoglobin noted again most variance attributable to the AC (F ⫽ 80.89; p⬍0.05). Conclusions: These data demonstrated less error with the CN POC device with HGB ⬍8 g/dL and demonstrated there as a potentially serious variance in resulting glucose concentrations when AC was used in patients with low hemoglobins.

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ISONATREMIC SIADH IN PATIENTS UNDERGOING SPINAL FUSION SURGERY

CONTINUOUS GLUCOSE TISSUE MONITORING IN CRITICALLY ILL PATIENTS WITH DISTRIBUTIVE SHOCK. CORRELATION WITH CAPILLARY BLOOD GLUCOSE CONTROL INTERMITENTLY

Irfan Khan, University of Iowa Hospital and Clinics Introduction: Hyponatremia is one of the criteria for Syndrome of Inappropriate AntiDiuretic Hormone(SIADH).We believe that administration of isotonic saline prevents development of hyponatremia and delays diagnosis of SIADH. Hypothesis: 1.Administration of IS in patients undergoing spinal fusion prevents development of hyponatremia and failure to recognize SIADH.2. Free water retention and continued fluid administration contributes to dilutional anemia. 3. Patients undergoing spinal fusion have relative cortisol deficiency. Methods: 24 consecutive pediatric patients undergoing spinal fusion were approached. Demographic, clinical and laboratory data were abstracted at predetermined time intervals. Using published criteria for diagnosing SIADH [excluding serum sodium (Na)] we separated patients into two groups based on whether or not they met these criteria.The criteria used for diagnosing SIADH were urine osmolality ⬎600 mOsm/K, serum osmolality ⬍300 mOsm/K, serum potassium ⬎3.5 MEQ/L, urine output ⬍0.5 cc/kg/hr, urine Na ⬎30 MEQ/L, serum bicarbonate ⬎20 MEQ/L and fractional excretion of Na ⬎0.5. Results: 20 patients were enrolled over 6 months.10 (50%) met all the criteria for SIADH except serum Na levels.The serum Na (MEQ/L) levels between the SIADH and no SIADH group were different (Na ⫽ 137.4 vs. 140.9, p ⫽ 0.007).The group with SIADH showed a trend towards lower serum chloride levels (MEQ/L) [104.36 vs.110, p ⫽ 0.053] and postoperative serum cortisol levels (mcg/dl) [7.93 vs.11.96, p ⫽ 0.440), more positive fluid balance (ml) [431 vs. 235, p ⫽ 0.142] but similar mean hemoglobin (g/dl) [8.67 vs. 9, p⬎0.99] and ADH levels (pg/dl) [128.56 vs. 91.36, p⬎0.99] compared to the no SIADH group. Duration of surgery, blood loss, fluids administered and segments fused were similar. Conclusions: SIADH like physiology was noted in 50% of our patients with normal serum sodium levels.This supports our hypothesis that SIADH can be present in the absence of hyponatremia. SIADH thus needs to be considered in isonatremic patients in the era of Isotonic Saline use. Our data on serum cortisol and dilutional anemia is inadequate to arrive at any conclusion and needs further study.


Daniel Ballesteros, Oscar Martinez, Rafael Blancas LA˘ez-Casero, Carmen Martin, Blanca Lopez Matamala, Hospital Del Tajo, Miriam Chana, Hoapital Del Tajo, Belen Estebanez, Hospital Del Tajo Introduction: Optimization of glycemic control in critically ill patient has demonstrated to decrease mortality and morbidity for surgical and medical patients. To date, an intermitent glucose control is performed, with episodes of inadecuated control and inadverted hypoglucemia and its complications. Subcutaneus continuous glucose monitoring system (CGMS) would increase safety and decrease adverse effects of the strict glycemic control, but at the moment is not clear the usefulness in the critically ill patients. Hypothesis: Assess correlation between tissular glycemia and capillary glucose control in the critically ill patient setting. Methods: We will perform a prospective study, monitoring tissular glucose continously in adults patients (⬎18 years) with distributive shock. A subcutaneous sensor for determination of tissular glucose will be implanted in all patients admitted to the Intensive Care Unit with a dignosis of distributive shock. Meassures obtained will be compared with standard capillary glucose samples. Statistical analysis: Difference and relative difference were calculated for each reference pair and to calculated the mean. To quantify the method correlation and variability the Pearson correlation coefficient and the intraclass correlation coefficient were calculated for the entire group. Results: We analyzed 12 patients with 188 CGMS reference pairs in a medical-surgical ICU. 8064 GCMS measurements and 190 capillary glucose control were done. The mean glucose value were 128.78 (SD 29.87) and 132.17 (SD 30.83) respectively. The mean differences between the two methods were -3.28 (SD 28.97) and -0.1% (SD 21.8%). The Pearson correlation coefficient, showing conformity between the two methods, was 0.57 and the intraclass correlation coefficient was 0.56. Accordingly 44% of the total variability is explained by glucose measurement. Conclusions: The continuous glucose monitoring system values showed a weak correlation with capilar glucose controls. More studies are needed to regard to use the continuous glucose monitoring system to guide insulin therapy in critically ill patients.

Posters: GI/Nutrition 268

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IMPLEMENTATION OF SCCM/A.S.P.E.N. NUTRITION GUIDELINES: A PROSPECTIVE 3-YEAR COHORT STUDY

THE RELATIONSHIP BETWEEN FEEDING INTOLERANCE AND GHRELIN IN CRITICALLY ILL CHILDREN AGE 0–3 YEARS

Gaurav Sachdev, University of Michigan Hospitals, Anna Krzak, University of MI Hospitals, Cory Vatsaas, Sharon Dickinson, University of Michigan Hospitals, Pauline Park, University of Michigan, Krishnan Raghavendran, UMHS, Lena Napolitano, University of Michigan School of Medicine

Patrick Maynord, Vanderbilt University School of Medicine, Fredrick Barr, University of Mississioppi Medical Center, Marshall Summar, Children’s National Medical Center, Jefferson Lomenick, Vanderbilt University School of Medicine

Introduction: SCCM/A.S.P.E.N. nutrition guidelines advocate the use of early enteral nutrition (EN) since it is associated with improved outcomes, and either gastric or small bowel (SB) feeding is acceptable. Increased concern about gastric tolerance and reliance on SB feeds is associated with delayed EN due to challenges in SB tube placement. Hypothesis: Protocol driven implementation of early EN via gastric enteral access reduces time to achieve enteral access and to reach caloric goals. Methods: An interdisciplinary surgical ICU team developed a protocol to obtain gastric enteral access within 48 hours of ICU admission and reach caloric goal within 72 hours of feeding initiation. Data in eligible patients, with the surgical teams consent, were collected prospectively with a baseline period of April 2008 to September 2008 (n ⫽ 30), compared to a protocol implementation period of October 2008 to June 2011 (n ⫽ 360). Patients already on enteral or parenteral nutrition were excluded. Contraindications to gastric EN were gastric outlet obstruction, high output proximal fistula, gastric feeding intolerance, and repeated high gastric residual volumes. Patients who failed gastric EN were transitioned to SB EN. Statistical analysis was Chi square. Data analyzed included days to feeding tube placement, tip location, and days to reach caloric goal after feeding initiation. Results: Since protocol implementation, we achieved a 41% increase in obtaining enteral access within 48 hours (97% protocol period vs. 56% baseline, p ⫽ 0.0001) and a 25% increase in achieving caloric goal within 72 hours (93% protocol period vs. 68% baseline, p ⫽ 0.0001). We achieved a 56% increase in implementing EN via gastric access (75% protocol period vs. 23% baseline). Only 6% (n ⫽ 21) required transition to SB EN due to gastric intolerance; 19% (n ⫽ 57) required SB EN due to contraindications to gastric feeding. Caloric goals were achieved within 72 hours equally in both groups (94% gastric vs. 91% SB, p ⫽ 0.68). Conclusions: Protocol driven implementation of early EN via the gastric route significantly reduced time to achieve enteral access, reach caloric delivery goals and significantly increased adherence to the current SCCM/A.S.P.E.N. guidelines.

Introduction: Feeding intolerance is common in critically ill children, but the diagnosis is primarily clinical, using markers such as emesis or abdominal girth–no serum diagnostic tests are available. Ghrelin is a peptide produced in the stomach that stimulates feeding via interactions with the hypothalamus, increases gastric acid secretion and intestinal motility. Ghrelin concentrations are also known to be elevated in malnourished children. Hypothesis: We sought to assess if fasting levels of ghrelin prior to initiation of enteral feeds correlate with feeding tolerance, hypothesizing that children who did not tolerate feeds would have elevated concentrations of ghrelin compared to those who were tolerant. We also hypothesized that ghrelin levels would decrease following the establishment of enteral feeds. Methods: Thirty eight critically ill children age 0 –3 years were recruited. Serum was obtained in the fasting state prior to initiation of feeds and then daily until the patient tolerated full volume feeds. Samples were frozen and then analyzed by radioimmunoassay. Subjects achieving full volume feeds within 48 hours were considered tolerant. Subjects requiring greater than 48 hours were considered intolerant. Results: Fasting total ghrelin in the tolerant group was 1106 ⫾ 128 pg/ml compared to 1602 ⫾ 318 pg/ml in the intolerant group. Serum ghrelin levels did not change demonstrably during advancement of feedings in the tolerant group. Feeding tolerant subjects had mean ghrelin Day 1 1106 ⫾128 pg/ml, Day 2 1287 ⫾ 183, Day 3 1238 ⫾ 172. Feeding intolerant subjects had a decrease in mean daily levels during their last 3 days of study when they achieved tolerance of enteral nutrition; Day 4 1932 ⫾ 176 pg/ml, Day 5 1858 ⫾304 pg/ml, Day 6 1806 ⫾ 150 pg/ml. Conclusions: In our study, subjects with feeding intolerance had elevated ghrelin levels prior to starting feeds. This elevation is likely an adaptive response, reflecting a greater energy defecit. The trend toward a decrease in ghrelin levels during establishment of enteral nutrtion in the intolerant subjects may represent an improvement in energy balance. Measurement of ghrelin could provide a way to predict response to feeding in young, critically ill children.

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NO FOOD LEFT BEHIND! SIGNIFICANT COST SAVING BY AVOIDING UNNECESSARY DIET ORDERS

THE PERIOPERATIVE CONTINUATION OF POST-PYLORIC ENTERAL NUTRITION IS SAFE IN CRITICALLY ILL PATIENTS

Iqbal Ratnani, DeBakey Heart and Vascular Center, Ann Holmes, David Baker, Faisal Masud, Amanda Hodgson, The Methodist Hospital Introduction: Meal trays are routinely ordered for patients in the ICU. Due to the changing clinical situations of these patients, including intubation or application of non-invasive ventilation, NPO order for procedures, suspected ischemic bowel/ileus, failed swallowing, new aspiration event and other clinical scenarios, food trays may go unused causing considerable waste. Reducing wasted meal trays is a potential mechanism to reduce hospital costs while maintaining quality care. Hypothesis: Education for caregivers using a multi-disciplinary approach will save a significant amount of meal tray wastage. Methods: A retrospective study tracked the number of meal trays wasted from May 2010 until June 2011. In June 2011, a multi-disciplinary education was provided to physicians, nurses, midlevels, residents and dietitians. 3 point intervention was done; 1) avoid routine meal tray ordering, 2) order only 1 meal tray for a patient who has been recently extubated and able to eat, 3) direct intervention of unit dietitian at kitchen-level to stop tray preparation for new NPO patients after meals were already ordered. The number of wasted meal trays was tracked after the intervention. Results: On average, 36 meal trays are delivered daily to patients in the CVICU at The Methodist Hospital. From May 2010 through June 2011, a total of 219 meal trays were delivered to the CVICU for patients who were unable to eat. After the intervention, July and August 2011, just 2 meal trays were wasted. There was a significant reduction in number of wasted trays before and after the intervention (p ⫽ 0.039, t-test). If 1 wasted tray per month is projected for an entire year, the estimated 12 trays is a highly significant reduction in waste (n ⫽ 219 vs 12, p ⫽ 6.5x10 – 6). Conclusions: Educating caregivers resulted in significantly fewer wasted diet trays in the CVICU, and fewer tray preparations had to be stopped after being ordered. Institution wide implementation of this program could result in significant cost savings by reducing food waste.

Lisa McElroy, Panna Codner, Karen Brasel, Medical College of Wisconsin and Affiliated Hospitals Introduction: To challenge the notion that traditional 8 hour fasting prior to surgery is unnecessary. Hypothesis: It is safe to continue post-pyloric enteral nutrition in any critically ill patient undergoing surgery. Methods: A policy was instituted at our hospital allowing patients undergoing surgery with a secure airway to continue post-pyloric enteral nutrition up until entry into the operating room. The study population included consecutive intubated or tracheotomized patients from July 2010 to July 2011 in the surgical intensive care unit who received enteral nutrition via a naso-jejunal (NJ) feeding tube and underwent one or more surgical procedures. Demographic, illness and injury information were obtained from record review. Length of time to NJ placement, time to initiation of tube feedings, tube feed interruptions and complications (defined as a perioperative aspiration event either during induction or several hours after surgery, high gastric residuals, clinical sepsis, pneumonia, or a perioperative death defined as within 24 hours after surgery and related to an aspiration event) were also recorded. Results: 14 patients with mean age 44.3 (⫾19.9) were included. Average injury severity score was 26.2 (⫾9.2). Mean number of operations was 3.4 (⫾1.5). Reason for ICU admission included traum (N ⫽ 11.0, 78.5%) and general surgical cases including necrotizing soft tissue infection (N ⫽ 2.0, 14.3%) and incarcerated bowel (N ⫽ 1.0, 7.1%). The most frequent operation was an orthopedic procedure (N ⫽ 17.0, 46.1%). Length of tube feed interruptions for a single procedure was 222.4 (⫾206.9) minutes. Patients received an additional 11.9 (⫾4.7) hours of enteral nutrition and 1064.9 (490.0) calories per day per operation as a result of not having their nutrition stopped at midnight on the evening preceding an operation. There were no complications. Conclusions: Perioperative continuation of post-pyloric enteral nutrition is safe and feasible in many critically ill surgical patients. A multi-disciplinary approach and an institutional policy can increase the ability to meet nutritional goals in these patients.


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INDIRECT CALORIMETRY IN THE CRITICALLY ILL: CHALLENGES AND IMPACT ON NUTRITION PRESCRIPTION

EFFECT OF THE ENTERAL NUTRITIONAL PROTOCOL INITIATED BY NURSES

Anna Krzak, University of MI Hospitals, Gaurav Sachdev, University of Michigan Hospitals, Jill Cherry-Bukowiec, University of Michigan Health System, Pauline Park, University of Michigan, Krishnan Raghavendran, UMHS, Lena Napolitano, University of Michigan School of Medicine

Takehiro Niwa, Ryuichi Hasegawa, Masaki Kawase, Yoshihito Nakashima, Toshihiko Ichihara, Tosei General Hospital

Introduction: Indirect calorimetry (IC) is the gold standard for determination of energy requirements for mechanically ventilated (MV) critically ill patients, allowing intensivists to design optimal nutrition support regimens while minimizing under- or over-feeding. We sought to examine the number of IC studies successfully completed, and those which resulted in nutrition regimen modification. Hypothesis: IC is frequently contraindicated in MV patients and does not change nutrition regimen by predictive nutrition equations. Methods: All MV patients were monitored daily for eligibility of IC over a 2-month period. IC was performed using a DeltaTrac metabolic cart and results were evaluated for validity. Steady state was defined as a 5 minute interval where respiratory quotient (RQ) was within human physiologic range (0.67–1.3) and coefficient of variation for the resting energy expenditure (REE), RQ, VO2 and VCO2 were less than 15%. All IC studies were validated using specific equations for Coefficient of variation and variability of VO2 and VCO2. Results: Mean APACHE III score on ICU admission was 72. Of the 146 MV patients, 98 (67%) patients were ineligible for IC. Contraindications to IC were identified as FiO2 ⱖ60 (22%), extracorporeal membrane oxygenation (8%), MV ⬍48 hours (25%), oscillator (9%), PEEP ⬎12cm H2O (5%), anticipated extubation (14%), and other reasons (17%) including inability to collect all expiratory flow; palliative/comfort care status; absence due to procedures; recent REE obtained with no significant change in clinical status; inspiratory gases; frequent changes in vent settings. IC validity was confirmed for 41 of 48 studies. In patients with valid IC results, only 11 (26.8%) nutrition regimens were changed due to a large variation between the previously prescribed nutrition regimen and IC results. Most of the changes made were for overfeeding. Conclusions: IC is frequently contraindicated in MV patients and infrequently results in change in nutrition prescription. Although IC remains the gold standard in determining nutrition requirements in MV ICU patients, clinicians must be prepared to utilize predictive equations when IC is unavailable to design the optimal nutrition support regimen.

Introduction: The enteral nutrition which is initiated by physicians often leads to delay in achieving the target calories. Underfeeding is associated with weakness, infection, an increased duration of mechanical ventilation, and death. The use of enteral nutritional protocol is recommended for critically ill patients in nutritional guidelines. We have used the enteral nutritional protocol initiated by nurses since 2010. Hypothesis: Our hypothesis is that the enteral nutritional protocol initiated by nurses is effective in nutritional support, leading to better outcomes in critically ill patients. Methods: A historical cohort study was conducted to patients who have been admitted to intensive care unit (ICU) for more than 7 days and received nutritional support. We compared enteral feeding managed with or without the protocol in 2010 (protocol group) to enteral feeding managed manually in 2008 (control group). In both groups the initiation of enteral feeding was judged by physicians. In the control group the infusion rate for enteral nutrition was increased at the discretion of the attending physicians, and in the protocol group it was increased by nurses every 8 hours. We have investigated mortality at day 30, trend in total energy, duration of ICU stay, ventilator free days and adverse events. Results: Sixty-eight patients in the protocol group and 57 patients in the control group were enrolled. There were no significant differences in the patient characteristics between two groups. The enteral nutrition was initiated at 49 hours on the average after ICU admission, and then the target calories were achieved within day 7 in the protocol group. Patients in the protocol group, as compared with the control group, had more ventilator free days (15.9 versus 12.0 days; p ⫽ 0.039), and shorter duration of ICU stay (11.3 versus 14.5 days; p ⫽ 0.005). Rates of death in the ICU and in the hospital were similar in the two groups. Patients in the protocol group had fewer ICU infections (38% versus 58%; p ⫽ 0.03), and patients in both groups had diarrhea similarly. Conclusions: The enteral nutritional protocol initiated by nurses was safe and effective in reducing the duration of ICU stay and mechanical ventilation, and ICU infections.

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PREVALENCE OF STRESS ULCER PROPHYLAXIS INITIATED IN THE PICU AND CONTINUED UPON HOSPITAL DISCHARGE

ELECTROMAGNETIC GUIDED CONFIRMATION OF NASOGASTRIC TUBE INSERTION: EHANCING PATIENT SAFETY

Kimberley Benner, Samford University/Childrens of Alabama, Salley Thompson, Samford University McWhorter School of Pharmacy, Aisha Wilson, Childrens of Alabama, Nancy Tofil, Margaret Winkler, University of Alabama at Birmingham Introduction: Up to 81% of adult patients receive stress ulcer prophylaxis (SUP) upon ICU discharge with only 29% having an appropriate indication. The primary objective was to evaluate the frequency, indication and continuation of SUP in the pediatric intensive-care unit (PICU). Hypothesis: Many PICU patients are inappropriately continued on SUP after PICU and hospital discharge. Methods: A retrospective chart review evaluating the use of SUP in a 19 bed PICU was performed. Inclusion criteria were patients with PICU stay of at least 48 hours from January to June 2010. SUP utilized during PICU stay, route, dose in mg and mg/kg/day and frequency were recorded. Risk factors that increase the risk of stress-related mucosal damage (i.e. mechanical ventilation, coagulopathy) were recorded as well as continuation of stress ulcer prophylaxis upon PICU and hospital discharge. Results: 642 patients were admitted to the PICU during the study period; 244 patients (38%) met the inclusion criteria. 136 patients (55.7%) were male with a median age of 48 months (IQR 15–132) and median weight of 18 kg (IQR 9 – 45). 160 patients (65%) were initiated on SUP while in the PICU; 50 patients (20%) were on acid suppressive therapy at home. The most frequent patient risk factors included mechanical ventilation (58%), non-steroidal antiinflammatory agents (42%), corticosteroids (38%) and surgery (34%). Ranitidine was utilized in 45.5% of patients, followed by pantoprazole (32%), lansoprazole (5.7%) and omeprazole (2.9%). 101 (63%) patients were continued on SUP when discharged from the PICU with 48 (30%) of those being continued upon hospital discharge. Interestingly, only 76% of patients admitted on home acid suppressive therapy were discharged on their home regimen. Conclusions: Many patients admitted to this PICU received SUP. The use appears appropriate in this population since 90.5% of patients receiving SUP in this PICU had either an absolute risk factor, multiple relative risk factors, or were on home acid suppressive therapy. However, many patients were also discharged from the PICU and home on SUP. Due to the long term risks of these medications, use of SUP should be restricted to patients with indications for such therapy.


Steven Trottier, Saint John’s Mercy Medical Center, Erik Glassl, St. John’s Mercy Introduction: Opinions differ regarding the optimal method of confirmation of nasogastric (NG) or orogastric (OG) tube insertion. Auscultation, pH analysis, character of the NG aspirate, or the radiograph has been suggested to confirm placement with the radiograph remaining as the gold standard. Hypothesis: The purpose of this study is to compare electromagnetic guidance/confirmation of NG or OG tube placement to that of radiographic confirmation. Methods: Medical surgical intensive care unit patients requiring NG or OG tube insertions were eligible for the study. The NG or OG tubes were inserted in the standard fashion by the bedside nurse. Prior to the insertion, a guide wire with an electromagnetic tip was inserted through the tube and secured. Care was taken to assure the tip did not protrude from the NG tube. A receiver for the electromagnetic signal was placed on the patient in the subxiphoid region. The guide wire was attached to a bedside unit that energized the guide wire tip and tracked the placement on a display. Following the NG or OG insertion, an abdominal radiograph was obtained. Results: Twenty-seven patients, 16 male and 11 female, with an average age of 69 ⫹/⫺ 14 years were enrolled. Two patients were excluded due one guide wire not energizing and one patient intolerant to the NG placement. Of the 25 patients receiving an NG or OG tube, the electromagnetic guided placement correlated with the abdominal radiograph 100%. Real time tracking of one of the NG tubes avoided placement of an NG tube into the airway. Conclusions: Electromagnetic guided NG or OG tube insertion correctly tracked 100% of the tubes compared to the abdominal radiograph results. These preliminary data suggest that electromagnetic guided placement of NG or OG tubes have the potential to replace the abdominal radiograph for confirmation thus enhancing patient safety by avoiding radiation exposure and inadvertent airway placement.

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RESTRUCTURING OF A MULTIDISCIPLINARY NUTRITIONAL SUPPORT (NS)/ENTERAL NUTRITION (EN) TEAM PROCESSES FOR EFFECTIVE CARE

PREVENTION OF POSTOPERATIVE HYPERGLYCEMIA USING ISOMALTULOSE-BASED ENTERAL FORMULA: A PILOT RANDOMIZED TRIAL

Margaret Myslinsky, Lawrence Feldman, Annette Keys, Sheryl Lowery, Charlene Powell, Jesse Brown VAMC, Stuart Lipnick, Jesse Brown Medical Center

Moritoki Egi, Shiho Takenouchi, Satoshi Kimura, Yuichiro Toda, Kiyoshi Morita, Okayama University Hospital

Introduction: Research indicates NS/EN barriers include: NS/EN team staffing, time constraints, prioritization of nutrition among other treatment tasks, nutrition beliefs, and weaknesses in communication between providers. Disparity remains between providers’ (physicians, residents, medical students, nurses, dietitians) knowledge and actual nutritional care. Hypothesis: A weekly oversight NS/EN Team with structured communication/documentation processes enhances NS/EN care. Methods: A written Ordinal (ranking) question survey determined nutrition communication issues. For 2 weeks, a random sample of 65 providers (attending physicians, residents, medical students from two urban medical schools) was surveyed at JBVAMC. A computerized nutrition survey evaluated provider perception of nutrition adequacy as defined by nutrition subset of the Braden Skin Risk Scale. Literature reviews show the Braden Scale is a well validated tool using nutrition adequacy risk as a component. Additional research indicates visual prompts enhance effective communication between diverse populations of healthcare providers. A Cause and Effect diagram was used to restructure NS/EN team process. Results: The written survey return rate was high (95.4%). Top comments from the Ordinal ranking were: 1. computerized record notes had inconsistent content; 2. nutritional care varied by individuals. The computerized provider adequacy survey showed 50.2% (47/94) could not correctly identify when nutritional intake was inadequate. Visual NS/EN nutrition prompts to be posted at bedside plus computerized NS/EN documentation templates were created. The NS/EN Oversight Team (MDs (2), RD, RN, PharmD) monitors daily but rounds weekly. The structure allows for involvement by main providers/staff, education, efficiency in NS/EN Team time: decreasing 50 hours (5 staff/1–2 hours daily) to 10 hours weekly. NS consultations to the Team increased 200%:63 (2007) to 189 (2010); EN consultations increased 85%:240 to 444. The yearly average (2007) for correct RN documentation/EN labeling 54% (145/270) increased to 87% (386/444) in 2010. Conclusions: The weekly Oversight NS/EN Team using visual prompts/structured documentation processes creates effective NS/EN care.

Introduction: Preventing harmful hyperglycemia is important in critical illness. However, insulin therapy increases the risk of hypoglycemia. In patients with diabetes, isomaltulose-based enteral formula (IF) feeding has been shown to reduce glycemia. We reported IF feeding for 16 hours could be prevent postoperative hyperglycemia compared with standard feeding formula (SF). However, there was no information for the effect of long term IF feeding in postoperative critically ill patients. Hypothesis: We hypothesized that IF feeing could be reduce maximum glucose value without any incidence of hypoglycemia (⬍80 mg/dL) for postoperative 7days. Methods: In this randomized controlled trial, patients who required intensive care more than 8 days after esophagectomy were included. Patients were randomized to either the IF or SF arm. Feeding jejunostomy was placed during surgery in all candidates. Enteral feeding with SF was administered according to feeding protocol and fixed at 100% of basal energy expenditure calculated by the Harris-Benedict formula. Patients with liver failure (defined as bilirubin level ⱖ1.2 mg/dL), kidney failure (creatinine level ⱖ1.2 mg/dL), or with contraindication to IF or SF were excluded. Blood glucose levels was measured every 6 hourly of 7day of feeding period. Primary outcomes were maximum blood glucose values during 7 days. Secondary outcomes were minimum, average glycemia and glycemic variability during 7 days. Results: Maximum blood glucose concentration was 161 mg/dL with IF, significantly lower than the 181 mg/dL with SF (P ⫽ 0.03). Glycemic variability was 11.6 mg/dL with IF, significantly lower than the 15.2 mg/dL with SF (P ⫽ 0.01). The This effect was seen without any risk of hypoglycemia and complication. Minimum and mean glycemia during feeding periods was no significant difference between IF and SF feeding (mean 148 vs. 159 mg/dL (P ⫽ 0.13), minimum 121 vs. 127 mg/dL (P ⫽ 0.41). This effect was seen without any risk of hypoglycemia and complication. Conclusions: Isomaltulose-based enteral formula might be useful for safer glycemic control in postoperative critically ill patients. Further study to determine clinical benefit of IF feeding is justified.

278 IMPACT OF A CONSENSUS-BASED FEEDING ALGORITHM ON ENTERAL NUTRIENT DELIVERY IN THE PICU Susan Hamilton, Diane McAleer, Nicole Stenquist, Katelyn Ariagno, Nilesh Mehta, Children’s Hospital Boston Introduction: In a prospective survey of enteral nutrition (EN) practices conducted in 2008, we reported multiple avoidable EN interruptions. These deficiencies resulted in failure to reach energy goal and higher reliance on parenteral nutrition (PN). In an effort to optimize EN, we implemented a multidisciplinary quality improvement (QI) effort over the next 2 years. This included the development of a comprehensive EN algorithm based on available evidence and multidisciplinary consensus. The algorithm was implemented in March 2011 after intensive education. Hypothesis: The aim of our current audit was to examine the effect of QI efforts on optimizing nutrient intake in the PICU. Methods: Nutrition practice parameters, including daily nutrient intake, acceptable and avoidable interruptions to EN, and PN usage were recorded prospectively in patients admitted to the PICU over 4 weeks. Clinical and nutritional characteristics were compared between the 2 cohorts. Results: Daily record of nutrient intake was obtained in 150 consecutive patients. Eighty (54%) patients received EN for at least 24 hours, and were included in the comparative analyses. There were no significant differences in age, gender, or need for mechanical ventilation between the 2 cohorts. Time to initiating EN (median 1 day), use of post-pyloric feeding route (19%), total number of EN interruptions (83 in 28 patients) and overall PN usage were also similar. However, in our current cohort we observed a significant decrease in time to reach energy goal (1.5 vs. 4 days, p⬍0.05), higher incidence of patients reaching goal (99% vs 61%), and decreased total interruption hours (796 vs. 1483). In particular, the number of avoidable interruptions to EN decreased from 51 to 3 (p⬍0.001), and PN use in this group of patients decreased from 6 patients (median 8 days) to 1 patient (3.5 days). Conclusions: The implementation of a comprehensive EN algorithm significantly improved nutrient delivery by decreasing avoidable interruptions to EN and decreasing the reliance on PN in this subgroup. Nutrition goal was reached earlier and in a higher proportion of patients. Future studies are needed to examine the impact of optimizing nutrition on improving clinical outcomes.


Posters: Hematology 279

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RECOMBINANT ACTIVATED FACTOR VII USE IN CRITICALLY ILL PATIENTS: CLINICAL OUTCOMES AND THROMBOEMBOLIC EVENTS

OXYGENATION INDEX PREDICTS PEDIATRIC INTENSIVE CARE UNIT MORTALITY IN HEMATOPOIETIC STEM CELL TRANSPLANT RECIPIENTS

Christina Candeloro, Virginia Commonwealth University Health System, Jaime Robles, Gretchen Brophy, Virginia Commonwealth University

Courtney Rowan, Kerry Hege, Richard Speicher, Riley Hospital For Children, Mara Nitu, Riley’s Hospital for Children, Susan Perkins, James Slaven, Indiana University, David Westenkirchner, Riley Children’s Hospital, Paul Haut, Riley Hospital for Children

Introduction: Recombinant activated Factor VII (rFVIIa) has been administered to ICU patients for off-label uses over the past several years. The objectives of this study were to compare clinical outcomes and incidence of thromboembolic events in ICU patients who received rFVIIa versus those who did not. Hypothesis: Differences will exist in the clinical outcomes and thromboembolic events between those who received rFVIIa and a control group. Methods: This is a retrospective study of ICU patients from US hospitals admitted between Jan 2001–Dec 2005. Data were retrieved from a pre-existing ICU Solucient® ACTracker® database. Adult patients who received rFVIIa and had an ICU admission of ⱖ24 hours were identified for inclusion and matched 1:1 to a control group. Patients were excluded if they had hemophilia. Chi square tests were used for association between categorical variables. Adjusted odds-ratios and survival analysis estimates were obtained using a multivariate logistic model and a multivariate Cox proportional hazards regression model. Results: There were 2918 patients included in the study. The most common primary admission diagnoses were cirrhosis (6.4%) and non-traumatic ICH (5.3%). Patients receiving rFVIIa (n ⫽ 1459) were more likely to be mechanically ventilated, have acute renal failure, sepsis, GI bleed, or receive hemodialysis (p⬍0.001). The median [IQR] dose of rFVIIa was 4.8 mg [2.4, 7.2] and 82% of patients received only one dose. Patients who received rFVIIa were 2.7 times more likely to die [95% CI 2.22–3.20], with mortality rates of 36% vs 16% (p⬍0.001), respectively. Thromboembolic events occurred in 16% of patients and were similar between groups (17% rFVIIa vs 15% control, p ⫽ 0.255). Myocardial infarction was the most common event (7%) in both groups. Receipt of transfusion was significantly higher in the rFVIIa group (49% vs 30%, p⬍0.001). Conclusions: ICU patients most likely to receive rFVIIa were admitted for cirrhosis and intracranial hemorrhage. rFVIIa patients had significantly more co-morbidities, higher mortality rates and received more transfusions; however, the rate of thromboembolic events was similar between groups. Funded by an Investigator Initiated Research Grant (Novo Nordisk).

Introduction: The mortality in the intensive care unit for pediatric hematopoietic stem cell transplant (HSCT) recipients remains high, especially if these patients require mechanical ventilation. Recent studies show a mortality of 55–71% for patients mechanically ventilated. Despite improvements from previously reported fatality rates close to 100%, early pulmonary complications have continued to be an obstacle to the success of hematopoietic stem cell transplantation. Trachsel et al. in 2005, found that a higher oxygenation index (OI) was associated with a higher mortality, but that there was no OI threshold beyond which death was inevitable. Hypothesis: We hypothesize that OI is a predictor for mortality from respiratory failure in critically ill pediatric stem cell transplant recipients. Methods: A retrospective, single center review of pediatric HSCT recipients between 2002–2010 who required intensive care at Riley Hospital for Children during the same hospital admission as their stem cell transplant was conducted looking at maximum daily OIs while intubated. The following calculation was used OI ⫽ [(mean airway pressure x fiO2)/PaO2] x 100. Results: Twenty-nine patients accounted for 32 ICU admissions. Twenty-seven (84%) of these admissions required mechanical ventilation. Eleven (41%) of the 27 mechanically ventilated admissions were placed on high frequency oscillatory ventilation (HFOV). The mortality of those mechanically ventilated was 70%. An OI ⱖ20 at any point during ventilation was associated with 94% mortality, while an OI ⱖ25 was associated with 100% mortality. There is a significant association between maximum OI at any point during mechanical ventilation and ICU mortality, with the odds of dying increasing by 13% for each unit increase of max OI. (OR ⫽ 1.13, 95% CI ⫽ {1.01, 1.26}, p-value ⫽ 0.03). A ROC curve was done with an area under of curve of 0.91. This revealed a OI of 20 to have a sensitivity of 0.89 and specificity of 0.83 for predicting mortality. Results from 2010 are still being analyzed. Conclusions: Mortality among mechanically ventilated stem cell transplant recipients remains high. OI has a strong association with ICU mortality among pediatric stem cell recipients.

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WEIGHT-BASED DOSING OF PROTHROMBIN COMPLEX CONCENTRATES FOR THE RAPID REVERSAL OF WARFARIN COAGULOPATHY: A COMPARISON OF IDEAL VERSUS ACTUAL BODY WEIGHT

FROZEN PLASMA TO RED BLOOD CELL RATIO AND MORTALITY IN PATIENTS REQUIRING MASSIVE TRANSFUSION

Emily Hutchison, Indiana University Health-Methodist Hospital, Jennifer Morse, Purdue University, Serena Harris, Spectrum Health–Butterworth, Joseph Skinner, Timothy Ellender, Indiana University Health-Methodist Hospital Introduction: International guidelines recommend Prothrombin Complex Concentrates (PCC) as an option for urgent reversal of warfarin coagulopathy. Although literature supports use of the international normalized ratio (INR) and weight for PCC dosing, use of ideal body weight (IBW) versus actual body weight (ABW) is variable in clinical practice. The purpose of this study is to compare INR reversal with PCC based on INR and either ABW or IBW. Hypothesis: We hypothesize that PCC dosed with ABW will have a faster time to INR reversal compared to use of IBW. Methods: A retrospective data review from a Level 1 Trauma Center was conducted from June 1, 2010-July 5, 2011. Inclusion criteria were: age ⱖ18 years, initial INR ⱖ1.5, and need for urgent reversal of warfarin coagulopathy. Data collected included reason for INR reversal, serial INR values, PCC dose, patient demographics (age, height, weight, and gender), adjunct therapy given for INR reversal, surgical interventions, bleeding complications, adverse events, and all-cause hospital mortality. Statistical analyses were performed using two-sided Fisher’s exact test, Mann-Whitney U test, and the t-test. Results: PCC was added to formulary June 1, 2010 and was dosed on initial INR and IBW. Dosing with IBW was changed to ABW on March 1, 2011. Eighty-three patients received PCC during the study period, 63 of these meeting inclusion criteria (45 with IBW and 18 with ABW). Baseline demographics were similar between the two groups. Initial INR was 2.7 in the IBW group and 2.3 in the ABW group (p ⫽ 0.66). Median time to obtain an INR ⬍1.5 was 190 min (IQR 80 –730 min) in the IBW group and 600 min (IQR 223–705 min) in the ABW group (p ⫽ 0.47). There was no difference in the percent of patients who received FFP (p ⫽ 0.20), amount of FFP administered (p ⫽ 0.57), or INR at 24 hours (p ⫽ 0.39). A single adverse event of a superficial clot and venous thromboembolism was identified in the IBW group 9 days following PCC administration. Conclusions: Time to INR reversal with PCC was not significantly different when dose was based on INR and ABW as opposed to IBW. PCC dosing with ABW was associated with a similar amount of FFP administration and a low rate of adverse events.


Bryce Makar, Erin Weldon, Aaron Webb, Harold Peters, University of Manitoba, Alexis Turgeon, Hopital De L’Enfant-Jesus, Donald Houston, Emily Rimmer, Anand Kumar, University of Manitoba, Dean Fergusson, Ottawa Hospital Research Institute, Ryan Zarychanski, University of Manitoba and CancerCare Manitoba Introduction: Massive transfusion, defined as the administration of ⱖ10 units of packed red blood cells (PRBCs) within 24 hours, is associated with considerable mortality and morbidity. Hypothesis: The primary objective of this study is to evaluate the association between the FP:RBC ratio and hospital mortality in patients requiring a massive blood transfusion. Methods: In this multicenter retrospective cohort study, patients in the Winnipeg Regional Health Authority (Winnipeg, Canada) receiving a massive transfusion between January 2004 to April 2010 were identified through the Canadian Blood Services database. We used a standardized, and pre-piloted case report form to extract data from the clinical record. All data was extracted using trained data collectors and all data was collected in duplicate. Results: The final sample size included 248 patients. At the time of abstract submission, electronic data had been validated for 115 or 248 patients. The average age of patients was 56.5 ⫾18.4 years. Males accounted for 69% (79/115) of the evaluable population. The overall hospital survival was 50% (58/115). Trauma (27%), gastrointestinal hemorrhage (23%), vascular surgery (18%), and cardiothoracic surgery (10%) were the most common indications for massive transfusion. The average FP:RBC ratio at 24 hours was 0.66 (⫾0.39), and this ratio increased over time as the massive transfusion event evolved. At 24 hours, the survival of patients receiving a ⬍1:2 FP:RBC ratio compared to a ratio ⱖ1:2 was 49% vs. 52% (p ⫽ NS). In multivariable Cox proportional hazard model that accounted for the dynamic change in the FP:RBC ratio over time, a high (ⱖ1:2) FP:RBC ratio was not associated with increased survival (Hazard Ratio 0.89 (95%Confidence Interval 0.49 to 1.61). Conclusions: In this retrospective cohort study of patients requiring a massive blood transfusion, the FP: RBC ratio, at 24 hours or analyzed dynamically over time, was not associated with hospital survival. Due to conflicting results among published studies, and the resource implications associated with the clinical outcome, prospective randomized trials evaluating the effect of differing FP:RBC ratios in patients requiring massive transfusion are warranted.

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CORRELATION OF LABORATORY MEASUREMENTS TO DEGREE OF ANTICOAGULATION IN PATIENTS SUPPORTED ON EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

THE DIFFERENCES OF CRITERIA FOR DIC (DISSEMINATED INTRAVASCULAR COAGULATION) BETWEEN BY THE INTERNATIONAL SOCIETY OF THROMBOSIS AND HAEMOSTASIS AND BY JAPAN ASSOCIATION FOR ACUTE MEDICINE

Len Tanaka, Kapiolani Medical Center, Janna Taylor, Hawaii Pacific Health, Olga Geling, University of Hawaii Introduction: The Activated Clotting Test (ACT) has been the mainstay for monitoring anticoagulation on ECMO. However studies suggest the ACT poorly correlates with heparin levels, and the Partial Thromboplastin Time (PTT) correlates better to heparin activity. In this study, we will examine and compare performance of bedside ACT and laboratory PTT in predicting antifactor Xa (heparin) levels. Hypothesis: Both PTT and ACT drawn at the same time correlate with heparin levels. A laboratory cutoff measurement maximizing sensitivity can be determined. Methods: We performed an IRB approved retrospective chart review on ECMO patients treated at Kapiolani Medical Center for Women & Children (KMCWC) in Honolulu, HI from 2007–2011. Data included laboratory results for heparin level, ACT, and PTT when available simultaneously. ACT analyzers included ACT Plus (Medtronic) from 2007-July 2009 and iSTAT ACT (Abbott) from July 2009 –2011. Performance of ACT and PTT as predictors of heparin levels was examined using the Quantile Regression and Receiver Operating Characteristic (ROC) curves with the Area Under the Curve (AUC) statistical methods. Heparin level was defined as low (⬍0.3 IU/mL) or as elevated (⬎0.7 IU/mL). We determined cutoffs where sensitivity was 100%. Results: Data from 13 neonates and 9 pediatric patients yielded 190 simultaneous lab measurements. PTT values were significant predictors of heparin across the entire range of observed heparin levels, especially when elevated. ACT values were correlated only with elevated heparin levels, with no significant association for the lowest 70% of observed heparin levels. ROC curves for PTT predicting heparin level found an AUC of 0.834 for elevated and 0.703 for a low heparin level. A cutoff PTT value of 89 seconds or more had 100% sensitivity for an elevated heparin level. ROC curves for ACT predicting heparin value had an AUC of 0.711 for elevated and 0.507 for low heparin value. Conclusions: Our analyses suggested that PTT outperforms ACT as a predictor for heparin level. There was increasing correlation of PTT to heparin as the heparin level became elevated. ACT correlated with heparin only when elevated. A level of PTT ⬎89 seconds showed high sensitivity for an elevated heparin level.

Yoshito Nagura, Noriko Saito, Taijiro Goto, Reon Nagai, Makiko Saito, Takuya Oshiro, Mari Yokota, Arino Yaguchi, Tokyo Women’s Medical University Introduction: To diagnose the presence of DIC (disseminated intravascular coagulation) is an eminently important because it correlates with the mortality. Some criteria and the scoring system for diagnosis of DIC exist, but those utilities have been disputable. Hypothesis: Our hypothesis is there are no significant differences in each criterion for diagnosis of DIC. Methods: From January to December 2009, all adult patients admitted to our ICU were included in this study. Patients with hemorrhagic shock were excluded. Patients were diagnosed whether with DIC status or not on admission using each criterion by the International Society of Thrombosis and Haemostasis (ISTH) in 2001 and by Japan Association for Acute Medicine (JAAM) in 2005. The differences of scoring system and correlations with severity of underlying disease were observed between those criterions. Values were expressed as median. Data was analyzed by chisquare test. Peason’s correlation coefficient and Spearman’s rank correlation were used for correlation. P values less than 0.05 were considered significant. Results: Of four hundred and eighty patients, there were 34 patients with DIC (7.1%) [mortality 82%, SOFA 13] by ISTH’s criteria and 95 patients with DIC (19.8%) [mortality 63%, SOFA 11] by JAAM’s criteria. All patients with DIC by ISTH’s were included in the patients with DIC by JAAM’s. Consequently 61patients (42 men, 19 women; median age 71, mortality 52%, SOFA 8) were diagnosed with DIC by JAAM’s, but not by ISTH’s. In those 61 patients, DIC score had a no statistically correlation between ISTH’s and JAAM’s (r ⫽ 0.013, p ⫽ 0.923). There were significantly good correlations in scorings of platelet count (x103/␮l) (r ⫽ 0.832, p⬍0.0001) and FDP (␮g/ml) (r ⫽ 0.735, p⬍0.0001), while a no correlation in PT prolongation (seconds) (r ⫽ 0.321, p ⫽ 0.011) between ISTH’s and JAAM’s. SOFA score correlated with DIC score by ISTH’s (p ⫽ 0.0008), but did not correlate that by JAAM’s (p ⫽ 0.235). Conclusions: One possibility exists that the scoring of PT prolongation makes a difference in diagnosis of DIC between by ISTH’s and JAAM’s. JAAM’s diagnosis of DIC showed a low mortality, however it could not correlate with severity of disease.

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DIC (DISSEMINATED INTRAVASCULAR COAGULATION) STATUS ON ADMISSION INCREASES FOURFOLD ICU MORTALITY RATE

A RETROSPECTIVE REVIEW OF THE OFF-LABEL USE OF ACTIVATED RECOMBINANT FACTOR VII AT A TERTIARY CARE CENTER

Taijiro Goto, Noriko Saito, Yoshito Nagura, Munekazu Takeda, Ryuichi Moroi, Tomoyuki Harada, Mizuho Namiki, Miri Kang, Arino Yaguchi, Tokyo Women’s Medical University

Janice Pan, WakeMed, Justin Rak, Borgess Medical Center

Introduction: The occurrence of DIC (disseminated intravascular coagulation) in sepsis or in trauma patients during their clinical course doubled the risk of death were shown in previous studies. DIC status depends on the speed of consumption balanced by speed of synthesis of platelets and coagulation factors. Hypothesis: Our hypothesis is whether the occurence of DIC on admission effects on the mortality in critically ill patients. Methods: From January to December 2009, all adult patients admitted to our medico-surgical ICU were enrolled in this study. Hemorrhagic shock patients on admission were excluded. The criteria for DIC were those defined by the Subcommittee on Disseminated Intravascular Coagulation of the International Society of Thrombosis and Haemostasis [based on platelet count, FDP, PT, and fibrinogen concentration]; a score above 5 was considered as DIC. Values are expressed as mean ⫾ SD. Data was analyzed by chi-square test, Mann-Whitney U test and Peason’s correlation coefficient. P values less than 0.05 were considered significant. Results: Four hundred and eighty patients (292 men, 188 women; age range 18 –101 years [mean 59 ⫾ 22]) were studied. There were 34 DIC patients (7.1%) and 446 non-DIC patients on admission with no significant differences in age, sex or primary diagnosis. ICU mortality rate and SOFA score on admission were statistically significantly higher in DIC patients than in non-DIC patients (82 vs. 20.9 %, p⬍0.0001; 12 ⫾ 4.2 vs. 5 ⫾ 3.9, p⬍0.0001, respectively). DIC score correlated well with SOFA score (r ⫽ 0.56, p⬍0.0001), especially with its cardiovascular system (r ⫽ 0.46, p⬍0.0001) except for coagulation system (r ⫽ 0.52, p⬍0.0001). Each of platelet count, FDP, PT and fibrinogen were significantly different between DIC and non-DIC patients (13.8 ⫾ 13.5 vs. 21.9 ⫾ 13.1 x103/␮l, 134.3 ⫾ 68.5 vs. 24.6 ⫾ 100.5 ␮g/ml, 36.6 ⫾ 19.5 vs. 86.8 ⫾ 44.6 %, 183.8 ⫾ 180.8 vs. 303.3 ⫾ 136 mg/dl, respectively, p⬍0.0001). Conclusions: The prognosis with the occurrence of DIC on admission should be guarded, since it caused fourfold ICU death and related to the severity of the underlying disease. Especially delayed resuscitation from shock should be avoided.

Introduction: Recombinant activated factor VII is a prohemostatic agent with increasing off-label use in a wide range of conditions. To date, there have been few well designed studies providing guidance on dosing and administration or confirming its safety and efficacy when used off-label. Hypothesis: The purpose of this study was to describe the clinical practice and to review the efficacy, safety, and institutional drug cost of off-label activated recombinant factor VII use at a community tertiary care center. Methods: Medical records were retrospectively reviewed in patients receiving at least one dose of recombinant factor VII for off-label indications between January 1st, 2007 and January 1st, 2011. Outcomes evaluated included changes in transfusion requirements and coagulation parameters before and after recombinant factor VII. Patient disposition, lengths of stay, mortality, thromboembolic adverse effects (TAEs), and institutional costs were also assessed. Results: Fifty-two patients received recombinant factor VII for off-label indications, most commonly for vitamin K antagonist (VKA) reversal (21%) and spontaneous intracranial hemorrhage (19%). The median dose was 25.1 mcg/kg with an average drug acquisition cost of $4,831 per patient. There was a reduction in the PT/INR after administration of recombinant factor VII (17.05 seconds/2.1 vs. 2.1 seconds/0.7). The mean units of blood products used per patient were also reduced after recombinant factor VII (10.71 vs. 7.58), but was not statistically significant. Seventeen patients (33%) died. The highest and lowest rates of mortality by indication were surgical bleeding (50%) and VKA reversal (12.5%). Eight patients (15%) experienced TAEs; 75% of which were arterial. Conclusions: This study found that off-label use of recombinant factor VII was able to rapidly normalized PT/INR values but did not significantly reduce transfusion requirements. Off-label use of recombinant factor VII was also associated with high costs and a high incidence of TAEs, especially arterial TAEs.


Posters: Immunology 287

288

GENETIC PREDISPOSITION AND IMMUNE RESPONSE IN GRAM-POSITIVE AND GRAM-NEGATIVE SEPSIS: IS THERE A DIFFERENCE?

NATURAL KILLER CELL CYTOTOXICITY IS REDUCED IN PEDIATRIC SIRS/SEPSIS PATIENTS

Maja Surbatovic, Sonja Radakovic, Nikola Filipovic, Military Medical Academy, Dusko Jovanovic, Military Medical Academy, Belgrade, Serbia, Dragan Djordjevic, Military Medical Academy Introduction: Despite recent advances in critical care medicine, the mortality of severe sepsis in ICU remains high. There is tremendous variability seen in the clinical profile and outcome in septic patients. Whether host immune response differences in sepsis are related to different causative bacterial species remain unclear (1). Hypothesis: Differences in TNF-alpha, IL-10 and IL-1ra serum levels exist between Gram-positive and Gram-negative septic patients. Different genotype distributions of TNFalpha308, IL-101082, CD-14159 and IL-1ra gene intron 2 polymorphisms are associated with either Gram-positive or Gram-negative sepsis. Methods: Blood samples were obtained from 110 septic patients; 50% developed Gram-positive and 14.5% Gram-negative sepsis. In rest of the patients (35.5%) mixed bacteria were present. Concentrations of TNF-alpha, IL-10 and IL-1ra were determined in plasma using ELISA assays. Genotyping was performed by PCR– RFLP. Results: When comparing Gram-positive and Gram-negative group of septic patients we found that mean values of TNF-alpha were 3-fold, IL-1ra 2-fold higher in Gram-negative group and IL-10 3.7-fold higher in Gram-positive group (p⬍0.01). Distribution of IL-101082 genotypes was significantly associated with the type of bacteria (p⬍0.01). Relative risk of developing either Gram-positive sepsis in patients with AA genotype or Gram-negative sepsis in patients with GG genotype was 2.67; OR was 6.00. Distribution of CD14159 genotypes was also significanly associated with type of bacteria (p⬍0.05). Relative risk of developing either Gram-positive (CT genotype) or Gram-negative (TT genotype) sepsis was 1.63; OR was 3.11. No significant association of any TNFalpha308 or IL-1ra gene intron 2 genotypes with type of bacteria was found. Conclusions: Cytokine profile was significantly different in Gram-positive compared to Gram-negative septic patients. But, only in IL-10 both serum levels and genotype distribution were different between two groups. Distribution of IL-101082 and CD14159 genotypes clearly demonstrate genetic predisposition in sepsis. Reference: 1. Cohen J. Diagnosing sepsis: does the microbiology matter? Crit Care 2008; 12:145


E. Halstead, Penn State University, Joseph Carcillo, Children’s Hospital of Pittsburgh, Bastian Schilling, Theresa Whiteside, University of Pittsburgh Introduction: As of 2007 low/absent natural killer (NK) cell activity has been used as one of eight diagnostic criteria for hemophagocytic lymphohistiocytosis (HLH). Hypothesis: We hypothesized that NK cell cytotoxicity would be decreased in pediatric SIRS/sepsis patients as compared to healthy controls. Methods: We investigated the NK cytotoxic function of thirty-eight (38) pediatric intensive care patients who demonstrated signs and symptoms of either systemic inflammatory response syndrome (SIRS) and/or sepsis using a flow cytometric cytotoxicity assay. Results: Mean NK cell cytotoxicity was significantly reduced in pediatric SIRS/sepsis patients as compared to healthy controls (12.04⫾1.64 vs. 2.18⫾1.09 LU20/107 PBMC, p⬍0.001). When the NK cell cytotoxicity was corrected for the percentage of CD56dim CD16⫹ cytotoxic NK cells of PBMC, the difference in cytotoxicity was negated (2.72⫾0.84 vs. 3.48⫾1.64 LU20/105 CD56dim CD16⫹ NK cells). Conclusions: This data indicates that pediatric SIRS/sepsis patients have quantitative rather than a qualitative NK cell cytotoxic dysfunction. Assaying NK function while in the midst of a SIRS/sepsis episode may not be diagnostically useful. By calculating lytic units per cytotoxic NK cells, the discrimination of SIRS/sepsis versus disease processes where there is a qualitative dysfunction of cell-mediated cytotoxicity such as primary (familial) HLH should be possible.

Posters: Infection-1 289

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RISK FOR ENDOCARDITITS IN PATIENTS WITH METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA AND SEVERE SEPSIS

FLUCONAZOLE VERSUS ECHINOCANDIN FOR CANDIDA GLABRATA FUNGEMIA

Anindita Chowdhury, Vinay Patel, Christian Woods, Andrew Shorr, Washington Hospital Center Introduction: Methicillin-resistant Staphylococcus aureus(MRSA) remains an important cause of bacteremia and often results in severe sepsis(SS) and sometimes patients progress to endocarditis.Factors associated with the development of endocarditis remain unclear.Specifically, the impact of both an elevated minimum inhibitory concentrations(MIC) for MRSA to vancomycin(VAN) and severity of illness on the potential for endocarditis are uncertain. Hypothesis: We hypothesized that severity of illness and the MRSA MIC to VAN correlate with the risk for endocarditis in MRSA bacteremia with SS. Methods: We retrospectively identified(Jan 2009- Dec 2010) persons diagnosed with MRSA bacteremia and SS.The eventual diagnosis of endocarditis served as the primary endpoint.We examined potential confounders (demographics, comorbidities, severity of illness, infection characteristics).We employed logistic regression to determine independent factors associated with endocarditis and created a risk score to determine the likelihood of endocarditits.We determined the score’s screening characteristics by calculating the area under the receiver operating characteristic curve (AUROC). Results: The final cohort included 225 subjects and endocarditis arose in 12.4%, while an MIC of 2 ␮cg/ml occurred in 5.3%.We noted endocarditis in 11.3% if the MICs was ⬍2 ␮cg/ml compared to 33.3% when the MICs ⫽ 2 ␮cg/ml (p ⫽ 0.047).Subjects in the ICU when diagnosed with bacteremia were 4.1 times (95% CI: 1.7–10.1, p⬍0.001) more likely to suffer endocarditis.Four variables were independently linked with endocarditis:ICU care, underlying CHF, primary bacteremia or infection related to an intravascular device,and an MIC ⫽ 2 ␮cg/ml.We assigned points in the score as follows:2 points for ICU care;1 for the remaining 3 factors.As the total score rose from 0 to 5, the prevalence of endocarditis climbed from 0% to 66.7%(p⬍0.001).The risk score AUROC equaled 0.77(95% CI:0.68 – 0.86). Conclusions: Endocarditis remains a frequent complication of MRSA bacteremia and SS.Although elevated MICs to VAN in MRSA occur rarely, they are linked to endocarditis, as is severity of illness.A simple score based on baseline characteristics stratifies subjects as to their risk for endocarditis.

Gregory Eschenauer, Minh-Hong Nguyen, University of Pittsburgh Medical Center, Shu-Wen Lin, National Taiwan University, Cornelius Clancy, University of Pittsburgh Medical Center, Kenneth Klinker, Shands Hospital, Yee-Chun Chen, National Taiwan University, Peggy Carver, University of Michigan College of Pharmacy, Ryan Shields, Brian Potoski, University of Pittsburgh Medical Center, Simon Lam, Cleveland Clinic Introduction: Current IDSA guidelines recommend echinocandin (EC) therapy for C. glabrata fungemia with conversion to fluconazole (FLU) upon confirmation of azole susceptibility. However, evidence supporting the superiority of EC therapy over FLU for C.glabrata infection is lacking. Hypothesis: We sought to delineate whether FLU is equally effective as EC therapy for the treatment of C. glabrata fungemia. Methods: We performed a multi-center, retrospective study of 131 adult patients with C. glabrata fungemia who received ⬎5 days of therapy with either FLU or an EC as their first antifungal treatment. The primary outcome was global response at day 14, which was defined as a composite of clinical (survival and resolution of signs/ symptoms) and microbiologic success. Secondary outcomes included day 28 global response rates and survival at days 14, 28, and at 12 weeks. Results: Baseline characteristics were similar between the 2 groups, except that more patients who received FLU had solid organ malignancy (45% vs 21%, p ⫽ 0.004), whereas more patients who received EC were solid organ transplant (SOT) recipients (18% vs 4%, p ⫽ 0.02). Patients receiving EC also had a higher median modified Acute Physiology Score (APS) (9.6⫾ 4.5 vs 8.1⫾ 4.0; p ⫽ 0.047). There was no difference between the groups regarding the need for renal replacement therapy or vasopressors. Global success rates at Day 14 (FLU: 86% vs. EC: 76%, p ⫽ 0.16) and Day 28 (FLU: 61% vs. EC: 63%, p ⫽ 0.81) were not significantly different between the 2 groups on univariate analysis. However; after adjusting for malignancy, SOT, APS, fluconazole sensitivity, and ICU admission; EC therapy was independently associated with failure at day 14 (AOR: 4.63; 95% CI: 1.4 –15.2; p ⫽ 0.011). Survival rates between groups were similar for all evaluated time points. Conclusions: FLU, as employed at our centers, had similar success rates as EC for the treatment of C. glabrata fungemia. The multivariate finding of higher failure rate among the EC group warrants further investigation.

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A MULTICENTER EVALUATION OF PROLONGED EMPIRIC ANTIBIOTIC THERAPY IN ADULT INTENSIVE CARE UNITS IN THE UNITED STATES

PULMONARY IMMUNE IMPAIRMENT AFTER CARDIAC SURGERY PRECEDES POSTOPERATIVE PNEUMONIA

Zachariah Thomas, Farooq Bandali, Rutgers, the State University of New Jersey, Jayashri Sankaranarayanan, Tom Reardon, Keith Olsen, University of Nebraska Medical Center Introduction: Limited data suggests that empiric antibiotics are often continued in the critically ill in the absence of confirmed infection, however, prospective multicenter data are lacking. Hypothesis: We hypothesized that prolonged empiric antibiotic therapy (PEAT) is common in the intensive care unit (ICU). We defined PEAT as empiric antibiotics that are continued for ⱖ72 hours in the absence of adjudicated infection. Methods: A prospective observational prevalence study was conducted over a 3-day period. Demographic, physiologic, and bacteriologic data were collected for each patient. The indication for each antibiotic the patient received was noted and the presence of infection was adjudicated using standard definitions from the Centers for Disease Control. The PEAT rate was calculated as the number of empiric antibiotics that were continued for ⱖ72 hours in the absence of adjudicated infection divided by the total number of empiric antibiotics. Results: A total of 68 ICUs from 27 health centers provided 998 patient case reports. The mean age and APACHE II score of the entire cohort were 58.3 ⫾ 17.4 years and 17.1⫾7.9, respectively. The majority of the cohort (66%) received at least one antibiotic for either prophylactic therapy, definitive therapy, or empiric therapy. A total of 649 unique antibiotics were prescribed as empiric therapy to 366 patients. Of the 649 empiric antibiotics, 377 (58%) were categorized as PEAT. Suspected pneumonia accounted for approximately 60% of the empiric antibiotic use. Conclusions: Nearly 60% of all empiric antibiotics ordered in critically ill patients are continued for ⱖ72 hours in the absence of adjudicated infection. To our knowledge, this is the first multicenter study to describe the prevalence of PEAT.

Katharina Chalk, Charite University Medicine, Anaesthesiology, Christian Meisel, Charite University Medicine, Institute of Medical Immunology, Claudia Spies, Karin Thuenemann, Charite University Medicine, Anaesthesiology, Joerg LInneweber, Charite University Medicine, Cardiovascular surgery, Michael Sander, Charite University Medicine, Anaesthesiology Introduction: Patients undergoing cardiac surgery have an elevated risk of pulmonary complications. We, therefore, characterized the function of alveolar macrophages (ALMOs) after surgery in comparism to peripheral blood mononuclear cells (PBMCs). HLA-DR and TLR-2/-4 expression as well as the capacity to produce cytokines after LPS stimulation were determined to assess functional changes. To identify high risk patients we correlated these changes to the development of postoperative pneumonia. Hypothesis: Pulmonary immune impairment contributes to the development of postoperative pneumonia. Methods: After ethical approval and written informed consent 32 patients undergoing elective CABG surgery were included in this pilot study. Peripheral blood cells and bronchoalveolar lavages were collected directly after anaesthesia induction and two hours after separation from CPB. HLA-DR expression was quantified using a standardized flow cytometric assay. Leukocytes subsets and TLR-2/-4 expression on ALMOs were assessed by flow cytometry and LPS dependent cytokine production was measured via CBA inflammation assay. Postoperative pneumonia was determined according to the criteria of the Center of Disease Control. Statistical analysis was performed with the Mann-Whitney-U and Wilcoxon test. Results: The three patients with postoperative pneumonia showed significantly reduced HLA-DR (p ⫽ 0.027) and TLR-4 expression (p ⫽ 0.042) on ALMOs after surgery. On PBMCs no significant phenotypic or functional immune markers were observed with regard to postoperative pneumonia. All patients had a significant lower HLA-DR expression after surgery (PBMCs p ⫽ 0.001; ALMOs p ⫽ 0.001). Conclusions: Our results indicate that an early immune impairment of the lung predisposes for postoperative pneumonia. Interestingly patients with postoperative pneumonia had a significant reduction of HLA-DR expression on ALMOs but not on PBMCs. This indicates that besides the systemic immune suppression there is a local pulmonary immune impairment. This could serve as a marker for interventional approches providing perioperative immune regulation in the lung in these high-risk patients to counteract their postoperative susceptibility to pneumonia.


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NATURAL HISTORY AND OUTCOMES OF VENTILATED PATIENTS WITH HEAVY TRACHEAL COLONIZATION AND INFECTION

EVALUATION OF CLINICAL SIGNS FOR THE DIAGNOSIS OF VENTILATOR-ASSOCIATED RESPIRATORY INFECTIONS (VARI)

Yuxiu Lei, Lahey Clinic Medical Center, Jana Hudcova, Lahey Clinic Medical Center, Tufts University School of Medicine, Akmal Sarwar, Lahey Clinic Medical Center, Robin Ruthazer, Tufts Medical Center, Donald Craven, Lahey Clinic Medical Center,Tufts University School of Medicine Introduction: We studied the natural history of tracheal aspirates (TA) in intubated patients and compared clinical outcomes of patients based on the degree of colonization and infection. Hypothesis: Heavy tracheal colonization will not affect patients’ outcomes when compared with infection. Methods: We collected daily quantitative (Q), semiquantitative (SQ) TA and clinical data in 234 patients who were ventilated ⱖ48h. Heavy bacterial colonization (HC) was defined as SQ-TA ⱖmoderate (⫹⫹⫹) growth. VARI was defined as SQ-TA ⱖ⫹⫹⫹ plus clinical signs of infection including (1) two of : temperature ⱖ100.4°F, leukocytosis ⱖ12,000/ml, purulent TA sample or (2) clinical pulmonary infection score (CPIS) ⱖ6. The outcomes of patients with HC were compared to the patients with insignificant colonization (IC ⫽ SQ-TA ⱕ⫹⫹) as well as with VARI, using Wilcoxon rank sum test. Results: Excellent correlation was found between SQ-TAⱖ⫹⫹⫹ andQ-TA ⱖ10 5 cfu/ml (? ⫽ 0.86). 100 patients (42%) were heavily colonized. Predominant pathogens isolated were methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Enterobacterieaceae, Pseudomonas, and Acinectobacter. At 48h, 29% of patients had HC, and 12% of patients had VARI. Rates of HC and VARI kept steady for the first 8 ventilator days, reached 33% on the 9th day and increased to 40% at 15th day of intubation. The VARI rate followed the same trend: 17% at 9th day and 20% at 15th day. Median incident time of HC was 8 days. Comparison of outcomes of HC with IC patients showed significantly longer extubation time (Tex), ICU and hospital stay, but no difference in mortality. Outcomes of patients with VARI were similar to outcomes HC patients except that Tex was significantly longer in VARI patients. Conclusions: Surprisingly almost one third of patients were heavily colonized upon entering the study after 48 hours of intubation. Patients with heavy colonization and VARI had worse outcomes when compared to patients not colonized or with insignificant bacterial growth. Heavy colonization is a risk factor for VARI and is associated with poor outcome. Investigation of conditions leading to early heavy colonization is warranted. Grant: Pfizer and R.E.Wise.

Jana Hudcova, Lahey Clinic Medical Center, Burlington, Yuxiu Lei, Lahey Clinic, Robin Ruthazer, Tufts Medical Center, Akmal Sarwar, Lahey Clinic, Donald Craven, Tufts University School of Medicine, Lahey Clinic Medical Center Introduction: Diagnosis of VARI, which includes ventilator-associated tracheobronchitis (VAT) and pneumonia (VAP), is based on moderate/heavy bacterial growth from a tracheal aspirate (TA), clinical signs and ⫾ radiological findings. We compared different clinical criteria used for the VARI diagnosis in this natural history study. Hypothesis: Different clinical criteria yield different incidence of VARI. Methods: We studied 188 mixed ICU patients intubated for ⱖ48h, using daily quantitative (Q) and semi-quantitative (SQ) TA surveillance cultures that were not reported to providers. Three different sets of clinical signs were compared: CPISⱖ6, CLIN1 (two of: temperature ⬎38°C, leukocytosis ⬎12,000/ mm3, purulent sputum), and CLIN2 (fever and/or leukocytosis and purulent sputum and/or hypoxia). SQ-TA and clinical criteria (⫾1 day of positive culture) were compared to Q-TA in terms of sensitivities, specificities, and tests of correlated proportions. Incidence of VARI (micro⫹clinical criteria) was also calculated. Results: Q-TA 105 was positive in 46% and SQ-TA ⫹⫹⫹ in 44% patients. Q-TA 106 was positive in 31% and SQ-TA ⫹⫹⫹⫹ in 27% patients; showing an excellent agreement between both SQ and Q tests (kappas ⱖ0.85). Correlation of clinical signs with Q-TA 105 in terms of sensitivities was 51% for CPISⱖ6, 62% for CLIN1, and 69% for CLIN2, in terms of specificities: 81% for CPISⱖ6, 61% for CLIN1, and 49% for CLIN2, and in terms of kappa: 0.33 for CPIS, 0.22 for CLIN1, and 0.17 for CLIN2. Incidence of VARI was 20% with CPIS, 23% with CLIN1 and 27% with CLIN2 when SQ-TA ⫹⫹⫹ criteria used and decreased to 13% (CPIS), 15% (CLIN1), and 17% (CLIN2) with SQ-TA ⫹⫹⫹⫹ criteria. Conclusions: Incidence of VARI diagnosis ranged from 13%-27% based on criteria used. The lowest incidence was observed with the CPIS, intermediate with CLIN1 and the highest incidence with CLIN2. CPIS is the most specific but the least sensitive test out of the three clinical tests compared, while CLIN2 is the most sensitive but the least specific test. More strict micro criteria reduced the incidence significantly. Further studies are needed to determine the risk benefit ratio of earlier therapy for VARI to improve patient outcomes. Pfizer;R Wise.

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DOES ANTIBIOTIC THERAPY REDUCE WOUND INFECTION AFTER PERCUTANEOUS DILATATIONAL TRACHEOTOMY IN CRITICALLY ILL PATIENTS IN THE INTENSIVE CARE UNIT?

VENTILATOR-ASSOCIATED PNEUMONIA IN PEDIATRIC TRAUMA PATIENTS: ASSESSMENT OF RISK FACTORS AND OUTCOMES IN A RURAL POPULATION

Hideharu Hagiya, Hiromichi Naito, Shuji Okahara, Shingo Hagioka, Naoki Morimoto, Tsuyama Central Hospital Introduction: Compared to surgical tracheotomy (ST), percutaneous dilatational tracheotomy (PDT) is less expensive, causes fewer complications, and needs lesser time. A previous study states the incidence rate of post-PDT wound infections would be less than that of ST. Generally, prophylactic antibiotic is not administered or recommended during the perioperative period because of the lack of adequate evidence about its effectiveness. Hypothesis: Antibiotic therapy during the perioperative period of PDT reduces the incidence of wound infections. Methods: PDT was performed for 385 patients using Ciaglia Blue Rhino technique (NEO PERC; Tyco Healthcare, Tokyo, Japan) with bronchoscopic assistance. We checked the medical records whether antibiotics were administered during the perioperative period of PDT or not. The wound infection was defined as redness, tenderness, or swelling around the tracheotomy site within 30 days after PDT. The data were analyzed using chi-square test. Results: A total of 297 cases were analyzed. The 3 most commonly used antibiotics were penicillins (25.5%), cephems (22.9%), and anti-MRSA drugs (14.7%). Totally, the wound infections were noted in 7 cases (incidence rate, 2.36%). Of 69 cases without antibiotic administration, 5 (incidence rate, 7.25%) developed wound infections, whereas 2 (incidence rate, 0.88%) developed wound infections among 228 cases with antibiotics (p ⫽ 0.002; risk ratio, 8.82, 95% confidence interval; 1.67– 46.6). Of these 7 cases of wound infections, no cases of death were recorded, 1 case required incision and pus drainage procedure, while the others were treated with antibiotics. Focusing on early period after PDT (within 7 days), 5 cases occurred the wound infection. All of these infection cases were among 69 cases without antibiotic administration, whereas no wound infections were noted among 228 cases with antibiotics (Yates’ continuity correction, p⬍0.001). Conclusions: Administration of prophylactic antibiotics reduced the incidence rate of post-PDT wound infection. We suggest administering antibiotics during the perioperative period of PDT to prevent wound infection.


Megan Jensen, Wesley McMillian, Fletcher Allen Health Care, Turner Osler, University of Vermont, John Ahern, Cassie Barton, Timothy Higgins, Amelia Hopkins, Fletcher Allen Health Care Introduction: While ventilator-associated pneumonia (VAP) remains one of the most common nosocomial infections in the pediatric intensive care unit (PICU), limited data has been published on its impact on pediatric trauma patients. Hypothesis: This study was conducted to determine the incidence and characterize risk factors, microbiology, and associated outcomes of VAP in pediatric trauma patients. Methods: A retrospective observational cohort study was undertaken at a rural, level 1 trauma center. An in-hospital trauma database identified all pediatric trauma patients admitted between January 1, 2000 and December 31, 2009. A medical chart review was conducted on patients mechanically ventilated ⱖ48 hours. The Center for Disease Control and Prevention age-based clinical criteria was used to define VAP. Results: A total of 917 pediatric trauma patients were admitted during the ten-year study period. Eighty-two patients were mechanically ventilated ⱖ48 hours. Four patients met the study criteria for VAP, making the incidence of VAP 0.4% of all trauma admissions or 5.9% of those mechanically ventilated ⱖ48 hours. The VAP rate was 8.4 cases/1000 ventilator-days (95% CI, 2.3–21.4). Patients who developed VAP had a significantly longer duration of mechanical ventilation (median, 15.0 vs 5.0, p ⫽ 0.01) and PICU length of stay (LOS) (median, 19.0, vs 7.0, p ⫽ 0.03) compared to those who did not develop VAP. There were no differences between hospital LOS (median, 25.5 vs 15.0, p ⫽ 0.14) and in-hospital mortality (0 vs 8%, p ⫽ 1.00) between groups. Conclusions: The rate of VAP in pediatric trauma patients appears to be higher than the rate of VAP in the general PICU population, and is associated with prolonged mechanical ventilation and longer PICU LOS. However, VAP did not appear to be associated with an increase in mortality.


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PREVALENCE AND FACTORS ASSOCIATED WITH PROLONGED SURGICAL PROPHYLAXIS: ANALYSIS FROM THE PROLONGED EMPIRIC ANTIBIOTIC THERAPY STUDY

COMPARISON OF CRITICALLY-ILL CHILDREN WITH SEASONAL VS PANDEMIC INFLUENZA IN A NEW YORK CITY CHILDREN’S HOSPITAL

Farooq Bandali, Saint Peter’s University Hospital, Zachariah Thomas, Hackensack University Medical Center, Jayashri Sankaranarayanan, Tom Reardon, Keith Olsen, University of Nebraska Medical Center

John Baird, Thyyar Ravindranath, Columbia University Medical Center, Adnan Bakar, Morgan Stanley Children’s Hospital, Amanda Buet, Lisa Saiman, Columbia University Medical Center

Introduction: Prolonged use of antibiotics for surgical prophylaxis has been associated with increased resistance rates. The Surgical Care Improvement Project (SCIP) performance measures recommend that prophylactic antibiotics should be discontinued within 24 hours after the end of surgery. Hypothesis: To determine the frequency and the factors associated with prolonged use (⬎24 hours) for surgical prophylaxis in adult ICU patients in the United States. Methods: A subgroup analysis was conducted for patients receiving surgical prophylaxis in the Prolonged Empiric Antibiotic Therapy (PEAT) study. The PEAT study was a 3-day multi-center, prospective observational prevalence study. Patient factors associated with prolonged surgical prophylaxis (PSP) were determined using univariate logistic regression analyses. Results: There were a total of 998 adult patients from 68 intensive care units (ICUs) across 27 healthcare facilities. One hundred twenty-nine patients (13%) were on one or more antibiotics for either medical or surgical prophylaxis. Of this subset, 83 patients were on greater than or equal to 1 antibiotic for surgical prophylaxis. There were 43 patients (52%) that received surgical prophylaxis for less than or equal to 24 hours and 40 patients (48%) for greater than 24 hours. Digestive and trauma related procedures represented the majority of cases of PSP. The patients who received PSP were older (mean age 57.5 years versus 54.2 years) and were in the ICU for a longer period prior to the study (mean 4.2 days versus 1 day). There was an association between patients who received PSP and ICU length of stay prior to the start of the study (unadjusted odds ratio, OR 1.77, 95% CI: 1.30 –2.41). Patient’s age, gender, admitting service, ICU admission diagnosis, APACHE II Score, SOFA score, SIRS score and type of surgery were not associated with PSP. Conclusions: Approximately 50% of critically ill patients received prolonged surgical prophylaxis and this was associated with ICU length of stay prior to the start of the study.

Introduction: We previously described the epidemiology and clinical presentations of children admitted to our children’s hospital with 2009 novel H1N1 (pandemic) influenza A. We found that critically-ill children had a broad spectrum of illness severity and a low mortality rate. Hypothesis: We hypothesized that critically-ill children with seasonal (non-pandemic) influenza would have a similar spectrum of illness severity. Methods: We performed a retrospective study to assess characteristics of patients ⬍18 years old admitted to the PICU from January 2000 to April 2009 with ⬎1 positive test for influenza. We compared illness severity and outcome to our previously described cohort of PICU patients with pandemic influenza (n ⫽ 50). Results: We identified 20 patients with seasonal influenza (A/B: 16/4). Compared to those with pandemic influenza, patients with seasonal influenza were younger (median: 0.6 vs 4.4 years; p⬍0.0001) and their PICU length of stay was longer (median: 9 vs 4 days; p ⫽ 0.05). In contrast, the proportions of children with seasonal vs. pandemic influenza were similar in terms of underlying conditions excluding young age (90 vs 66%; p ⫽ 0.07), non life-threatening (upper respiratory infection, gastroenteritis, or self-limited infantile apnea) vs life-threatening (bronchiolitis, pneumonia, or myocarditis) influenza symptomatology (seasonal: 30 vs 70%, pandemic: 43 vs 58%; p ⫽ 0.42), PRISM III score (median: 3 vs 2; p ⫽ 0.98), respiratory failure (68 vs 56%; p ⫽ 0.6) and its duration (median: 11 vs 7 days; p ⫽ 0.44), use of high frequency oscillatory ventilation (10 vs 8%; p ⫽ 1) and ECMO (5 vs 2%; p ⫽ 0.49), peak oxygenation index (median: 23 vs 10; p ⫽ 0.29), lowest PaO2/ FiO2 (median: 132 vs 115; p ⫽ 0.87), bacterial superinfection (25 vs 8%; p ⫽ 0.21), and mortality (10 vs 2%; p ⫽ 0.19). Conclusions: Few children were critically-ill at our children’s hospital with seasonal influenza during the decade prior to the 2009 pandemic: these children were younger and had a longer PICU stay compared to those with pandemic influenza. However, illness severity of seasonal vs pandemic influenza was otherwise similar.

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EVALUATION OF VANCOMYCIN SUSCEPTIBILITY TESTING METHODS ON TREATMENT FAILURE IN A CRITICALLY ILL POPULATION

HIGH MORTALITY IN PATIENTS WITH ENDEMIC MYCOSES WHO REQUIRE INTENSIVE CARE UNIT SUPPORT

Jonathon Pouliot, Marcus Dortch, C. Buddy Creech, Addison May, Vanderbilt University Medical Center Introduction: To determine which of two methods (e-test or an automated system) used to measure vancomycin Minimum Inhibitory Concentration (MIC) for methicillin-resistant Staphylococcus aureus (MRSA) isolates, correlate with treatment failure. Hypothesis: Vancomycin MIC for MRSA as measured by e-test compared to automated system is a better predictor of treatment failure in the critically ill. Methods: A single center retrospective cohort study was conducted in patients admitted to either a surgical or trauma ICU. Isolates were identified based on positive MRSA cultures obtained from patients treated for infection. Isolates were then matched to clinical data related to treatment course. Vancomycin failure was defined as positive MRSA culture on therapy, change to another therapy based on clinical judgement, or mortality during therapy. Logistic regression analyses were performed for both MIC tests to assess correlation with vancomycin failure. Results: Of isolates identified, 74 unique MRSA isolates were identified as having vancomycin MIC data by e-test and 34 of those isolates also had MIC data by automated system. A majority of the isolates were from bronchoalveolar lavage/sputum cultures (65%) or blood (12%). Patient demographics were similar between all patients and subset of isolates with MIC results from both tests. The overall mean admission APACHE II score was 18.8. A statistically significant mean difference of 1.15 (95% CI 0.097–1.35, p⬍0.001) was found between e-test and automated system MIC values. There was no statistically significant correlation was found between the testing methods and vancomycin treatment failure. A weak positive correlation was found between e-test MIC values and both ICU (r2 ⫽ 0.207, p⬍0.001) and hospital length of stay (r2 ⫽ 0.203, p⬍0.001) however no such correlation was found with automated system MIC values. Conclusions: The results indicate that there did not appear to be a correlation between MIC values and vancomycin failure with either method of MIC determination. This study showed that higher MIC values were reported by e-test than automated test. Additionally, there did appear to be a weak positive correlation between e-test MIC and ICU/hospital length of stay.

Anil Paturi, Mayo Clinic, Mohammed Alhyraba, Everett Providence Hospital, Bekele Afessa, Larry Baddour, Mayo Clinic Introduction: In the United States, endemic mycoses include infections due to dimorphic fungi, including Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides immitis. The spectrum of diseases caused by these infections includes severe illnesses that can require intensive care management. Respiratory failure, ARDS/ALI, failure of other organ systems, and severe sepsis/septic shock have been described in prior case reports and small case series. The literature lacks a large sample that examines endemic mycoses in a critically ill population that requires intensive care support. We conducted an institutional review of all endemic mycoses in patients admitted to the intensive care units (ICU) at Mayo Clinic, Rochester, USA over 15 years (1995–2010). The aim of this study is to report the outcomes of patients diagnosed with endemic mycoses requiring intensive care support. Hypothesis: Patients admitted with endemic mycoses to an intensive care unit have high morbidity and mortality. Methods: This is a retrospective study of patients with endemic mycosis admitted to the ICU. They were identified by use of multiple methods including review of microbiologic and pathologic results of clinical specimens. Electronic medical records of all these patients were abstracted for relevant information regarding demographics and hospital course. Descriptive statistics were used to summarize data. Results: Thirty-four patients (23 males, 11 females) were included in the study and their mean (SD) age was 60 (14.8) years. The cases included 21 (62%) histoplasmosis, 11 (32%) blastomycosis and 2 (6%) coccidiomycosis. Twenty-one (62%) patients developed ARDS/ALI and 26 (77%) required mechanical ventilation, 12 (35%) required renal replacement therapy and sixteen (47%) required vasopressor drugs. The median (interquartile range) duration of ICU stay among survivors was 6.5 (2–10) days. The 28-day mortality was 47% (16 patients). Conclusions: Patients admitted with endemic mycoses to an intensive care unit have high morbidity and mortality. Future investigation should include an evaluation of risk factors that predispose to mortality among patients who require intensive care support.



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RETROSPECTIVE EVALUATION OF THE INCIDENCE OF VANCOMYCIN AND/OR PIPERACILLIN-TAZOBACTAM INDUCED ACUTE RENAL FAILURE

PREVALENCE OF EXTENSIVELY DRUG-RESISTANT GRAM NEGATIVE BACILLI IN SURGICAL INTENSIVE CARE IN EGYPT

Thaddaus Hellwig, South Dakota State University/Sanford USD Medical Center, Rhonda Hammerquist, Beth Loecker, Jaime Shields, Sanford USD Medical Center

Ahmed Hasanin, Samaa Wageh, Ahmed Gado, Ahmed Lotfy, Sara Farouk, Ahmed Mukhtar, Cairo University

Introduction: Vancomycin and piperacillin-tazobactam are antibiotics used to treat a variety of infections. Acute renal failure (ARF) has historically been associated with vancomycin while incidence rates of ARF with piperacillin-tazobactam are limited. Anectdotal observations at our facility have demonstrated higher than expected rates of ARF with piperacillin-tazobactam. Hypothesis: The rate of ARF with piperacillin-tazobactam is equal to rates with vancomycin. Methods: Retrospective review of all patients 18 years and older admitted to Sanford USD Medical Center receiving either vancomycin and/or piperacillin-tazobactam for at least 48 hours over a 6 month period. ARF was defined as either an increase of serum creatinine (SCr) equal to ⱖ0.5 mg/dL or a ␮ 50% increase from baseline. Data collection included SCr, vancomycin levels, nephrotoxic medications, additional antibiotics, unit of hospital during initiation of therapy (floor or ICU), dialysis, and death. A p-value (␣ ⫽ 0.05) was used for comparisons between treatment groups and development of ARF. The 95% confidence intervals and p-values were also computed for further analysis. Results: A total of 735 subjects were evaluated with an overall rate of 10.5% of subjects developing ARF in the groups of vancomycin, piperacillin-tazobactam, or combination therapy. The respective proportions of all patients developing ARF were 4.9%, 11.1%, and 18.6% (vancomycin vs. piperacillin-tazobactam, p ⫽ 0.014; vancomycin vs. combination, p ⫽ 0.0001); respective proportion of patients within the ICU developing ARF were 6.0%, 12.2%, and 21.2% (vancomcyin vs. piperacillintazobactam, p ⫽ 0.279; vancomycin vs. combination, p ⫽ 0.005). Significant characteristics leading to ARF included: unit of admission during initiation of antibiotics and total number of nephrotoxic medications. There was no statistical difference noted in baseline SCr or number/duration of additional antibiotics leading to ARF. Conclusions: Piperacillin-tazobactam demonstrated a significant increased rate of ARF compared to vancomycin in the overall population but not in the ICU population. Combination therapy showed an increased rate of developing ARF compared to vancomycin amongst both populations.

Introduction: The prevalence of extensively drug resistance gram negative (XDR-GNB) is rapidly progressing, however, in Egypt data are sparse. Hypothesis: We conducted the present study to quantify the incidence, risk factors, and outcome of patients harboring XDR-GNB. Methods: Prospective study of all patients admitted to surgical intensive care SICU over 6-month period in a teaching hospital in Egypt. XDR-GNB were defined as any gram negative bacilli resistant to all but one or two classes of antimicrobial agents. Patients with XDR-GNB compared with those sustaining non-extensively drug-resistant infection. A multivariate logistic regression model was created to identify independent predictors of multi-resistance. Results: In 120 patients admitted to SICU, 48 (40%) developed XDR-GNB infection. their mean age was 40 ⫾6, and APACHE II was 23 ⫾ 10. During the 6-month surveillance period, 95 nonduplicate species were isolated. The most common isolates, in order of frequency, were Acintobacter 28 (30% of isolates); Pseudomonas aeruginosa 26 (27.3 %); Klebsiella species 18 (19 %); and Escherichia species (15.7%). Colistin was the most effective antibiotic (100% susceptibility), whereas resistance against cephalosporins was 83% fluoroquinolones was 70%, and carbapenems was 60 %. Mortality in the XDR group also was higher; than non-XDR group ((52.1% vs. 25 %, p ⫽ 0.04). Septic shock at admission (p ⫽ 0.1), mechanical ventilation (p ⫽ 0.04), and reoperation (p ⫽ 0.02) were risk factors for multi-resistance in univariate analysis. Multivariable analysis identified only reoperation as independent risk factors for harboring XDR-GNB (OR, 4.1; 95% CI, 1.1–16.1; p ⫽ 0.04). Conclusions: Extensively drug-resistant gram negative infections are frequent and associated with high mortality. Increase antibiotic resistance is an alarming health care issue in Egypt which emphasizes the need to rigorously implement infection control practices, to minimize the risk of resistance development and spread.

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SAFETY OF VORICONAZOLE AND ITS INTERACTING MEDICATIONS IN TAIWAN

CHARACTERIZATION OF STAPHYLOCOCCUS LUGDUNENSIS ENDOCARDITIS IN PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICES

Yu-Ju Tseng, National Taiwan University Hospital, Wei-Ting Chen, Koo Foundation Sun Yat-Sen Cancer Center, Yee-Chun Chen, Li-Jiuan Shen, Fe-Lin Wu, Shu-Wen Lin, National Taiwan University Introduction: Voriconazole (VORI), a triazole antifungal agent, was approved for use in Taiwan in 2003. It is metabolized via CYP enzymes, and also inhibits CYP 2C19, 2C9, and 3A4 activities. Poor CYP activities and other factors may increase plasma VORI concentrations and lead to adverse events (AEs), such as liver enzyme elevations, visual disturbance, and hallucination, etc. Many interactions between VORI and other drugs have been concerned, especially in critically ill patients. However, limited data of its safety evaluation in Taiwanese patients have been reported. Hypothesis: The purpose of this study was to evaluate the safety of VORI and medications which have potential major interactions with VORI. Methods: This retrospective cohort study reviewed medical records of patient who received systemic VORI at National Taiwan University Hospital from January 1st until Dec 31st, 2008. Patients’ concomitant medications and AEs were analyzed. Safety of medications with potential major interactions with VORI was evaluated, too. Results: Among 94 patients prescribed systemic VORI, 70% had hematological malignancies. Seven (7.4%) patients were hepatitis B or C carriers. Approximately half of the patients were diagnosed proven or probable invasive fungal infections. The median treatment duration was 29 days (1⬃701 days). A total of 55 AEs were identified, with the most common AEs were abnormal liver functions (31/94, 33%) followed by visual disturbance (10/ 94, 10.6%). Three AEs were determined “definite” and 24 were “probable.” Nine patients developed AEs (over-therapeutic drug levels, renal/hepatic toxicities, elevated INR) among 23 patients who used medications potentially interacting with VORI, including immunosuppressants, anticonvulsants, amiodarone, and warfarin, etc. Conclusions: VORI demonstrated relatively high AE rate in Taiwanese patients compared to other ethnicity in the literatures. CYP enzyme polymorphism, underlying diseases and concomitant medications may play important roles in the safety of VORI therapy. VORI concentration monitoring and hepatitis status should be considered as routine laboratory tests in Taiwan.


Yu-Tzu Tsao, Taoyuan General Hospital, Taiwan, Shih-Wei Lee, Jin-Chyr Hsu, Feng-Ming Ho, Wei-Jie Wang, Taoyuan General Hospital Introduction: Although the application of cardiac implantable electronic devices (CIED) has greatly increased over the past few decades, CIED endocarditis is an occasional but challenging complication. Recently, Staphylococcus lugdunensis is an importantly emerging pathogen among coagulase-negative staphylococci endocarditis. However, a detailed phenotypic characterization of S. lugdunensis endocarditis in patients with CIED has not been addressed. Hypothesis: We sought to analyze the cases on this subject and to test whether the defect of innate immunity may play a permissive role in host susceptibility to non-ischemic myocardial necrosis. Methods: We conducted a systematic PubMed/Medline review covering the period between 1989 and 2011. All cases included had CIED in use and met the modified Duke criteria of infective endocarditis with isolates of S. lugdunensis. The clinical features, predisposing factors, echocardiographic findings, and therapeutic strategies/outcomes were evaluated and polymorphonuclear neutrophil (PMN) functions were examined. Results: Eleven patients of CIED endocarditis caused by S. lugdunensis were recognized. The mean age was 61.7⫾11.2 years, with a male preponderance (72.7%). Six patients (54.5%) had undergone re-manipulation of the pacing system before the occurrence of symptoms. The median time of symptoms before the diagnosis of CIED endocarditis was 60 days (3–360 days in range). Vegetation on the wire of CIED was detected in eight cases (72.7%) on echocardiography. Nine patients (81.8%) underwent surgical removal of the pacing wire, and one patient received medical treatment alone. The overall mortality rate was 18.2%. One patient had septic perforation of interventricular septum, with a high serum level of NT-pro-BNP in the absence of pump failure. The assessment of PMN functions revealed normal responses to the various stimuli and normal oxidative burst responses. Conclusions: Clinicians should never consider the isolation of S. lugdunensis as contamination. In selected individuals, therapeutic abstention may be preferable to exposing patients to a high risk of CIED infection due to re-manipulation of the pacing system. The prognostic value of NT-pro-BNP warrants further investigations.

Posters: Neurology–Diagnostics 305

306

CEREBROSPINAL FLUID 11–12 AND 14 –15 DHET AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

ANALYSES OF BRAIN DAMAGE BIOMARKERS IN PATIENTS WITH PENETRATING BRAIN INJURY: A CASE SERIES STUDY

Elizabeth Crago, University Of Pittsburgh School of Nursing, Mark Donnelly, Univ of Pittsburgh School of Pharmacy, Dianxu Ren, P Sherwood, University of Pittsburgh School of Nursing, M Horowitz, University of PIttsburgh Medical Center, S Poloyac, University of Pittsburgh School of Pharmacy

Stefania Mondello, Banyan Biomarkers, inc and University of Florida, Andras Buki, University of Pecs, Andreas Jeromin, Banyan Biomarkers, Inc., Andrea Gabrielli, University of Florida, Kara Schmid, Frank Tortella, Walter Reed Army Institute of Research, Kevin Wang, Ronald Hayes, Banyan Biomarkers, inc

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with abnormal cerebral blood flow (CBF) and ischemia. Epoxygenated acids (EETs) are cytochrome P450 metabolites of arachidonic acid (AA) that are considered key regulators of CBF especially in cerebral ischemia. EETS are rapidly hydrolyzed by soluble epoxide hydrolase to measurable metabolites known as DHETs. Their relationship to the ischemic events associated with aSAH has not been explored. The presence of DHET in cerebrospinal fluid (CSF) may provide surrogate measurement of EETs after aSAH. The purpose of this study was to explore DHET levels in CSF after aSAH. Hypothesis: DHET levels in CSF after aSAH will be related to severity of injury and ischemia. Methods: Prospective longitudinal study of 64 acute adult aSAH patients with CSF metabolites.CSF samples were collected 0–14 days after aSAH and analyzed via UPLC triple quadrupole mass spectrometry for 11–12 and 14–15 DHET. Patient information was obtained from the medical record. Group-based trajectory analysis was performed using PROC TRAJ in SAS V9.2 to identify distinct DHET subgroups with similarly behaving patterns. Associations between DHET trajectory groups and outcomes were determined using weighted Chi-square tests. Results: Trajectory analysis identified 2 distinct groups for 11–12 and 14–15 DHET: 11–12 DHET high (44%) and low (56%), 14–15 DHET high (58%) and low (42%). Patients in the high 11–12 DHET trajectory were significantly more likely to have Hunt and Hess grade 3–5 than those in the low group (p ⫽ .014) and there were more patients with ischemia and increased intracranial pressure (not statistically significant). Patients in the 14–15 DHET low trajectory were significantly younger than those in the high trajectory group (p⬍.001). There were no differences between either DHET group by race, gender, Fisher grade or cerebral vasospasm. Conclusions: This preliminary data suggests a possible relationship between severity of cerebral insult and 11–12 DHET levels in CSF after aSAH. Research is ongoing with additional sample and statistical methods to further explore the relationship of these metabolites to outcomes and to other metabolites in CSF after aSAH. Funding NINR-R01NR004339.

Introduction: Penetrating brain injury (PBI) is a devastating insult associated to significant morbidity and mortality. To date, there are no therapies. In order to develop new therapeutic strategies, biomarkers represent a novel approach which may assess injury severity, provide objective and unique temporal information and insight into the pathophysiologic mechanisms following PBI. Hypothesis: We hypothesized that the magnitude of the increase in biomarker concentrations would reflect the severity of brain damage differentiating between mechanisms of injury, and that the time course of the biomarkers would mirror Blood-BrainBarrier (BBB) dysfunction. Methods: Therefore, we evaluated concentration of Ubiquitin Carboxyl-Terminal Hydrolase-L1 (UCHL1) and glial fibrillary acidic protein (GFAP) in CSF and serum and compared their time course after PBI, closed head trauma and in uninjured controls. Samples were taken from each TBI patient at admission and every 6hrs up to 24hrs. Brain injury biomarkers were measured using absorbance-based ELISAassays. Results: CSF and serum levels of UCH-L1 and GFAP were significantly higher after PBI compared to closed head trauma and in uninjured controls. Initial and peak UCH-L1 and GFAP concentrations in CSF and serum were higher after PBI. Different temporal release patterns of biomarkers were observed. The temporal profile of CSF GFAP and UCH-L1 was more sustained in patients with PBI compared to patients with closed head trauma. Correlation between CSF and serum levels of both GFAP andUCH-L1 indicated an increased permeability of BBB in the first 12 hrs post-injury. Conclusions: Our findings including magnitude of the increase in biomarker concentrations and prolonged and elevated biomarker release suggest that the injury that occurs after PBI is particularly deleterious to the brain, and may explain the poor outcome in these patients. In addition, these preliminary results support the potential of brain biomarkers as monitoring parameters of BBB disruption following penetrating brain injury. These findings may have important implications for the management and treatment of patients with PBI.

307 EARLY STROKE IN CHILDREN WITH CANCER Corina Noje, Johns Hopkins University, Kenneth Cohen, Johns Hopkins University School of Medicine, Lori Jordan, Vanderbilt University School of Medicine Introduction: Adult survivors of childhood cancer have an increased risk of cerebrovascular disease, but little is known about strokes early in the course of childhood cancer. Strokes result in increased morbidity and a high need for critical care services. Hypothesis: Our primary goals were 1) to retrospectively review the prevalence of stroke in children with cancer 2) to determine which children are most likely to have stroke and assess stroke type and 3) to determine if stroke was a cancer complication or if modifiable risk factors were present. Methods: An ICD-9 code search was used to identify children 0 –17 years with ischemic stroke, intracranial hemorrhage (ICH) and cerebral sinus venous thrombosis. Existing pediatric oncology and pediatric stroke databases were also searched. Children with both stroke and cancer were reviewed and compared to all children seen for pediatric cancer at a single institution from 2000 –2009. The significance of independent risk factors was analyzed using the Fisher exact test. Results: Of 1339 children seen for pediatric cancer, 33 had some form of stroke, but 18 were found to have intra-tumoral hemorrhage. Excluding these children, 11 had ICH, 2 had ischemic stroke, 1 mixed hemorrhagic and ischemic, and 1 sinus thrombosis; thus, 1.1% of all children with cancer had stroke. Median age at time of stroke was 11 years (range 2–17). Stroke occurred at a median of 5 months, post diagnosis (IQ range 0 –24 months), and 5/15 had stroke as their initial presentation in the PICU at the time of cancer diagnosis. There were 11 strokes in children with leukemia; 3 in children with brain tumors, and 1 in a child with lumbar myxopapillary ependymoma. Two children had a second stroke. Of these 15 patients, 12 died and 7 died via withdrawal of care. Our sample size was too small to identify definite risk factors, but white blood cell count ⬎40K was found in 4 children and all had hemorrhagic not ischemic stroke. The median platelet count was 70, and 4/7 children with ICH had platelets ⬍50K but this was not significant. Conclusions: Hemorrhagic stroke is more common than ischemic stroke and rarely is an early complication of childhood cancer, particularly leukemia.

308 OUTCOME OF CHILDREN WITH ACUTE ENCEPHALITIS AND REFRACTORY SEIZURES IN A PEDIATRIC INTENSIVE CARE UNIT Jun Sasaki, Balagangadhar Totapally, Miami Children’s Hospital Introduction: Acute encephalitis in children is one of the life-threatening neurologic emergencies often presenting to a Pediatric Intensive Care Unit (PICU) with seizures. Little is known about the outcome of these children who present with refractory seizures (seizure activity that fails to remit despite treatment with adequate doses of two anti-convulsants). Hypothesis: Children with acute encephalitis presenting with refractory status epilepticus have worse outcome. Methods: We retrospectively reviewed the charts of the patients with acute encephalitis admitted to PICU at Miami Children’s Hospital in Miami, FL during 2006 and 2011. Demographic data,presenting symptoms, CSF data, serology for infections, electroencephalogram result (EEG), neuroimaging studies and pediatric cerebral performance categoryscale (PCPC) were recorded for the patients. Results: Of 41 patients who met our inclusion criteria, most common presenting symptom was fever (65.9%), followedby altered mental status (61%) and seizures (58.5 %). Only 5 patients (12.2%) had confirmed etiologic agent from CSF study. In 23 patients (56.1%), serology was positive for various agents with mycoplasma being the most common (29%). No agent was isolated in 18 (43.9%) cases. CT and/or MRI studies were abnormal in 31(77.5%). Of 37 patients who had EEG, 9 patients (24.3%) had normal findings, 16 patients ( 43.2%) had seizure and 11 patients ( 29.7%) noted to have cerebral dysfunction. Eight patients (19.5%) who presented with refractory status epilepticus had longer median length of PICU stay (46 vs 4 days;p⬍0.0001[Mann-Whitney-U test]) and worsening PCPC score on discharge by 2 or more points (OR 20.38; 2.89 – 143.52 CI 95%; Fisher’s Exact test). All children survived to hospital discharge. Conclusions: Children with acute encephalitis and refractory status epilepticus have worse outcome and stay longer in the PICU.


309 FULMINANT CEREBRAL EDEMA: A POTENTIAL NEW PHENOTYPE EMERGING IN CHILDREN WITH ENCEPHALITIS Preetha Krishnan, Jay Tureen, University of California San Francisco, Arup Roy-Burman, Children’s Hospital Oakland, Audrey Foster-Barber, University of California San Francisco, Carol Glaser, California Department of Public Health Case Reports: Since the inception of the California Encephalitis Project (CEP) in 1998, 1968 pediatric encephalitis cases have been enrolled. Within the CEP, 10 distinct clinical constellations of clinical and laboratory features are described (profiles). Profile 1 refers to a pediatric encephalitis cohort with rapid evolution to fulminant cerebral edema and unknown etiology. This case series describes 19 such patients. The median age was 7y [range: 14 m-18y], with 68% being female. Race/Ethnicity included: 9/19 Asian/Pacific Islander (47%), 7 Hispanic (37%), 2 Caucasian (11%), 0 African-American, 1 unknown (5%). All had a febrile prodrome and 16/19(84%) presented to an ER with a first time seizure or altered mental status. (1 presented with croup and the other 2 with headache and emesis). Respiratory (R), GI or both R and GI (R/GI) symptoms [GI:10, R:2, R/GI:6] were found in 18/19(95%); 12/19(63%) had headache. Upon admission, 16/ 19(84%) had a normal head CT but all had evidence of cerebral edema upon repeat imaging; 3 had signs of edema upon initial CT. Most (74%) had a seizure 24 – 48 hours prior to showing signs of increased intracranial pressure. Laboratory data [median; range] included: CSF WBC [4; 0 –516], CSF glucose[70; 48 – 135], CSF protein [87.5, range 14 – 648], serum Na [137; 131–145], serum glucose [127.5; 20 –390]. Management included placement of extraventricular drains/intracranial pressure monitors, hyperosmolar therapy, steroids, IVIG, and barbiturate coma. Most (74%) died. Autopsy for 11/14 showed severe cerebral edema with no other etiology for death. Despite extensive investigation, no confirmed agent was found. Although profile 1 is relatively uncommon, the severity and rapid evolution of the disease process highlight the importance of understanding why certain children progress along this pathway. Compared to CEP non-profile 1 cases and California as a whole, Asian/Pacific Islanders are overrepresented in our cohort (12% in the CEP cohort and 10% in California), while African-Americans are underrepresented, suggesting a potential host-pathogen interaction that is genetically or environmentally based.


Posters: Neurology-Monitoring 310

311

CHARACTERIZATION OF FREE PHENYTOIN CONCENTRATIONS IN NEUROINTENSIVE CARE UNIT PATIENTS

INTRACRANIAL HYPERTENSION AND HYPOPERFUSION IN CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY (STBI): QUANTIFYING THE SECONDARY INSULT AND ITS EFFECT ON OUTCOME

Sean Kane, University of Illinois At Chicago Introduction: Prior studies examining the accuracy of the Winter-Tozer equation (WT) in critically ill patients have conflicting results and suffer from small patient enrollment and stringent exclusion criteria which limit external validity. Hypothesis: To determine whether the WT equation, or its variants, are appropriate in neurointensive care unit patients. Methods: A retrospective chart review was conducted of patients admitted to the neurointensive care unit at the University of Illinois Medical Center at Chicago (UIMCC) between 1/2004 and 6/2011 that had both a free and total phenytoin level (drawn concurrently), as well as corresponding serum album level (drawn within 12 hours). Markers of hepatic and renal function were also collected. Bias and precision were estimated using mean prediction error (MPE) and root mean squared error (RMSE). Data analysis was conducted using SPSS and Microsoft Excel. Results: A total of 100 patients met inclusion criteria (51 subarachnoid hemorrhages, 15 intracranial hemorrhages, 15 elective neurosurgical procedures, and 19 other). Using a traditional coefficient of 0.2 with an assumed 10% free fraction, the WT equation predicted a mean (⫾ SD) free phenytoin concentration of 1.82 ⫾ 0.74 mg/L compared to a mean measured free concentration of 1.41 ⫾ 0.66 mg/L (MPE 0.41, RMSE 0.63). The WT equation overpredicted the free phenytoin level by more than 50% in 37 patients (37%). In all but one case, the overprediction occurred in patients with higher renal function (CrCl ⬎50 mL/min, n ⫽ 85). A new revised equation, using a coefficient of 0.3, improved free phenytoin prediction in patients with higher renal function (MPE -0.07, RMSE 0.36). The new equation over- or underpredicted phenytoin levels by ⬎50% in only two patients (2.4%). Conclusions: The WT equation, using a coefficient of 0.2, significantly overpredicts free phenytoin concentrations in neurointensive care unit patients. This may result in suboptimal therapy. While the equation was appropriate in patients with reduced renal function (CrCl ⬍50 mL/min), a coefficient of 0.3 may be more appropriate for most patients with normal renal function.

Nikki Miller Ferguson, Children’s Hospital of Pittsburgh, Patrick Kochanek, University of Pittsburgh Medical Center, Stephen Wisniewski, University of Pittsburgh, Robert Clark, Elizabeth Tyler-Kabara, Michael Bell, Children’s Hospital of Pittsburgh Introduction: Management of intracranial hypertension (by measuring intracranial pressure (ICP)) and maintenance of cerebral perfusion pressure (CPP) are mainstays of neurotrauma care. Evidence of the relationship between potential secondary insults and outcome is limited in children and quantification of these factors has not been evaluated. Hypothesis: We hypothesized that (i) # hourly readings of increased ICP and decreased CPP (based on defined thresholds), (ii) intracranial hypertension index (IHI), (iii) hypoperfusion index (HYPI) and (iv) mean ICP and CPP would vary based on outcome in children with sTBI (GCS ⱕ8). Methods: A prospective TBI database was interrogated. Hourly ICP and CPP (in mm Hg) were collated and compared to various thresholds. IHI ([# h ICP ⬎20/total # h] x 100), HYPI ([# h CPp⬍50/total # h x 100] for ⬍2 y; [# h CPp⬍60/total # h x 100] for ⬎2 y) and means were calculated. GOS at 6 m was used dichotomously (GOS 3–5 ⫽ UNFAV) and categorically. Data were compared with MWRS, regressions, and goodness-of-fit models (R2). Results: Children (n ⫽ 85, GCS ⫽ 6.4 ⫾ 0.2, 9 deaths) were analyzed. UNFAV (n ⫽ 34, 40%) had increased # h of ICP ⬎20 (20.1 ⫾ 4.6 v. 7.6 ⫾ 1.4; p ⫽ 0.02), greater mean ICP (14.6 ⫾ 1.7 v. 10.8 ⫾ 0.6; p ⫽ 0.049) and greater IHI (17.1 ⫾ 4.0 v. 6.0 ⫾ 1.1; p ⫽ 0.014). UNFAV had increased # h of CPp⬍thresholds [⬍40, (3.3 ⫾ 1.4 v. 0.3 ⫾ 0.1); ⬍45, (6.2 ⫾ 2.0 v. 1.2 ⫾ 0.4); ⬍50, (11.8 ⫾ 2.8 v. 3.6 ⫾ 0.9); ⬍55, (21.4 ⫾ 3.8 v. 9.7 ⫾ 1.6); ⬍60, (36.4 ⫾ 4.7 v. 20.9 ⫾ 2.7), all p⬍0.05]. HYPI tended to be greater in UNFAV (15.9 ⫾ 1.8 v. 12.2 ⫾ 1.7, p ⫽ 0.06). Strong associations between GOS and (i) # h ICP ⬎ 30, (ii) # h ICP ⬎ 20, (iii) mean ICP and (iv) IHI were observed (all p⬍0.001). The best goodness-of-fit models adjusted for age/GCS were # h ICP ⬎ 20 (R2 ⫽ 0.28) and # h CPp⬍40 (R2 ⫽ 0.19). Conclusions: ICP and CPP were associated with outcome in children with sTBI, with intracranial hypertension explaining a larger portion of the association than hypoperfusion. Despite the strong associations, they explained less than 50% of the observed variability. A more thorough understanding of fundamental parameters associated with outcome is needed to advance the field.

312

313

POSITION OF PROBE DETERMINES PROGNOSTIC INFORMATION OF BRAIN TISSUE PO2 IN SEVERE TRAUMATIC BRAIN INJURY (TBI)

TRANSCRANIAL DOPPLER (TCD) ASSESSMENT OF CEREBRAL PERFUSION IN CRITICALLY ILL SEPTIC PATIENTS: A PILOT STUDY

Lucido Ponce, Shibu Pillai, Jovany Cruz Navarro, Xiaoqi Li, Baylor College of Medicine, Hilda Hannay, University of Houston, Shankar Gopinath, Claudia Robertson, Baylor College of Medicine

Charalampos Pierrakos, Aurelie Antoine, Dimitrios Velissaris, Isabelle Michaux, Pierre Bulpa, Evrard Patric, Michel Ossemann, Alain Dive, Mont-Godinne University Hospital, University Catholique de Louvain

Introduction: Monitoring brain tissue pO2 (PbtO2) is part of traumatic brain injury (TBI) patients care. PbtO2 measurement is a localized, sampling a small area of tissue immediately surrounding the sensor tip. Hypothesis: The purpose of this study was to examine the effect of catheter location on the relationship between PbtO2 and long-term neurological outcome. Methods: 415 severe TBI patients who had PbtO2 monitoring as part of their standard monitoring. Inclusion criteria: 1- traumatic brain injury, 2- motor Glasgow Coma Score (GCS) ⱕ5 (post-resuscitation or following subsequent deterioration), 3- valid PbtO2 data collected and 4- demographic and injury characteristics and neurological outcome collected. Results: When the probe was located in normal brain, the average PbtO2 was 30.3⫾ 13.2 mm Hg, compared to 25.6 ⫾ 14.7 mm Hg when then probe was placed in abnormal brain (p⬍0.001). The cumulative hours that PbtO2 stayed below the thresholds of 20, 15 and 10 mm Hg were a median of 24 (5–50), 11 (1–33.75), and 1 (0 –18), respectively in all patients. The time that PbtO2 was below each threshold was significantly longer in patients where the PbtO2 probe was placed in abnormal brain. In univariate analyses, age, sum GCS and the motor component of the GCS, pupil reactivity, type of injury, all of the PbtO2 variables, and the ICP and CPP variables were significantly related to outcome. In the final logistic regression model, age, PbtO2 probe position, initial motor GCS, and the PbtO2 trend pattern were related to neurological outcome. Average PbtO2 was not significant in the final logistic model. The interaction between PbtO2 and probe position was statistically significant. In patients where the PbtO2 probe was placed in abnormal brain, the average PbtO2 was higher in those with a favorable outcome, 28.8⫾12.0 mm Hg compared to 19.5⫾ 13.7 mm Hg in those with an unfavorable outcome (p ⫽ 0.0139). There was no significant difference in PbtO2 with outcome when the probe was placed in normal appearing brain. Conclusions: These results suggest that the final location of the PbtO2 probe determines the PbtO2 values and also the relationship of PbtO2 to neurological outcome.

Introduction: TCD is an easily applicable, non-invasive examination which can be used to evaluate the cerebral perfusion in everyday clinical practice. Hypothesis: The aim of this pilot study is to evaluate TCD feasibility and TCD capability of detection of cerebral perfusion changes in septic patients (pts). Methods: 28pts without any known neurologic deficit and treated in our 24-bed Critical Care Unit were assessed. Sepsis was defined according to standard criteria. Using TCD, we measured the mean velocity in the middle cerebral artery (VMCA) and calculated the pulsatility index (Pi) and the cerebrovascular resistance index (CVRi). Measurements were made at the first day of their admission or at the first day of sepsis development and were repeated the second day and pooled together. Patients with signs of sepsis for more than 48h before assessment were excluded. Results: Data are presented as mean ⫾ SD and were analyzed using unpaired t-test. Sepsis Group Control Group P valueN ⫽ 28 11 17 Feasibility of TCD 91% 88%Age (years) 75 ⫾ 8 67 ⫾ 12 0.08 Mean arterialpressure (mmHg) 67 ⫾ 12 75 ⫾ 8 0.08PaCO2 (mmHg) 45 ⫾ 15 39 ⫾ 4 0.09SOFA score 10 ⫾ 2 9 ⫾ 2 0.12VMCA (cm/s) 114 ⫾ 36 97 ⫾ 22 0.09Pi 1.29 ⫾ 0.20 0.97 ⫾ 0.10 ⬍0.01CVRi 0.68 ⫾ 0.06 0.59 ⫾ 0.05 0.01No correlation was found between Pi or CVRi and age, MAP and CO2 in both groups. Conclusions: Our results suggest a cerebral vasoconstriction in septic patients compared to control group.TCD is an efficient tool to evaluate changes in cerebral perfusion in septic patients even at the early phase of sepsis. Further studies are warranted to confirm the observed increase in Pi and CVRi in septic pts and to assess the clinical significance of these data.


314

315

THE IMPACT OF SODIUM LEVEL ON NEUROLOGIC DETERIORATION AFTER SUBARACHNOID HEMORRHAGE

THE ASSOCIATION OF MELATONIN LEVELS WITH DELIRIUM IN POSTOPERATIVE CRITICALLY ILL PATIENTS

Khalil Yousef, Chien-Wen Kuo, Elizabeth Crago, University of Pittsburgh, School of Nursing, Jeffrey Balzer, University of Pittsburgh Medical Center, Samuel Poloyac, University of Pittsburgh School of Pharmacy, Paula Sherwood, University of Pittsburgh School of Nursing

Shiho Yoshitaka, Moritoki Egi, Hiroshi Morimatsu, Yuichiro Toda, Kiyoshi Morita, Okayama University Hospital

Introduction: Clinicians often consider hyponatremia as a potential source of neurologic deterioration (ND) following aneurysmal subarachnoid hemorrhage (aSAH), yet there is a paucity of data to support this hypothesis. The purpose of this analysis was to examine the relationship between sodium levels and ND after aSAH. Hypothesis: Low sodium levels are related to ND after aSAH. Methods: Data from an ongoing, longitudinal, descriptive study (R01 NR004339) were used (n ⫽ 405). Eligibility criteria were: diagnosed within 5 days with aSAH verified by CT/angiography, age 18 –75 years, Hunt/Hess[HH]⬎2 and/or Fisher⬎1, and no history of neurological disorder. Sodium levels and ND assessments were obtained from chart review from time of admission until day 14 after bleeding. ND was defined as one of the following in the absence of sedatives or paralytics: 2 increment increase in NIH Stroke Scale or decrease in Glasgow coma score, focal deficit, or change in level of consciousness or pupil size. Minimum sodium was defined as the lowest value following bleeding. Logistic regression was performed using SPSS 19 to predict ND. Results: Subjects were predominantly female (73%) and white (90%) with HH grade 3–5 (57%). Over half (60%) had ND, 47% had sodium ⬍135 mEq/l, and 4% had sodium ⱕ125 mEq/l. In univariate logistic regression, a borderline significant relationship existed between minimum sodium level and ND (OR .95, 95%CI .90-.99). After controlling for age and HH, minimum sodium level had no significant effect on ND. HH was the only variable significantly associated with ND. Subjects with poor HH(3–5) were 1.9 times more likely to have ND than those with good HH(1–2) (OR 1.9, 95%CI 1.3–2.8). Conclusions: Although sodium ⬍135 mEq/l was common, severe hyponatremia (sodium ⱕ125 mEq/l) occurred in only 4% of the subjects. After controlling for age and HH, minimum sodium level had no significant effect on ND. While sodium monitoring and maintenance are important in this patient population, sodium level may not be a primary contributing factor for ND.

Introduction: Delirium is one of the most common complications in postoperative critically ill patients. Currently, etiology and pathophysiology of delirium are not fully understood. Melatonin is chiefly produced in the pineal gland and might have a potential role in postoperative delirium. Hypothesis: We hypothesized that the abnormality of postoperative melatonin levels would be associated with increased risk of postoperative delirium. Methods: In this prospective observational study, 39 postoperative patients required intensive care ⬎48 hours were included. We measured serum melatonin levels and assessed delirium using CAM-ICU before and after surgery (control and POD0) and at the morning of POD1 and 2. We compared melatonin levels between patients with and without delirium. As the relationship between melatonin levels and delirium may not be linear, we performed further analysis using all observations with considering melatonin levels as a categorical variable. We divided melatonin levels into three bands: (A) ⬍2, (B) 2–3.9, (C) ⱖ4 pg/ml. We report odds ratios relative to a reference melatonin levels as category (B) (2–3.9 pg/ml). Each variable were compared between groups using the chi square test and Wilcoxon rank-sum test. P values of less than 0.05 were considered statistically significant. All statistical analyses were performed using SPSS 19.0. Results: The postoperative delirium was occurred in 12 patients (31%). Preoperative melatonin levels in non-delirium patients was median of 1.9 pg/dl, which was not significantly difference comapred with 1.7 of patients with delirium. Melatonin levels on POD0 and 1 were significantly lower in delirium patients. (POD0; 0.6 vs. 2.5 pg/ml, P ⫽ 0.021) (POD1; 1.6 vs. 2.5 pg/ml, P ⫽ 0.039), but not at POD2 (2.2 vs. 2.3, p ⫽ 0.38). The incidence of delirium in melatonin category of (A)(⬍2pg/dl) and (C)(ⱖ4pg/dl) was 25.5% and 18.5%, which is significantly higher compared with 2.7% in those of reference range (2–3.9 pg/ml). ((A)Odds ratio;10.6, p ⫽ 0.01), (C) odds ratio; 7.05, p ⫽ 0.048). Conclusions: The melatonin levels significantly associated with increased the risk of postoperative delirium.

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FULL OUTLINE OF UNRESPONSIVENESS SCORE VERSUS THE GLASGOW COMA SCALE AS A PREDICTOR OF OUTCOME AFTER TRAUMATIC BRAIN INJURY: A PROSPECTIVE COMPARATIVE STUDY

MEDICAL COMPLICATIONS OF PROLONGED REFRACTORY STATUS EPILEPTICUS.

Akram Fayed, University of Alexandria, Ahmad Said Okasha, Ahmad Sabry, Unviersity of Alexandria

Introduction: Refractory status epilepticus (RSE) is defined as generalized convulsive or non-convulsive status epilepticus that continues clinically or electrographically despite initial first and second line therapies. Hypothesis: We sought to describe the medical complications of RSE. Methods: We retrospectively analyzed all episodes of RSE treated between 1999 and 2011 at Mayo Clinic. Results: We identified 55 episodes in 46 patients aged 50⫾17.9 years. Induction of anesthetic coma was necessary in 49/54 cases and continued for a mean of 10.4 (4, 0 –72) days. Mechanical ventilation was necessary in 52/55 (94.6%) cases for an average of 8.72 days and 16/49 (32.7%) required tracheostomy. Pneumonia occurred in 35/48 (73%) of cases and was diagnosed on mean 4.29 (4, 1–11) days after onset of status. Acid-base abnormalities were present in 37/49 (75.5%) cases. Respiratory alkalosis 12/49 (24.5%) was the most common abnormality. Electrocardiogram findings included: ST elevation (7%), ST depression (4.7%), T wave inversion (4.7%), nonspecific ST changes (54.6%). Cardiac arrhythmias included: asystole (11.5%), ventricular tachycardia/fibrillation (7.69%), atrioventricular block (3.9%), atrial fibrillation/flutter (7.7%), paroxysmal supraventricular tachycardia (1.9%), sinus bradycardia (46%), and sinus tachycardia (75%). Intervention was required for cardiac arrhythmias in 22.5%. One patient met criteria for non ST elevation myocardial infarction. Pulmonary edema was present in 35%. Eight of 20 patients evaluated with echocardiograms during SE had possible stress-induced cardiomyopathy. Clinically significant hypotension requiring vasopressor administration occurred in 37/40 (92.5%) cases. Asystole (p⬍0.0098), cardiac arrhythmias requiring treatment (p⬍0.0540), pulmonary edema (p⬍0.0498) and longer duration of mechanical ventilation (p⬍0.0492) were associated with in-hospital death. Conclusions: Cardiopulmonary complications are common in RSE and increase the risk of mortality. These disturbances may require specific treatment and may be reversible. Careful monitoring for neurocardiogenic injury is necessary in these patients.

Introduction: The Glasgow coma scale (GCS) has been universally utilized as a common diagnostic tool to evaluate the level of consciousness and the prognosis of traumatic brain injury (TBI). The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed to overcome the limitations of the GCS. It has been validated in different clinical studies. Hypothesis: To determine whether FOUR score is an appropriate predictor of outcome in TBI patients and to compare its performance to GCS. Methods: 60 adult TBI patients were enrolled. The initial FOUR score and GCS were assessed at the emergency Department after hemodynamic stabilization. Both scores were compared regarding Outcome parameters. Results: Under the unadjusted model, for every one point increase in the FOUR total score, there is an associated 38% reduction in the odds of in-hospital mortality. Similarly, for every one point increase in total GCS score, there is an associated 40% reduced odds of experiencing in-hospital mortality. In predicting in-hospital mortality, the area under the curve (AUC) was 0.85 for the FOUR score and 0.80 for the GCS. The difference between Area under the Curve (AUC) of the two scores was statistically significant (p ⫽ 0.025). Considering the total FOUR score, for every one-point increase the score, there was an estimated 36% reduction in the odds of unfavorable outcome. Similarly, for every one-point increase in the total GCS, there is an estimated 39% reduced odds of experiencing unfavorable outcome under the unadjusted model. Both scores showed significant negative correlation with length of ICU stay (R ⫽ -0.54 [FOUR score] &-0.57 [GCS score]) and hospital stay (R ⫽ -0.51 [FOUR score] &-0.52 [GCS score]). In predicting need for intubation & MV, the AUC was 0.96 for the FOUR score and 0.97 for the GCS; no statistical difference between the two scores. Conclusions: Although both scores are accurate predictors of in-hospital mortality after traumatic brain injury in this study, the FOUR score is superior to GCS. Both scores equally predict the GOSE at one month, need for intubation and MV as well as the length of ICU & hospital stay.


Sara Hocker, Jeffrey Britton, Jay Mandrekar, Eelco Wijdicks, Mayo Clinic, Alejandro Rabinstein, Mayo Clinic and Foundation

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PREVALENCE OF DELIRIUM IN THE SURGICAL-TRAUMA ICU

TRANSCRANIAL DOPPLER ULTRASONOGRAPHY MONITORING OF CEREBRAL BLOOD FLOW AFTER PEDIATRIC CARDIAC ARREST

Lindsay Fairfax, Brittany Russell, Lauren Rowell, Susan Evans, Carolinas Medical Center Introduction: The intensive care delirium screening checklist (ICDSC), validated for used in mechanically ventilated and sedated patients, was implemented in the surgical-trauma ICU (STICU) as part of a delirium process improvement initiative. The purpose of this pilot study was to evaluate compliance with use of the ICDSC as well as determine the prevalence of delirium in our study population. Hypothesis: We hypothesized that use of the ICDSC in the STICU would identify a high prevalence of delirium in this population. Methods: Patients admitted to the STICU during the one month pilot period were prospectively evaluated. Demographics, ICDSC scores, and ICU length of stay were recorded. Prior to the start of the pilot, all bedside nurses received comprehensive education surrounding delirium and use of the ICDSC. Delirium and subsyndromal delirium were defined as an ICDSC score ⱖ4 or 1–3, respectively. The unit standard for recording ICDSC scores was twice daily. Results: Of the 221 patients admitted to the STICU during the pilot period, 42% (n ⫽ 93) had a least one ICDSC recorded for a total of 427 scores over 304 patient days. Of the patients with an ICDSC score recorded, the majority were surgical (46%), followed by medical (28%), and trauma (26%) patients. Twenty-nine percent (27/93) of patients screened positive for delirium at least once, representing 68 delirium days. Separating by patient type, 42% of trauma patients screened positive for delirium compared to 26% of surgical patients and 23% of medical patients (p ⬎ 0.05). Delirium and subsyndromal delirium were identified in 20% and 35% of patient assessments, respectively. Conclusions: Compliance with use of the ICDSC during the pilot period was 42%. Incorporation of the ICDSC into the electronic medical record will be pursued as a strategy to improve this. The prevalence of delirium was 29%, with no difference between trauma, surgical and medical patients. This prevalence is lower than in other studies of mixed ICU populations. Further study is needed to identify optimal management strategies for both delirium and subsyndromal delirium in the STICU population.

Craig Smith, Children’s Memorial Hospital, John Condie, Phoenix Children’s Hospital, Elora Hussain, Michele Grimason, Josh Goldstein, Children’s Memorial Hospital, Mark Wainwright, Northwestern University Feinberg School of Medicine Introduction: Compromised regulation of cerebral blood flow (CBF) after cardiac arrest (CA) may cause cerebral ischemia or hyperemia and secondary injury. Noninvasive quantification of CBF using Transcranial Doppler Ultrasonography (TCD) has potential to be a powerful tool in the management and monitoring of children with acute neurologic injury. Hypothesis: Serial monitoring of CBF using TCD following CA can be used to identify abnormal CBF and to guide acute management. Methods: Analysis of TCD data acquired as part of the care of children above 1 year of age with out of hospital CA in an single, tertiary care PICU in 2011. TCD studies were performed at the bedside using a 2-MHz pulsed probe, and measurements of flow velocities performed using standardized protocols. Results: 4 cases of CA ages 5.1 ⫾2.7 yr (3 M, 1F) had TCDs performed. One patient was treated with therapeutic hypothermia and was analyzed separately. All survived to hospital discharge, and 1 required gastrostomy tube and tracheostomy. Peak flow velocity in the MCA (mean cm/sec ⫾ SEM), on days 1–2 post CA were 140.9⫾8.3; on days 3– 4, 92.5⫾9.2 (p⬍0.01 vs D1–2 by ANOVA) and days 5– 6, 102.6⫾4.6 (P⬍0.01 vs D1–2). During hypothermia (days 1–2) peak velocity was 134.5⫾7.5; during rewarming (days 3– 4), 152.5⫾11; and at normothermia (days 5– 6) 174.7⫾10.6. The effect of hypothermia was significant (P⬍0.01) by two-way ANOVA. Blood pressure parameters and HOB position were adjusted to optimize CBF based on these results. Conclusions: This small series suggests that the use of TCD to monitor CBF during recovery after CA can detect changes which guide management, and that hypothermia alters the pattern of recovery of CBF following CA.


Posters: Neurology-Therapeutics 320

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HYPER- AND HYPOCARBIA ARE COMMON AMONG VENTILATED PATIENTS WITH INTRACEREBRAL HEMORRHAGE BUT NOT INDEPENDENTLY ASSOCIATED WITH INCREASED MORTALITY

HYPOTENSION IN THE EMERGENCY DEPARTMENT IS COMMON AMONG VENTILATED PATIENTS WITH INTRACEREBRAL HEMORRHAGE BUT NOT INDEPENDENTLY ASSOCIATED WITH INCREASED MORTALITY

Jonathan Elmer, Massachusetts General Hospital and Brigham and Women’s Hospital, Peter Hou, Brigham and Women’s Hospital, Susan Wilcox, Yuchiao Chang, Ikenna Okechukwu, Massachusetts General Hospital, Carlos Camargo, Masachusetts General Hospital, Steven Greenberg, Jonathan Rosand, Massachusetts General Hospital, Daniel Pallin, Brigham and Women’s Hospital and Children’s Hospital Boston, Joshua Goldstein, Massachusetts General Hospital

Jonathan Elmer, Massachusetts General Hospital and Brigham and Women’s Hospital, Peter Hou, Brigham and Women’s Hospital, Susan Wilcox, Yuchiao Chang, Ikenna Okechukwu, Massachusetts General Hospital, Carlos Camargo, Masachusetts General Hospital, Steven Greenberg, Jonathan Rosand, Massachusetts General Hospital, Daniel Pallin, Brigham and Women’s Hospital, Joshua Goldstein, Massachusetts General Hospital

Introduction: Development of hyper- or hypocarbia early in the ventilation of patients with traumatic brain injury (TBI) is common and associated with increased mortality, likely because they worsen secondary brain injury. The incidence and impact of early hyper- and hypocarbia among patients with spontaneous intracerebral hemorrhage (ICH) are not known. Hypothesis: Hyper- and hypocarbia are common in ventilated patients with ICH and associated with increased mortality. Methods: We performed a structured review of a prospective cohort of consecutive patients presenting to a single center from December 2000-August 2010 with spontaneous ICH and requiring emergent endotracheal intubation. We excluded patients who were admitted for comfort care only, or if no arterial blood gas sample (ABG) was obtained. ABGs were checked at the discretion of the treating physician. We defined hypercarbia as an ABG with PaCO2⬎55 mmHg and hypocarbia as an ABG with PaCO2⬍30 mmHg. Each episode was considered “prolonged” if present on at least two consecutive samples. ABGs from the first 24 hours after presentation were analyzed. Results: During the study period, 504 patients presented with ICH, of whom 327 met inclusion criteria. The incidence of hypocarbia was 32%, with 39% of episodes prolonged, and the incidence of hypercarbia was 28%, with 60% episodes prolonged. Overall mortality was 57%. In unadjusted analysis, hypocarbia was associated with increased mortality (67% vs. 52%, P ⫽ 0.02), while hypercarbia was associated with decreased mortality (44% vs. 62%, P⬍0.01). Results were similar when analysis was limited to prolonged episodes. In multivariable analysis controlling for disease severity, modeled by ICH Score (validated predictor of mortality which includes age, initial Glasgow Coma Scale score, hematoma volume and location), the association with hypocarbia disappeared (OR 1.4, 95%CI 0.8 –2.3, P ⫽ 0.27), while the association with hypercarbia persisted (OR 0.5, 95%CI 0.3– 0.9; P ⫽ 0.025). Conclusions: Early hyper- and hypocarbia are common in ventilated patients with ICH and frequently uncorrected. However, neither was independently associated with increased mortality. In fact, hypercarbia was associated with reduced mortality.

Introduction: Evidence suggests that even a single episode of hypotension after severe traumatic brain injury more than doubles mortality, and hypotension is avoided in these patients. Hemodynamic goals in the acute management of patients with spontaneous intracerebral hemorrhage (ICH) are less clear. These patients are often hypertensive on presentation, and management may focus on rapid blood pressure reduction at the expense of transient hypotension. The impact of transient hypotension on patients with ICH is not known. Hypothesis: Development of hypotension in the emergency department (ED) among intubated patients with ICH is common, and associated with increased mortality and worse neurologic outcome. Methods: We performed a structured review of a prospective cohort of consecutive patients presenting to a single center from December 2000-August 2010 with spontaneous ICH and requiring emergent endotracheal intubation. We excluded patients who were admitted for comfort care only. We defined hypotension as a systolic blood pressure⬍90 mmHg at any time in the ED. Neurologic outcome was quantified with the Glasgow Outcome Score (GOS) at hospital discharge. For unadjusted analysis, chi-squared and Cochran-Mantel-Haenszel tests were used. We performed multivariable logistic regression controlling for disease severity modeled by ICH Score, a validated predictor of mortality which incorporates age, Glasgow Coma Scale score, hematoma volume and location. Results: During the study period, 504 patients presented with ICH, of whom 351 met inclusion and exclusion criteria. The median GOS was 1.0, and overall mortality was 64%. The incidence of hypotension was 19%. In unadjusted analysis, hypotension was associated with a significant increase in mortality (75% vs. 62%, p ⫽ 0.048), but there was no difference in neurologic outcome (p ⫽ 0.06). In multivariable analysis controlling for ICH score, hypotension was not independently associated with mortality (OR 1.4, 95%CI 0.7–2.6) or lower GOS score (OR 0.9, 95%CI 0.2–3.3). Conclusions: Hypotensive episodes among intubated patients with ICH are common. However, they appear to be markers of disease severity, and are not independently associated with death or worse neurologic outcome.


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HYPERTONIC SALINE REDUCES ICP CRISIS FOLLOWING TRAUMATIC BRAIN INJURY

UTILITY OF NEUROSURGICAL CONSULTATION FOLLOWING NON-SEVERE TRAUMATIC BRAIN INJURY WITH MILDLY ABNORMAL HEAD IMAGING

Patricia Simonowicz, Hartford Hospital, Joao Gomes, Cleveland Clinic, Ilene Staff, Jennifer Freund, Maria Rinaldi, Violet Chrostowski, Norah Liang, Marc Palter, Karyn Butler, Hartford Hospital Introduction: The purposes of this study were to determine if the use of hypertonic saline (HTS) is effective in reducing ICP crisis (intracranial pressure ⬎20 cmH20) and if this efficacy is associated with changes in serum sodium concentration ([Na⫹]). Hypothesis: We hypothesized that intracranial pressure would vary inversely with serum [Na⫹]. Methods: A retrospective review of TBI patients admitted to the neurotrauma unit at a large tertiary referral center that provided care to 3827 traumatic and non-traumatic neurocritically ill patients from January 2006 thru August 2010 was performed. Patients with TBI were included if they had an admission GCS ⱕ8 and received ICP monitoring and HTS treatment during the first three days of their ICP crisis. Patients who died within the first 3 days of admission were excluded. Data collected included gender, age, ethnicity, admission GCS, APACHE II, mortality and discharge disposition. Continuous data are represented as mean ⫾SD Results: There were 66 consecutive patients who fulfilled eligibility criteria. Seventy percent of the patients were male, mean age was 36⫾16 years, mean APACHE II 22 ⫾ 5, mean admission GCS 5⫾3 and mean baseline ICP 24⫾18 cmH20. Sodium administration increased from day 1 to day 2 (568⫾ 342 mEq vs. 874⫾374 mEq, day 1 vs. day 2 respectively, P⬍0.001) and was associated with a significant increase in serum [Na⫹] from baseline (140⫾4 mEq, 146⫾5 mEq, 154⫾5 mEq and157⫾6 mEq; baseline, days 1, 2 and 3 respectively, P⬍0.001) through days 1, 2 and 3. There was a significant (P⬍0.001) reduction in maximum daily ICP from day 1 (27⫾17cmH20) to day 2 (23⫾17 cmH20) to day 3 (20⫾15cmH20). Importantly, the decrease in ICP correlated with increasing mean daily serum [Na⫹] (r ⫽ -0.330, P ⫽ 0.022). Fifty-four percent of patients survived and were transferred to rehab (44%), long term care (8%) or home (3%). Conclusions: HTS was effective in reducing intracranial hypertension in patients with severe TBI. The efficacy of HTS on ICP crisis’ reduction correlated with an increase in serum sodium concentration.

Jeff Fletcher, University of Michigan, Chris Wu, Univeristy of Michigan, Daniel Orringer, University of Michigan Introduction: Neurosurgical consultation is routinely requested for patients with non-severe TBI and mildly abnormal head CT findings. Hypothesis: We hypothesized neurosurgical consultation rarely results in neurosurgical interventions and sought to identify clinical and radiographic features that would predict this uncommon occurrence. Methods: The University of Michigan trauma registry was used to identify patients with non-severe TBI admitted over a 10 year period. Patient demographics, measures of disease severity and head CT findings were documented. Patients were excluded from analysis for the following reasons; GCS score of ⬍8, no initial head CT available, initial head CT demonstrating midline shift of ⬎2 mm, diffuse cerebral edema, a subdural or epidural ⬎5 mm, a contusion or intracerebral hemorrhage ⬎30 mL, intraventricular or subarachnoid hemorrhage (SAH) described as extensive or associated with acute hydrocephalous. A neurosurgical intervention was defined as placement of an intracranial pressure monitor or external ventricular drain, craniotomy, angiographic study recommended solely by neurosurgery, the use of osmotic therapy, hyperventilation, or sedation to specifically lower intracranial pressure, lumbar drain placement and diagnosis of a missed spine injury. Multivariable logistic regression was used to identify independent predictors of neurosurgical intervention. Results: The incidence rate of neurosurgical intervention was 7.5% (51/677). In multivariable analysis coagulopathy (p ⫽ 0.02, OR 2.23 (95% CI 1.14 – 4.37)), suspected CSF leak (p⬍0.001, OR 10.1 (95% CI 2.52– 40.5)), depressed skull fracture (p ⫽ 0.017, OR 2.67 (95% CI 1.19 –5.95)), any basal cistern or sylvian fissure SAH (p⬍0.001, OR 2.94 (95% CI 1.54 –5.6)), and unstable repeat head CT (p⬍0.001, OR 2.81 (95% CI 1.52–5.2)) predicted the need for neurosurgical intervention. Conclusions: Mandatory neurosurgical consultation following non-severe TBI in patients with mildly abnormal initial head CT findings is an inefficient utilization of resources. Future research should focus on validating clinical and imaging findings to increase the utility of neurosurgical consultation.

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CLINICAL AND SOCIAL FACTORS ASSOCIATED WITH WITHDRAWAL OF CARE IN PATIENTS WITH TRAUMATIC BRAIN INJURY

LABETALOL VERSUS NICARDIPINE FOR EARLY INTENSIVE BLOOD PRESSURE CONTROL AFTER ACUTE PRIMARY INTRACEREBRAL HEMORRHAGE

Shuai Shao, Deborah Stein, University of Maryland School of Medicine, Joseph Kufera, R Adams Shock Trauma Center, Bizhan Aarabi, University of Maryland School of Medicine, Thomas Scalea, University of Maryland Medical Center R Adams Cowley Shock Trauma Center, Kevin Sheth, University of Maryland School of Medicine

Dustin Gladden, St. Joseph Mercy Oakland, Jeffrey Barletta, Midwestern University College of Pharmacy, Karen McAllen, Spectrum Health

Introduction: Prior studies in non-traumatic intracerebral hemorrhage have identified withdrawal of care as a leading cause of death, as part of a self-fulfilling prophecy. To date, there is limited information regarding the impact of withdrawal of care on mortality in patients with traumatic brain injury (TBI). Hypothesis: We tested the hypothesis that withdrawal of care in patients with TBI is associated with increased mortality and that there are specific clinical and social or cultural factors that are associated with withdrawal of care in patients withTBI. Methods: Using a prospective TBI registry at a tertiary academic level I trauma center, we performed a retrospective analysis of all patients with traumatic brain injury, defined by admission diagnosis, in 2009. Baseline clinical characteristics, etiology of death, and in-hospital mortality were prospectively collected and entered into the trauma registry. Recorded etiology of death was confirmed by review of the medical record. Descriptive statistics were performed and differences were analyzed using t-test and Wilcoxon rank sum. Results: Among 948 patients admitted with TBI, 70 (7.3%) patients underwent withdrawal of life support, representing 57% of all deaths. There were lower rates of black race (21% vs 29%) and Hispanic ethnicity(1% vs 4%) in patients who underwent withdrawal of care compared to those who did not (p ⫽ .02). Marital and insurance status was not different between the two groups. Known risk factors associated with increased mortality included age (p ⫽ .004), lower Glasgow Coma Scale (GCS) score (p⬍.001), and abnormal pupils (p⬍.001). Deceased patients were more likely to receive craniectomy (18% vs 4%, p⬍.001), intracranial pressure monitoring (34 vs 13%, p⬍.001), and packed red blood cell transfusions (44 vs 16%, p⬍.001). Conclusions: Withdrawal of care is the leading proximate cause of death in patients with TBI, especially in patients with severe injury. In addition, older age made withdrawal of care more likely, and black race made withdrawal less likely. Further study is needed regarding the process of patient selection for withdrawal of care.This work was supported with funding from the American Academy of Neurology (KNS).

Introduction: The ideal antihypertensive agent for early intensive blood pressure control after acute primary intracerebral hemorrhage (ICH) remains unknown. The objectives of this study are to compare the ability of labetalol versus nicardipine to achieve control of blood pressure and examine their impact on patient outcomes in ICH. Hypothesis: Nicardipine will lead to superior blood pressure control and improved patient outcomes compared to labetalol following ICH. Methods: We performed a retrospective cohort study including adult patients with primary ICH who received ⬎1 dose intermittent IV labetalol (L) or ⬎3 hours nicardipine continuous infusion (N) for elevated blood pressure within 24 hours of presentation. Patients were excluded for reasons including secondary etiology of ICH, hospital stay ⬍24 hours, and administration of recombinant Factor VIIa. Blood pressure recordings were obtained for the first 24 hours of hospital stay to evaluate global blood pressure control, which was reported as: mean SBP per patient, percentage of SBP recordings within patient-specific goal, and treatment failure, defined as switch to alternative antihypertensive or failure to achieve SBP within goal for at least 3 consecutive hours. Patient outcomes included adverse events, length of stay (LOS), favorable Glasgow Outcome Score (GOS ⫽ 5), and mortality at day 28 or hospital discharge. Results: Seventy-five patients (n ⫽ 28 N v. n ⫽ 47 L) with similar baseline demographics were included. Mean SBP was lower in the nicardipine group (152 N v. 165 mmHg L, p ⫽ 0.003) and percent SBP within goal was higher in the nicardipine group (75% N v. 50% L, p ⫽ 0.04) during the initial 6 hours after antihypertensive initiation. The incidence of hypotension (11% N v. 6% L, p ⫽ 0.67), bradycardia (25% N v. 30% L, p ⫽ 0.66), LOS (9 N v. 8 days L, p ⫽ 0.23), GOS ⫽ 5 (11% N v. 17% L, p ⫽ 0.46), and mortality (14% N v. 11% L, p ⫽ 0.72) did not differ between groups. Treatment failure occurred significantly more often with labetalol (7% N v. 55% L, p⬍0.001). Conclusions: Nicardipine is the preferred antihypertensive for early intensive blood pressure control and should be considered a first-line treatment option in patients with primary ICH.


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COMPARISON OF SAFETY WITH FULL ANTICOAGULATION WITH ENOXAPARIN AND UNFRACTIONATED HEPARIN IN PATIENTS WITH A RECENT ISCHEMIC STROKE

SUCCESSFUL TREATMENT OF DISSEMINATED INTRAVASCULAR COAGULATION WITH RECOMBINANT HUMAN SOLUBLE THROMBOMODULIN IN A PATIENT WITH NEUROLEPTIC MALIGNANT SYNDROME

Terence Chau, Teresa Allison, Memorial Hermann Hospital, Imo Aisiku, The University of Texas Medical School Introduction: An increased risk of symptomatic intracranial hemorrhage (ICH) with Enoxaparin bridging to Warfarin in post-ischemic stroke patients has been described. It is unknown whether anticoagulation with subcutaneous Enoxaparin vs. intravenous unfractionated Heparin increases the risk of ICH. Hypothesis: Anticoagulation with unfractionated Heparin may be associated with a lower incidence of ICH vs. Enoxaparin after an ischemic stroke. Methods: This was a retrospective study at an academic hospital of adult patients with a diagnosis of ischemic stroke who received anticoagulation with Enoxaparin or unfractionated Heparin. The primary endpoint was the rate of ICH. Secondary endpoints included time between ischemic stroke and detection of ICH, time between initiation of anticoagulation and detection of ICH, length of stay, and mortality. Results: One hundred fifty patients were included (68 in Heparin group and 82 in Enoxaparin group). Median NIHSS scores were lower in the Heparin group than the Enoxaparin group [5 (IQR, 2–10.5) vs. 9 (IQR, 4 –13; p ⫽ 0.06)]. Median APACHE II scores were similar between the Heparin and Enoxaparin groups [14 (IQR, 11–17.5) vs. 13 (IQR, 10 –15; p ⫽ 0.53)]. Eleven patients in the Heparin group (16.2%) and 20 patients in the Enoxaparin group (24.4%) received Alteplase (p ⫽ 0.22). Common indications for anticoagulation were atrial fibrillation (36%) and venous thromboembolism (23.3%). Three patients in the Heparin group (4.4%) and 3 patients in the Enoxaparin group (3.7%) had an ICH (p ⫽ 1.0). Five of the 6 ICHs occurred within 2 days of initiation of anticoagulation. Heparin was initiated sooner after a stroke than Enoxaparin (2.3 ⫾ 3.1 vs. 6.0 ⫾ 5.8 days, p⬍0.001). There was no difference in time between stroke and detection of bleeding or hospital length of stay. Two patients in the Enoxaparin group died (p ⫽ 0.5) due to reasons unrelated to the Enoxaparin. Conclusions: Safety, defined as new rates of ICH, appears to be equal in patients who received anticoagulation doses of Heparin or Enoxparin. Further evaluation is required to confirm these results. Close monitoring of the patient’s clinical status is warranted with full anticoagulant doses of either agent after an ischemic stroke.


Kei Hayashida, Seitaro Fujishima, Shingo Hori, Emergency & Critical Care Medicine, School of Medicine, Keio University Case Reports: Neuroleptic malignant syndrome (NMS) is rarely complicated with rapidly progressive disseminated intravascular coagulation (DIC), which mostly resulted in fatal outcome. We present a case of NMS complicated with severe DIC, but was successfully treated with a recombinant human soluble thrombomodulin (rTM), a recently approved drug for DIC in Japan. A 44-yearold man with a chief complaint of seizure and high fever was brought to our ER by ambulance. He had past histories of depression and mental retardation, and a dose of levomepromazines had been increased one week before the episode. On arrival, he was comatose and his tympanic temperature was 41.1 degrees Celsiu. Neurological examination revealed systemic muscular rigidity, but no other abnormal neurological findings including neck stiffness was observed. The findings of brain computerized tomography, brain magnetic resonance imaging and cerebrospinal fluid finding were unremarkable. The results of laboratory blood tests was as follows; a white blood cell count 4400/␮L, hemoglobin 14.1 g/dL, platelet counts 208000/␮L, C-reactive protein 0.2 mg/dL, procalcitonin 0.07 ng/ml, creatinine kinase 690 IU/L, fibrin degradation product (FDP) 2.9 mg/mL, Ddimer 0.7 ␮g/mL. He was immediately intubated and admitted to the ICU. Since his body temperature (BT) remained high even after systemic cooling with blankets, and no significant signs of infection were observed, we also started to give dantrolene sodium and bromocriptine, in addition to broad spectrum antibiotics, with the diagnosis of NMS. Although his BT started to decrease, at 15 hours after admission, his platelet counts decreased to 18000/␮L and FDP increased to 199.8 mg/mL. He was diagnosed as acute severe DIC secondary to NMS, and rTM 130U/kg/day was administered for 5 consecutive days. He quickly responded to rTM administration and his platelet counts increased to 37000/␮L on the 3rd hospital day, and 143000/␮L on the 5th day. He was successfully discharged from hospital on the 55th day with the final diagnosis of NMS complicated with DIC. Thus, we speculated that rTM may become an innovative therapy for DIC especially induced by NMS.

Posters: Pulmonary-Diagnostics 328

329

NON-INVASIVE MONITORING OF TIDAL VOLUME AND MINUTE VENTILATION IN NON-INTUBATED PATIENTS

THE RELIABILITY AND VALIDITY OF CURRENT VENTILATOR ASSOCIATED PNEUMONIA DEFINITION

Jenny Freeman, Michael Lalli, Nicole Yocum, Alexander Panasyuk, Svetlana Panasyuk, Robert Lew, Respiratory Motion, Inc.

Ahmad Nusair, Marshall University, Shifang Ding, Qilu Hospital, Shandong University, Balwinder Singh, Guangxi Li, Ognjen Gajic, Mayo Clinic

Introduction: Monitoring of respiratory status is inadequate in extubated patients in the critical care setting. Currently, subjective status assessments and lagging O2 saturation levels act as the basis for clinical decision making. A Respiratory Variation Monitor (RVM) has been developed to provide quantitative, continuous, real-time data to serve as a leading indicator of respiratory insufficiency and facilitate diagnostic and therapeutic decisions. Hypothesis: A noninvasive RVM system can provide an accurate, continuous assessment of tidal volume, respiratory rate, and minute ventilation in non-intubated patients. Methods: An impedance based RVM system was created with adaptive electronics to reduce variability. Respiratory signals were collected from four leads specifically placed on the thorax and were run through advanced algorithms (96 patients, 306 visits, 7226 breathing tests). RVM measurements were compared for accuracy against a spirometry standard providing simultaneous data for tidal volume, respiratory rate, and minute ventilation during normal and erratic breathing. Results: RVM data correlated strongly with spirometric volume data, with median correlation across all subjects noted to be r ⫽ 0.98 for normal breathing and r ⫽ 0.96 for erratic breathing with an overall ICC ⫽ 0.92. A calibration algorithm compensated for daily variation among subjects. Calibrated RVM data demonstrated clinically relevant accuracy (10% mean error). RVM data was noted to be adequate for advanced analysis of respiratory curve parameters & complexity. Conclusions: RVM data can be used to determine tidal volume, respiratory rate, and minute ventilation with sufficient accuracy for clinical utility and with the capability to provide measures of respiratory curve features, inter-breath variability and respiratory complexity. These results project to the development of RVM as a useful tool for respiratory assessment in the Intensive Care Unit, decreasing complications, reducing costs and saving lives. Follow-on experiments in the critical care setting are underway including studying patients following ventilator weaning and assessing the effects of narcotic pain management.

Introduction: The reliability and validity of current clinical Ventilator Associated Pneumonia (VAP) definitions remained controversial. Hypothesis: We hypothesize that clinical VAP definition is neither reliable nor valid. Methods: All adult patients on invasive mechanical ventilation (IMV) greater than 48 hours in year 2006 from Olmsted County were included excluding those who developed pneumonia within the first 48 hours or got tracheostomy. Two expert physicians independently reviewed the following data for each patient: indication and duration of IMV, vital signs, oxygen requirements, frequency of suctioning, amount, color and consistency of secretion, ventilator settings, leukocytes count, microbiologic and radiographic data. The six definitions [The Loose, The Rigorous, The Modified Clinical Pulmonary Infection Score (CPIS), The Canadian Critical Care Trials Group(CCCTG), The International Sepsis Forum Consensus (ISFC) and The Center for Disease Control and Prevention (CDC)] were applied and their findings were compared using kappa coefficient. The external validity was tested using measures of hospital mortality and ventilator days correlation. Results: Total 115 patients on the ventilator greater than 48 hours were screened. Reviewer A found 14 patients who met one or more definition while reviewer B found 5 patients. Kappa value for The Loose, The Rigorous, CPIS, CCCTG, ISFC and CDC Definition was; 0.22, 0.49, 0.33, 0.41, 0.38 and 0.68 respectively. None of these definitions had good correlation with hospital mortality or IMV duration. Conclusions: VAP definitions used are unreliable with the exception of the CDC definition which has the least interrater variability. No current definition had good validity.

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EXTRAVASCULAR LUNG WATER AND ITS ASSOCIATION TO WEIGHT, HEIGHT, AGE AND GENDER: A STUDY IN 233 ICU-PATIENTS

COMPARISON OF THORACIC INTRAVASCULAR VOLUME AND OXYGENATION FUNCTION OF THE LUNG

Wolfgang Huber, Technical University of Munich, Bernd Saugel, Klinikum Rechts Der Isar Der TEchnischen Universitat Munchen, Veit Phillip, Klinikum rechts der Isar der Technischen Universitat Munchen, Josef Hoellthaler, 2nd Medical Department; Klinikum Rechts Der Isar Technical University of Munich, Roland Schmid, Klinikum rechts der Isar der Technischen Universitat Munchen Introduction: With regard to large inter-individual variability of height, weight and age, several volumetric hemodynamic parameters are adjusted for biometric data. This also applies for extravascular lung water (EVLW) which traditionally has been indexed to actual bodyweight (BW-act), termed EVLW-index (ELWI). Since indexation to BW-act might inappropriately diminish ELWI-act in obese patients, the indexation has been changed to predicted BW (ELWI-pred). BW-pred is a weight-correction-formula derived from height and gender. However, there is a lack of data investigating other options for biometric indexation of ELWI. Hypothesis: Regarding other parameters of pulmonary function, heightmightbemoreappropriateforindexationofELWIthanBW-act,weightcorrection formulas and gender. Methods: Therefore, we analysed a prospectively maintained hemodynamic database including 3814 transpulmonary thermodilution measurements in 233 consecutive ICU-patients (99 female; 134 male) equipped with PiCCO-monitoring (Pulsion, Munich/Germany). Univariate (Spearman correlation) and multivariate (multiple regression analysis) association of EVLW with BW-act, height, age and gender was calculated using SPSS 19 software. Results: Age 62⫹/⫺13 years; BW-act 75⫹/⫺18kg; height 171⫹/⫺9cm; BMI 25.4⫹/⫺5.6kg/sqm; APACHE-II 21⫹/⫺8.In univariate analysis EVLW significantly correlated to height (r ⫽ 0.262; p⬍0.001) and male gender (r ⫽ 0.241; p⬍0.001), but neither to BW-act (r ⫽ 0.123; p ⫽ 0.064) nor to age (r ⫽ 0.004; p ⫽ 0.953). Among these parameters, the strongest association was found for height and male gender (r ⫽ 0.689; p⬍0.001). In multivariate analysis including BW-act, height, age and gender, only height was independently associated with EVLW. EVLW increased with each cm in height by 7.08 ml (95%-CI: 3.51–10.64 ml; p⬍0.001). Conclusions: In 233 adult ICU-patients, height was the only biometric parameter with independent association to EVLW.By contrast, neither BW-act (which is the only parameter used for indexadtion of ELWI-act) nor gender (which is part of the indexation of ELWIpred) were independently associated to EVLW. Therefore, in adult patients EVLW should be indexed to height.

Keilla Schmidt, Sho Furuta, Erin Suydam, Uy Vu, Michael Hayashi, David Inouye, Maimona Ghows, Danny Takanishi, Mihae Yu, University of Hawaii Introduction: Information on circulating blood volume (BV) is clinically important to guide fluid management. An ultrasound dilution method (COstatus system, Transonic Systems, Ithaca, NY) measures central blood volume index (CBVI) defined as the intravascular volume of the heart, lungs, and major vessels divided by weight (kg). 22 mL/kg is the upper limit of normal for CBVI. Extravascular lung volume and its relationship to pulmonary function is well documented. This study was done to determine if a relationship exists between CBVI and the oxygenation function of the lung. Hypothesis: CBVI correlates with oxygenation function of the lung: intrapulmonary shunt (Qs/Qt) and PaO2/ FiO2. Methods: Qs/Qt and PaO2/FiO2 were calculated in critically ill surgical patients with pulmonary artery catheters and/or arterial line. COstatus utilizes ultrasound sensors attached to an extracorporeal arterial-venous loop that bridges arterial and central venous catheters. After 30 mL injection of isotonic saline, the sensors record the change in velocity of blood and the CBVI is calculated. Spearman’s correlation was evaluated between CBVI and Qs/Qt, and between CBVI and PaO2/FiO2. For CBVI values ⬎22 mL/kg versus CBVI ⱕ22 mL/kg, differences in PaO2/FiO2 and Qs/Qt were analyzed using t-test. Results: 14 patients contributed 32 data points including CBVI ⬎22 mL/kg, ⱕ22 mL/kg. Their demographics were: age 68 ⫾ 11 years, Female:Male 6:8, APACHE II 22 ⫾ 7. Diagnoses included severe sepsis/septic shock (n ⫽ 11), ALI/ARDS (n ⫽ 3). There was no correlation between CBVI and Qs/Qt (r ⫽ 0.29, p ⫽ 0.23) or CBVI and PaO2/FiO2 (r ⫽ 0.31, p ⫽ 0.09). Comparing the 2 groups with CBVI ⬎22 mL/kg versus CBVI ⱕ22 mL/kg, there were no statistically significant difference in Qs/Qt (p ⫽ 0.702) or PaO2/FiO2 (p ⫽ 0.064). PaO2/FiO2 mean ⫾ SD was 286 ⫾110 for CBVI ⬎22 (n ⫽ 10), and 218 ⫾ 81 for CBVI ⱕ22 (n ⫽ 20). Qs/Qt was 25 ⫾ 10% for CBVI ⬎22, and 23 ⫾ 11 for CBVI ⱕ22. Conclusions: There was no relationship between intravascular thoracic volume (CBVI), and the oxygenation function of the lung, Qs/Qt and PaO2/ FiO2 ratio.


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DIGITALIZED ACOUSTIC RECORDINGS OF LUNG CONGESTION

UTILITY OF LUNG ULTRASOUND BEFORE AND AFTER CENTRAL VENOUS CATHETER PLACEMENT TO RULE OUT PNEUMOTHORAX

Shaul Lev, Rabin Medical Center Beilinson Campus, Lior Wolloch, Deep Breeze Ltd., Ilya Kagan, Maury Shapiro, Milana Grinev, Pierre Singer, Rabin Medical Center Beilinson Campus Introduction: Changes in lung water content are known to change the acoustics of breath sounds [1]. We previously reported that lung sound amplitude is significantly elevated in patients with evolving congestion, as opposed to in pleural effusion, atelectasis, or normal lung [2]. Recently we showed, in two different pig models, that continuous elevation of lung sound amplitude, recorded at fixed flow rate, may indicate an increase in total lung water content [3]. Hypothesis: The objective was to assess changes in the acoustic profiles of patients following aggressive fluid administration as a potential method to detect development of pulmonary congestion. Methods: We retrospectively analyzed clinical cases in which aggressive fluid administration was employed simultaneously with acoustic monitoring (VRI, Deep Breeze Ltd) and extravascular lung water index (EVLWi) monitoring (PiCCO, Pulsion). Correlation between lung sound amplitude and EVLWi was calculated using Pearson’s correlation coefficient. Cases were excluded if airflow rate was not constant (flow rate also influences lung sound acoustics [4]). Results: Simultaneous recordings were performed in a total of 8 patients. Three cases were excluded from the analysis due to changes in airflow rate. There was good correlation (r ⫽ 0.65; n ⫽ 28 recordings) between EVLWi and lung sound amplitude. Significant elevation in EVLWi was associated with a significant increase in lung sound amplitude during fluid administration in 3 cases. In the 2 cases where EVLW remained unchanged during resuscitation, lung sound amplitude also remained stable. Conclusions: An increase in lung water content tends to cause elevation of lung sound amplitudes, probably due to improved lung sound conduction, or due to an increase in bronchial content [5]. These preliminary results indicate that monitoring lung sound amplitudes has the potential to detect development of pulmonary congestion during aggressive fluids administration. References:1.Donnerberg et al, Br J Dis Chest (1980)74,232.Lev et al, Respiration (2010)80,5093.Lev et al, Crit Care (2011)15 (Suppl 1)P1744.Yosef et al, Open Respir Med J (2009)3,1165.Lev et al, Crit Care (2011)15 (Suppl 1)P173.

334 RADIOLOGIC FINDINGS OF SEVERE CASES OF PANDEMIC H1N1 PNEUMONIA REQUIRING INTENSIVE CARE Cecilia Jude, Tarik Ngab, Kelvin Chan, Natalya Kolesnikova, Nader Kamangar, Olive View-UCLA Medical Center Introduction: The objective of this study was to describe the chest radiographic (CXR) and computed tomography (CT) findings of patients with severe H1N1 pneumonia admitted to the intensive care unit (ICU) during the 2009 pandemic. Prior reports describing imaging findings of H1N1 infection have included a heterogeneous patient population with a wide spectrum of clinical manifestations. Our imaging study comprises the largest number of patients with severe H1N1 pneumonia who required intensive care. Hypothesis: Patients with severe H1N1 pneumonia requiring ICU admission have extensive radiographic and CT abnormalities. Methods: A retrospective study of 18 patients, ages 23 to 62 (mean 41), admitted to the ICU at Olive View-UCLA Medical Center with a primary diagnosis of pandemic H1N1 infection, confirmed either via rapid influenza detection test (RIDT) or by real-time reverse transcriptase polymerase chain reaction (rRT-PCR) assay. Twelve (67%) patients–meeting critieria for ARDS– required mechanical ventilation and 3 (17%) died. All patients had CXR on admission and 5 patients had CT examinations. Imaging studies were evaluated for the pattern (ground glass opacities, consolidation, reticular opacities), distribution (unilateral/bilateral, upper/middle/lower, central/peripheral/diffuse) and extent (number of lung zones) of abnormalities. Results: All (100%) patients had abnormal CXR and CT studies. The predominant radiographic findings were ground glass opacities (16/18; 89%), consolidation (16/18; 89%) and reticular opacities (6/18; 33%). The radiographic abnormalities were bilateral in 17 (94%) patients; involved the mid and lower lung zones in 16 (89%) patients; and had diffuse distribution in 14 (78%) patients. Sixteen (89%) patients had extensive abnormalities involving 3 or more lung zones. Sixteen (89%) patients had pleural effusions. The predominant CT abnormalities were consolidation (4/5; 80%) and ground glass opacities (3/5; 60%). The CT findings were extensive and bilateral in all (100%) patients. Conclusions: Patients with H1N1 pneumonia admitted to the ICU have bilateral, multifocal, and extensive CXR and CT abnormalities. Consolidation and ground glass opacities are the most common imaging findings.


Satyanarayana Reddy Mukkera, John Oropello, Arif Shaik, Aditya Uppalapati, Zafar Akram Jamkhana, Roopa Kohli-Seth, Mount Sinai School of Medicine, Adel Bassily-Marcus, Mount Sinai School of Medicine- Mt. Sinai Hospital, Ernest Benjamin, Mount Sinai School of Medicine, Anthony Manasia, Mount Sinai Medical Center Introduction: Central venous catheter (CVC) placement in the neck, a relatively safe procedure under real time vascular ultrasound, is not without risk of pneumothorax (PTX). Lung ultrasound both before and after placement can improve the diagnostic accuracy of pneumothorax. Hypothesis: Ultrasound has been extensively studied in the early detection of the PTX and also to diagnose occult PTX, which can be missed by conventional chest x-ray (CXR). The presence of lung sliding rules out a complete PTX, but only lung point can rule in a PTX. However, a lung point may be difficult to demonstrate, and in a complete PTX, it is absent. Comparing post- CVC insertion to pre-CVC insertion lung ultrasound patterns may improve the diagnostic accuracy of pneumothorax. Methods: Patients undergoing neck-inserted CVCs during the course of their treatment in the Surgical Intensive Care Unit and the Central Venous Access Service were studied. Lung ultrasound was performed by placement of a linear probe over the chest in the mid-clavicular line, orineted in the saggital plane in the intercostal spaces of ribs 2–5 bilaterally, before and after CVC insertion, for lung sliding and B-lines. Video clips and M-mode still images were recorded. The physician performing the CVC inserion recorded the ultrasound findings before and after the CVC insertion. A different physician, blinded to the results of the procedure physician also recorded the ultrasound findings both pre and post-CVC insertion. In addition, baseline patient demographics, results of the post procedure CXR and complications were collected. Results: 9 patients were enrolled in study. 33% were male. Lung sliding was present in 100% the patients on both pre and post-scan, which ruled out PTX when compared to chest x-ray. No delayed PTX was identified.The average time needed for scan was ⬍2 min per physician compared to 54 min for CXR results. Conclusions: The disappearance of lung sliding and⶿ or B-lines after CVC placement in comparison to a a pre-insertion scan may be a more accurate sign to rule in a PTX, than the currently recommended post-insertion scan done only if there is a suspected complication. This study is ongoing with a target enrollment of 500 patients.

Posters: Pulmonary–Mechanical Ventilation 335

336

PATTERNS OF PATIENT-VENTILATOR ASYNCHRONY AS PREDICTORS OF PROLONGED MECHANICAL VENTILATION

A PROSPECTIVE CLINICAL COMPARISON OF THE MEDICAL GRAPHICS ULTIMA WITH THE DELTATRAC II AND DOUGLAS BAG COLLECTIONS

Ryan Brimeyer, Vijay Gogineni, Creighton University Medical Center, Ariel Modrykamien, Creighton University School of Medicine Introduction: The purpose of this study is to assess whether specific patterns of patient-ventilator asynchrony perform differently in their ability to predict mechanical ventilation for more than 7 days. Hypothesis: Specific patterns of patient-ventilator asynchrony may predict prolonged mechanical ventilation better than others. Methods: Over a period of 2 months, patients mechanically ventilated within 48 hours of ICU admission were included. Subjects who spent at least 72 hours on mechanical ventilation (MV) were deemed eligible. Tracheostomy prior to admission, MV dependency, treatment with neuromuscular blockers, and GCS lower than 8, in the absence of sedatives, were exclusion criteria. Patient-ventilator asynchrony patterns were collected on daily evaluations for 3 days. Each evaluation was performed over 1 minute. Patterns of asynchrony included: missed and double triggering, dish-out and overshoot of the pressure waveform, delayed termination, and auto-PEEP. Pattern-specific, and composite asynchrony indexes were calculated. Each index was a ratio: average number of specific pattern to average respiratory rate. Demographics, APACHE 2, PaO2/ FIO2, PEEP, and Richmond Agitation Sedation Scale (RASS) were collected. Continuous data were expressed as means ⫾ SD. Categorical data were expressed as percentages. ROC curves to assess the performance of each specific asynchrony index, for their ability to predict prolonged MV were constructed. Results: Twenty-eight patients were deemed eligible. Patient age was 54 ⫾ 17. Seventyone percent were men. APACHE 2, PaO2/FIO2, and PEEP, were 18 ⫾7, 249⫾117, and 5.8⫾ 2.4, respectively. RAAS was -3.1 ⫾ 1.3. Days on MV were 5.4 ⫾ 6.5. AUC for missed and double-triggering indexes were 0.66 ⫾ 0.12, and 0.60 ⫾ 0.12, respectively. AUC for dish-out index was 0.88 ⫾0.09. AUC for overshoot, delay termination, and composite indexes were 0.55 ⫾ 0.12, 0.62 ⫾0.12, 0.70 ⫾0.10, respectively. A dish-out index of zero was the best cut-off point, with sensitivity, specificity, PPV, and NPV of 83%, 91%, 71%, and 95%, respectively. Conclusions: Dish-out asynchrony index is the best predictor of prolonged mechanical ventilation, compared with pattern-specific and composite asynchrony indexes.

Claire Black, Mervyn Singer, Mike Grocott, University College London Introduction: There are scant data describing the validity of measurements obtained from metabolic monitoring devices available for clinical use in ventilated patients. We prospectively compared oxygen consumption (VO2), carbon dioxide production (VC02) & resting energy expenditure (REE) measured by Medical Graphics Ultima (MGU), Deltatrac II (DTII) & Douglas Bag Collection (DBC) techniques. Hypothesis: There is no difference between V02, VC02 & REE measurements of the MGU when compared to either DTII or DBC. Methods: 16 mechanically ventilated patients were recruited between May 2010 & January 2011. Patients were excluded if they had burns, endotracheal/tracheal leaks ⬎10%, open chest drainage, FiO2 ⱖ0.6, pregnant, ⬍18 years, or had cardiorespiratory instability (requiring frequent changes in ventilator settings, FiO2, inotropic or sedative drug dosages). Ventilator settings were kept stable in the hour preceding & during the test period. Measurements were recorded breath-by-breath by the MGU over a 30 –75 minute period with simultaneous measurements taken with DTII (each minute) &/or DBC (gas collected over three 5-minute periods into 100L gas collection bags; gas volumes were measured and samples of gas analysed from each bag). Data for all three techniques was excluded if the RQ ⬍0.6 or ⬎1.2. Bland Altman plots were created to evaluate systematic error & to calculate the level of agreement between the techniques. Results: The bias & precision (95% limits of agreement) were; MGU vs. DTII: 19 tests, 10 patients. V02: bias -10 ml/min, precision -56 to 35. VC02: ⫹34 ml/min, -0.6 to 68. REE: -28 kcal, -305 to 249.MGU vs. DBC: 20 tests, 9 patients. V02: bias ⫹7 ml/min, precision -56 to 70. VC02: bias ⫹31 ml/min, precision -22 to 85. REE: bias 93kcal, precision -263 to 449. Conclusions: The MGU demonstrated a small systematic V02 bias & clinically acceptable random error when compared to both DTII & DBC measurements. However, the MGU has a clinically unacceptable systematic VC02 bias and random error. Although VC02 contributes proportionally less to the calculation of REE than VO2, improved measurement of VC02 by the MGU could reduce the systematic bias of the REE values.Supported by a NIHR Clinical Doctorate Fellowship.

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ULTRASOUND EVALUATION OF DIAPHRAGM MUSCLE IN PATIENTS WITH FAILED AND SUCCESFUL WEANING

BENCH EVALUATION OF PROPORTIONAL PRESSURE VENTILATION (PPV) MODE ON THE V60 BIPAP VENTILATOR

Shalim Rodriguez Giraldo, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru, Luis Esteves Lecaros, Hospital Nacional Edgardo Rebagliati Martins

Richard Branson, University of Cincinnati Medical Center, Thomas Blakeman, University of Cincinnati, Robert Campbell, Phillips Respironics, Jay Johannigman, University of Cincinnati Medical Center

Introduction: Dificult weaning is a frecuent problem in ICU. Tests to evaluate respiratory muscles are indirect, and bedside evaluations are not easy in daily clinical practice. Hypothesis: Diaphragm muscle has diferent contractile characteristics in patients with succesful weaning and patients with failed weaning, and this can be evaluated with Ultrasound. Methods: We made a comparative, prospective, observational study in patients with weaning criteria, between August and December 2009 in a polivalent ICU, Edgardo Rebagliati Hospital Lima, Peru. Ten patients were included in the group of failed weaning (FWG), and ten patients in the group of succesful weaning (SWG). Ultrasound evaluation in FWG was performed after three spontaneous breathing test failed, and in the first succesful SBT in SWG. Movement of right diaphragm was evaluated with Ultrasound, with a 3.5–5 MHz convex probe, 14cm-16cm deep, on media clavicular line, observing diaphragmatic dome, and crural (posterior) and costal (anterior) segments. Distance of displacement was recorder in inspiration and forced espiration, and it was obtained the aritmetical media of both. Diaphragmatic inspiratory thickness (DIT) was evaluated with a lineal probe (7–9 MHz, 4cm-6cm deep), and was expressed as percentage: DIT ⫽ [(Inspiratory thickness–Espiratory thickness)/Espiratory thickness]x100. Analisis was made with non parametric Mann-Wihitney test. Results: Diaphragmatic movement was, for both, FWG and SWG: Crural: 0.65 cm ⫾ 0.11cm vs 2.14 cm ⫾ 0.8 cm p ⫽ 0.009); Costal: 0.96 cm ⫾ 0.55 cm vs. 2.13 cm ⫾ 0.7 cm (p ⫽ 0.021). Media: 0.81 ⫾ 0.31 cm vs. 2.14 ⫾ 0.7 cm (p ⫽ 0.009) respectively. DIT was 16.2% ⫾ 1.1%, for FWG, and 55.9 ⫾ 8.4 % (p⬍0.0001), for SWG. Conclusions: There is a significative difference between displacement and contraction of the diaphragm in patients with successful weaning and failed weaning that can be evaluated with ultrasound.

Introduction: PPV is a mode intended for non-invasive and invasive application that is a form of proportional assist ventilation. Hypothesis: Determine the response of PPV to changes in simulated patient effort and the presence of leaks compared to pressure support ventilation (PSV). Methods: An ASL 5000 Lung Simulator (Ingmar, Pittsburgh, PA) was used to mimic spontaneous breathing at a rate of 12, with three patient (pt) effort settings (-4, -8, and -12 cmH2O), with no leak, and a leak of 20 L/min. Compliance was 50 mL/cmH2O and resistance was 5 cmH20/L/sec. The V60 was set to ventilate the ASL in PPV mode with Max Elastance of 20, Max Resistance of 5, and 80% support. PSV was also used with a pressure of 15 cm H2O and PEEP of 5 cm H2O. Measurements from the ASL included Total Inspiratory Work (Wtot), Pt Inspiratory work (Wpt), Tidal Volume (VT), and peak pressure (PIP). (Pt) work as a percentage of total work (Wpt%) was calculated in mjoules/L. Results: With PSV, delivered VT was 491 mL, 583 mL, and 690 mL at efforts of -4, -8, and -12 cm H2O respectively. The Wtot/Wpt/Wpt% were 691/115/16.6% at -4, 1001/310/30.9% at -8, and 1376/ 561/40.8% at -12. During PSV with leak, the VT was 484, 563, and 668 at each pt effort and Wtot/Wpt/Wpt% were 659/109/16.5%, 928/294/31.7%, and 1284/537/41.8%. With PPV, VT was 395, 878, 1356 at each effort setting and Wtot/Wpt/Wpt% were 450/73/16.2%, 1852/338/18.2%, and 4013/748/ 18.6%. During PPV with leak, the VT was 322, 748, 1115 and Wtot/Wpt/ Wpt% were 330/65/19.6%, 1369/289/21.1%, and 2853/663/23. Due to the fixed pressure output during PSV, increasing effort resulted in dramatic increases in work measurements and in Wpt%, and only a small increase in VT. With PPV, increasing effort also resulted in dramatic increases in work, but Wpt% remained relatively constant and delivered VT increased. Adding a leak resulted in a small decrease in work and VT and did not affect triggering. Conclusions: Compared to PSV, PPV maintains a relatively constant Wpt% and allows greater VT variability in the face of changing effort, which may result in improved pt comfort during mechanical ventilation. Further clinical studies are indicated.


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SURVIVAL OF ALI/ARDS IS ADVERSELY AFFECTED BY AN UNDERLYING DIAGNOSIS OF ADVANCED COPD

CONTINUOUS CAPNOGRAPHY DECREASES THE UTILIZATION OF BLOOD GASES

Mohamed H. Abou El Fadl, John Komara, Jorge A. Guzman, Cleveland Clinic Foundation

Courtney Rowan, Sheikh Ahmed, Terri Hedlund, Richard Speicher, Riley Hospital For Children

Introduction: ALI/ARDS is associated with high morbidity and mortality. The published landmark trials excluded patients with common comorbidities managed in most ICUs. The purpose of this study is to describe the outcomes of ALI/ARDS in patients from our institution who were enrolled in the published ARDS Network studies and compare them to patients who were excluded due to the presence of severe COPD. Hypothesis: Patients with ALI/ARDS and advanced underlying COPD have worse outcomes compared to patients otherwise enrolled in ARDS Network trials. Methods: Retrospective chart review of patients admitted to the MICU who met ALI/ARDS criteria between August 2007 and March 2011. Patients who were enrolled in the ARDS Network studies were included in Group I, whereas those that were excluded due to COPD criteria (FEV1 ⬍20 ml/kg PBW, FEV1/VC ⬍50 %, chronic hypercapnia PaCO2 ⬎50 and/or chronic hypoxemia PaO2 ⬍55 on FiO2 0.21) were included in Group II. Results: Four hundred and twenty five patients met ALI/ARDS criteria during the study period, 96 patients were analyzed, 34 in Group I and 62 in Group II. Mean ⫾ SD age and APACHE III score were 47 ⫾ 17 vs. 61 ⫾ 15 years and 65.9 ⫾ 24.3 vs. 77.2 ⫾ 28.3 for Groups I and II respectively, p⬍0.05 for both. All patients were full code (no restrictions on any medical intervention) upon ICU admission.Patients in Group II had a shorter duration of mechanical ventilation (5.4 ⫾ 7.3 vs. 8.9 ⫾ 12.6 days, respectively, p⬍0.05), shorter ICU LOS (9.4 ⫾ 9 vs. 13.0 ⫾ 12 days, respectively P ⫽ 0.08), but higher ICU readmission rates (29 vs. 12 %, respectively; P ⫽ 0.08). Hospital LOS was comparable (19.4 ⫾ 14 vs. 20.9 ⫾ 14 days for Groups I and II, respectively; P ⫽ 0.66). Patients in Group II had higher ICU and hospital mortality (33.5 and 53.2 vs. 20.1 and 23.5 %, P ⫽ 0.02 and 0.08, respectively). The proportion of survivors discharged home was comparable (36.4 vs. 42.2 % for Groups I and II, respectively). Conclusions: Patients with ALI/ARDS and advanced underlying COPD had higher readmission rates and higher ICU and hospital mortality. Hospital LOS and survivors’ disposition were comparable. These data support keeping advanced COPD as exclusion criteria for ALI/ARDS trials.

Introduction: Capnography provides a continuous, noninvasive monitoring of the CO2 to assess adequacy of ventilation. It’s reported to correlate well with the PaCO2 obtained from arterial blood gas analysis, with a difference ranging from 4 to 6 mmHg. These monitors provide added safety features in mechanically ventilated patients by allowing for quick identification of unplanned extubation. Hypothesis: These monitors may enable decreased utilization of blood gases resulting in decreased cost. Methods: Standard continuous capnography was implemented for all mechanically ventilated patients in March 2011. Prior, it was available, but was not routinely used. The utilization of blood gas measurement in the pediatric intensive care unit was retrospectively analyzed. The time period of April 2010 to July 2010 was compared to April 2011 to July 2011. Parameters collected included total number of blood gases analyzed, cost of blood gas analysis, ventilator days, and patient days. Results: The total number of blood gases in the time period after the institution of end-tidal CO2 (ETCO2) monitoring compared to the year prior decreased from 8667 to 3738. The average number of blood gases per encounter decreased from 21.3 to 11.0. When comparing the blood gases per ventilator days there was a decrease from 5.37 to 2.33. The total blood gas charge decreased from $1,487,886 to $717,006 for a total cost savings of $770,880. During this time period, however, the cost of an individual blood gas analysis increased from $171.68 to $192.05. When adjusting for the increased cost the savings rise to $947,491. Our initial purchase of the ETCO2 monitors was approximately $111,700. Therefore, adjusting for the increased cost of the blood gas analysis and the cost of the ETCO2 monitoring, the total savings over a 4 month period was $835,791. Future months will still be analyzed. Conclusions: Continuous capnography resulted in a significant cost savings over a 4 month period by decreasing the utilization of blood gas measurements. Decreasing the number of blood gases analyzed may also have other cost savings advantages such as decreased blood transfusions and decreased catheter associated blood stream infections.

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SUCTIONING TECHNIQUES AND AIRWAY MANAGEMENT PRACTICES (STAMP 2011) OF REGISTERED NURSES (RNS) AND RESPIRATORY CARE PRACTITIONERS (RCPS)

POST-INTUBATION CARE IN MECHANICALLY VENTILATED PATIENTS BOARDING IN THE EMERGENCY DEPARTMENT

Mary Sole, University of Central Florida, Melody Bennett, Orlando Health

Rahul Bhat, Munish Goyal, Anu Bhooshan, Bill Frohna, Jeffrey Dubin, Daniel Moy, Vikaas Kataria, Linn Lung, Georgetown University Hospital/Washington Hospital Center, Mihriye Mete, Medstar Health Research Institute, David Gaieski, University of Pennsylvania

Introduction: Both RNs and RCPs assume responsibility for airway management of mechanically ventilated patients, and past studies have identified differences in practices. The importance of standardized practices to improve outcomes is now emphasized. The purpose of this study was to describe suctioning techniques and airway management practices (STAMP) and compare practices between providers. Hypothesis: Airway management practices will follow recommended guidelines; however, practices will differ between disciplines. Methods: A descriptive comparative design was used. Subjects were RNs and RTs from a multi-hospital system who care for intubated, ventilated adult patients at least 50% of the time. Following an email invitation and posted recruitment flyers, data were collected for a 2-week period via an online survey. The validated STAMP (Sole, 2003) instrument was updated and converted to a 33-item online format. Completion of the survey indicated consent. Results: The survey was completed by 85 staff: 48 RNs (56%) and 37 RCPs (44%). Median critical care experience was 8 years, and 68% held at least a bachelor’s degree. The majority of RNs (69%) held certification while most RCPs (89%) were registered. Most participants regularly used closed endotracheal (ETT) suction (95%) and hyperoxygenate beforehand (86%); 23% instill saline prior to ETT suction and more RCPs reported this practice (p⬍.001). Only 49% reported oral suction after ETT suction. RNs (98%) brush teach at least every 12 hours compared to 13% of RCPs (p⬍.001). More RNs also perform oral swabbing and suctioning (p⬍.001). RCPs assume greater responsibility for measuring ETT cuff pressure and adjusting to at least 20 cm H2O; repositioning the ETT; and maintaining ETT subglottic suction tubes (all p-values ⬍.001). Conclusions: Compared to the 2003 STAMP study, improvements were noted in ETT suction practices, including reduced use of saline; improved oral hygiene frequency; and higher ETT cuff pressures. Although practices are considered a shared responsibility, differences in techniques and frequency of completion were noted between providers. Opportunities exist to develop a collaborative approach to airway management to ensure quality and consistency.


Introduction: Emergency Department (ED) crowding has led to increased length of stay for intubated patients leaving early post-intubation care to the emergency physician. The quality of post-intubation care in the ED has not been extensively studied. We sought to determine how frequently common post-intubation interventions are performed while patients board in the ED. Hypothesis: We hypothesized that few intubated patients receive all interventions while boarding in the ED. Methods: This is a retrospective chart review of all patients intubated in the Washington Hospital Center ED between 11/14/09 to 6/1/11. Patients were excluded if they were in the ED for ⬍two hours post-intubation, had emergent surgery within six hours post-intubation, were managed by the trauma team, had incomplete data, or had their status changed to “do not resuscitate”(DNR) during their admission. Trained research assistants blinded to the objectives reviewed each chart to determine if the following interventions were performed in the ED post-intubation: Appropriate initial tidal volume (6 –10cc/kg ideal body weight), sedation given ⬍30 minutes of intubation, oro/nasogastric tube (OGT) placement, chest xray (CXR), arterial blood gas (ABG) sampling, and use of continuous end-tidal capnography (ETCO2). Additionally, ventilator duration, ICU length of stay, mortality, and development of ventilator-associated pneumonia (VAP) were recorded. Results: 622 charts were reviewed, with 453 charts excluded (158 in the ED for ⬍two hours post-intubation, 143 trauma patients, 112 DNR, 40 other reasons), leaving 169 patients in our cohort. Of the six post intubation interventions, CXR was obtained most frequently (96.4%), followed by OGT placement (84.0%), sedation (83.4%), ABG sampling (76.9%), appropriate tidal volume (71.0%), and least frequently ETCO2 monitoring (8.3%). The percentage of patients receiving all interventions was 2.4%; 5 of 6 interventions was 42.0%. Mean duration of ventilation and ICU length of stay were 3.4 days, and 5.2 days respectively with a VAP rate of 5.9% and a mortality rate of 8.9%. Conclusions: In this single center study, few patients received all six measured post-intubation interventions while boarding in the ED.

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PREDICTORS OF FAILURE OF NONINVASIVE POSITIVE PRESSURE VENTILATION IN PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME

SIGNAL ANALYSIS DURING WEANING TRIALS: EVALUATION OF A NEW METHOD AND OF ITS PROSPECTS FOR INTEGRATION IN A DECISION SUPPORT SYSTEM

Shuji Okahara, Hiromichi Naito, Hideharu Hagiya, Shingo Hagioka, Naoki Morimoto, Tsuyama Central Hospital

Fabrice Daviaud, Laurent Allart, Ruddy Valentino, Dabor Resiere, Jean-Louis Ferge, Maud Jonas, Emilie Souchaud, Cyrille Chabartier, Hossein Mehdaoui, CHU Fort De France

Introduction: The efficacy of noninvasive positive pressure ventilation (NPPV) for acute exacerbations of chronic obstructive pulmonary disease and cardiogenic pulmonary edema has already been proven. The efficacy of NPPV for acute lung injury and acute respiratory distress syndrome (ALI/ARDS) has not been fully proven yet. We actively use NPPV for cases of ALI/ARDS at our center, depending on the severity. NPPV may reduce the complications associated with intubation and invasive mechanical ventilation, but intubation is still required in severe cases. Hypothesis: Respiratory rate (RR) and APACHE II score are predictors of failure of NPPV in patients with ALI/ARDS. Methods: The data for the 341 patients who had been treated with NPPV at our center from 2008 to 2010 were retrospectively reviewed. Of these patients, 31 (mean age, 78.2 ⫾ 10.4 years) had ALI/ARDS and were included in this study. These 31 patients were divided into 2 groups: success group, which included 19 patients who had achieved remission with NPPV, and failure group, which included 12 who had died or required intubation. The ages and male:female ratios did not significantly differ between the 2 groups. The clinical data for both groups were compared to determine the predictors of NPPV failure. The data were analyzed using Student’s t-test and logistic regression. Results: The success rate of NPPV for ALI/ARDS was 62%, whereas those for other diseases ranged from 80% to 90%. The RR of the failure group was significantly higher (35.9 ⫾ 8.6 vs. 27.1 ⫾ 6.3, p ⫽ 0.002) before using NPPV. In addition, the RRs of the 2 groups showed the same tendency (27.8 ⫾ 5.0 vs. 22.9 ⫾ 3.6, p ⫽ 0.003) after using NPPV. The APACHE II score for the failure group was significantly higher (12.6 ⫾ 3.1 vs. 10.1 ⫾ 2.9, p ⫽ 0.03). Univariate analysis identified an RR of more than 30 (OR 5.00, 95% CI 1.46 –17.2) and an APACHE II score of more than 12 (OR 2.83, 95% CI 1.13–7.12) as factors associated with failure of NPPV. Conclusions: NPPV is successful in select populations of patients with ARDS. When patients have a high RR or high severity score, the risk of failure is higher. An RR greater than 30 or an APACHE II score greater than 12 may suggest the need for intubation.

Introduction: Decision of extubation is based on spontaneous breathing trial (SBT). The success or failure of this test is determined based on a set of internationally accepted criteria. Analysing variations of physiological signals by a decision support system during weaning trial could be a more informative alternative for clinicians. Hypothesis: As a decision method during weaning trials, signals variations analysis is at least informationally equivalent to the existing internationally accepted protocol. Methods: We carried out a prospective study involving patients who had received mechanical ventilation for more than 48 hours and who were considered ready for weaning. They underwent a 30 mins SBT with a low-level pressure support (7cm H2O). Outcome of the SBT was based on consensus criteria. In parallel, we recorded data using a bedside information system (with a frequency of 0.5 Hz). Five parameters were recorded (respiratory frequency, tidal volume, EtCO2, mean blood pressure, heart rate) and one was computed (rapid shallow breathing index). Recording started 30 minutes before SBT and ended when trial was over. During the test we studied the evolution of the physiological parameters using a scoring method: on the basis of medical knowledge, each signal is divided into zones; transition from a zone to another is associated to a cost. A score is obtained by summing these costs for each recorded parameter. The score increases as the patient’s health worsens. Finally we used a cluster analysis to classify each patient based on their score. Results: 55 patients were considered for the study and 45 were subsequently included and registered. SBT was successful for 60% of patients based on consensus criteria. Scores using our method were obtained for each patient. The cluster analysis clearly separated patients in two groups. Patients classifications under the consensus criteria and using our new method were similar. Conclusions: Our original approach to weaning process using signal analysis and medical knowledge appears to be efficient in predicting success or failure of SBT. This method seems promising. Its integration in a decision support system would need to be validated on a larger population.

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PATIENT-VENTILATOR DYSSYNCHRONY IN A TRAUMATICALLY INJURED POPULATION

TRAINING AND EDUCATION REDUCES FACIAL PRESSURE ULCERS IN PATIENTS RECEIVING NON-INVASIVE POSITIVE PRESSURE VENTILATION

Bryce Robinson, Chris Blakeman, Peter Toth, Dennis Hanseman, Eric Mueller, Richard Branson, University of Cincinnati Introduction: Prolonged mechanical ventilation, increased length of hospital stay, and a lower rate of home discharge have been reported with patient-ventilator dyssynchrony in medical patients. Though commonly encountered, dyssynchrony is poorly defined within an injured population. Hypothesis: Dyssynchrony in trauma patients arises from unique etiologies and results in alternative outcomes. Methods: Mechanically ventilated trauma patients at our urban, level I center were enrolled. Breath waveforms were recorded over 30 minutes within the first 48 hours following intubation. Dyssynchronous breaths were defined as ineffective patient triggering, triggering of 2 simultaneous mechanical breaths, short cycle breaths, and long cycle breaths. Dyssynchronous patients were defined as having dyssynchrony in ⱖ10% of total breaths. Demographic, injury, sedation/delirium scores, clinical and discharge outcomes were prospectively collected. Results: 35 patients were enrolled. Median age was 47 years, 77.1% male, 28.6% with penetrating injuries, 16% with COPD, median ISS of 22 (IQR 17–27), and a median chest AIS of 2 (IQR 0 – 6). 15,445 breaths were analyzed. Dyssynchrony was present in 25.7% of patients. No statistical differences between dyssynchronous and non-dyssynchronous patients were found for age, sex, injury mechanism, COPD history, delirium/sedation scores, PaO2/FiO2 ratios, PEEP, blood gas values, or weight adjusted sedatives. Dyssynchronous patients more commonly used synchronized intermittent mandatory ventilation (SIMV) (100% vs. 38.5%; p ⫽ 0.002) and took lower median spontaneous breaths per minute (4 (IQR 3– 8) vs 12 (IQR 9 –14); p ⫽ 0.007). SIMV with set respiratory rates ⱖ10 breaths per minute were associated with increased dyssynchrony rates (85.7% vs. 25.0%, p ⫽ 0.02). We found no difference in ventilator days, ICU and hospital lengths of stay, % discharged home, or mortality between dyssynchronous and non-dyssynchronous patients. Conclusions: Ventilator dyssynchrony is common in trauma patients. It may beassociated with SIMV with a set respiratory rate ⱖ10 breaths per minute, though not with increased duration of mechanical ventilation, length of stay, or discharge disposition.

Michael Bocci, Ken Hargett, Margaret Berger, Jose Rodriguez, Tory Schmitz, The Methodist Hospital Introduction: Iatrogenic pressure ulcers are included in the CMS do not pay category. This has been extended to include Stage III and Stage IV ulcers that result from the application of nasal mask for BiPAP and Non-Invasive Positive Pressure Ventilation (NPPV). The incidence of ulceration is reported as high as 6%. In 2010 our institution experienced an increase in mask related pressure ulcers due to increased surveillance. Hypothesis: A hypothesis was formed that interdisciplinary education and training of mask fitting and mask selection would reduce/eliminate facial pressure ulcers. Methods: A quality and education project was developed utilizing Performance Improvement methodology. The process included a survey of nursing and respiratory knowledge/awareness of facial pressure ulcers, mask fitting, allowable leak and mask selection. Also included was a survey to determine the number of mask interventions done daily. It was determined that an average of 18 interventions/adjustment were performed daily and that nasal full face mask were adjusted to minimize/eliminate leaks. Both respiratory and nursing perception was that no leak was allowed. An education program was implemented to increase awareness and surveillance of signs of beginning pressure ulcers and teach staff how to quantify allowable leak. Each shift redness and skin integrity is evaluated and charted. Additionally, the institution switched to a mask that was easily removed and replaced without strap adjustment. A set of guidelines were developed to select the proper mask and utilize a full face mask that rest on the forehead instead of the bridge of the nose anytime redness is identified. Results: Since the completion of the education, a total of 761 patients have been on NPPV for the period of Jan 2011 till July 2011. No incidences of Stage III or Stage IV pressure ulcers have occurred. Conclusions: Many approaches to reduce nasal breakdown during NPPV have been reported. A combination of Education to increased awareness, proper adjustment of mask to establish an allowable leak and mask type that eliminates the need for constant strap adjustment has reduced the incidence of pressure ulcers at our institution.


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ONE EVIDENCE BASED PROTOCOL DOESN’T FIT ALL: BRUSHING AWAY VENTILATOR ASSOCIATED PNEUMONIA IN TRAUMA PATIENTS

EARLY VERSUS LATE TRACHEOSTOMY; A SURVEY OF PATIENTS’ SATISFACTION

Kari Johnson, John C Lincoln North Mountain Hospital, Alisa Domb, John C. Lincoln Hospital Introduction: Evaluate the effectiveness of an evidence based practice (EBP) oral hygiene intervention to reduce ventilator associated pneumonia (VAP) in trauma patients and measure relationships among nurse’s attitudes, beliefs, training, education and frequency of delivery of oral hygiene. Hypothesis: An EBP oral hygiene program will reduce VAP in mechanically ventilated trauma patient’s; An EBP oral hygiene program will change nurse’s attitudes and beliefs toward oral hygiene. Methods: Data on nurses’ attitudes and beliefs was coded and analyzed using SPSS 16.0. Categorical data is described with means and standard deviations. Comparison between groups including education and implementation of an oral hygiene program and protocol was made using 2 sample t-tests when data was normally distributed. When not normally distributed, nonparametric, chi square and Mann Whitney U test were used. Level of significance was set at p⬍/⫽ 0.05. Descriptive statistics were used for nursing demographics including age, time worked in ICU, shift and level of education. A Poisson regression with a log link was used to measure differences in VAP rates historically and post intervention using SAS 9.2. Results: VAP rates were 4.9 cases/1000 ventilator days historically and 2.7 cases/1000 ventilator days post intervention. Trauma rates increased from 6.4% to 10.0% (p ⫽ 0.346), and medical/surgical rates decreased from 3.3% to 1.0% (p ⫽ 0.042). Results revealed changes in nurses’ beliefs regarding pre-admission colonization (p ⫽ 0.027), having adequate training, suitable equipment and readily available supplies. Foam swabs with moisture agents at 4 hours or less was 88.6% and toothbrush use at 12 hours or less was 71%, with significant changes in frequency of oral care practice post intervention. Conclusions: Understanding the trauma patients’ risk and prognostic factors, mechanisms of transmission and systemic inflammatory response are important when implementing an EBP oral hygiene program. Oral care practices do not fall under a “one protocol fits all” category. Nurses’ attitudes and beliefs regarding oral care practice enhance the success and adherence of an EBP protocol, and should be considered when initiating EBP changes.


Eric Mitchell, Grand Rapids Medical Education Partners/Michigan State University, Rocco Piazza, Piazza Center for Plastic Surgery, James Hoogeboom, Spectrum Health Hospitals Introduction: The incidence of percutaneous tracheostomy (PT) placement has increased 190% over the past fifteen years. Earlier placement of a tracheostomy has been shown to decrease duration of mechanical ventilation and length of ICU stay. However, the exact parameters of who and when a PT should be placed is still debated. To our knowledge no one has investigated the patients’ perspective on their PT. Hypothesis: This survey study hypothesized that patients would have a positive experience overall when reflecting on PT placement regardless of timing. We also sought to compare patients’ perspectives in relation to the timing of their tracheostomy. Methods: 285 mail surveys were sent to patients who underwent PT between 2005 and 2007 in the Surgical Intensive Care Unit at our institution. All patients were asked questions regarding the timing of their tracheostomy, effects on their hospital course, and care and complications experienced after hospital discharge. The patients were divided into groups based on the timing of their tracheostomy placement, very early (1–5 days on mechanical ventilation), early (6 –10 days), and late (11⫹ days). Results: 53 completed surveys were returned, 1–5 days–13, 6 –10 days–30, 11⫹ days-10. Regardless of when their PT was placed, 91.3% felt it was placed at the right time, 8.7% said it was placed too late, and no one responded their tracheostomy was placed too early. 82.6% of patients were completely satisfied with their PT experience, and 87.2% stated the PT improved their respiratory function. All of the patients who received their PT between 1–5 days stated it was placed at the right time and that they were completely satisfied. Of the patients who had one placed between days 6 –10, 96% stated it was at the right time, and 83.3% were completely satisfied. Of those who had a PT placed 11 days or later, only 62.5% stated it was at the right time and 55.6% were completely satisfied. Conclusions: A large percentage of patients are completely satisfied with their PT and feel that they had it placed at the right time. Patients undergoing earlier PT placement were more satisfied and were more likely to state that they had it placed at the right time.

Posters: Pulmonary-Therapeutics 349

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INHALED EPOPROSTENOL VERSUS INHALED NITRIC OXIDE FOR HYPOXEMIA IN CRITICALLY ILL PATIENTS AT A TERTIARY ACADEMIC MEDICAL CENTER

EFFICACY OF AMBROXOL FOR PREVENTION OF RESPIRATORY FAILURE IN SEVERE ACUTE PANCREATITIS

Heather Torbic, Paul Szumita, Kevin Anger, Paul Nuccio, Susan Lagambina, Gerald Weinhouse, Brigham and Women’s Hospital Introduction: Inhaled nitric oxide (iNO) and inhaled epoprostenol (iEPO) are potent pulmonary vasodilators that have been given off label as rescue therapy for severely hypoxic, critically ill patients. There are, however, limited data evaluating the efficacy of these agents in a diverse cohort of critically ill patients. Hypothesis: There is no difference in efficacy or safety outcomes in patients who received either iNO or iEPO for pulmonary vasodilation. Methods: This was a retrospective, single-center analysis of adult mechanically ventilated (MV) patients receiving iNO or iEPO for pulmonary vasodilation between January 1, 2009 and October 31, 2010 and was approved by our institutional IRB. Baseline demographics were collected. Outcomes included change in PaO2/FiO2 ratio, intensive care unit (ICU) and hospital length of stay, duration of MV, pulmonary vasodilator therapy, and adverse events. Results: A total of 105 patients were included in the analysis; 53 patients received iNO and 52 patients received iEPO. The groups were similar at baseline except more iEPO patients had acute respiratory distress syndrome compared to the iNO group (28.4 vs 55.8%; p ⫽ 0.008). Inhaled NO and iEPO groups had similar median durations of therapy (2.3 (0.6 – 4.8) vs 2.0 (0.9 – 4.3) days; p ⫽ 0.63). There was no difference in the mean PaO2/FiO2 ratio after 1 hour of therapy (174 vs 153; p ⫽ 0.13) in the iNO and iEPO groups respectively. No difference was seen in median duration of MV (7 (3–17) vs 9.5 (6 –19) days; p ⫽ 0.07), ICU length of stay (15 (6 –31) vs 15.5 (8 –23) days; p ⫽ 0.67) and hospital length of stay (33 (12–53) vs 20.5 (14 –33) days; p ⫽ 0.26) in the iNO and iEPO groups respectively. There were also no adverse events attributed to pulmonary vasodilator therapy reported in either group. Conclusions: We found no difference between iNO and iEPO in terms of PaO2/FiO2 ratio, duration of MV, ICU and hospital length of stay, and safety profile in hypoxic, critically ill patients.

Guanqing Sun, The First Affiliated Hospital, Sun Yat-Sen University, Juan Chen, The First Affiliated Hospital of Sun Yat-sen University, Bin Ouyang, Minying Chen, Hanping Shi, The First Affiliated Hospital, Sun Yat-Sen University, Tiantian Xie, Sun Yat-Sen University, Zhiqiu Xia, The First Affiliated Hospital, Sun Yat-Sen University, Xiangdong Guan, 1. The First Affiliated Hospital, Sun Yat-Sen University Introduction: Severe acute pancreatitis (SAP) patients are susceptible to respiratory failure. However, there has been no method to prevent this complication. Our purpose is to look for an efficacious prophylactic therapy for respiratory failure secondary to SAP. Hypothesis: To evaluate whether administration of intravenous ambroxol is associated with lower incidence of respiratory failure in SAP patients. Methods: During 2003–2010, 101 SAP patients were admitted to our clinical center. Clinical data, prescription messages and outcomes of the patients were retrospectively documented. 29 indices were analyzed, including history of respiratory disease, oxygenation index on admission, APACHE-II scores, Ranson scores, medication and others. Chi-square test and logistic regression analyses were performed. Respiratory failure was defined as an oxygenation index ⱕ300 mmHg. Results: According to our data, 66.3% of the patients developed respiratory failure. For the 25 patients administered with intravenous ambroxol, the incidence was reduced to 28.0%, which was significantly lower than those without the treatment (28.0% vs. 78.9%, p⬍0.001). Both groups had similar severity of illness (oxygenation index, APACHE-II scores, Ranson scores and so on) on admission. Low arterial blood base excess (OR ⫽ 1.1, 95%CI: 1.0 –1.3; p ⫽ 0.023), low serum calcium concentration (OR ⫽ 738.5, 95%CI: 9.4 –57,914.9; p ⫽ 0.003) and no intravenous ambroxol administration during hospitalization (OR ⫽ 66.1, 95%CI: 9.8 – 445.6; p⬍0.001) were independent risk factors for respiratory failure. Additionally, beginning of ambroxol administration within 12 hours after the onset of disease or a dosage over 60 mg of ambroxol per day had the trend to improve the outcome further. Conclusions: Given the beneficial effect of intravenous ambroxol administration on respiratory outcome of SAP, the data indicate early and adequate intravenous ambroxol administration may be capable of protecting SAP patients from respiratory failure.

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STATINS AND ACE INHIBITION IN PREVENTION OF ARDS

NITRIC OXIDE-ASSOCIATED PULMONARY EDEMA IN CHILDREN

Paul Dobesh, Donald Klepser, Timothy McGuire, University of Nebraska Medical Center College of Pharmacy, Kristina Bailey, University of Nebraska Medical Center, Heidi Brink, Sloane Schneider, Janelle Weber, Keith Olsen, University of Nebraska Medical Center College of Pharmacy Introduction: Angiotensin converting enzyme (ACE) is found in the endothelial cells of the normal lung. Endothelial cell damage is the catalyst for inflammation and coagulation associated in acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). ACE inhibitors provide a protective effect on endothelial cells, which helps to preserve vascular structure and function. This protective effect of ACE inhibition may be beneficial in patients susceptible to ALI/ARDS. Statins have demonstrated the pleiotropic effects, which may have a protective effect on ALI/ARDS. Hypothesis: Exposure to ACE inhibition or statin therapy will protect against the development of ALI/ARDS in patients with severe sepsis. Methods: This retrospective cohort study included all patients over age 40 with a diagnosis of severe sepsis and an ICU admission at our academic medical center from 1/1/2009 to 3/31/2011. ACE inhibitor/ARB use, statin use, patient demographics, and APACHE II score at the time of sepsis were collected from patient charts. ALI was defined as a P/F of 200 to 299, and ARDS as a P/F of ⬍200. Both also had to have evidence of bilateral infiltrates on chest x-ray. Results: We identified 275 patients who met the inclusion criteria of severe sepsis. Of those patients, 101 (37%) had exposure to an ACE inhibitor/ARB. There were 98 patients exposed to statin therapy (36%). Of the patients with severe sepsis, 72 also had ARDS (26%). Patients exposed to ACE inhibition had an incidence of ARDS of 31% compared to 24% for patients not exposed (p ⫽ NS). Patients exposed to statins had an incidence of ARDS of 29% compared to 25% for patients not exposed (p ⫽ NS). Only 12 patients in our study met the criteria for ALI. The incidence of ALI was not different in patients exposed to ACE inhibition (2.0% vs. 5.8%) or in patients exposed to statins (4.1% vs. 4.5%). The incidence of ALI/ARDS was not reduced by exposure to ACE inhibition (p ⫽ 0.193) or statins (p ⫽ 0.825) Conclusions: Patients with severe sepsis are susceptible to the development of ALI/ARDS. Despite the potential pharmacological benefits of ACE inhibition and statin therapy, in patients with severe sepsis there was no impact on the development of ALI/ARDS.

Vinod Havalad, Linda Aponte-Patel, Morgan Stanley Children’s Hospital - Columbia University Medical Center, Tessie Bruce, Children’s National Medical Center, Thyyar Ravindranath, Arthur Smerling, John Baird, Morgan Stanley Children’s Hospital - Columbia University Medical Center Introduction: Nitric oxide (NO)-associated pulmonary edema in children is rarely reported; in adults, it is often associated with left-sided heart failure. Hypothesis: NO-associated pulmonary edema is underreported in children. Methods: IRB-approved review of pediatric patients at our children’s hospital from 7/03– 8/11 with NO-associated pulmonary edema, defined as new multi-lobar alveolar infiltrates with worsening hypoxemia within 24 hours of initiation or escalation of NO with radiologic and clinical improvement following NO discontinuation. Results: We identified 6 patients (0.4 to 4 years old) with 8 episodes of NO-associated pulmonary edema. Diagnoses included atrioventricular canal defect (2), pulmonary atresia and major aorta-pulmonary collateral arteries (2), total anomalous pulmonary venous return (1), and pulmonary veno-occlusive disease (1). Patient 1 was previously treated with NO on 3 occasions without developing pulmonary edema. Patient 3 was treated successfully with a lower dose of NO one month after an episode of NO-associated pulmonary edema. Pulmonary edema was unilateral in both patients with pulmonary atresia. Pulmonary edema resolved within 24 (range: 6 –24) hours of discontinuing NO. All 6 patients had previously unappreciated pulmonary venous hypertension, and one had evidence of mitral valve disease resulting in clinical evidence of left-sided heart disease. Five patients underwent cardiac catheterization within 2 months of an episode of NO-associated pulmonary edema: mean left atrial pressure was ⬍15 mm Hg in 4 patients, but not measured in the patient with mitral valve disease. Conclusions: We describe 6 children with NO-associated pulmonary edema due to pulmonary venous hypertension; only one of these patients had evidence of left-sided heart disease. Prior response to NO did not always predict future response. NO-associated pulmonary edema is under-reported in children. The use of NO in the PICU may uncover relative pulmonary venous insufficiency in some children.


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ETANERCEPT FOR THE TREATMENT OF PULMONARY COMPLICATIONS AFTER HEMATOPOIETIC STEM CELL TRANSPLANTATION

EXTRA-LONG TRACHEOSTOMY TUBES IN THE PRESENCE OF OBESITY AND ANASARCA: SIZE DOES MATTER

Jeremy DeGrado, Kelly Babcock, Kevin Anger, Paul Szumita, Brigham and Women’s Hospital

Introduction: The impact of extra-long tracheostomy tubes (XLT) in the setting of obesity or anasarca is unknown. Hypothesis: XLT in the presence of obesity or anasarca reduces the incidence of major airway complications related to tube dislodgement. Methods: Institutional retrospective review of all tracheostomies, 2001–2011. Tracheostomy dislodgement was compared before and after a policy change mandating XLT in patients with a BMI ⬎35 kg/m2 or significant anasarca. Results: 3162 bedside percutaneous (BPT) and 1680 surgical (ST) tracheostomies were performed. Prior to policy change, 2242 BPT and 1126 ST were performed. 6 airway complications (3 BPT, 3 ST) related to regular length tube dislodgement occurred in the setting of obesity or anasarca. 920 BPT and 554 ST were performed since the policy change, with one regular length tube dislodgement, despite meeting XLT criteria. Conclusions: XLT in the setting of obesity or anasarca significantly reduces the incidence of major airway complications related to tube dislodgement.

Introduction: The use of etanercept for the treatment of pulmonary complications in patients who have received hematopoietic stem cell transplantation (HSCT) is not well described in the literature. While some data suggest favorable outcomes in patients who received etanercept, concerns such as development of new infections still exist. Hypothesis: The purpose of this study was to evaluate the safety of the administration of etanercept for pulmonary complications after HSCT. Methods: Adult patients receiving at least one dose of etanercept for the treatment of pulmonary complications after HSCT from January 2005 to December 2010 were retrospectively evaluated. Pulmonary complications included idiopathic pneumonia syndrome (IPS), diffuse alveolar hemorrhage (DAH), and cryptogenic organizing pneumonia (COP). Data included patient demographics, APACHE II score, type of pulmonary complication, and comorbidities. Outcomes included incidence of new infection after etanercept administration, requirement of ICU admission, time to administration of first dose of etanercept from HSCT, and mortality. Results: Seventeen patients who received etanercept at our institution from January 2005 to December 2010 were included in this retrospective analysis. The mean APACHE II score was 22 ⫾ 9. On average, etanercept therapy was initiated 249 days after transplant. Ten patients (59%), five patients (29%), and two patients (12%) received etanercept for suspected IPS, DAH, and COP, respectively. Thirteen patients (76%) were initiated on etanercept in the ICU while 16 (94%) required ICU admission during their hospital stay. Four patients (24%) developed at least one new infection after the initiation of etanercept therapy, with two of those patients developing multiple new infections. Three patients (18%) were alive at both 100 days and 1 year from the initiation of etanercept therapy. Conclusions: Patients receiving etanercept for the treatment of pulmonary complications following HSCT had a rate of infection consistent with previous analyses. Both moderate and long-term survival in our cohort was low. More research needs to be completed to determine the benefits and risks of the use of etanercept in this specific patient population.

355 EFFICACY, SAFETY AND MEDICATION ERRORS ASSOCIATED WITH THE USE OF INHALED EPOPROSTENOL IN ACUTE RESPIRATORY DISTRESS SYNDROME Kisha Dunkley, Lawnwood Regional Medical Center, Patricia Louzon, Florida Hospital, Jinjoo Lee, Florida Hospital East Orlando, Steve Vu, Central Florida Pulmonary Group Introduction: Acute respiratory distress syndrome (ARDS) results in severe hypoxemia as a result of ventilation/perfusion mismatching. Inhaled epoprostenol may result in a relaxation of smooth muscle cells in the vascular endothelium. Hypothesis: We hypothesized that the utilization of inhaled epoprostenol produces a 10% or greater increase in the ratio of arterial partial pressure of oxygen (PaO2): fraction of inspired oxygen (FIO2) in ARDS patients but poses high risk for medication errors. Methods: A retrospective observational chart review was performed based on a report generated from the electronic medical record system. Patients who received at least one dose of inhaled epoprostenol from January 1, 2008 to December 31, 2010 at any hospital within our health system were included. Demographics, dose, duration of therapy, adverse effects, medication errors, and outcomes data was collected. Results: Sixteen patients were included in the study. Oxygenation improved in 62.5 % (10/16) of the patients with an initial median increase of 44.5% in PaO2/FIO2. The mean starting dose was 30 ng/kg/min (⫾ 10 ng/kg/min). Three of the six patients that did not respond to therapy were on high frequency oscillatory ventilation. Medication errors were observed in 18.8% (3/16) of patients. Hypotension was the most frequently observed adverse event, with a rate of 18.8% (3/16). Survival was 43.8% (7/16). Conclusions: Inhaled epoprostenol may improve oxygenation in patients with ARDS. The significance of these effects on improving clinical outcomes remains unknown. Medication errors are a significant concern. Further studies are needed to determine the role of inhaled epoprostenol in ARDS patients.


Matthew Eckert, Kelly Sims, Addison May, Vanderbilt University Medical Center

Posters: Renal 356

357

CHLORIDE IS ASSOCIATED WITH MORTALITY IN THE CRITICALLY ILL

HYPOTONIC VERSUS ISOTONIC SALINE IV FLUID HYDRATION: INCREASED RISK OF HYPONATREMIA?

Gearoid McMahon, Brigham and Women’s Hospital, Fiona Gibbons, Massachusetts General Hospital, Kenneth Christopher, Brigham and Women’s Hospital

Francis Raymund Carandang, Lucile Packard Children’s Hospital at Stanford University, Andrew Anglemyer, Stanford University School of Medicine, Gomathi Krishnan, Stanford Center for Clinical Informatics, Chris Longhurst, Madelyn Kahana, Scott Sutherland, Lucile Packard Children’s Hospital at Stanford University

Introduction: Although conditions that result in hyperchloremia and hypochloremia are common in the ICU, the epidemiology and outcomes of chloride balance disorders in the critically ill are not well characterized. Hypothesis: We hypothesized that chloride at critical care initiation at would be associated with all cause mortality. Methods: We performed an observational cohort study on 51,789 patients, age ⱖ18 years, who received critical care between 1998 and 2009 in two tertiary care hospitals in Boston. The exposure of interest was chloride categorized a priori into deciles as Cl ⱕ98, 99 –101, 102–103, 104, 105, 106, 107–108, 109, 110 –111, or ⬎112. Data was obtained from a hospital computerized data registry. Vital status was determined by the Social Security Administration Death Master File. The primary endpoint was 30 day mortality. Logistic regression examined death by day 30 post-critical care initiation. Adjusted odds ratios were estimated by multivariable logistic regression models. Adjustment included age, gender, race, patient type (medical vs surgical), Deyo-Charlson Index, sepsis, sodium, creatinine, hematocrit, anion gap, HCO3, and WBC count. Results: Chloride was a particularly strong predictor of all cause mortality 30 days following critical care initiation: Cl ⱕ98 OR 2.56 (95% CI, 2.33–2.80; P⬍0.001); Clⱖ112 OR 1.84 (95% CI, 1.66 –2.03; P⬍0.001); all relative to patients with Cl 107–108. Following multivariable adjustment not including sodium, chloride remains a strong predictor of mortality: Cl ⱕ98 OR 1.53 (95% CI, 1.38 –1.69; P⬍0.001); Clⱖ112 OR 1.33 (95% CI, 1.19 –1.48; P⬍0.001); all relative to patients with Cl 107–108. Following multivariable adjustment including sodium, only hypochloremia remains a strong predictor of mortality: Cl ⱕ98 OR 1.66 (95% CI, 1.48 –1.88; P⬍0.001); Clⱖ112 OR 1.01 (95% CI, 0.90 –1.14; P ⫽ 0.8); all relative to patients with Cl 107–108. Estimating the ROC AUC shows that chloride has strong discriminative power for 30-day mortality following multivariable adjustment including sodium (AUC ⫽ 0.76). Conclusions: Following adjustment for sodium, hypochloremia but not hyperchloremia is a robust predictor of the risk of all cause patient mortality in the critically ill.

358 ACUTE KIDNEY INJURY AND OUTCOME IN SEVERE ARDS PATIENTS DUE TO 2009 INFLUENZA A (H1N1) VIRUS

Introduction: Hyponatremia (hypoNa) is a common pediatric condition with significant morbidity. Recent studies have linked administration of intravenous (IV) hypotonic maintenance fluid (HMF) with increased risk of hypoNa, but these studies were small and underpowered. On a larger scale, we evaluated hospital-acquired hypoNa and its associated outcomes in children receiving HMF or isotonic maintenance fluids (IMF). Hypothesis: The use of HMF increases the risk of developing hypoNa and is associated with adverse effects in children. Methods: Using data from electronic medical record, we performed a restrospective, cohort study of all children under 18 years admitted to a tertiary referral center between 4/1/09 and 3/31/11. Relative risk (RR) for development of hypoNa and hospital length of stay (LOS) for children who received ⬎90% of their IV maintenance fluids with either IMF or HMF were analyzed. We used simple logistical regression analysis to estimate the risk of hypoNa, analysis of variance to test for any difference in mean LOS across sodium groups, and t-test to compare mean LOS between sodium outcome groups. All statistical analyses were performed in R software (Vienna, Austria), with p⬍0.05 considered as statistically significant. Results: We analyzed 4245 pediatric patients (6079 admissions) with a serum sodium obtained in the first 24 hours. On admit, 4580 (75.3%) were normonatremic [Na 135–145]. 1079 (17.7%), 120 (2.0%) and 27 (⬍1%) were mildly [Na 130 –135], moderately [Na 120 –129] and severely [Na ⬍120] hyponatremic, respectively. 273 (4.5%) were hypernatremic [Na⬎145]. Of the 4580 admissions with initial normonatremia, 1988 received ⬎90% of their maintenance as either HMF (n ⫽ 1528) or IMF (n ⫽ 460). For children receiving HMF, the unadjusted RR of progressing to moderate/severe hypoNa was 1.98 (95% CI:1.11–3.86), and 1.49 (95% CI: 1.18 –1.88) for progressing to any hypoNa state. Compared to patients who received IMF, those who received HMF and developed hypoNa had increased LOS (p⬍0.05); as severity of hypoNa increased, so did LOS (p⬍0.05). Conclusions: Compared to children who receive IMF, children who receive HMF have increased risk of developing hypoNa and a prolonged hospital LOS.

Cory Vatsaas, Gaurav Sachdev, University of Michigan Hospitals, Muhammed Masood, Pauline Park, Michael Heung, University of Michigan, Krishnan Raghavendran, UMHS, Lena Napolitano, University of Michigan School of Medicine Introduction: The 2009 Influenza A (H1N1) virus caused a worldwide pandemic of severe pneumonia which often progressed to acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI). The incidence and outcome of AKI in these critically ill patients, particularly related to renal recovery and critical care resource utilization, has not been examined. Hypothesis: AKI associated with severe ARDS due to H1N1 is not associated with long-term need for hemodialysis. Methods: Retrospective observational cohort study (2009 –2011) of adult patients with severe ARDS due to H1N1, confirmed by PCR or viral culture, admitted to the SICU of a single institution for ECMO evaluation. Severe ARDS was defined as PaO2/FiO2 ratio ⬍100. AKI was defined by RIFLE criteria and as patients requiring continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD). We evaluated baseline characteristics, presence of AKI, CRRT or IHD duration, need for ECMO, survival to discharge or transfer, and renal recovery. Results: The study cohort included 57 adult patients with severe ARDS due to H1N1 with mean age 41.6 years, 63.8% male gender, mean APACHE III score 60.5 (range 40 –155) and mean BMI 37.6. By RIFLE criteria, all patients had AKI, 54 (94.5%) with Class F (Failure), and 3 with Class I (Injury). CRRT was required in 38 patients (66.7%) with a total of 714 CRRT days (mean 12.5 per patient). ICU survival was 47.4% in CRRT patients compared to 100% in the 19 patients that did not require CRRT/IHD (p⬍.001). Of the 18 CRRT patients who survived, all but one (94.4%) had return of normal renal function. Increasing time on CRRT was not associated with increased mortality (mortality 51.6% with CRRT ⬎7 days vs. 56.2% with CRRT ⬎14 days, p ⫽ 0.671). Transition to IHD for persistent renal failure was required in 15 CRRT patients prior to discharge with 247 total IHD days (mean 16.5 per patient). ECMO was required in 17 patients (29.8% of total cohort) and 15 (88.2%) ECMO patients required CRRT. Conclusions: AKI was present in all patients with severe ARDS due to H1N1 and the need for CRRT is a significant risk factor for increased mortality. However, patients requiring CRRT who survive are likely to have full renal recovery.


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EFFECTS OF FLUID CHALLENGE AND VASOACTIVE AGENTS ON RENAL HEMODYNAMICS

EARLY RENAL REPLACEMENT THERAPY IN CRITICALLY ILL PATIENTS

Mouhamed Moussa, Erasme University Hospital, ULB, Sabino Scolletta, Erasme University Hospital, ULB, Pierre Pasquier, Erasme University hospital, Universite`n˜ibre de Bruxelles (ULB), Fabio Silvio Taccone, Jean-Louis Vincent, Daniel De Backer, Erasme University Hospital, ULB

Ryoko Kyan, Kunihiko Maekawa, Yoshiki Masuda, Hitoshi Imaizumi, Yasufumi Asai, Sapporo Medical University

Introduction: Renal failure frequently occurs in critically ill patients and is associated with a poor outcome. The effects of various interventions on renal perfusion are not well defined. Hypothesis: Regional hemodynamics assessed by renal interlobar arteries Doppler (RIAD) may better reflect the renal response to therapeutic interventions than general hemodynamic variables. Methods: We measured general hemodynamic variables and RIAD in 53 critically ill patients before and after volume expansion or administration of vasoactive agents (Norepinephrine or dobutamine). RIAD was performed on both kidneys to access resistivity index (RI), pulsatility index (PI), systolic and diastolic velocities (SV, DV). Urine output (UO) was measured for three hours before and after the intervention. Renal responsiveness was defined as an increase in UO⬎0.2 ml/kg/h. Variables were compared using Student’s T-test and are expressed as mean ⫾ SD. Analysis of ROC curves was also applied. Results: RI decreased (from 0.74 ⫾ 0.09 to.0.72 ⫾0.09, p⬍0.01), while PI increased from 1.19 ⫾ 0.21 to.1.14 ⫾ 0.21, p⬍0.01, DV increased from 12.4 ⫾ 6.4 to 13.3 ⫾ 7.5 cm/s (p ⫽ 0.02). Mean arterial pressure increased concurrently from 74.4 ⫾ 13.2 to. 81.4 ⫾ 13.3 mmHg, (p⬍0.01). UO increased from 59.9 ⫾ 80.2 to 87.8 ⫾ 97.1 ml/h, (p⬍0.01). Changes in RI (delta RI) and PI (delta PI) had an AUC to predict increase in urine output of 0.75 (p ⫽ 0.002) and 0.74 (p ⫽ 0.003), respectively, while changes in mean arterial pressure and pulse pressure failed to do so (Respectively, AUC: 0.55, p ⫽ 0.55 and AUC: 0.61 p: 0.18). Conclusions: Changes in resistance and pulsatility of renal interlobar arteries estimated by Doppler ultrasonography during interventions are better predictors of an increase in urine output than general hemodynamic variables.

Introduction: Acute kidney injury (AKI) requiring dialysis in critically ill patients is associated with high mortality.But the optimal timing of Renal Replacement Therapy (RRT) initiation is controversial. Hypothesis: Early initiation of RRT might be associated with improve outcomes in critically ill patients with AKI. Methods: We conducted a retrospective cohort study on critically ill patients with AKI treated by RRT in a single tertiary care ICU over 3 years (2008 – 2010). We excluded patients who have malignant disease with bone marrow suppression, chronic renal failure on dialysis and post cardiac arrest syndrome. Analyzed data included demographic, SOFA, APACHE II score, the presence/ absence of shock and AKI stageat the initiation of RRT. AKI stage was stratified according to Acute Kidney Injury Network criteria. We used propensity-score matching to adjust for differences between the early initiation group (patients were initiated RRT at AKIN stage⬍ ⫽ 2) and the late initiation group (AKIN stage ⫽ 3). Outcome measures were the recovery rate of kidney function, length of ICU stay and survival to ICU/hospital discharge. Results: Of 88 patients, 48 were enrolled in the early group and 40 were enrolled in the late group. Propensity-score matching process selected 19 patients each from both groups. The early and late-matched group had similar clinical profiles including age, SOFA, APACHE II score and the rate of shock at the initiation of RRT. Compared with the late group, the early group had a significant increase in the recovery rate of kidney function (84% vs. 53%, p ⫽ 0.046), the rate of survival to ICU discharge (84% vs. 47%, p ⫽ 0.038) and the rate of survival to hospital discharge (74% vs.32%, p ⫽ 0.023), but there was no significant difference in length of ICU stay. Conclusions: Early initiation of RRT (AKI⬍ ⫽ 2) may be effective for improve outcomes in critically ill patients with AKI.

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EFFECT OF CONTINUOUS VENOVENOUS HEMOFILTRATION DOSE ON THE ACHIEVEMENT OF ADEQUATE VANCOMYCIN TROUGH CONCENTRATIONS

RELATIONSHIP BETWEEN FLUID OVERLOAD, ACUTE KIDNEY INJURY AND MORBIDITY IN CRITICALLY ILL CHILDREN

Erin Frazee, Philip Kuper, Garrett Schramm, Scott Larson, Kianoush Kashani, Nelson Leung, Mayo Clinic

Ziyad AlSani, Yasser Kazzaz, Maria Pourasadi, Ronald Gottesman, Michael Zappitelli, Montreal Children’s Hospital

Introduction: The purpose of this study was to evaluate the success rate of a vancomycin dosing recommendation in achieving target vancomycin trough concentrations during continuous venovenous hemofiltration (CVVH). Hypothesis: Investigators hypothesized that use of high hemofiltration rates (HFR) would portend failure to achieve goal troughs more often than low HFR. Methods: This was a retrospective cohort study of critically ill adults on CVVH and vancomycin between 2006 and 2010 with a steady state vancomycin trough. The 87 included patients were grouped according to low (ⱕ30 mL/kg/h; N ⫽ 10) or high (⬎30 mL/kg/h; N ⫽ 77) HFR for analysis. Goal troughs were in accordance with guideline recommendations for the suspected/documented source of infection. Categorical variables were compared with the Chi-square test and continuous variables were analyzed by the Wilcoxon rank sum test. Statistically significant differences in univariate comparisons (Pⱕ0.05) were included in a multivariate logistic regression analysis to evaluate factors associated with failure to achieve goal troughs. Results: Vancomycin goal trough achievement occurred in only 32 (36%) patients. The primary endpoint of goal trough achievement in the low HFR subgroup was 90% compared to 30% in the high HFR subgroup (P⬍0.001). Irrespective of goal trough, an inverse correlation exists between HFR and vancomycin concentration (R ⫽ -0.423; P⬍0.001). Increases in HFR (P⬍0.001), reductions in body mass index (BMI; P⬍0.001), and goal trough 15–20 mg/L (P⬍0.001) were associated with failure to reach goal at the univariate level. In the multivariate analysis, BMI [odds ratio 0.89 (95% confidence interval 0.81– 0.97); P ⫽ 0.016] and goal trough 15–20 mg/L [7.12 (2.31–24.4); P ⫽ 0.001] were associated with increased risk of failure. Conclusions: Critically ill CVVH patients on vancomycin may experience clinically significant reductions in goal trough attainment. Independent of HFR, lower BMI and desired serum concentrations of 15–20 mg/L may contribute to failure to reach goal vancomycin trough concentrations. Prospective studies are necessary in critically ill patients on CVVH to determine the optimal vancomycin dosing strategy for attainment of goal trough concentrations.

Introduction: Fluid overload (FO) is associated with poor outcome in critically ill children receiving dialysis and other extremely critically ill children. The importance of FO on outcome in all children admitted to the pediatric intensive care unit (PICU) and the association between acute kidney injury (AKI) and FO is unclear. Hypothesis: 1) Children with AKI have worse FO early in PICU admission compared to non-AKI children. 2) Higher FO early in PICU admission is associated with higher morbidity. Methods: We conducted a retrospective cohort study of children admitted to our PICU for ⱖ3 days, from 2004 –2007. Clinical variables were from a hospital PICU registry. Daily fluid ins and outs, weights and serum creatinine (SCr) were collected retrospectively. FO was calculated as [fluid in-fluid out](L)/PICU admission weight (kg) X100. AKI was defined as ⱖ50% or 0.3 mg/dl SCr rise from baseline. We compared PICU day 1 (D1) and D2 FO between AKI and non-AKI subjects. We determined if D1 FO discriminated for presence of AKI, controlling for other variables, by calculating the C-statistic (AUC). We evaluated the association of D1 FO with PICU length of stay (LOS) and of ventilation (LOV) using multiple linear regression. Results: 243 children were included: median [interquartile range] (IQR) age ⫽ 1.7[6.9] years, Pediatric Risk of Mortality ⫽ 5[7], LOV ⫽ 5.5[4.1], PICU LOS ⫽ 6.5[5.3] days. D1 FO was higher in AKI patients (2.3⫾3.3% vs. 1.4⫾2.4%, p⬍0.03), as was D2 FO (5.3⫾5.8% vs. 4.0⫾4.1%). In ventilated patients, worse D1 FO discriminated for presence of AKI (AUC ⫽ 0.65); in non-ventilated patients, discrimination was poor. Adding D1 FO to an AKI clinical prediction model (age, gender, illness severity score, post-op, infection status) increased AUC for AKI diagnosis from 0.71 to 0.76. D1 FO predicted longer LOV (p⬍0.04), independent of other variables. AKI (p⬍0.05), but not D1 FO, predicted longer PICU LOS. Conclusions: This is the first study evaluating FO in PICU children with a wide illness severity spectrum. PICU day 1 FO may be an early biomarker of AKI and is associated with longer LOV. Future studies should now evaluate the impact of early FO avoidance on AKI incidence and PICU outcomes.


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OUTCOME OF EARLY ACUTE KIDNEY INJURY IN THE ELDERLY AFTER TRAUMA – DOES CONTRAST EXPOSURE PLAY A ROLE?

ACUTE KIDNEY INJURY AFTER LUNG TRANSPLANATATION AND ITS ASSOCIATION WITH 500 DAYS SURVIVAL

George Nassif, Adrian Ong, Allegheny General Hospital , Shalin Patel, Drexel University College of Medicine, Quyen Tran, Stephen Smith, Allegheny General Hospital Introduction: Age is a risk factor for contrast –induced nephropathy. However, in elderly patients developing early acute kidney injury (EAKI) after trauma, the influence of contrast exposure (CE) is not well studied. Hypothesis: We hypothesize that CE is not associated with EAKI and that the outcome of EAKI is benign in elderly trauma patients. Methods: We retrospectively reviewed data for trauma patients ⱖ65 years over 13 months from a single trauma center. EAKI was defined based on meeting at least Acute Kidney Injury Network criteria for stage 1 AKI (increase in the serum creatinine [Scr] by⬎0.3 mg/dl or a 50% increase from baseline) occurring up to 96 hours after admission. Patients on renal replacement therapy (RRT) or who had only a single Scr measured were excluded. Results: Of 1150 patients ⱖ65 years old, 967 patients remained after exclusions. Of these, 442 (46%) had CE. These patients were significantly younger (mean age, 78 vs 81 years, p ⬍0.01), weighed more (mean 78 vs 71 kg, p⬍0.01), were more severely injured (median Injury Severity Score [ISS] 14 vs 10, p ⬍0.01), had a lower median Glasgow Coma Score (GCS) (14 vs 15, p ⫽ 0.02), a lower mean systolic blood pressure (SBP) ( 147 vs 150 mmHg, p ⫽ 0.04), a higher mean heart rate (HR) (86 vs 83/minute, p⬍0.01) and a lower mean Scr (0.89 vs 0.92 mg/dl, p⬍0.01) than those without CE. The incidence of EAKI was similar (CE, 4.5%; no CE, 5.1%, p ⫽ 0.5). Only two (0.2%) patients required RRT. Excluding patients who died or were discharged before 96 hours, mortality was 6.0% (35/ 586). The following variables were analyzed to determine their association with EAKI: age, Scr, SBP, HR, ISS, weight, GCS, CE. Only Scr (odds ratio, [O.R.] 1.49, 95% C.I. 1.04 to 2.13) and weight (O.R. 1.02, 95% C.I. 1.00 to 1.03) independently predicted EAKI. With respect to mortality occurring after 96 hours, the following were predictive: age, GCS, ISS, heart rate, Scr (O.R. 1.7, 95% C.I. 1.1–2.7) and EAKI (O.R. 5.5, 95% C.I. 1.7–18). Conclusions: EAKI develops in 5% of geriatric trauma patients, is almost always self-limiting, and is not associated with CE. However, EAKI predicts in-hospital mortality. The reasons for this association are unclear and warrant further studies.

Satoshi Kimura, Moritoki Egi, Motomu Kobayashi, Keiji Goto, Kiyoshi Morita, Okayama University hospital Introduction: Acute kidney injury (AKI) is frequently occurred in post lung transplantation (LTx) patients. We have reported that incidence of AKI during 28 days after LTx was associated with decreased 500 days survival. The aim of current study was to determine which day of AKI have significant predictive power for longer term survival. Accordingly, we conducted retrospective analysis using prospectively collected database. Hypothesis: We hypothesised association of AKI with the risk of death after transplantation might be varied accroding to timing of observation. Methods: Sixty-three consecutive LTx patients undergone in our tertiary teaching hospital from 2001 to 2010 were eligible for inclusion. We measured serum creatinine (Cre) prior to surgery (baseline) and daily for post-LTx 28 days. We defined AKI as elevation of Cre ?0.3 mg/dL from baseline according to AKIN criteria. To compare between AKI and non-AKI patients, we used Mann-Whitney, Chi-square and log-rank test. P values of less than 0.05 were considered statistically significant. All statistical analyses were performed using commercially available statistical software (SPSS 19.0, SPSS Inc, Chicago, IL). Results: The incidence of AKI on each day was varied from 15.9% (10/64, POD11, 13, 15) to 31.7% (20/63, POD22) during post-LTx 28 days. The incidence of AKI was significantly associated with increasing the risk of death at 500 days after LTX from postoperative 5th day to 13th day. Highest odds ratio for risk of death have observed at on POD6 –7 and POD12 (Odds ratio; 10.0, p ⫽ 0.001.) The odds ratio of POD1–14 was significantly higher than that of POD15–28 (p⬍0.001). Conclusions: We found that the assciation of AKI with the risk of death after transplantation varied accroding to timing of observation. AKI occurred on POD5–13 had strongly associated with increased the risk of death at 500days. This information may be helpful in the design of future interventional trials, in regard to the statistical power and choice of appropriate outcome measures.

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NURSE-LED INTERDEPARTMENTAL COLLABORATION RESULTS IN INITIATION OF ALTERNATIVE RENAL REPLACEMENT THERAPY AND IMPROVED OUTCOMES

KIDNEY DISEASE PROGRESSION IN PATIENTS WITH PREEXISTING CHRONIC KIDNEY DISEASE UNDERGOING CARDIAC SURGERY

Petra Grami, St/Luke’s, Sohrab Sardual, St. Luke’s Episcopal Hospital

Annette Mizuguchi, Aya Mitani, Rebecca Gersten, Ian Shempp, Sushrut Waikar, Prem Shekar, Gyorgy Frendl, Brigham and Women’s Hospital

Introduction: Critically ill patients who require renal replacement therapy (RRT) challenge hospitals in areas of staffing, material and financial resources. Increased demand for RRT coupled with a limited number of machines and staff, sparked nurses to develop an alternative therapy program that: offers comparable hemodynamic stability; excellent solute control; requires fewer machines; and demands less nurse staffing. Hypothesis: Expansion of a renal replacement program to include SLED is feasible and beneficial to a tertiary hospital. Methods: Nurse-led taskforce reviewed literature, studied best practices, and performed comparative analysis of currently available RRTs. Findings demonstrated no appreciable difference in outcomes despite the need for increased nurse staffing, equipment, cost, and hemodynamic instability. A hybrid RRT treatment, Slow Low Efficiency Dialysis (SLED), however, maintains hemodynamic stability and decreases cost per case. Consultation with key stakeholder resulted in: revising ICU documentation; and developing an order set; and piloting SLED in two ICU units. Dialysis RNs provided didactic education and practical instruction to ICU RNs, and validated nurse competency. Results: Pilot evaluation demonstrates: improved electrolyte and hemodynamic stability; increased availability of machines for patients requiring RRT; lower nurse staffing; and decreased cost relative to fewer laboratory tests and less anticoagulant use, electrolyte replacement and treatment time. SLED demonstrated: better solute control; 50% decreased average non-labor costs; and decreased duration of 1:1 nursing care from 24 to 12 hours without increasing mortality rate, when compared to continuous RRT. In addition, SLED demonstrated: improved hemodynamic stability with comparable cost when compared to intermittent RRT (hemodialysis). Conclusions: ICU and Dialysis nurses and Medical staff collaboratively designed, and implemented a SLED program, offering an effective alternative to traditional RRT in the ICU without impacting outcomes.

Introduction: Kidney injury during cardiac surgery leads to significant morbidity and mortality. Most of the recent studies focused their attention on the development of acute kidney injury (AKI) primarily in cohorts without chronic kidney disease (CKD). Hypothesis: Disease progression following cardiac surgery in CKD patients leads to more frequent need of renal replacement therapy (RRT) and significantly higher mortality. Methods: Of the patients (n ⫽ 6045) who underwent coronary artery bypass surgery at our institution between 2006 – 2010 with or without additional valve repair, 1868 had preexisting Stage III-IV CKD. They were retrospectively identified by their preoperative estimated glomerular filtration rate (eGFR) ⬍60 ml/min/1.73 m2. The mean preoperative serum creatinine (sCr) for CKD patients was 1.4⫹0.41 mg/dl; eGFR was 46⫹10 (vs. 1.13⫹0.73 mg/dl and 69⫹21 ml/min, respectively, for non-CKD patients). We defined AKI as ⬎/⫽ 0.3 mg/dl increase of sCr from baseline in the first 48 hours. Results: The incidence of renal failure requiring RRT was 3.3% for CKD patients vs. 1.8% for those without CKD. In-hospital mortality was 5.1%, and 30 day mortality 4.7% (2.5% and 2.3%, respectively for those without CKD). AKI occurred in 20.6% of CKD patients and in 12.6% of those without CKD. The peak sCr was 2.57 mg/dl and the incidence of RRT rose to 10.9% for those with CKD and AKI while they were 1.59 mg/dl and 1.3% for those CKD patients without AKI. In hospital mortality was 12.2% for CKD patients with AKI and 3.3% for CKD patients without AKI. Thirty day mortality was 11.2% and 3% for the same groups. The length of hospital stay was 18.1⫹16.4 (median: 13 [9 –21] IQR]) days for CKD patients with AKI and 13.5⫹13.3 days (median: 10[7–15] IQR]) for those CKD patients without AKI. Conclusions: CKD patients have a significantly higher mortality, longer length of stay than those who undergo cardiac surgery without preexisting CKD. Once AKI develops in patients with CKD their chances of survival are significantly decreased and their need for RRT is exponentially increased.


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EVALUATION OF THE RIFLE AND AKIN CRITERIA FOR DETECTION OF ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS

SEPSIS SYNDROME-ASSOCIATED RISK FOR ACUTE KIDNEY INJURY IN HOSPITALIZED CHILDREN

Ian Wee, Ronald Lee, Changi General Hospital Introduction: Acute kidney injury (AKI) is a common occurrence amongst critically ill patients. Because AKI is also associated with increased morbidity and mortality, its early detection is imperative. Hypothesis: This study compared (1) the detection rates of AKI between conventional physician recognition and two commonly-used diagnostic-staging criteria (Risk-Injury-Failure-Loss-End-stage renal disease [RIFLE] and Acute Kidney Injury Network [AKIN]), and (2) mortality rates amongst patients with RIFLE- or AKIN-detected AKI. Methods: All patients admitted to the medical intensive care unit of our institution between 1st April to 30th June 2010 underwent initial screening. Patients were excluded if they were less than 18 years old, not critically ill, had a history of significant chronic kidney disease, or were admitted for hemodialysis only. The medical records of all eligible patients were reviewed and relevant patient information recorded. Results: Of 60 patients reviewed, more patients were detected to have AKI using the RIFLE and AKIN criteria compared with physician recognition. While physician recognition was as effective as RIFLE or AKIN for patients with severe AKI, detection rates by physicians was markedly poorer in patients whose AKI was less severe (RIFLE ‘Risk’ to ‘Injury’, or AKIN ‘Stage 1’ to ‘Stage 2’). The AKIN criteria detected 28.6% more patients than RIFLE with early AKI (‘Stage 1’ and ‘Risk’, respectively). However, the opposite effect was observed when patients had more serious AKI (RIFLE ‘Injury’ to ‘Failure’, or AKIN ‘Stage 2’ to ‘Stage 3’). The mortality rate amongst patients with ‘Risk’ or ‘Stage 1’ AKI was lower than those with ‘Injury’ or ‘Stage 2’ AKI (35.7% and 27.8% vs 64.7% and 64.3%, respectively) but was lowest in patients with ‘Failure’ or ‘Stage 3’ AKI (13.3% and 22.2%). Conclusions: Both the AKIN and RIFLE criteria were superior to conventional physician recognition for detecting AKI and determining its severity amongst critically ill patients. Mild and moderate-to-severe AKI were better detected using AKIN and RIFLE, respectively. Mortality rates were generally similar when comparing between AKIN- and RIFLE-detected AKI groups.


Julie Fitzgerald, Robert Berg, Susan Furth, Vinay Nadkarni, Richard Aplenc, Children’s Hospital of Philadelphia Introduction: Acute kidney injury (AKI) is common in sepsis and is independently associated with mortality, morbidity, length of stay, and costs. A pediatric AKI risk, injury, and failure score (pRIFLE) has been validated for use in ICU populations. Mortality is an increasingly rare outcome, and organ failure (AKI) is an alternative relevant surrogate outcome for ICU sepsis studies. Our objective was to describe the incidence and AKI risk factors among pediatric inpatients with sepsis at high risk for ICU transfer and organ failure. Hypothesis: AKI in hospitalized pediatric oncology patients with sepsis is common and associated with antibiotic exposure and documented central line associated blood stream infections (CLA-BSI). Methods: Retrospective review of children 2 months through 18 years admitted to the oncology unit who had a blood culture drawn and antimicrobial therapy initiated for suspected infection between January and June 2010. Maximum pRIFLE strata in the subsequent 10 days was determined using change in estimated creatinine clearance calculated by the Schwartz formula. Analysis used descriptive statistics and Chi square tests to evaluate exposures and proportion developing AKI. Results: Among 130 oncology inpatients: 50% had leukemia/lymphoma, 25% received stem cell transplants; 12% had documented BSI, 11% had CLA-BSI. 51% had AKI (95% CI 43– 60%), maximum pRIFLE rank of Risk occurred in 42% and Injury in 9%. Exposure to amphotericin was associated with AKI. 8% of patients were transferred to the ICU, 4% of patients (50% of those transferred) had initiation of vasoactive support or mechanical ventilation in the first 12 hours after ICU transfer. Conclusions: AKI in hospitalized pediatric oncology patients with sepsis is common and associated with exposure to amphotericin, but not associated with exposure to aminoglycosides or CLA-BSI. Opportunity to study high risk inpatients for risk of ICU organ injury exists, and factors that influence organ function prior to ICU admission should be accounted for in ICU studies of sepsis.

Posters: Sepsis – Guidelines and Bundles 369

370

PHARMACIST IMPACT OF EARLY-GOAL DIRECTED THERAPY INTERVENTIONS ON A RAPID RESPONSE TEAM

USE OF A PROTOCOLIZED APPROACH TO THE MANAGEMENT OF SEPSIS CAN IMPROVE TIME TO FIRST DOSE OF ANTIBIOTICS

Kaitlin Starosta, Michael Peters, Mark Mlynarek, Audwin Garcia, James Kalus, Henry Ford Hospital Introduction: It is unknown whether pharmacists would add value as members of rapid response teams (RRT). The purpose of this study was to define the role of pharmacists during rapid response team consultations. Hypothesis: We hypothesized that including a pharmacist on RRT consultations would improve the care and outcomes of patients. Methods: This was a quasi-experimental study. Critical care trained pharmacists participated in RRT consultations on alternating weeks for 6 months. Patient outcomes where pharmacists participated on RRT (intervention) were compared to outcomes of patients during weeks without a pharmacist (control). Measures of appropriate sepsis management (empiric antimicrobial selection, fluid bolus administration, and time to antimicrobial therapy) and a composite of cardiopulmonary arrest and ICU transfer rates were compared. Results: A total of 98 patients (n ⫽ 37 [intervention],; n ⫽ 61 [control]; age ⫽ 65.4 ⫾ 7.8 years; males ⫽ 52.4%; sepsis ⫽ 41.0%) were included. Among septic patients, fluid boluses were administered consistent with the early-goal directed therapy algorithm more often in the intervention group (40.0%) than the control (11.1%, p ⫽ 0.05). Appropriate empiric selection of antimicrobial therapy occurred more often in the intervention group (60.0%) compared to the control group (18.5%, p ⫽ 0.03). There was also a shorter time to administration of antimicrobials in the intervention group (57.3 ⫾ 27.2 min) compared to the control (252.3 ⫾ 57.9 min, p ⫽ 0.04). The composite endpoint occurred in 66.7% in the intervention group and 65.4% in the control group patients (p ⫽ 0.94). Conclusions: Critical care pharmacist involvement during RRT consults led to improved care of septic patients, while in-hospital cardiac arrests and ICU transfers were not affected.

Pamela Meyers, Cristin Mount, Madigan Army Medical Center, Jeremy Pamplin, Brooke Army Medical Center, Vincent Mysliwiec, Madigan Army Medical Center Introduction: In July 2009, our institution created a Sepsis Protocol which was intended to rapidly identify patients with sepsis, expedite antibiotic delivery, apply early goal directed therapy and streamline transfer to the ICU. Our goal was to determine if the Sepsis Protocol improved the time to first dose of empiric, broad spectrum antibiotic therapy in patients diagnosed with sepsis. Hypothesis: We hypothesized that initiation of the Sepsis Protocol, which included increased access to broad-spectrum antibiotics, would improve time to first dose of antibiotics and bring us closer to the one hour time goal of the Surviving Sepsis Guidelines. Methods: We performed a retrospective chart review from Jan 2008 – Dec 2010, comparing the time from diagnosis of sepsis to the first dose of IV antibiotic therapy. Patients 18 years or older with sepsis or septic shock who received at least one dose of IV antibiotics within 24 hours of diagnosis were included. Patients who received Vancomycin and Ciprofloxacin underwent additional sub-group analysis as these antibiotics became available for use without Infectious Disease consultation if the Sepsis Protocol was activated. Results: A total of 209 patients met inclusion criteria; 77 patients before 1 July 2009 and 132 patients after 1 July 2009. The average time to first dose of antibiotics for the Pre-Sepsis Protocol group was 2.67 hours (⫾ 2.14 hours) and the average time for the Sepsis Protocol group was 1.65 hours (⫾ 1.83 hours) (p ⫽ 0.0003). 58 patients received Vancomycin and 30 received Ciprofloxacin with a decrease in time of 1.09 hours (p ⫽ 0.02) and 0.69 hours (p ⫽ 0.462) respectively. Conclusions: Initiation of a Sepsis Protocol which emphasizes early goal directed therapy including early broad-spectrum , empiric antibiotic therapy can improve time to administration of first dose of antibiotics. Time to first dose of antibiotics has been lined to mortality and the Surviving Sepsis Guidelines recommend administration within an hour of diagnosis. Although our time to first dose of antibiotics does not yet meet the goals set forth by the guidelines, our protocol made substantial improvement in the delivery of antibiotics to septic patients.

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EFFECT OF A MEDICAL EMERGENCY TEAM FOR PATIENTS WITH MALIGNANCY IN SEVERE SEPSIS AND SEPTIC SHOCK

REACHING IMPROVED OUTCOMES THROUGH THE INNOVATIONS OF A MULTI-DISCIPLINARY TEAM: CHANGING PROCESS OF CARE FOR PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK

SoHee Park, SunHui Choi, Asan Medical Center, JeongSuk Son, Asan Medcial Center, EunMi Cho, Jin Won Huh, Asan Medical Center, Chae-Man Lim, Asan Medicial Center, Younsuck Koh, ASAN Medical Center Univ. of Ulsan College of Medicine, Sang-Bum Hong, Asan Medical Center Introduction: Mortality for severe sepsis and septic shock was high, although the advances of treatment and especially so in patients with malignancy. In cancer patients(solid or hematology), the treatment of sepsis is often delayed or inadequate, because altered immunity may not mount the classical inflammatory response. It is important that clinicians are alert to presentations of severe sepsis or septic shock. There have been a number of studies showing that medical emergency team(MET) have improved major outcome in shock. However, there are few reports for patients with malignancy in severe sepsis or septic shock. Hypothesis: MET could improve hospital mortality of patients with malignancy in severe sepsis and septic shock. Methods: This study was a single center retrospective observation study that included cancer patients with severe sepsis or septic shock admitted to general wards. We analyzed the compliance of sepsis resuscitation bundle, mortality, ICU transfer rate and stay 1.5 year before(June 2006 -December 2007) and until 3 year after MET introduction (January 2008-December 2010). The MET consisted of critical care nurse, resident, fellow, and medical staff. The activation of MET was according to set physiologic criteria in combination with weekly feedback. Results: The total patients were forty before and one hundred forty after MET introduction. There was no significant difference in baseline data and severity scores such as APACH II and SOFA score between the two groups. ICU transfer rate and stay significantly reduced after the intervention (97.5% vs. 66.4%, p⬍0.001 and 14.4⫾25.3 days vs. 7.1⫾11.7 days, p⬍0.001). The hospital mortality was lower after MET introduction from 60% to 41% (p ⫽ 0.047). Lactate clearance as defined by formula (lactate clearance ⫽ lactate presentation-lactate after 6hrs)/lactate presentation) was an independent predictor of the hospital mortality (OR ⫽ 0.42, 95% CI ⫽ 0.227– 0.791, P⬍0.001) and there was significant difference (-0.03 vs. 0.11, P ⫽ 0.37) Conclusions: Implementation of MET increased the early lactate clearance which was a significant predictor of mortality and reduced the hospital mortality in patients with malignancy.

Leonardo Seoane, Fiona Winterbottom, Teresa Nash, Jawad Niazi, Katie Harrington, Jessica Berhorst, Erik sundell, Ochsner Medical Center Introduction: Treatment protocols that bundle best practices which include early goal directed therapy and early antibiotics have been shown to improve outcomes in patients with severe sepsis and septic shock (SS&SH). Hypothesis: A multi-disciplinary approach to the management of patients with SS&SH using protocols would lead to improved process of care demonstrated by patients receiving key components of the surviving sepsis guidelines. Methods: A prospective study of 197 consecutive patients admitted through the emergency department(ED) to a tertiary medical center with a diagnosis of SS&SH from January 2010 to June 2011. All patients were enrolled as part of the institution’s performance improvement project for SS&SH; a multi-disciplinary effort involving ED and critical care(CC) physicians, Nurses, Pharmacists, Respiratory Therapy and Administration. The project involved team development, creation of ED and CC evidence-based order sets and education. The implementation used rapid cycle feedback to change institutional behaviors. The ED was responsible for indentifying SS&SH patients, starting the protocol, and placing the mixed- venous oxygen saturation (ScVO2) monitoring catheter. The CC team was responsible for responding to the ED within one hour of consult to continue the protocol and expedite patient transfer to the intensive care unit. Success was measured by the number of patients receiving perfect care (PC). PC was defined as meeting all “goals” in process of care for patients with SS&SH: time to antibiotics, antibiotics within 2 hours, cultures prior to antibiotics, use of ED bundle order set, use of CC bundle order set, placement of ScVO2 catheter, and achieving EGDT goals within 6 hours(CVP ⬎8, MAP of 65 mmHg, and ScVO2 ⬎70 %). Results: 130 (66%) patients received PC while 67 did not receive PC (NPC). PC group had a median age of 63 years compared to 65 years for the NPC. PC group’s hospital LOS was 14 versus 18 days for the NPC. In-hospital mortality for the PC group was of 12 % versus 16 % for the NPC. Conclusions: Multi-disciplinary team collaboration and protocols lead to improved process of care for patients with SS&SH which may lead to decrease hospital LOS and improved in-hospital mortality.


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EARLY LACTATE-DIRECTED RESUSCITATION IS PLAUSIBLE, BUT WE NEED MORE INDICATORS FOR INFLAMMATION IN PATIENTS WITH SEPTIC SHOCK

EARLY ADMINISTRATION OF EMPIRIC ANTIBIOTICS IN PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK RESULTS IN DECREASED HOSPITAL LENGTH OF STAY

Yoshitaka Hara, Osamu Nishida, Tomoyuki Nakamura, Naohide Kuriyama, Miho Yumoto, Chizuru Yamashita, Yasuyo Shimomura, Kazuhiro Moriyama, Junpei Shibata, Fujita Health University

Leonardo Seoane, Fiona Winterbottom, Teresa Nash, Jawad Niazi, Katie Harrington, Jessica Berhorst, Erik sundellSundell, Ochsner Medical Center

Introduction: To evaluate the prognostic utility and severity of septic shock that will determine the feasibility of EGDT, indicators of inflammation, a pivotal role in the pathophysiology of septic shock, should be considered. Hypothesis: The aim of this study was to evaluate a new scoring system classified by blood lactate as a hemodynamic indicator and JAAM (The Japanese Association for Acute Medicine) DIC score as an inflammation indicator. Methods: We performed retrospective analysis on a case series. A total of 23 septic shock patients were enrolled. We used two indicators: blood lactate (L) and JAAM DIC score (D) which adopted SIRS criteria for inflammation monitoring. Patients on admission were classified into four clinical subsets by the two indicators of (L) and (D): I (L⬍36 mg/dL, Dⱕscore 4), II (Lⱖ36 mg/dL, Dⱕscore 4), III (Lⱖ36 mg/dL, Dⱖscore 5), and IV (L⬍36 mg/dL, Dⱖscore 5). APACHE II score and SOFA score at the time of enrollment and 28-day all-cause mortality were assessed. Average fluid rate for 2 days after admission and achievement rate of EGDT in these four subsets were evaluated. Results: The patient characteristics were as follows: age 63.1⫾16.3 years, APACHE II score 26⫾9, (D) 4.1⫾1.8 and (L) 52.4⫾47.6 mg/dL on ICU admission. (L) was not related to APACHE II or SOFA score, but (D) was related to both severity scores. Total survival rate at 28 days was 74%. Survival rates of subsets I, II, III, and IV were 100%, 66%, 50%, and 66%, respectively. Patients with (L) of more than 36 mg/dl showed lower survival rate (55% vs. 92%; p ⫽ 0.043) and patients with (D) of more than 5 showed lower survival rate (55% vs. 92%; p ⫽ 0.043). Average fluid rates for 2 days after admission were 202 mL/hr (I), 247 mL/hr (II), 355 mL/hr (III), and 206 mL/hr (IV) and achievement rates of EGDT were 44% (I), 66% (II), 75% (III), and 100% (IV). Subset III needed the largest volume of fluid with 75% EGDT achievement. Subset I showed the lowest EGDT achievement, but its survival rate was 100%, indicating no need for EGDT management. Conclusions: The combination of blood lactate and JAAM DIC score may useful for the management of septic shock patients.

375 THROMBIN-ANTITHROMBIN COMPLEX: A POSSIBLE INDICATOR OF THE SEVERITY OF SEPTIC SHOCK Naohide Kuriyama, Osamu Nishida, Yoshitaka Hara, Junpei Shibata, Yasuyo Shimomura, Kazuhiro Moriyama, Tomoyuki Nakamura, Chizuru Yamashita, Miho Yumoto, Fujita Health University Introduction: Microcirculation and hemodynamics can be monitored by blood lactate in patients with septic shock, however inflammation which is a pivotal role in the pathophysiology of septic shock is another key for evaluation of the severity of septic shock. We use a new scoring system classified by blood lactate as a hemodynamic indicator and JAAM (The Japanese Association for Acute Medicine) DIC score as an inflammation indicator for evaluation of the severity of sepsis. In JAAM DIC score, SIRS are newly cited criteria based on the concept of crosstalk between inflammation and thrombosis. Hypothesis: We added thrombin-antithrombin complex (TAT) level to our severity score of septic shock for the purpose of achieving more sensitivity to our severity score of septic shock. Methods: We performed a retrospective case series. Between Jun 2009 and December 2010, a total of 23 septic shock patients were admitted to ICU of Fujita Health University Hospital. Patients on admission were classified into four clinical subsets by above two indicators: blood lactate (L) and JAAM DIC score (D); I (L⬍36 mg/dL, Dⱕscore 4), II (Lⱖ36 mg/dL, Dⱕscore 4), III (Lⱖ36 mg/dL, Dⱖscore 5), and IV (L⬍36 mg/dl, Dⱖscore 5). APACHE II score and SOFA score at the time of enrollment and 28-day all-cause mortality were assessed. TAT level in these four subsets were evaluated. Results: The patients were: aged 63.1⫾16.3 years. APACHE II score 26⫾9, (D) 4.1⫾1.8 and (L) 52.4⫾47.6 mg/dL on ICU admission. Total survival rate at 28 days was 74%. Survival rates of subsets I, II, III, and IV were 100%, 66%, 50%, and 66%, respectively. TAT level of subsets I, II, III and IV were 18.7ng/mL , 15.1ng/mL , 74.2ng/mL , 35.1ng/mL, respectively. Patients with (D) ⱖscore 5 demonstrated higher TAT level and subset III which indicated severe tissue dysoxia indicated the highest TAT level. Conclusions: This result suggests the rationality of our severity score and TAT will be useful indicator for not only coagulation activation but also systemic inflammation response.


Introduction: Sepsis is a leading cause of death in the United States and the incidence continues to rise with a cost estimate of around 17 billion dollars per year. Time to antibiotics has been shown to improve outcomes in patients with severe sepsis and septic shock (SS&SH). Hypothesis: SS&SH patients who receive antibiotics within to 2 hours as part of a sepsis protocol would have improved outcomes as measured by a decrease hospital length of stay (LOS). Methods: This prospective study evaluated 619 consecutive patients admitted though the emergency department (ED) to a 530 bed tertiary referral medical center with a diagnosis of SS&SH from July 2008 to June 2011. All patients were enrolled as part of the institutions performance improvement project for the management of SS&SH. Time to antibiotics was calculated from diagnosis of SS&SH to time of first antibiotic infusion. The two cohorts consisted of patients who received antibiotics within 2 hours (Abx⬍2) versus patients who did not reach this goal (Abx⬎2). Abx⬍2 hours was an a priori identified goal of the sepsis protocol. Results: The Abx⬍2 cohort consisted of 456 patients with a median age of 65 and mean hospital LOS of 9 days (range 1 to 65 days) compared to Abx⬎2 cohort consisting of 163 patients with a median age of 63 and a mean hospital LOS of 12 days (range 1– 68). There was a significant decrease in hospital LOS for the Abx⬍2 cohort p ⫽ 0.008. The in-hospital mortality was 19% vs 21% for the Abx⬍2 vs Abx⬎2 respectively. Conclusions: Patients admitted through the ED with SS&SH who receive antibiotics within 2 hours have a decreased hospital length of stay.

Posters: Sepsis – Nosocomial (VAP, BSI, UTI) 376

377

INTRAHOSPITAL TRANSPORT INCREASES THE RISK OF VAP IN CRITICALLY ILL SURGICAL PATIENTS

RELAPSE AND RECURRENCE OF VENTILATOR-ASSOCIATED PNEUMONIA IN A RURAL TRAUMA POPULATION

Kristine Kelliher, Michael Nailor, Ilene Staff, Robert Brautigam, Karyn Butler, Hartford Hospital

Joseph Aloi, Brian Waldron, Wesley McMillian, John Ahern, Cassie Barton, William Charash, John Fortune, Fletcher Allen Health Care

Introduction: The purpose of this study was to determine whether intrahospital transport (IHT) is a risk factor for ventilator associated pneumonia (VAP). Hypothesis: We hypothesized that IHT of critically ill surgical patients was an independent risk factor for VAP. Methods: A retrospective review of consecutive admissions to the neurotrauma/general surgery intensive care unit (SICU) from January thru September 2010 was performed. Patients were included if they were intubated within 24 hours of admission and required mechanical ventilation for ⬎48 hours. Clinical suspicion of VAP was based on ATS/IDSA criteria and confirmed by sampling lower respiratory secretions (BAL⬎104 cfu/ml). Age, gender, ethnicity, BMI, APACHE II, length of stay, mortality and discharge disposition were collected. Data are expressed as mean⫾SD. Results: A total of 1300 patients were admitted to the SICU, 413 patients required mechanical ventilation, 128 (31%) met inclusion criteria. The mean age was 54⫾21 years, 67% were male, APACHE II 19⫾6, mean BMI 29⫾8 and mean SICU LOS 16⫾13 days. VAP was identified in 51 (40%) patients and occurred more frequently (85%) in patients ⬎50 years compared to younger patients (P ⫽ 0.015). There were no differences in ethnicity, APACHE II, or BMI in the VAP(⫹) or VAP(-) groups. ICU LOS (21⫾13 days vs. 13⫾11 days, (⫹)vs.(-), P⬍0.01) and hospital LOS (31⫾19 days vs. 22⫾19 days, (⫹)vs.(-), P ⫽ 0.01) were significantly longer for VAP (⫹) patients. The mean number of IHT’s for all patients was 3⫾2 (range 0 –9) with 75% of patients transported more than once. The most common destination was radiology for CT imaging (75% of all patients and 93% of those with multiple transports). On multivariate analysis patients transported out of the ICU ⱖ2 times had a significantly greater rate of VAP independent of demographic and illness severity measures (OR ⫽ 2.8, CI ⫽ 1.02–7.6, P⬍0.045). Sixty-four percent of patients survived to hospital discharge; home (18%), rehab (29%) or skilled nursing facility (17%). Conclusions: Intrahospital transport is an important risk factor for VAP in the SICU patient. Quality improvement initiatives aimed at reducing the rate of VAP must address risks inside and outside of the intensive care unit.

Introduction: Ventilator-associated pneumonia (VAP), is a common infection in the intensive care unit (ICU), associated with high morbidity and healthcarerelated costs in mechanically ventilated (MV) trauma patients. Although previous studies have examined risk factors for primary VAP infection (1VAP), few studies have assessed factors for relapse and recurrence (2VAP). Hypothesis: The null hypothesis is there are no risk factors associated with VAP relapse or recurrence. Methods: We conducted a retrospective cohort study of all MV ICU trauma patients with a clinical diagnosis of VAP between 2003 and 2009. Patients with more than one VAP infection were identified and categorized as having either relapse or recurrence. A univariate analysis of risk factors for VAP relapse or recurrence was performed. Results: A total of 134 trauma patients met criteria for VAP, of which 117 (87.3%) had only a primary VAP and 17 (12.7%) had 2VAP. Traumatic injury involving the spine was two-fold higher in patients with 2VAP (76.5% vs. 37.6%, p ⫽ 0.003). The most common organisms for the primary episode in both 1VAP and 2VAP groups were Hemophilus influenzae (23.6%), Methicillin-sensitive Staphylococcus aureus (20.1%), and Pseudomonas aeruginosa (7.4%). Mortality was similar between 1VAP and 2VAP (11.8% vs. 8.5%; p ⫽ 1.0). Mean duration of mechanical ventilation (16.1 vs 35.9 days, p⬍0.001) , ICU (21.7 vs 40.3 days; p⬍0.001) and hospital LOS (31.4 vs 54.2 days; p⬍0.001) were significantly longer in the 2VAP group. Conclusions: Traumatic spine injury may be a potential risk factor for 2VAP in MV ICU trauma patients. No association was seen between microbiologic pathogens responsible for the primary VAP infection and 2VAP. Patients who developed 2VAP were MV longer and had longer ICU and hospital LOS compared to patients with 1VAP, however; there were no differences in mortality between groups.

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IDENTIFYING AND PREVENTING VENTILATOR-ASSOCIATED TRACHEOBRONCHITIS (VAT) IN A MIXED MEDICAL/ SURGICAL PICU

CHECKLISTS & BEYOND: A SYSTEMATIC APPROACH TO CLABSI REDUCTION

LeeAnn Christie, Ann Bailey, Laurel Rogers, Vickie Simpson, Dell Children’s Medical Center of Central Texas, Renee Higgerson, Pediatric Critical Care Associates Introduction: Ventilator associated pneumonia (VAP) has become a rare occurrence in the PICU, however lower respiratory tract infections without radiographic changes diagnostic of pneumonia are not uncommon in mechanically ventilated pediatric patients. The last case of VAP at our hospital was in April 2007. Since that time, our interdisciplinary team has tracked ventilator-associated tracheobronchitis (VAT) as a separate category of healthcare-associated infection (HAI). Hypothesis: A significant number of patients with positive respiratory cultures meet diagnostic criteria for ventilator associated tracheobronchitis (VAT), a distinct, clinically significant HAI. Development of a targeted care bundle will reduce the rate of VAT in PICU patients. Methods: Dell Children’s Medical Center of Central Texas (DCMC) houses a 24 bed mixed medical/ surgical PICU with approximately 1100 discharges per year. Using continuous quality improvement methodology, DCMC formed an interdisciplinary team tasked with identifying VAT cases and refining the existing ventilator care bundle to reduce the VAT rate. Following an initial data collection period, the team performed multiple small tests of change and the final bundle was implemented in March 2009. Our team has performed case analyses on every positive respiratory culture collected since January 1, 2007 to determine whether criteria are met for VAT. Results: For the time period from January 2007-February 2009, mean VAT rate was 14.7/1000 ventilator days and mean days between infections was 12.5. From March 2009-July 2011, mean VAT rate is 8.7/1000 ventilator days, a 41% decrease, and mean days between infections is 26.4, a 111% increase. Median ventilator utilization ratio has remained stable at 0.36, which is consistent with the median National Healthcare Safety Network (NHSN) ratio of 0.35. Conclusions: These data demonstrate that VAT is a significant HAI in the PICU population that can be reduced or prevented through implementation of a refined, focused care bundle. Further study of VAT and standardized definitions of diagnostic criteria are needed to determine appropriate treatment. Patient safety initiatives should be developed to benchmark rates of VAT across pediatric hospitals.

Judy Dillworth, New York Langone Medical Center, Sandra Hardy, Michael Phillips, NYU Langone Medical Center Introduction: Central line associated bacteremias (CLABSI) are a significant cause of patient morbidity & mortality, increased LOS and cost. The literature emphasizes central line insertion & management in the ICU, but other factors/ locations need to be considered: site access, line maintenance, the environment and patient transport. Hypothesis: Sustenance of a reduced CLABSI rate requires continuous literature review and critique, adoption of new practices and teamwork amongst all disciplines. The CLABSI checklist, designated kit/cart and line insertion procedures facilitate adherence to the CLABSI bundle but are not sufficient to achieve a CLABSI rate of 0. Methods: A transdisciplinary collaborative approach was utilized to reduce CLABSI in an academic medical center. With the CLABSI checklist and CLABSI bundle, the following were implemented 1) evidence based literature review and vigilance, 2) implementation of procedures for central venous catheter/PICC line insertion, access and maintenance, 3) root cause analyses for every identified bacteremia, 4) communication and unending education for professional/non-professional staff to ensure meticulous technique for every step of catheter management, 5) education of patient families, 6) partnering with housekeeping to create ‘clean teams‘ for patient areas, 7) utilization of the Six Sigma Rapid Improvement Event (RIE) process for PICC lines, and 8) institutional willingness to change devices, processes and practices. The process originated in the MICU, but has expanded to all patient areas including the OR, ED, procedural areas and patient transport. Results: There was a 70% decrease in CLABSI/1000 line days from 1st qtr 2005 (7.6) to 2nd qtr 2011 (2.2),with 0 CLABSI in the adult ICUs since February 2011. A timeline from Jan 2005 to the present illustrates the interventions which facilitated the reduction of CLABSI throughout the hospital and over time. Ongoing challenges persist. Conclusions: It takes more than a checklist to reduce CLABSI. Aseptic technique, protection of site/line integrity wherever the patient is, communication, administrative leadership support, collaboration, vigilance, education and implementation of innovative strategies all contribute to success.


Posters: Sepsis- Diagnostics 380

381

USEFULNESS OF DELTA NEUTROPHIL INDEX (DNI) FOR SIRS PATIENT IN EMERGENCY DEPARTMENT

KINETICS AND PREDICTIVE VALUE OF PROCALCITONIN IN MICU PATIENTS

Hyung Jin Shin, Yonsei University, Wonju College of Medicine

Brandon Hobbs, Orlando Regional Medical Center, Derek Burden, Grady Health System, Prasad Abraham, Grady Health Systems, Marina Rabinovich, Lewis Satterwhite, Grady Health System, Matthew Hoffman, Emory University, Naasha Talati, Wayne Wang, Grady Health System, Greg Martin, Grady Memorial Hospital

Introduction: DNI is a quantified index of difference between two methods of measuring leukocyte differentials, namely cytochemical myeloperoxidase (MPO) reaction and nuclear lobularity channel assay, and reflects the number of immature granulocyte (IG) in circulating blood. IG count can be used as sepsis marker, and is reported to be a predictive factor of infection, but there has not been many studies done on this subject. This study aims to associate the prediction and severity of sepsis with DNI measured from patient visting emergency room with systemic inflammatory response syndrome (SIRS). Hypothesis: The higher the DNI value increases, the more the probability of Sepsis is. Methods: 707 patients who are 18 years and older (450 males, mean age 63⫾15.7 years) and visited Our ED from October 2009 to August 2010, diagnosed with SIRS and suspected of having sepsis, were initially enrolled. The patients were assigned to one of five groups of DNI (1: 5–10%, 2: 11–20%, 3: 21–30%, 4: 31– 40%, 5: ⬎40%), and comparisons on blood culture result, mortality rate, admission duration, and prognosis upon discharge were made among the groups. Also, all patients were divided into either “living” or “dead” group, and DNI values from each group were compared to see whether DNI is a predictor of mortality. Results: A total of 274 patients were finally enrolled after excluding patients who met the exclusion criteria or who could not be followed up. 71 patients received diagnosis of sepsis, and 56 of them died. Higher DNI value led to an increase in mortality rate (p⬍0.001). Increased DNI value led to increased ratio of positive blood culture result (p ⫽ 0.045). The admission duration for DNI group 1 was 3.1⫾7.3 days, which was significantly different from that of group 5, which was 5.5⫾7.3 days (p⬍0.01). The DNI value of “living” and “dead” group was 19.0 ⫾ 14.0,% and 10.80 ⫾ 7.54%, respectively, and was significantly higher in “dead” group (p⬍0.001). Conclusions: DNI is useful in diagnosis of sepsis and prediction of mortality in patients visiting the emergency department with SIRS.

Introduction: To evaluate the time kinetics and predictive value of procalcitonin (PCT) concentrations in medical intensive care unit (MICU) patients with presumed infection. Hypothesis: We hypothesized that PCT concentrations would be higher in infected patients. Methods: Prospective, observational, single center study at an urban academic medical center. Inclusion criteria were MICU admission, suspected infection per SCCM sepsis guidelines, and planned initiation of antibiotic therapy. Consecutive patients were enrolled; serum PCT was measured at enrollment, day 2, day 4, and the final day of antibiotic therapy or day 7 (whichever was first). Patients were excluded for liver disease, if withdrawal of care was expected or if baseline PCT was not obtained. After antibiotic therapy, infection status was adjudicated by two independent physician assessments. PCT concentrations were compared over time and between groups; p-values ⬍0.05 were considered significant. Results: Of 105 enrolled patients, 89 had serial PCT measurements available for evaluation. The majority of patients were AfricanAmerican (87%) and male (57%); mean age was 57 years. At enrollment, mean APACHE was 24 and SOFA was 8. Median enrollment PCT was significantly higher (4.36 vs. 0.85 ng/mL, p ⫽ 0.002) in the 51 patients with a confirmed infection. By repeated measures ANOVA, PCT rose from baseline to day 2 (p ⫽ 0.03) and fell by day 7 (p ⫽ 0.05). In multivariable modeling, PCT predicted infection independent of WBC (OR 1.07, p ⫽ 0.03) while only infected status and WBC independently predicted mortality. Conclusions: In MICU patients with suspected infection, PCT is significantly higher in infected than uninfected patients and is superior to WBC for predicting infection. The reported kinetics of PCT in this population may assist in developing utilization protocols and guidelines.

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C-REACTIVE PROTEIN (CRP) KINETICS IN POSTOPERATIVE PATIENTS

THE USE OF PERIPHERAL VENOUS BLOOD FOR THE ANALYSIS OF ACID BASE STATUS DURING SEPTIC SHOCK

Cristina Santonocito, Erasme University Hospital, Isabelle De Loecker, Katia Donadello, Erasme Hospital, Mouhamed Moussa, Department of Intensive Care, Erasme University Hospital, ULB, Antonino Gullo, Trieste University School of Medicine, Jean-Louis Vincent, Erasme University Hospital

Matthew Maiden, University of Adelaide, Tim Kuchel, SA Pathology, Coralie Nash, Mark Finnis, Marianne Chapman, Guy Ludbrook, University of Adelaide

Introduction: Diagnosis of infection is a challenge. Measurements of inflammatorymarkers like the C-reactive protein (CRP) have been proposed in medical patients but their interpretation in surgical patients is more difficult. Hypothesis: To evaluate the time course of CRP in postoperative patients with and without infection. Methods: Over a 5 month period (March-August 2011), we prospectively screened all postoperative patients from elective or emergency surgery admitted in our 32-bed ICU; APACHE II on admission, SOFAscore, biological and microbiological data were daily collected. CRP and leucocytes values were recorded up to one week after surgical intervention. The patients were screened in infected (I) and non-infected (NI) according to the ISF definitions. Exclusion criteria were: age⬍15, laparoscopic interventions, orthopedic surgery, interventional neuro-vascular radiology, transplantations and polytrauma. Results: 114 patients were included: age 60⫾16, APACHE II 10⫾5, SOFA 5⫾3, elective surgery 90, emergency surgery 24, I patients 85, NI patients 29, cardiac surgery 46, neurosurgery 44, abdominal surgery 14, vascular surgery 6, thoracic surgery 4. CRP values at the admission day were 7.8⫾9.7 mg/dL for I patients and 0.9⫾1.9 mg/dL for NI patients. CRP increased and peaked at day 2 and 3 (18.3⫾9.2 and 17.2⫾9.2 for I, 9.7⫾6.9 and 9.9⫾7.5 for NI, respectively). CRP was higher in I than NI until day 7 (p⬍0.01). CRP values correlated with APACHE II (r ⫽ 0.589, p⬍0.01). Leucocytes values were higher in I than in NI only on day 5, 6 and 7 (13⫾6, 14⫾7and 14⫾8 x103/mm3, respectively. P ⬍0.05). Conclusions: CRP trend is higher in infected than in non-infected patients in the first week after surgery. CRP decreases in non-infected patients after day 3. These observations can help to interpret CRP levels in the postoperative period.


Introduction: Observational clinical studies suggest peripheral venous blood is suitable for analysing acid-base disturbance. However it is unclear whether this applies in septic shock. Hypothesis: Peripheral venous blood is a reliable measure of acid-base state in septic shock. Methods: Eleven sheep had cannulae placed in the carotid artery and femoral vein. Alternate animals received an infusion of E.coli (septic sheep n ⫽ 6, non-septic sheep n ⫽ 5). All animals received protocolguided ventilation, sedation, parenteral fluids and inotropic support for 24 hours. Nine paired samples of arterial and peripheral venous blood were taken from each animal for acid base analysis. Main outcomes were the arterial-venous (a-v) difference, limits of agreement and concordance for pH, pCO2, calculated bicarbonate (HCO3) and base excess (BE) in septic and non-septic sheep. Results: All sheep given E.coli developed septic shock, while non-septic sheep remained stable. The a-v difference in acid-base parameters was similar in non-septic and septic animals (pH ⫹0.06 vs ⫹0.07, p ⫽ 0.91; pCO2 -9 vs -10, p ⫽ 0.36; HCO3 -2.3 vs. -2.6, p ⫽ 0.50; BE -0.5 vs. -0.7, p ⫽ 0.51). Assuming a constant a-v bias of pH ⫹0.06, HCO3 -2.5 mmol/L and BE 0.0, peripheral venous blood had strong concordance and acceptable limits of agreement with arterial blood in non-septic and septic sheep. In contrast, the a-v relationship for pCO2 was poor. Conclusions: In a controlled ovine model of resuscitated septic shock, peripheral venous blood provides a reliable measure of metabolic acid-base disturbance. This supports conclusions from previous uncontrolled clinical studies.

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385

THROMBOCYTOPENIA IN ADULT PATIENTS WITH SEPSIS

ANTITHROMBIN III (AT III) ACTIVITY IN CRITICALLY ILL PATIENTS

Chakradhar Venkata, Mayo Clinic Health System Mankato, Bekele Afessa, Mayo Clinic Introduction: To describe the incidence, risk factors and prognostic importance of thrombocytopenia in adult patients admitted to intensive care unit (ICU) with sepsis. Hypothesis: Thrombocytopenia is thought to be an independent risk factor for mortality in ICU patients. However, limited data are available in patients with sepsis. Methods: Observational study of patients admitted to the ICU of Mayo Clinic, Rochester, MN, between January-May 2008. Patients who declined research authorization, history of platelet disorders, hematologic malignancies, chemotherapy, mechanical heart valves, alcohol use, and cirrhosis were excluded. Results: 109 patients were included in the study, of whom 55 (50.5%) were men. Mean (SD) age was 67.6 (17.2) years. Pneumonia was the most common infection. Thrombocytopenia developed in 52 (47.7%): 29 (26.6%) at admission and 23 (21.1%) during the hospital course. The median (IQR) duration of thrombocytopenia was 5 (2–7) days. Disseminated intravascular coagulation developed in 15 (13.8%) and drug induced thrombocytopenia in 7 (6.4%), thought to be from antibiotics. Major bleeding developed in 12 of 52 patients (23.1%) with thrombocytopenia compared to 4 of 53 patients (7.0%) without thrombocytopenia (P ⫽ 0.018). Patients with thrombocytopenia had significantly higher lactate, prolonged vasopressor therapy, higher APACHE scores (p⬍0.05). Patients with thrombocytopenia had longer ICU stay (median 3.0 vs. 2.0 days, P ⫽ 0.019). The 28-day mortality rate of patients was similar between patients with and without thrombocytopenia (31% Vs 21%, p ⫽ 0.246). Six of 32 patients (19%) who resolved thrombocytopenia died compared to 10 of 20 (50%) who did not resolve thrombocytopenia (P ⫽ 0.02). Conclusions: Thrombocytopenia is common among patients admitted to ICU with sepsis. Patients with thrombocytopenia had more episodes of major bleeding and prolonged ICU stay. Non-resolution of thrombocytopenia, but not thrombocytopenia perse, is associated with increased mortality.

Noriko Saito, Taijiro Goto, Yoshito Nagura, Munekazu Takeda, Ryuichi Moroi, Mizuho Namiki, Hideaki Suzuki, Arino Yaguchi, Tokyo Women’s Medical University Introduction: Anti-inflammatory response of antithrombin III (AT III) has been known as well as its anticoagulation as our natural defense system. In our previous study, AT III deficiency was occurred with a no relation to DIC status in sepsis. Hypothesis: Our hypothesis is AT III activity does not relate with DIC status in sepsis, while its activity relates with DIC in other critically ill patients. Methods: From January to December 2009, all adult patients admitted to our medicosurgical ICU were included in this study. Patients with hemorrhagic shock or with hepatic dysfunction in their past history were excluded. Serum AT III activity (%) was measured in all patients on admission. The measurement of AT III was using by chromogenics assay (Sysmex®, Kobe) (normal: 80 –130%; AT III deficiency ⬍80%). Patients were divided into three groups, 1) Trauma patients, 2) Non-septic patients and 3) Septic patients due to primary diagnosis on admission. AT III activity was compared in three groups. Values are expressed as median. Data was analyzed by chi-square test, Kruskal-Wallis test and MannWhitney U test. Peason’s correlation coefficient was used for correlation. P values less than 0.05 were considered significant. Results: Of four hundred and eight patients (247 men, 161 women; age range 18 –100 years [median 62]), there were 1) 83 trauma patients, 2) 281 non-septic patients and 3) 46 septic patients on admission. AT III activity was statistically significantly lower in septic patients than in trauma patients and in non-septic patients (70 vs. 95, 92 %, respectively, p⬍0.0001). SOFA score was statistically lower in trauma patients than in nonseptic and in septic patients (3 vs. 5, 5 respectively, p⬍0.0001). In trauma patients and in non-septic patients, AT III activity related to DIC score (r ⫽ 0.52, p⬍0.0001 and r ⫽ 0.47, p⬍0.0001, respectively). In sepsis, there was no correlation between AT III activity and DIC score (r ⫽ 0.30, p ⫽ 0.04). Conclusions: AT III alterations could be related with DIC status in trauma patients and in non-septic patients. However, AT III deficiency already happened in sepsis on admission without hepatic dysfunction or DIC status.

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IS PROCALCITONIN USEFUL TO THE DIAGNOSIS OF INFECTED PANCREATIC NECROSIS AND PANCREATIC ABSCESS?

EVALUATION OF PROCALCITONIN IN A SURGICAL/ TRAUMA INTENSIVE CARE UNIT AT A LEVEL I TRAUMA CENTER

Hideto Yasuda, Shinichiro Suzaki, Japanese Red Cross Musashino Hospital

Derek Burden, Grady Health System, Brandon Hobbs, Orlando Health, Prasad Abraham, Grady Health System, Brian Williams, Parkland Memorial Hospital, Bryan Morse, Greenville Hospital System, Mitchell Chaar, Naasha Talati, Greg Martin, Wayne Wang, Grady Health System, Jeffrey Salomone, Grady Health Sytem

Introduction: The infected pancreatic necrosis and pancreatic abscess (infective complications) represent serious complications of severe acute pancreatitis (SAP) and substantially affect the mortality and morbidity. The purpose of this study is to examine the utility of procalcitonin (PCT) as a method of early diagnosis for infective complications. Hypothesis: PCT concentrations will be elevated during infective complications. Methods: For the 19 patients diagnosed as SAP, the PCT was prospectively measured once daily during the initial one week after hospitalization and thrice weekly. When infective complications were suspected during the course of SAP, the fine needle aspiration (FNA) was administered. As for the patients with infective complications, the PCT during the complications was defined to be the maximum PCT recorded during the period of one week before the infective complications were proven by FNA and, in case of the patients without infective complications, their maximum PCT no earlier than one week after their hospitalization was recorded as the control. Results: Of the 19 patients, nine of them represented the infective complication (infected group) and ten of them represented the non-infective complication (non-infected group). All of the patients with infective complications developed the complication no earlier than one week after hospitalization. There were no significant difference between the infected group and non-infected group about average age, APACHE II score?Ranson score, and SOFA score. The maximum PCT of the infected group during infective complications was found to have increased showing statistical significance as compared to that of the non-infected group (0.66⫾0.53ng/dl vs. 0.26⫾0.26ng/dl : p ⫽ 0.04). Assuming the PCT cut off value being 0.5ng/dl, the sensitivity and specificity of PCT during the infective complication were 0.55 and 0.9, respectively. Conclusions: While the elevated PCT during course management of SAP will possibly give an indication of the infective complications, its clinical application requires further collection of the clinical data as it is no more than just slightly higher than the upper limit of normal level according our results of this study.

Introduction: To determine the utility of PCT in the diagnosis of sepsis in trauma/surgical intensive patients and evaluate the trend of procalcitonin (PCT) concentrations following treatment. Hypothesis: We hypothesized that PCT concentrations would aid in diagnosing true infection and in assessing response to antimicrobial therapy. Methods: This observational study was performed in a single, urban academic Level I trauma center. Inclusion criteria were admission to the Surgical ICU ⱖ72 hours, presumed sepsis per SCCM guidelines, and the initiation of antibiotic therapy. Patients were excluded if withdrawal of care was expected, known liver disease, and/or presence of burns. Consecutive patients were enrolled. PCT levels were obtained at enrollment, day 2, day 4, and on the final day of antibiotic therapy or day 7 (whichever was reached first). If a baseline PCT level was not obtained, the patient was excluded from analysis. Upon completion of antibiotic therapy, true infection was determined by two independent physicians who grouped patients into two categories: high probability for infection (sepsis) or low probability (non-infectious SIRS). Median PCT concentrations were compared over time and between groups; p-values ⬍0.05 were considered significant. Results: A total of 107 patients were enrolled and 70 included for analysis. 29 patients were excluded because of missing baseline PCT levels. The majority of patients were African-American (54%) males (80%) admitted for trauma (94%) with a median age of 54 years. At enrollment, median ISS was 19.5 and SOFA score was 6. Infection was present in 52 (74%) patients. There was no difference in median baseline PCT concentration between the two groups (1.0 ng/mL infected vs. 2.1 non-infected, p ⫽ 0.20). PCT concentrations fell significantly over time (ANOVA trend p ⫽ 0.003), most apparent comparing day 0 to day 7 (p ⫽ 0.04) and in the infected patients (ANOVA p ⫽ 0.007). Conclusions: In surgical/trauma patients, PCT concentrations do not accurately discriminate infected sepsis patients from uninfected SIRS patients. However, PCT concentrations decrease over the course of seven days, particularly in infected patients.


388 COMPARATIVE EVALUATION OF NEW JAAM AND ISTH DIC SCORES IN CRITICALLY ILL SEPTIC PATIENTS Ratender Singh, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Arvind Baronia, Jyoti Sahoo, SGPGIMS Introduction: DIC occurs in about 35% of cases of sepsis. However, no single clinical or laboratory test has an adequate sensitivity and specificity to confirm or reject a diagnosis of DIC. Hypothesis: We prospectively compared the new Japanese Association of Acute Medicine (JAAM) and International Society of Thrombosis and Hemostasis (ISTH) DIC score in critically ill septic patients. Methods: Septic patients with platelet count of ⬍150⫻109/L were considered eligible. Blood samples for parameters included in these scores were drawn from D1-D4. APACHE-II/SOFA scores were also recorded. Results: 42 patients (28 male/14 female) were included in the study. Pneumonia was the predominant cause of sepsis. Fifteen (35.7%) survived while 27(64.3%) died during their stay in ICU.JAAM score diagnosed DIC in 95%, 89.5%, 74% and 80% of patients on day 1, 2, 3, 4 respectively with an overall disparity of 44% (p ⬍0.001) with ISTH overt DIC.JAAM DIC had higher diagnostic rates on all four days of the study. Analysis of day wise values of JAAM, ISTH, APACHE II and SOFA scores yielded significant day wise variation in JAAM (p ⬍0.001) and ISTH (p ⫽ 0.001) DIC scores but not in APACHE II/SOFA scores. Significant correlation existed between JAAM and ISTH DIC score on D1 (r ⫽ 0.631, p⬍0.001) and D4 (r ⫽ 0.609, p⬍0.001). Survivors and non-survivors had similar co-morbidities in the study. In our patient population neither the severity scores (APACHE-II/SOFA) nor the DIC scores (JAAM/ISTH) had any discriminating ability to differentiate survivors from non-survivors. Health care associated infection (p ⫽ 0.049) and high lactate levels (p ⫽ 0.027) on day 1 were found to have significant discriminating ability. Conclusions: The JAAM DIC score identified most of the patients diagnosed by the overt ISTH score, but it did not help in differentiating between survivors and non-survivors amongst DIC patients. JAAM DIC score correlated significantly with ISTH DIC score but not with APACHE-II and SOFA score in severe sepsis.


Posters: Sepsis- Therapeutics 389

390

USE OF LOW DOSE (STRESS) CORTICOSTEROIDS IN PATIENTS WITH SEPTIC SHOCK

THE USE OF A “SEPTIC SHOCK CART” IMPROVES HEMODYNAMIC RESUSCITATION IN PATIENTS WITH SEVERE SEPSIS OR SEPTIC SHOCK IN AN ACADEMIC MEDICAL CENTER

Duane Funk, Shravan Kethireddy, University of Manitoba, Steve Doucette, Dalhousie University, Anand Kumar, University of Manitoba Introduction: Based on several small trials, there is the suggestion that low dose corticosteroids may reduce the risk of death in patients with septic shock. One large randomized controlled trial has failed to demonstrate such a benefit. Hypothesis: To evaluate the effectiveness of low (stress) dose corticosteroids (LDC) on mortality in patients with septic shock in a large septic shock database. Methods: Retrospective, propensity-matched, multi-center cohort study in 28 academic and community intensive care units in 3 countries. A total of 8670 eligible cases treated with low dose corticosteroid therapy within 48 hours of documentation of septic shock from which 1838 propensity-matched pairs were generated. Results: The primary outcomes of this study were in-hospital and 30 day mortality. Using a propensity matched Cox proportional hazard model we observed a non-significant 0.6% higher 30-day mortality [652/1838 (34.9%) vs. 652/1838 (35.5%), hazard ratio (HR) 1.02, 95%CI 0.91–1.13] associated with the use of LDC. Hospital mortality in the two groups was also similar [773/1838 (42.1%) vs. 797/1838 (43.4%), odds ratio (OR) 1.05, 95%CI 0.91–1.14]. There were no significant differences in 30 day mortality among the 3 lowest APACHE II quartiles; in the highest quartile of ⱖ30, the use of LDC was associated with a significantly lower 30 day mortality [232/461 (50.6%) vs. 251/450 (55.8%), HR 0.81, 95% CI 0.68 – 0.97]. Conclusions: In this retrospective, multi-center propensity matched cohort study the use of LDC in patients with septic shock was not associated with statistically significant reductions in 30-day or hospital mortality; a subgroup suggested that a survival benefit may exist in the highest APACHE II quartile.

Kevin Hatton, Univeristy of Kentucky, Pam Branson, University of Kentucky, Melissa Nestor, University of Kentucky Medical Center, Kevin McConeghy, University of Kentucky, Jeremy Flynn, University of Kentucky Chandler Medical Center Introduction: Our institution recently implemented a resuscitation strategy for patients with severe sepsis or septic shock that specifically includes the use of a mobile ‘septic shock cart‘ which can be rapidly deployed to any bedside location and contains all necessary supplies and drugs to rapidly initiate our institutional protocol for hemodynamic resuscitation. Hypothesis: The use of our institutional septic shock resuscitation strategy, including the use of the ‘septic shock cart‘, improves the resuscitation of patients with severe sepsis or septic shock. Methods: After IRB approval was obtained, the charts of 50 consecutive patients who were admitted with either severe sepsis or septic shock before September 2010 were evaluated as historical controls. Additionally, the charts of 33 patients from October 2010 to March 2010 who were resuscitated with the institutional septic shock strategy were also evaluated. Both sets of charts were reviewed to determine the effectiveness of resuscitation during the first six hours after the development of severe sepsis or septic shock. This information was collated and statistically analyzed using a commercial statistical software package. Results: When compared to the historical controls, the percent of patients who reached the MAP target increased from 54.3% to 81.5% (p ⫽ 0.01), the percent of patients who reached the CVP target increased from 50.0% to 72.7% (P ⫽ 0.04), and the percent of patients who reached the ScvO2 target increased from 19.6% to 33.3% (p ⫽ 0.17). Of the few additional measures of resuscitation that were also evaluated,the percent of patients who had their serum lactate measured increased from 34.8% to 97.0% (p⬍0.001) and the percent of patients who received steroids was not significantly changed (34.8% to 36.4%). Conclusions: The use of our institutional septic shock resuscitation strategy with the septic shock cart was associated with an increase in the percent of patients who had their serum lactate evaluated and the percent of patients who reached their MAP, CVP, and ScvO2 targets within six hours. The effect that these improvements in care may have on morbidity and mortality is not yet known.

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EFFECTIVENESS OF CONTINUOUS LONG-DURATION PMX-DHP THERAPY IN ABDOMINAL SEPTIC SHOCK

CLINICAL USE OF ACTIVATED PROTEIN C IN SEPTIC SHOCK: RESULTS FROM A MULTINATIONAL COHORT

Masaya Yamato, Keiko Yasuda, Koichi Sasaki, Rinku General Medical Center, Hiromi Rakugi, Yoshitaka Isaka, Osaka University Graduate School of Medicine

Emily Rimmer, Anand Kumar, University of Manitoba, Alexis Turgeon, Hopital De L’Enfant-Jesus, Bryce Makar, Donald Houston, Ryan Zarychanski, University of Manitoba

Introduction: Recent studies reported that a longer duration of polymyxin Bimmobilized fiber column hemoperfusion (PMX-DHP) therapy improves hemodynamics and pulmonary oxygenation in patients with septic shock. However, the optimal duration of PMX-DHP therapy remains unclear. Hypothesis: Continuous long-duration PMX-DHP therapy improves the 28-day mortality rate compared with conventional 2-hour PMX-DHP therapy in patients with abdominal septic shock. Methods: Between December 2004 and February 2009, 59 patients (19 in the long-duration group since July 2007 and 40 in the conventional 2-hour group) were treated with PMX-DHP for intra-abdominal septic shock. Endotoxin levels were measured. Isolated microorganisms and sites were obtained. There were no significant differences between the two groups in baseline characteristics, APACHE II score (24.0⫾5.98 vs. 22.6⫾6.42), SOFA score (8.31⫾3.46 vs. 8.51⫾2.90), mean arterial pressure (MAP), catecholamine index (CAI), PaO2/FiO2 ratio, lactate levels. There was no significant difference between the two groups in terms of indication for abdominal surgery. In conventional 2-hour group, PMX-DHP was performed for 2 hours and then the second PMX-DHP treatment was performed 24 hours after the end of the first treatment. The end point for continuous long-duration PMX-DHP treatment by a change of column approximately every 24 hours was determined by improvement of MAP (⬎65 mmHg), normalization of lactate levels (⬍2 mmol/L) and withdrawal in vasopressor/inotropic agents in each individual patient. 28-day mortality was recorded. Results: The mean duration of PMX treatment was 49.6⫾33.3 hours and 4.0⫾2.0 hours (p⬍0.01). Changes in MAP, SOFA score, PaO2/FiO2 ratio, urine volume, CAI and lactate levels were significantly (p ⬍0.01) improved in the long-duration group. 28-day mortality was 27.5% (11/40 patients) in the conventional 2-hour group and 5.3% (1/19 patients) in the long-duration group (p⬍0.05). The significant side effects in continuous long-duration PMX-DHP treatment were not shown in our study. Conclusions: These results suggest that the duration time appropriate for PMX-DHP therapy should be determined according to the clinical effects of each individual patient.

Introduction: In a large randomized controlled trial (PROWESS), recombinant human activated protein C (rhAPC) reduced 28-day mortality by 6.3% in patients with severe sepsis or septic shock. In November 2001, rhAPC was approved for use in adult patients with severe sepsis who have a high risk of death and is the only anticoagulant licensed for this indication. However, in a Canadian national survey of intensive care physicians, only 26% reported using rhAPC always or almost always in septic patients who meet the prescribing indications. Hypothesis: We hypothesize that the overall use of rhAPC is lower than reported by physicians. Methods: Using the Cooperative Antimicrobial Therapy of Septic Shock (CATSS) database, patients ⬎18 years of age who were admitted to an intensive care unit between 1996 –2008 with a diagnosis of septic shock were identified from 28 institutions in the US and Canada. Cases prior to date of rhAPC licensure (November 21, 2001 in the US and February 18, 2003 in Canada) were excluded. A multivariable logistic regression model was designed to determine which factors are associated with rhAPC use. Results: The overall rate of rhAPC use in the entire cohort was 6.8% (297/4355). The use in patients who met licensing indications was 6.9% (291/4193). The use in the US was 4.6% (33/719) and 7.3% (264/3636) in Canada. The majority of patients who received rhPAC met licensing indications for rhPAC [98% (291/297)]. 112 (37.7%) patients receiving rhAPC had one or more PROWESS exclusion criteria. Among patients with an indication for rhAPC in whom a PROWESS exclusion was not identified, the use was 7.2% (181/2523). In a multivariable logistic regression model, age, APACHE II score, absence of comorbidities (liver disease, kidney disease, and cancer) and number of organ failures on day 1 of ICU admission were significantly associated with rhAPC use. Patients treated in an academic institution had a two-fold increase in the odds of receiving rhAPC (OR 2.02, 95%CI 1.49 –2.75) compared to community ICUs. Conclusions: The use of rhAPC is low in whom the agent has a licensed indication. Further study is necessary to understand the barriers and facilitators to the use of rhAPC in patients with septic shock.


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EFFECTS OF ETOMIDATE ON ADRENAL SUPPRESSION: A REVIEW OF INTUBATED SEPTIC PATIENTS

ADSORPTION IS A PROMISING MECHANISM FOR HMGB1 REMOVAL BY HEMOFILTRATION IN VITRO

Melissa Thompson, Stephanie Baker, Kyle Weant, University of Kentucky

Osamu Nishida, Miho Yumoto, Kazuhiro Moriyama, Tomoyuki Nakamura, Naohide Kuriyama, Yoshitaka Hara, Yasuyo Shimomura, Fujita Health University, Shingo Yamada, Shino-Test Corporation, Taku Miyasho, Rakuno Gakuen University

Introduction: Etomidate, a commonly used sedative hypnotic for the induction of sedation during rapid sequence intubation (RSI), is desirable for its rapid and short-lived effects. It can inhibit cortisol production in the adrenal cortex, potentially causing or exacerbating hypotension in septic patients. Patients diagnosed with sepsis are at an increased risk of developing adrenal suppression which has been associated with increased mortality in some studies. Etomidate use in septic patients is controversial due to its effects on cortisol production; however, data are still lacking to prove that etomidate should be avoided in this patient population. Hypothesis: We hypothesize that etomidate will be associated with clinically significant hypotension when used in septic patients for RSI. Methods: A retrospective cohort study evaluated patients intubated in the emergency department and on medicine wards who had received either etomidate or another agent for RSI. The primary endpoint was clinically significant hypotension, defined as a systolic blood pressure⬍90 mmHg or a mean arterial pressure of ⬍60 mmHg within 24 hours of the intubation. Secondary endpoints included vasopressor use, corticosteroid use, days on mechanical ventilation, length of stay (LOS) and 28 day mortality. Results: One hundred fifty-seven patients, 110 etomidate and 47 non-etomidate, were included in the final analysis. Hypotension was seen in 79 (71.8%) patients who received etomidate and in 14 (29.8%) patients who received another sedative (pⱕ0.001). There were no statistically significant differences in the secondary endpoints: corticosteroids use 63 (60%) etomidate vs. 23 (48.9%) non-etomidate; vasopressor use 82 (74.5%) vs. 30 (63.8%); ventilator days (14.6 vs.12.2); ICU LOS (14.9 vs. 12.5); hospital LOS (25.7 vs. 20.3) and 28 day mortality (31.8% vs. 38.3%) respectively. Conclusions: Septic patients who received etomidate for RSI were more likely to have clinically significant hypotension within the first 24 hours following intubation, compared to those patients who received alternate sedatives. However, the hypotension was transient and did not translate into statistically significant differences in the secondary clinical endpoints.

395 NOREPINEPHRINE DOSING IN OBESE SEPTIC PATIENTS Jenna Bernabei, Mark Mlynarek, John Stine, Michael Peters, Henry Ford Hospital Introduction: Obesity in critically ill patients has been associated with increased morbidity and mortality. Medication management is challenging as little is known about drug dosing in this population. The purpose of this study is to determine if non-weight based norepinephrine (NE) dosing affects attainment of surrogate endpoints in obese septic patients. Hypothesis: Obese patients require a higher dose of NE and take longer to reach a target mean arterial pressure (MAP). Methods: This was a prospective, observational study of patients with septic shock receiving NE. Groups of obese (body mass index [BMI] ⱖ30) and non-obese (BMI⬍30) were formed. Demographics, baseline MAP, central venous pressure (CVP), total fluids administered, and NE dose at baseline and at target MAP were recorded. The primary endpoint was time to target MAPⱖ65. Results: A total of 58 patients (males ⫽ 50%, median APACHE II score 24) were included. BMI was higher in the obese group (OG) (41.2⫾10.8) than the nonobese group (NOG) (24.3⫾3.4, p⬍0.001). Baseline CVP was 7.8⫾7.3 in the OG and 9.4⫾9.6 in the NOG, p ⫽ 0.294. The OG received 2.7⫾2.3 L of fluid vs. 3.4⫾2.5 L in the NOG prior to NE initiation (p ⫽ 0.271) and achieved target CVP more quickly than the NOG (34 ⫾ 73 min vs. 116 ⫾ 177 min, p ⫽ 0.059). After fluid resuscitation and prior to NE, MAP was 51.8⫾7.3 in the OG and 51.4⫾7.2 in the NOG, p ⫽ 0.796. NE starting doses were 5.7⫾4.8 mcg/min in the OG and 9.5⫾11.5 mcg/min in the NOG, p ⫽ 0.114. Time to target MAP was 49.9⫾66.6 min in the OG vs. 52.2⫾61.6 min the NOG (p ⫽ 0.894) and doses at target MAP were 23.4⫾29.8 mcg/min and 28.4⫾42.3 mcg/min, respectively (p ⫽ 0.618). Dose per kg at target MAP was 0.26⫾0.37 mcg/kg/min in the OG and 0.34⫾0.45 mcg/kg/min in the NOG, p ⫽ 0.48. Conclusions: Obese patients do not require higher doses of norepinephrine when compared to nonobese patients to reach a target MAP of 65.


Introduction: High mobility group box 1 protein (HMGB1) which plays an important role in sepsis is hardly removable by normal hemofiltration because of its large molecular weight of 30 kDa. Here we demonstrate a removal capacity of HMGB1 using seven internationally available membranes: high cut-off (HCO), AN69ST, polysulfone and polymethylmethacrylate membranes with different pore sizes were tested. Hypothesis: The objective was to demonstrate the importance of adsorption mechanism for the removal of HMGB1 from blood. Methods: Three types of laboratory experiments were designed. First, in vitro experimental hemofiltration (solution flow of 100 mL/min and ultrafiltrate flow of 1000 mL/hr) was conducted for 360 min. The test solution contained 100␮g of HMGB1, similar concentration in patients with septic shock, in 1000 mL of albumin solution and subsequently in 1000 mL of bovine serum. HMGB1 were assayed by ELISA and Western blot analysis. The concentration and clearance were calculated. Second, to investigate the saturation of membrane, 100␮g of HMGB1 was added in the reservoir every 60 min, 7 times. Third, to investigate the adsorption mechanism, we performed immunostaining of membrane using HMGB1 antibody. Results: By the first experiment, among the seven membranes, AN69ST indicated biggest decline of HMGB1 concentration at 0, 60, and 360; 74.0 ⫾ 11.8, 2.1 ⫾1.2 to 0.5 ⫾ 0.6ng/mL significantly and showed a markedly high test solution clearance of 60.8 ⫾ 5.0 mL/min by adsorption without albumin loss at 15 min. HCO membrane was the second group of 18.7⫾4.4 mL/min by filtration with albumin loss. In the case of the serum, similar result was obtained. The second experiment indicated no saturation of AN69ST; whenever 100 ␮g of HMGB1 was added every 60 min, 7 times, the solution levels became zero immediately. In the third experiment, the bulk of AN69ST membrane prepared with a high concentration of HMGB1 was not stained at all. Conclusions: Adsorption is a promising mechanism to increase mediator clearance to blood flow rate and to remove large-molecular-weight cytokines such as HMGB1 effectively. In our study, AN69ST membrane was unsaturated.

396 ACTIVATED PROTEIN C IN SEPTIC HEMATOPOIETIC STEM CELL TRANSPLANT PATIENTS: A RETROSPECTIVE COHORT STUDY Kevin O’Neal, Caroline O’Neal, University of Oklahoma HSC, Meredith Moorman, University of Oklahoma HSC, Jennifer Holter, Jijo John, George Selby, Gary Kinasewitz, University of Oklahoma HSC Introduction: The mortality of severe sepsis in immunocompetent patients ranges from 20 –50%. In 2001, drotrecogin alpha (DAA) was approved for treatment of severe sepsis patients based on the decreased all-cause mortality in the PROWESS trial. However, bone marrow transplant patients were excluded from PROWESS enrollment due to their increased risk of bleeding. Frequent prolonged thrombocytopenia related to pre-transplant chemotherapy regimen and radiation, and a 2–3 week bone marrow insufficiency prior to engraftment increases their bleeding risk. Attempts to evaluate DAA use in this population in prospective trials have been unsuccessful due to slow enrollment and have been abandoned. Hypothesis: We sought to determine the efficacy and risks of DAA in bone marrow transplant patients with severe sepsis. Methods: Retrospective cohort study of 208 hematopoietic stem cell transplant patients (HSCT) within a 3 year period (Jun 2007-Jun 2010) at OU transplantation center. Patients transferred to MICU with severe sepsis who were candidates for DAA and had no contraindication other than thrombocytopenia were included. Differences between DAA⫹ and DAA- were determined by Fisher exact or Student’s t-test. Results: 26 of the 208 HSCT were transferred to the MICU with severe sepsis. 16 of the 26 had contraindications to DAA. Only 3 of the remaining 10 HSCT with severe sepsis received DAA. Age (range 20 to 71 DAA⫹ vs 37 to 68yrs DAA-), gender (2 of 3 vs 4 of 7 male), days post HSCT (range 4 to 226 vs 6 to 207), APACHE (21⫾9.0 vs 19.4⫾3.2) and baseline platelet count (16.7K⫾5.1K vs 24.1K⫾14.3K) were similar. All DAA⫹ received platelets during DAA therapy to keep counts above 30K. All DAA⫹ but only 1/7 DAA- survived the episode of sepsis (p ⬍0.03) and 3/3 DAA⫹ but no DAA- were discharged alive (p⬍0.01). There were no serious bleeds in DAA⫹. Conclusions: Based on these findings, we propose that drotrecogin alpha can be safely used in HSCT patients without increased risk of bleeding when platelet counts are maintained above a threshold of 30,000 by prophylactic infusions. We also conclude that similar mortality improvement can be seen in this population.

397

398

TIMING OF INITIATION DEFINED BY THE COMBINATION OF BLOOD LACTATE AND JAAM DIC SCORE FOR MEDIATOR-ADSORBING BLOOD PURIFICATION IN PATIENTS WITH SEPTIC SHOCK

RANDOMIZED CONTROLLED TRIAL OF NOVEL RECOMBINANT HUMAN SOLUBLE THROMBOMODULIN FOR SEPSIS WITH DIC PATIENTS IN JAPAN

Osamu Nishida, Yoshitaka Hara, Chizuru Yamashita, Kazuhiro Moriyama, Miho Yumoto, Junpei Shibata, Naohide Kuriyama, Natsumi Yasuoka, Tomoyuki Nakamura, Fujita Health University Introduction: For the treatment of septic shock, we have selected the intensive modality, sustained high-efficiency daily diafiltration using a mediator-adsorbing membrane (SHEDD-fA), for breaking the vicious cycle of mediators and achieved satisfactory results. The operation conditions are QB ⫽ 150 mL/min, QF ⫽ 1500 mL/h (post-dilution), and QD ⫽ 500 mL/min over 12 hours daily. Timing of SHEDD-fA initiation should be related to strength of inflammation. Hypothesis: The objective was to evaluate the initiation timing of SHEDD-fA incorporating inflammation indicator combined with lactate for hemodynamic management. Methods: We performed retrospective analysis on a case series. A total of 23 septic shock patients were enrolled. Blood lactate (L) and JAAM (The Japanese Association for Acute Medicine) DIC score (D) which adopted SIRS criteria for inflammation monitoring were used on admission. Patients were classified into four clinical subsets by two indicators: I (L⬍36 mg/dL, Dⱕscore 4), II (Lⱖ36 mg/dL, Dⱕscore 4), III (Lⱖ36 mg/dL, Dⱖscore 5), and IV (L⬍36 mg/dL, Dⱖscore 5). APACHE II score and SOFA score at the time of enrollment and 28-day all-cause mortality were assessed. Duration from ICU admission to SHEDD-fA and average frequency were evaluated. Results: The patient characteristics were: age 63.1⫾16.3, APACHE II 26⫾9, (D) 4.1⫾1.8, and (L) 52.4⫾47.6 mg/dL on ICU admission. (L) was not related to APACHE II or SOFA score, but (D) was related to both severity scores. Total survival rate at 28 days was 74%. Survival rates of subsets I, II, III, and IV were 100%, 66%, 50%, and 66%, respectively. Durations from ICU admission to blood purification were 324 min (I), 132 min (II), 204 min (III), and 167 min (IV) and average frequencies were 9.0 times (I), 8.7 times (II), 15 times (III), and 5.3 times (IV). Subset I was less serious and showed sufficient time for conventional treatment without SHEDD-fA. In contrast, subset III, the most severely affected patients, required immediate SHEDD-fA. Conclusions: The new combination of blood lactate with JAAM DIC score may indicate the initiation of blood purification for targeted mediator removal in patients with septic shock.

Hiroto Ushizawa, Eiji Isotani, Toshiki Sera, Yasuhiro Otomo, Tokyo Medical and Dental University Introduction: For patients of severe sepis with DIC, Surviving Sepsis Campaign Guideline 2008 recommends the use of recombinant human activating protein C (rhAPC). However, rhAPC has not licenced as sepsis with DIC yet in Japan. Like rhAPC, it is expected that recombinant human soluble thrombomodulin (rTM) plays a role for not only reversing hyper-coagulative status but also inhibiting inflammatory response through activating protein C. We started a randomized controlled trial of rTM for patients of sepsis with DIC. We introduce the preliminary report. Hypothesis: rTM improves surviving rate in 30 days, physiological scores and the amount of mediators in Day10. Methods: We enrolled and analyzed 32 patients who were admitted for treating sepsis with DIC from October 2008 to July 2011. They were randomized into rTM-treated group or placebo group (13 to 19). Primary outcome was survival rate in 30 days. As composite outcomes, we compared physiological scores; APACHE II score, SOFA score, acute phase DIC score, and SIRS score, indicators of coagulation, and indicators of inflammation among both groups in Day10. Statistical analysis was performed by Fisher’s exact test and Wilcoxon rank-sum test. Results: We found that all scores and indicators improved after administration of rTM in Day10, but there were no significant differences among both groups. Survival rate in 30 days was 61.5% in rTM group, 63.2% in control group (p ⫽ 1.00). Median of each score was as follows; APATCH II score: 22 to 16.5 (p ⫽ 0.61), SOFA score: 6 to 6 (p ⫽ 0.82), acute phase DIC score: 2.5 to 3 (p ⫽ 0.76), SIRS score: 2.5 to 2 (p ⫽ 0.19). Platelet improved at Day5 in rTM group and Day9 in control group significantly. CRP improved at Day 3 to Day6. Adverse hemorrhagic events were not observed in this trial. Conclusions: Further investigation will be needed to ascertain whether rTM is effective for sepsis with DIC. Earlier improvement of platelet and CRP in rTM group may be attributed to effect of anticoagulation and anti-inflammation of rTM. There were no hemorrhagic adverse events in this trial so far. It would appear that rTM is safer drug.


Posters: Sepsis-Antimicrobials 399

400

A MULTIDISCIPLINARY SEPTIC SHOCK RESPONSE PROCESS IMPROVES TIME TO ANTIBIOTIC INITIATION IN PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK IN A TERTIARY-CARE ACADEMIC MEDICAL CENTER

EFFECT OF ANTIBIOTIC DE-ESCALATION ON CLINICAL OUTCOMES IN CRITICALLY ILL SURGICAL PATIENTS WITH BACTEREMIA

Jeremy Flynn, University of Kentucky Chandler Medical Center, Pam Branson, University of Kentucky, Melissa Nestor, University of Kentucky Medical Center, Kevin McConeghy, University of Kentucky, Kevin Hatton, UK Chandler Medical Center

Joshua Guinter, Todd Miano, Hospital of the University of Pennsylvania, Babak Sarani, Trauma Center At Penn, Jimish Mehta, Shawn Binkley, Steven Morgan, Hospital of the University of Pennsylvania, Ebbing Lautenbach, Neil Fishman, University of Pennsylvania School of Medicine, Benjamin Kohl, University of Pennsylvania

Introduction: Septic shock is associated with high morbidity and mortality rates despite established guidelines for the delivery of rapid and appropriate care for these patients. Previous studies have demonstrated improved outcomes in patients receiving early, appropriate antimicrobial therapy. To improve our institutional delivery of these antimicrobial therapies, we recently implemented a multidisciplinary response process for patients with severe sepsis/septic shock. Once activated, personnel and our mobile “septic shock cart”, which contained institutionally-approved empiric antimicrobial agents, were deployed to the bedside. The responding pharmacist was responsible for selection, dosing and preparation of antibiotics while rapid response assisted the patient’s nurse with administration. Hypothesis: The use of a multidisciplinary septic shock response process improves the time to the first dose of empiric antimicrobials in patients with severe sepsis and septic shock. Methods: After IRB approval, the charts of 50 consecutive patients admitted with the diagnosis of severe sepsis or septic shock before September 2010 was used as historical controls. The charts of 33 patients from October 2010 to March 2011 who were resuscitated with the multidisciplinary response process were also reviewed. The data was evaluated to determine the number of patients who received appropriate antimicrobial therapy within 1 hour of recognition or 3 hours of ED admission. Also, data regarding blood cultures drawn prior to initial antibiotic therapy and the average time to the first dose of antimicrobial therapy was collected. Results: Compared to historical controls, the percent of patients receiving timely antimicrobial therapy increased from 43.5% to 97.0% (p ⬍0.001), the percent of patients who had blood cultures drawn prior to antimicrobial administration increased from 87% to 94% (p ⬎0.05), the average time to first dose antibiotics was reduced from 7.5 hours to 0.85 hours. Conclusions: The use of our multidisciplinary septic shock response process, including rapidly deployed personnel and supplies, was associated with a dramatically improved time to the administration of the first dose of empiric antimicrobial agents.

Introduction: Antimicrobial de-escalation is a commonly utilized strategy intended to decrease the emergence of resistant bacteria and lower overall costs. However, there are few data available that support the safety of this strategy in critically ill patients with bacteremia. Hypothesis: De-escalation is not associated with the risk of microbiological failure or relapse in critically ill patients with bacteremia. Methods: IRB approved retrospective cohort study of critically ill surgical patients with bacteremia that underwent de-escalation of antibiotic therapy compared to those without de-escalation. De-escalation was defined as any change in an antimicrobial regimen within 48 hours of microbiological culture results that produced a narrower spectrum of coverage. Variables included demographics, microbiological culture and sensitivity, antimicrobial use data, and severity of illness scores. Primary outcome was the combined incidence of microbiological failure (defined as recurrence of bacteremia with the same organism while on therapy) and relapse (defined as recurrence of bacteremia with the same organism after completion of therapy). Secondary outcomes were hospital length of stay from onset of first positive blood culture and 28-day, all-cause in-patient mortality. The primary endpoint was analyzed using Fisher’s exact test. Results: A total of 310 patients treated for bacteremia between 2005 and 2010 were screened. Application of inclusion/exclusion criteria left 100 patients: 58 in the deescalation group and 42 in the continued group. There was no statistically significant difference between the de-escalation group and the continued group in the incidence of microbiological failure or relapse (5.2% vs. 9.5%, respectively, p ⫽ 0.43). Similar results were found for the secondary outcomes of median hospital length of stay (19 days de-escalation vs. 22.5 days continued, p ⫽ 0.35) as well as 28-day, all-cause, in-patient mortality (12% de-escalation vs. 19% continued, p ⫽ 0.35). Conclusions: There was no observed increase in risk of microbiological failure or relapse associated with de-escalation of antimicrobial regimens in patients with bacteremia.

401 EFFECT OF PREVIOUS EXPOSURE TO FLUOROQUINOLONES ON CROSS RESISTANCE AND GRAM NEGATIVE SEPSIS MORTALITY Karen Berger, New York Presbyterian Hospital, Weill Cornell Medical Center, Michael Johnson, University of Illinois Medical Center at Chicago, Scott Micek, Barnes-Jewish Hosptial Introduction: Previous exposure to antimicrobials has been associated with increased in vitro resistance to broad spectrum antimicrobials, however, outcomes data in critically ill patients is lacking. Hypothesis: Previous fluoroquinolone exposure may cause cross resistance to broad spectrum antimicrobials leading to an increase in multidrug resistant organisms, inappropriate initial antimicrobials, and mortality in patients with severe sepsis and septic shock. Methods: This was a retrospective study of patients hospitalized in the intensive care unit of a large academic medical center from January 2002 to December 2007. Data was collected from electronic medical records to identify adult patients with gram negative bacteremia and severe sepsis or septic shock. Patients who were previously exposed to fluoroquinolones (within ninety days) were compared to patients who were not exposed. Results: A total of 532 patients were included (27 patients who were previously exposed; 505 who were not exposed). The most common pathogens included Escherichia coli (37%), Klebsiella pneumonia (22%), and Pseudomonas aeruginosa (15%). In patients who were previously exposed to fluoroquinolones, 22%, 37%, and 22% of organisms were resistant to cefepime, piperacillin-tazobactam, and carbapenems respectively, compared to 7%, 12%, and 3% in patients who were not exposed, p ⬍0.01. Additionally, blood cultures of 41% of patients who were previously exposed grew a multidrug resistant organism compared to 12% in patients who were not exposed, p ⫽ 0.001. Previous fluoroquinolone exposure also resulted in a higher proportion of inappropriate initial antimicrobials (44 vs 22%, p ⫽ 0.007). There was no difference in hospital mortality between patients who were previously exposed and those who were not exposed (48% vs 34%, p ⫽ 0.140), OR 1.67, p ⫽ 0.096. Conclusions: Previous exposure to fluoroquinolones within ninety days of severe sepsis or septic shock is associated with cross resistance to broad spectrum antimicrobials and an increase in multidrug resistant organisms and inappropriate initial antimicrobials. In this cohort, previous fluoroquinolone exposure was not associated with in an increase in hospital mortality.


Posters: Sepsis-Cardiovascular 402 THE ASSOCIATION OF ABSOLUTE MONOCYTE-COUNT AND OUTCOME OF SEPTIC SHOCK IN CHILDREN Ivanelsie Delgado, Andre Raszynski, Balagangadhar Totapally, Miami Children’s Hospital Introduction: Monocytes play important role in immune modulation during the sepsis. Monocyte dysfunction is known to affect the outcomes in septic patients. This retrospective study evaluates the relationship between absolute monocyte count and outcome of children with septic shock. Hypothesis: A decrease in absolute monocyte count affects the outcome of children with septic shock. Methods: After IRB approval, all charts of children who received vasoactive medications during 2006 and admitted to PICU were reviewed. Children with immunodeficiency, cardiogenic shock, and post-op conditions (eg. spinal surgery) were excluded. Data collected included CBC and absolute counts, serum electrolytes, dose of vasoactive medications, use of supportive measures, outcome, PIM-2 score, and PICU length of stay. Daily lab values were collected for 5 days. Inotropic score was calculated using the formula: dopamine (␮g/kg/min) x 1⫹dobutamine (␮g/kg/min) x 1⫹ milrinone (␮g/kg/min) x15 ⫹ epinephrine (␮g/kg/min) x 100 ⫹ nor-epinephrine (␮g/kg/min) x 100. Data from children who survived were compared with those expired. The binary data were analyzed using Chi-square test and continuous data were analyzed using either t-test or Mann-Whitney-U test. A p value ⬍0.05 will be considered significant. Results: Records of 26 children who were admitted to PICU with septic shock were analyzed. The mortality rate was 15.4%. These 26 children received multiple supportive therapies including, insulin (23%), hydrocortisone (42%), nitric oxide (15%), diuretics (61.5%), blood products (77%), ventilator support (85%), sedatives and analgesics (89%), and paralytics (61.5%). There were no significant differences in their use between two groups. Minimum and maximum absolute monocytes counts (313 vs 399 and 1047 vs 1693, respectively), length of stay (23 vs 5.6 days), PIM-2 score (7% vs 12.6%), and cumulative inotropic score (132 vs 150) in those who survived vs expired were not different between two groups. The change in absolute monocyte count (Max-Min count) was lower in those who survived (733 vs 1293; p⬍0.05, one tail). Conclusions: Monocyte count fluctuation is less among children who survived septic shock compared to those who die with septic shock.


CPR/Resuscitation-1 404

405

SURVIVAL AFTER IN-HOSPITAL CARDIAC ARREST (IHCA): A PERILOUS FIRST YEAR

FORTY-EIGHT HOURS OF THERAPEUTIC HYPOTHERMIA IS MORE EFFECTIVE IN ATTENUATION OF BRAIN APOPTOSIS AND ATP PRESERVATION IN SWINE CARDIAC ARREST MODEL

Paul Feingold, Emory School of Medicine, Barry Hashimoto, Emory University, Jessica Kanter, Michael Mina, Emory School of Medicine, Greg Martin, Grady Memorial Hospital, Sara Gregg, Kathryn McConnell, Emory Healthcare, Kenneth Leeper, Emory University Hospital Midtown, Timothy Buchman, Emory University Hospital Introduction: Length of survival after discharge (DC) for IHCA patients has potential value as a metric for quality of care analysis as well as an end-of-life talking point in discussions with patients and families. We compare the out-of-hospital survival of patients admitted to the ICU after an IHCA with a matched group of controls to estimate the excess mortality attributable to an IHCA. Hypothesis: The null hypothesis is that IHCA has no effect on mortality if the patient survives to hospital DC. Methods: We queried Emory Hospital records for IHCAs from 1/2008 through 12/2010. A 3:1 control cohort was selected among non-IHCA hospitalization survivors using exact matching with race, gender, age (⫹/⫺ 2 years), admission source, level of admission urgency, and admitting specialty. We searched the Social Security Death Index and Emory records to identify IHCA and control patients reported to have expired and determine their length of life after DC. We applied a log-rank test to the data, and we report Kaplan-Meier estimates of post-DC survival along with 95% confidence intervals, in brackets. Results: Of 1,264 patients that underwent IHCA from 2008 to 2010, 595 (47.1%) survived to transfer to the ICU. Of those that survived to reach the ICU, 263 (20.8% of total) survived to hospital DC. Of those 263 survivors, 154 (12.2% of total) were alive one year after DC. Kaplan-Meier analysis of discharged IHCA survivors estimated that 65.7% [59.8, 72.2] were alive at 6 months, 57.6% [51.4, 64.5] at 12 months, and 54.5% [48.2, 61.6] at 18 months after DC. The statically significant (p ⬍.001) absolute excess mortality attributable to having an IHCA was 21.7% [18.3, 24.7] at 6 months, 23.8% [20.5, 26.5] at 12 months, and 21.0% [18.0, 23.5] at 18 months after DC. Conclusions: IHCA significantly decreases out-of-hospital survival compared to control subjects. Probability of death for IHCA survivors increases sharply over the first year after DC and then plateaus. Accordingly, the excess mortality attributable to IHCA peaks between 6 and 12 months after DC. IHCA patients who survive a full year after DC have a death rate similar to patients that did not have an IHCA.

Gil Joon Suh, Woon Yong Kwon, Kyung Su Kim, Hui Jai Lee, Ki Young Jeong, Sang Hoon Na, Seoul National University Hospital Introduction: Our aim was to investigate whether 48 hrs of therapeutic hypothermia is more effective than 24 hrs of therapeutic hypothermia in attenuation of brain apoptosis and adenosine triphosphate (ATP) preservation in swine cardiac arrest model. Hypothesis: We hypothesized that prolonged hypothermia is more effective in attenuation of brain injury after cardiac arrest. Methods: After the induction of ventricular fibrillation and subsequent 6 min of no flow time, we provided cardiopulmonary resuscitation to pigs and acquired return of spontaneous circulation (ROSC). Then the subjects were randomly allocated to the sham, normothermia (NT, core temperature 36.5°C- 37.5°C), 24 hrs of hypothermia (24-HT, 32.0°C - 34.0°C), and 48 hrs of hypothermia (48-HT) groups. We collected data with respect to resuscitation performances, hemodynamic parameters, and laboratory data. After 60-hr post ROSC, we sacrificed animals and harvested and stained their brain tissues with H & E and TUNEL, respectively. We measured ATP levels and cleaved caspase-3 expressions and observed histologic changes in hippocampus CA-1 sector and occipital cortex. Results: There were no group differences with respect to resuscitation performances, hemodynamic parameters, and laboratory data. In hippocampus CA1 and occipital cortex, ATP levels in the 48-HT group were higher (p ⫽ 0.004 and 0.002, respectively) and cleaved caspase-3 expressions in the 48-HT group were lower (p ⫽ 0.002 and 0.002, respectively) than those in the NT group. However ATP levels and cleaved caspase-3 expressions in the 24-HT group were not different from those in the NT groups. Histologic analysis also showed that 48 hrs of therapeutic hypothermia significantly reduced brain apoptosis and neuronal damages. Conclusions: In conclusion, 48 hrs of therapeutic hypothermia was more effective than 24 hrs of therapeutic hypothermia in attenuation of brain apoptosis and ATP preservation during postresuscitation care.

406

407

HEMODYNAMIC GOAL-DIRECTED CPR IMPROVES SHORT TERM SURVIVAL FROM ASPHYXIA ASSOCIATED CARDIAC ARREST

NONINVASIVE HEMOGLOBIN MONITORING IN SERIOUSLY INJURED COMBAT CASUALTIES

Robert Sutton, Stuart Friess, Utpal Bhalala, Matthew Maltese, Maryam Naim, Anan Tawil, Dana Niles, George Bratinov, Vinay Nadkarni, Robert Berg, Children’s Hospital of Philadelphia

Introduction: Resuscitation of seriously injured combat casualties is complex. Intermittent Hgb measurement may not detect acute changes preceding deterioration or provide timely treatment response assessment. Continuous noninvasive Hgb measurement (SpHb) has not been studied in this population. Hypothesis: Compare precision of SpHb versus lab Hgb in seriously injured combat casualties. Methods: Prospective observational study. Data collected during resuscitation at two US military trauma hospitals in Afghanistan. SpHb obtained via pulse oximeter (Masimo Rainbow SET, Probe Rev E/Radical-7 Pulse COOximeter v.7.6.2.1). Clinically indicated Hgb analyzed in lab (Coulter, n ⫽ 32) or via iStat (n ⫽ 17) and compared to simultaneous SpHb values. Vital signs recorded every 15 minutes along with information on therapies (PRBC administration, tourniquet release, fluid bolus or vasoactive medications) that may affect Hgb or vital signs. Results: Twenty-four patients studied (ISS 20 ⫾ 10; age 29 ⫾ 9 years; male 97%; 100% normothermic). Injury cause: improvised explosive device (67%), gunshot (17%). Monitoring time: 256 ⫾ 76 minutes. PRBCs: 3.3 ⫾ 4.5 units/subject, median 2, range 0 –20 units. SpHb-Hgb pairs (n ⫽ 49); median 2/subject. Hgb range 4.4 –15 g/dL, mean lab Hgb 11 ⫾ 2 g/dL, mean SpHb 11.5 ⫾ 1.7 g/dL. SpHb-Coulter Hgb bias 0.3 ⫾ 1.6 g/dL (95% LOA -2.8, 3.4 g/dL). SpHb ⬍⫾ 1 g/dL of Hgb: 37% of pairs. There was moderate agreement (Kappa ⫽ 0.46) in identifying transfusion need based on Hgb ⬍9 g/dL, with a potential decision error in 5 cases (4/5 cases occurred when iStat used). SpHb signal present: 76 ⫾ 28% minutes monitored (95% CI: 65%-89%). SpHb dropout higher when perfusion index ⬍0.53, p ⬍.05. In 14 cases one or more clinical events (SBP ⬍90, MAP ⬍60, PRBC given) occurred and in 6/14 cases SpHb decreased ⬎10% or 1 g/dL before the clinical event. Conclusions: SpHb is not precise enough to serve as sole transfusion trigger in unstable trauma patients, but it is useful in trending and as an early indicator of deterioration. Funding: TriService Nursing Research Program

Introduction: Resuscitation teams frequently have invasive monitoring available to guide cardiopulmonary (CPR) quality; therefore, a one-size fits all “guideline-based” approach may not be optimal. Hypothesis: Hemodynamic goal-directed CPR will improve short term survival in an asphyxial model of cardiac arrest. Methods: With IACUC approval, 14 female 3 month old pigs (30 ⫾ 1kg) were intubated, anesthetized with isoflurane and fentanyl, underwent 7 minutes of asphyxia, followed by induction of ventricular fibrillation (VF). Using a CPR recording defibrillator, manual CPR was performed (rate 100/min, ventilation rate 6/min, 100%FiO2) for 10 minutes before first defibrillation attempt. Arterial blood pressure, coronary perfusion pressure (CPP), and end tidal CO2 were measured continuously. Physiologic variables (arterial/venous blood gases) and cardiac outputs were recorded at baseline and 30s pre-VF. Animals were randomly assigned to 3 CPR strategies: 1) chest compressions (CCs) guided to a target of 33 mm with standard ACLS based epinephrine dosing (St-33); 2) CCs guided to a target of 51 mm with standard ACLS epinephrine dosing (St-51); or 3) goal directed CCs titrated to a target systolic blood pressure of 100 mmHg and epinephrine (or vasopressin rescue) if CPPs were ⬍20 mmHg (GD). Treatment groups were compared using repeated measures nested ANOVAs/Fisher’s exact tests. The primary outcome variable was return of spontaneous circulation for 45 minutes. Results: There were no differences between groups for physiologic variables/cardiac outputs at baseline and 30s pre-VF. Average delivered CC depths were: 30 mm (St-33); 47 mm (St-51); and 38 mm (GD); significantly different across groups (p⬍0.01). Other CPR quality variables were similar. More animals received ⱖ3 doses of vasopressor before the first defibrillation in the GD group (5/5) compared to St-33 (0/5) or St-55 (0/4); p⬍0.01. Survival was significantly higher in the GD group (5/5) compared to St-33 (0/5) or St-55 (1/4) groups; p ⫽ 0.04. Conclusions: Hemodynamic and physiologic goal-directed CPR, compared to a one-size fits all “guideline-based” approach, improves short term survival in an asphyxial model of porcine cardiac arrest.


Elizabeth Bridges, Univ. Washington/USAFR

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409

COMPARISONS OF THREE MECHANICAL CHEST COMPRESSORS IN A PORCINE MODEL OF CPR

WIN 55,212–2 PHARMACOLOGICALLY INDUCED THERAPEUTIC MILD HYPOTHERMIA IN A PORCINE MODEL OF CPR

Yinlun Weng, Wei Chen, Xiaobo Wu, Sen Ye, Jiefeng Xu, Lingyan Lei, Shijie Sun, Joe Bisera, Max Weil, Wanchun Tang, Weil Institute of Critical Care Medicine Introduction: To compare the effects of a miniature chest compressor (Weil Mini) on first shock success, duration of CPR and doses of epinephrine prior to restoration of spontaneous circulation (ROSC), together with the incidence of recurrent ventricular fibrillation (VF) with both Thumper and Lucas devices. Hypothesis: We hypothesize that the miniature chest compressor (Weil Mini) would produce an equal efficacy for the ROSC as the Lucas device. Methods: Ventricular fibrillation (VF) was electrically induced and untreated for 7 mins in 30 male swine weighing 35⫾2kg. CPR was randomized to utilize either the Weil Mini, Lucas or the Thumper devices. Defibrillation was attempted after 5 mins of CPR. If ROSC was not achieved, CPR was continued for 2 min prior to another defibrillation attempt until ROSC or for a total of 15 mins. The first dose of epinephrine (20 mg/kg) was injected intravenously after 2.5 min of compression, the following doses were administered every 3 min after the first dose. Results: The Weil Mini and Lucas devices achieved a relatively higher rate of ROSC after first shock when compared to the Thumper (8/10 and 7/10 vs. 4/10). Significantly shorter durations of CPR and lesser doses of epinephrine were required in both the Weil Mini and Lucas groups when compared to the Thumper group (5.40⫾0.84 mins and 5.60⫾0.97 mins vs. 9.90⫾4.97 mins, p⬍0.05; 1.10⫾0.32 and 1.20⫾0.42 vs. 2.20⫾1.48, p⬍0.01). Significantly lower incidence of recurrent VF was observed in both the Weil Mini and Lucas groups than the Thumper group (0.50⫾0.97 and 1.60⫾3.50 vs. 8.10⫾7.84, p⬍0.01). The coronary perfusion pressures at the minute before the first shock in the Weil Mini group were significantly higher than in the Lucas and Thumper groups (34.26⫾8.10 mmHg vs. 26.88⫾4.34 mmHg and 19.02⫾2.26 mmHg, p⬍0.01and p⬍0.05, respectively). Conclusions: In this swine model of CPR, the Weil Mini device produced a similar effective chest compression as the Lucas device; both devices are significantly more effective in terms of ROSC than the Thumper compressor.

Yinlun Weng, Wei Chen, Xiaobo Wu, Shijie Sun, Max Weil, Wanchun Tang, Weil Institute of Critical Care Medicine Introduction: We have previously demonstrated that the non-selective cannabinoid receptor agonist, WIN 55,212–2, induced therapeutic hypothermia and improved outcomes of CPR in a rat model. In this study, we investigated the hypothermia-inducing effect of WIN 55,212–2 in a porcine model of CPR. Hypothesis: We hypothesized that WIN 55,212–2 could induce mild hypothermia and therefore benefit the neurological function in a porcine model of CPR. Methods: Ventricular fibrillation (VF) was electrically induced and untreated for 10 mins in male swine weighing 35⫾2 kg. Defibrillation was attempted after 5 mins of CPR. If ROSC was not achieved, CPR was continued for 2 mins prior to another defibrillation attempt until ROSC or for a total of 15 mins. The first dose of epinephrine (20 mg/kg) was injected intravenously after 2.5 mins of compression, the following doses were administered every 3 mins after the first dose. The resuscitated animals were randomized to receive either intravenous infusion of WIN 55, 212–2 (1.0 mg/kg/h) or the same amount of vehicle at 5 mins post resuscitation. WIN 55, 212–2 was continuously appied until the temperature reached 34.0 celsius degree. The temperature was continuously monitored, and the neurological function was measured by neurological alertness score (NAS) at 24 hrs interval until 72 hrs after resuscitation. Results: The blood temperature was significantly decreased from 37.6⫾0.3 celsius degree to 34.0 celsius degree within 3.5 hrs, and reached the lowest temperature of 32.2⫾0.7 celsius degree at 7.5 hrs post resuscitation in animals treated with WIN 55, 212–2. At least 12 hrs was needed for the temperature to return spontaneously to the baseline value, while the temperature in the control group was maintained at 38.4⫾0.4 celsius degree. Accordingly, NAS in the WIN 55, 212–2 group was significantly improved when compared to the control group at 24, 48 and 72 hrs post resuscitation (24 hrs: 95.0⫾0 vs 45.7⫾39.7, p ⫽ 0.037; 48 hrs: 100.0⫾0 vs 56.7⫾49.1, p ⫽ 0.034; 72 hrs: 100.0⫾0 vs 60.0⫾52.2, p ⫽ 0.037). Conclusions: WIN 55, 212–2 induced hypothermia and therefore significantly improved the neurological function in a porcine model of CPR.

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MARKED DIFFERENCES IN REGIONAL CEREBRAL BLOOD FLOW AFTER ASPHYXIAL CARDIAC ARREST IN ADULT VS. JUVENILE RATS

MINIATURIZED CHEST COMPRESSOR IMPROVES HEMODYNAMIC EFFICACY DURING CPR IN A PORCINE CARDIAC ARREST MODEL

Tomas Drabek, Safar Center For Resuscitation Research, Mioara Manole, Children’s Hospital of Pittsburgh, Lesley Foley, Carnegie Mellon University, Jason Stezoski, Henry Alexander, University of Pittsburgh, T. Kevin Hitchens, Carnegie Mellon University, Samuel Tisherman, University of Pittsburgh Medical Center, Robert Clark, Children’s Hospital of Pittsburgh, Chien Ho, Carnegie Mellon University, Patrick Kochanek, University of Pittsburgh Medical Center

Wei Chen, Weil Institute of Crit. Care Med., Yinlun Weng, Weil Institute of Critical Care Medicine, Xiaobo Wu, Weil Institue of Critical Care Medicine, Shijie Sun, Max Weil, Wanchun Tang, Weil Institute of Critical Care Medicine

Introduction: Asphyxial cardiac arrest (ACA) is the major cause of CA in children and important in adults. We previously reported cortical hypoperfusion and transient subcortical hyperemia after ACA in juvenile rats. Limited cerebral blood flow (CBF) data are available in adult ACA models. Hypothesis: Unique regional CBF patterns will be seen in adult vs. pediatric ACA. Methods: To compare global and regional CBF after ACA in juvenile (post-natal day 17) vs. adult rats, fentanyl-anesthetized rats were subjected to 8 min ACA (n ⫽ 8 per group). CBF was assessed via arterial spin-labeling magnetic resonance imaging at baseline (BL) and at 5, 10, 15, 30 and 60 min resuscitation time (RT). Results: There were no differences in global or regional CBF between groups at BL ( ⫽ 100%). There was a transient global hyperperfusion at RT5 in both groups (135% BL in juvenile, 153% BL in adult), followed by a return to BL and mild hypoperfusion (⬃80% BL) in juvenile rats. Hyperperfusion was prolonged in adults, peaking at RT10 (166% BL, p⬍0.001 vs. BL), then also gradually returning to ⬃ 80% BL. Regionally, in cortex there was no hyperperfusion in juvenile rats. After RT10, there was a sustained decrease in CBF to ⬃80% BL. In contrast, adult rats showed a cortical hyperperfusion at RT5–15 (up to 180% BL, p⬍0.001 vs. BL or juvenile at RT10) and hypoperfusion (⬃80% BL) at RT30–60. In thalamus, early hyperperfusion (RT5–10, up to 175% BL) was followed by mild hypoperfusion (⬃80% BL) in both groups. In hippocampus, hyperperfusion peaked at RT5 in juvenile rats (166% BL). In adults, this increase was delayed (160% BL at RT10). Amygdala showed hypoperfusion at RT10–60 only in juvenile rats (⬃50% BL, p⬍0.01 vs. BL or adults). Conclusions: 8 min ACA in juvenile vs. adult rats produced significant regional and temporal differences in CBF. In juvenile rats, hypoperfusion in cortex and amygdala was seen. Surprisingly, adult rats revealed more prolonged early global hyperperfusion with only modest delayed hypoperfusion. While the underlying mechanisms for this phenomenon are yet to be determined, our unique data suggest that hypoperfusion may be an important therapeutic target in developing animals.Support: AHA #09BGIA2310196, Laerdal Foundation, SCA

Introduction: During cardiopulmonary resuscitation (CPR), blood flow generated by chest compression is the most important factor for resuscitation. In this study, we investigated the effects of miniaturized chest compressor (MCC) on hemodynamic efficacy in a porcine model of cardiac arrest. Hypothesis: We hypothesized that the MCC would yield better hemodynamic efficacy with less injury during CPR when compared with currently available mechanical chest compressors. Methods: Ventricular fibrillation (VF) was induced in 30 male domestic pigs weighing 35⫾2 kg. CPR was initiated after 7 min of untreated VF. Animals were randomized to receive mechanical chest compression with either the MCC, LUCAS or Thumper devices with fixed compression rate of 100/min. The initial compression depth of both MCC and Thumper groups was adjusted to achieve a coronary perfusion pressure (CPP) over 10 mmHg. After 5 min of CPR, a 150J defibrillation (DF) was delivered. If resuscitation was not successful, CPR was continued for 2 min before the next DF. The protocol was continued until successful resuscitation or for a total of 15 min. Results: All animals were resuscitated except for 3 from the Thumper group. CPP and end tidal CO2 (ETCO2) during CPR were significantly better in the MCC group vs. the other 2 groups (CPP, 31.1⫾14.7 vs 25.3⫾10.5 and 16.4⫾5.9 mmHg, p⬍0.05; ETCO2 , 36.2⫾8.0 vs 32.1⫾8.6 and 19.0⫾6.9 mmHg, p⬍0.05). Significantly better intrathoracic positive pressure was observed in both the MCC and LUCAS groups compared with the Thumper group (26.9⫾7.2 and 30.5⫾13.2 vs 13.9⫾6.6 mmHg, p⬍0.01). The negative intrathoracic pressure was significantly better in the MCC group (-6.5⫾3.1 vs -0.8⫾3.3 and -1.5⫾1.5 mmHg, p⬍0.01). Lesser numbers of DF for achieving successful resuscitation were observed in the MCC and LUCAS groups compared with the Thumper group (1.2⫾0.42 and 1.3⫾0.48 vs 3.1⫾2.23, p⬍0.05). Significantly less compression depth was observed in the MCC group (32.9⫾4.8 vs 50.0⫾0 and 56.1⫾6.4 mm, p⬍0.01) vs. the other 2 groups. This was associated with fewer rib fractures (0 vs 0.43⫾0.45 and 1.78⫾1.72, p⬍0.05). Conclusions: The MCC substantially improved hemodynamic efficacy and the success of CPR with significantly less injury.


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OPTIMAL VALUES OF ARTERIAL PRESSURE AND TIME WINDOW RELATED TO FAVORABLE NEUROLOGICAL OUTCOME IN POST-CARDIAC ARREST PATIENTS TREATED WITH HYPOTHERMIA

THE EFFECTS OF EPINEPHRINE ADMINISTRATION BEFORE ARRIVAL AT THE HOSPITAL IN OUT-OF-HOSPITAL CARDIAC ARREST PATIENTS: A PROPENSITY ANALYSIS

Kunihiko Maekawa, Wakiko Aisaka, Kohei Kato, Keigo Sawamoto, Katsutoshi Tanno, Mamoru Hase, Kazuhisa Mori, Yasufumi Asai, Sapporo Medical University Introduction: Universal guidelines advocate hemodynamic optimization in the treatment of post-cardiac arrest syndrome. However, there is no adequate information on optimal values of arterial pressure and therapeutic time window affected by its’ optimization. Hypothesis: Early hemodynamic optimization is associated with favorable neurological outcome in post-cardiac arrest patients treated with hypothermia. Methods: We performed a single-center retrospective cohort study over 9 years. Inclusion criteria were witnessed out-of-hospital cardiac arrest of cardiac origin, successful return of spontaneous circulation (ROSC) and induction of therapeutic hypothermia (34 deg C). Data were abstracted including demographics, co-morbidity, downtime, pre/in-hospital care and continuously monitored mean arterial pressure (MAP) in 24 hours of hospitalization. Outcome measure was neurological status at hospital discharge (cerebral-performance category [CPC]). Receiver-operator characteristic (ROC) curve analysis was used to determine optimal values of MAP and time window. Logistic regression model was used to evaluate the association of hemodynamic optimization with favorable outcome (CPC1–2). Results: Of 48 eligible patients, 31 (64.6%) had favorable outcome. Compared to patients with poor outcome, patients with favorable outcome were significantly younger (55 [46 – 63] vs. 67 [60 – 75] yr), had shorter low-flow time (12 [8 –19] vs. 22 [18 –28] min), less often underwent PCI (25.8% vs. 58.8%) and higher values of mean MAP from ROSC to 3 hours (94 [86 –103] vs. 80 [76 –94] mmHg), 6 hours (94 [89 –107] vs. 75 [72– 89] mmHg), 12 hours (93 [84 –101] vs. 79 [71–91] mmHg), 24 hours (87 [81–92] vs. 79 [74 – 85] mmHg). ROC analysis showed that optimal values of MAP and time window were 90 mmHg from ROSC to 6 hours, with a highest area under the curve of 0.78. Multivariate logistic regression analysis showed that this optimization was significantly associated with favorable outcome (adjusted odds ratio; 5.8, 95%CI; 1.1–32.2). Conclusions: Hemodynamic optimization during first 6 hours was associated with favorable neurological outcome in post-cardiac arrest patients treated with hypothermia. Further studies are warranted to establish the therapeutic effects.


Mineji Hayakawa, Asumi Higashiyama, Satoshi Gando, Hokkaido University Hospital, Hirotoshi Mizuno, Yasufumi Asai, Sapporo Medical University Hospital, Isao Takahashi, Teine Keijinkai Hospital, Yasuo Shichinohe, National hospital organization Hokkaido Medical Center, Hiroshi Makise, Sapporo City General Hospital Introduction: Epinephrine administration has been advocated for CPR for decades. Despite the fact that epinephrine administration during CPR is internationally accepted, no study has indicated that epinephrine improved the neurological outcome in patients with cardiac arrest. Hypothesis: Epinephrine administration increased the frequency of return of spontaneous circulation (ROSC) and a favorable neurological state in patients with out-of-hospital cardiac arrest. Methods: The present study retrospectively analyzed the Utstein template records from April 1, 2007, to December 31, 2009. The patients who had outof-hospital cardiac arrest with bystander witnesses were included in the study. Patients who had cardiac arrest caused by non-cardiac disease, and had already restored spontaneous circulation before arrival of emergency medical technicians were excluded from the study. The study primary endpoint was a favorable neurological outcome 30 days after cardiac arrest. A favorable neurological outcome was defined as a cerebral performance category score of 1 or 2. Results: The epinephrine group included 318 patients who received epinephrine outside of the hospital. The no drug group included 315 patients who did not receive any drugs outside of the hospital. For ROSC, the odds ratio for epinephrine administration adjusted by the propensity score was 1.920 (95% CI1.249 - 2.952). After propensity score matching, the two matched groups both included 142 patients. The frequency of ROSC in the matched epinephrine group was higher than that in the matched no drug group (12% vs. 27%, P ⫽ 0.004). With regard to the frequency of a favorable neurological state in the patients, the adjusted odds ratio of the time span from cardiac arrest to the first epinephrine administration were able to administer epinephrine was 0.917 (95% CI: 0.850 - 0.988) per minute. Conclusions: Epinephrine administration increased the frequency of ROSC in patients with out-of-hospital cardiac arrest. Furthermore, the early administration of epinephrine improved the neurological outcome. Although the late administration of epinephrine increases the frequency of ROSC, it needs to be administered earlier to improve the neurological outcome.

Posters: CPR/Resuscitation-2 414

415

CENTHAQUIN DECREASES THE REQUIREMENT OF NOREPINEPHRINE, MAINTAINS BLOOD PRESSURE AND IMPROVES SURVIVAL FOLLOWING RESUSCITATION OF HEMORRHAGED RATS

MINIATURIZED CHEST COMPRESSOR IMPROVES NEUROLOGICAL AND CARDIAC FUNCTION RECOVERY IN A PORCINE CARDIAC ARREST MODEL

Anil Gulati, Zhong Zhang, Khalid Arshad, Midwestern University Introduction: We have reported that centhaquin reduces blood lactate, and improves cardiac output and survival of hemorrhaged rats. Hypothesis: In the present study, we determined the effect of centhaquin resuscitation on the amount of norepinephrine (NE) required to maintain mean arterial pressure (MAP), and time by which MAP falls back to 35 mmHg in hemorrhaged rats. Methods: Male, adult rats were anesthetized with urethane and a pressure catheter SPR-320 was placed in the femoral artery, and a pressure-volume catheter SPR-869 was placed in the left ventricle. Hemorrhage was induced by withdrawing blood and MAP was maintained at 35 mmHg for 30 minutes followed by resuscitation. Two sets of experiments were performed; first, we determined the amount of NE required to maintain MAP at 70 mmHg in normal saline (NS) or centhaquin (0.05 mg/kg) treated rats (volume equal to blood loss); and second, we determined the time by which MAP fell back to 35 mmHg in rats treated with 3% hypertonic saline (HS) or centhaquin (0.05 mg/kg) (volume one-fifth of blood loss). Results: Blood hematocrit decreased following hemorrhage and was similar in all the groups. Blood lactate was 4.10⫾1.02 mmol/L in NS compared to 1.65⫾0.23 mmol/L in centhaquin treated rats (P ⫽ 0.041), 60 min following resuscitation. The amount of NE needed in each rat to maintain MAP at 70 mmHg was 175 ␮g in NS and 17.5 ␮g in centhaquin group during the first 60 min of resuscitation. In second set of experiments, hemorrhaged rats were resuscitated with either HS or centhaquin (one-fifth the volume of blood loss). In centhaquin treated rats blood lactate was 44% lower compared to HS; and the time by which MAP fell back to 35 mmHg was 38⫾7 min in HS compared to 148⫾15 min in centhaquin treated rats (P ⫽ 0.0006). This was followed by blood transfusion (one-fifth the volume of blood loss) and rats survived for 53⫾7 min in HS compared to 78⫾8 min in centhaquin group (P ⫽ 0.046). Conclusions: Centhaquin is a highly effective resuscitative agent, which decreased the requirement of NE in hemorrhaged rats, possibly due to improved vascular responsiveness. Centhaquin, in small volume, maintained MAP of hemorrhaged rats for a considerable long time and improved the survival time.

Wei Chen, Weil Institute of Crit. Care Med., Yinlun Weng, Weil Institute of Critical Care Medicine, Xiaobo Wu, Weil Institue of Critical Care Medicine, Shijie Sun, Max Weil, Wanchun Tang, Weil Institute of Critical Care Medicine Introduction: During cardiopulmonary resuscitation (CPR), vital organ blood flow produced by chest compression reduces ischemic injury and contributes to better outcomes after successful resuscitation. In the present study, we investigated the effects of the miniaturized chest compressor (MCC) on the carotid blood flow (CBF) during CPR, neurological alertness score (NAS) and cardiac ejection fraction (EF) following successful resuscitation in a porcine model of cardiac arrest. Hypothesis: We hypothesized that the MCC would yield the same or better CBF during CPR, and the same or better NAS and EF following resuscitation when compared with the LUCAS and Thumper. Methods: Ventricular fibrillation (VF) was induced in 30 male domestic pigs weighing 35⫾2 kg. CPR was initiated after 7 minutes of untreated VF. Animals were randomized to receive chest compression with either the MCC, LUCAS or Thumper with a fixed compression rate of 100/min. The initial compression depth was adjusted to achieve a coronary perfusion pressure of above 10 mm Hg. After 5 minutes of CPR, a single 150J defibrillation (DF) was delivered. If resuscitation was not successful, CPR was continued for 2 minutes before the next DF. The protocol was continued until successful resuscitation or for a total of 15 minutes. After resuscitation the animals were observed for 72 hours, and the NAS was measured daily. Results: Significantly better CBF was observed in the MCC and LUCAS groups when compared with the Thumper group (42.1⫾11.9 ml/min, 38.6⫾17.8 vs 32.5⫾17.4 ml/min, p⬍0.05). This was associated with better NAS in both the MCC and LUCAS groups compared with the Thumper group at 24 hours (94.5⫾6.7, 93.7⫾ 5.3 vs 73.9⫾25.3, p⬍0.05) and 48 hours (100.0⫾0, 99.4⫾1.7 vs 83.6⫾24.8, p⬍0.05) after CPR. EF at 2 hours following successful resuscitation was significantly better in both the MCC and LUCAS groups compared to the Thumper group (56.3⫾ 6.6%, 57.8⫾ 8.3 % vs 49.4⫾5.4 %, p⬍0.05). Conclusions: Both the MCC and LUCAS devices generated better CBF and this was associated with better post resuscitation neurological and cardiac function when compared to the Thumper device.

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MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS) IN CRITICALLY ILL CHILDREN: VALUE OF TWO SETS OF DIAGNOSTIC CRITERIA

PREDICTORS OF POOR OUTCOME IN HYPOTHERMIC CARDIAC ARREST TREATED WITH EXTRACORPOREALCPR

Andreanne Villeneuve, Jacques Lacroix, University of Montreal, Francois Proulx, CHU Sainte-Justine, Thierry Ducruet, CHU Sainte-Justine Research Center, Nicole Poitras, CHU Ste-Justine

Keigo Sawamoto, Kunihiko Maekawa, Sapporo Medical University, Eiji Sakawaki, Hakodate Municipal Hospital, Naofumi Bunya, Sapporo Medical University, Yoshihiro Takeyama, Hakodate Municipal Hospital, Katsutoshi Tanno, Kazuhisa Mori, Yasufumi Asai, Sapporo Medical University

Introduction: MODS is a descriptor of illness severity and a predictor of mortality and morbidity in pediatric intensive care unit (PICU) patients. Many definitions of MODS are available in the literature. The purpose of this study is to compare the diagnostic value of two sets of criteria of MODS – Proulx et al. (Chest 1996; 109:1033–7) and Goldstein et al. (Pediatr Crit Care Med 2005; 6:2– 8) – and describe their concordance and predictive value. Hypothesis: Our hypothesis was that the diagnostic value of these two sets of criteria would not be similar. Methods: The occurrence of organ failure and 90-day all-caused mortality was followed daily and prospectively in 843 consecutive patients admitted in the PICU of CHU Ste-Justine from April 2009 to April 2010. Concordance ratio and kappa score were calculated. Sensitivity, specificity, predictive value of a positive and negative result of both sets of criteria to predict 90-day mortality (the reference standard) were estimated and compared. Results: According to 1996 and 2005 set of diagnostic criteria, 131 (15.5%) and 259 patients (30.7%) had MODS at entry in PICU, respectively. The concordance ratio is 81.3% (IC95% ⫽ 78.6%; 83.9%), and the kappa score is 0.56 (IC95% ⫽ 0.50 – 0.61). The proportion of patients who presented a MODS during their PICU stay was 22.3% with Proulx et al. and 38.6% with Goldstein et al. The sensitivity, specificity and predictive value of a positive and a negative result of 90-day mortality, are 62%, 87%, 20% and 98% with 1996 definition, compared to 69%, 71%, 11% and 98% with 2005 definition. Conclusions: The concordance of both sets of diagnostic criteria of pediatric MODS is high, but is not perfect. As an indicator of mortality, the 1996 set of criteria is more specific, and the 2005 set of criteria tends to be more sensitive. Those two definitions do not discriminate the same patients and are not interchangeable.

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) patients of severe accidental hypothermia (AH) origin has been reported with good results. However there are some patients with poor outcome even if ECPR initiated. Hypothesis: We can identify the patients with poor outcome before ECPR initiation to reduce the risks and expenses associated with ECPR. Methods: We conducted a two-center retrospective cohort study over 15 years (1996 –2010). All CA patients treated with ECPR were eligible for inclusion if they suffered from severe hypothermia caused by drowning or exposure to cold air. Severe hypothermia was defined as ⬍ ⫽ 28 degrees Celsius. Data were abstracted from their charts including demographics, cardiac rhythm on ED arrival, cause of AH, core temperature and the values of the blood gas analysis. Neurological outcome was measured by functional status (cerebral-performance category [CPC]) at hospital discharge. We used logistic regression analysis to develop a prediction score and receiving operating characteristic (ROC) curve analysis to evaluate a predictive power and a cut-off value. Results: Of 33 patients receiving ECPR 24 were eligible, and 11 (45.8%) had good outcome (CPC 1–2) and 13 (54.2%) had poor outcome (CPC 3–5). Compared to patients with CPC 1–2, patients with CPC 3–5 had significantly larger proportion of age ⫽ ⬍57 yrs (76.9% vs. 27.3%, odds ratio [OR] 8.9, awarded 1 point), cardiac rhythm on ED arrival; asystole (84.6% vs. 36.4%, OR 9.6, 1 point), cause of AH; drowning (92.3% vs. 18.1%, OR 54.0, 3 point), serum lactate level on ED arrival ⬎⫽ 12.5 mmol/L (84.6% vs. 9.1%, OR 55.0, 3 point). ROC analysis showed an area under the curve was 0.93 and identified a prediction score ⬎⫽ 5 as an optimal cut-off point, with a sensitivity of 92%, specificity of 91% and negative predictive value of 91% for predicting poor outcome. Conclusions: Our findings suggested that our prediction score can be used to identify the hypothermic CA patients with poor neurological outcome.


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PREDICTION OF NEUROLOGICAL OUTCOMES FOLLOWING CARDIAC ARREST BY COMPLEXITY ANALYSIS OF HEART RATE VARIABILITY

EPINEPHRINE INCREASES CORONARY PERFUSION PRESSURE BUT DECREASES CAROTID BLOOD FLOW IN A PORCINE CARDIAC ARREST MODEL

Hiroshi Endoh, Yusuke Hayashi, Hiroyuki Honda, Tadayuki Honda, Hidenori Kinosita, Satomi Oohashi, Advanced Emergency and Critical Care Center Niigata University

Jiefeng Xu, Weil Institute of Cri. Care Med., Shijie Sun, Katherine Tang, Max Weil, Wanchun Tang, Weil Institute of Critical Care Medicine

Introduction: Accurate and early prediction of the neurological outcomes of comatose patients following cardiac arrest (CA) is essential in clinical settings. Neurophysiological tests, neuroimaging, and biochemical markers have been reported to be reliable predictors. Hypothesis: In general, pathologic systems should degrade complexity (Goldberger, 2001). Thus, complexity analysis of heart rate variability within the first 24hours after return of spontaneous circulation (ROSC) can predict outcomes of comatose patients following CA. Methods: Between July 2010 and July 2011, adult patients with out-of-hospital CA, who were successfully resuscitated and admitted to our ICU, were enrolled. A 24-hour record of ECG was automatically stored and RR interval (RRI) during 0 - 6 am within the first 24 hours after ROSC was captured by using Wave Viewer (Phillips, Japan). Patients with af or AV block were excluded. Complexity analyses were performed by computing approximate entropy (ApEn) (Pincus, 1991), detrended fluctuation analysis (DFA) (Peng, 1995), and multiscale entropy (MSE) (Costa, 2005) over the 6-hour RRI data using a software program (downloaded from PhysioNet). MSE was the summation of quantitative values of scale (1–39). Glasgow outcome scale (GOS) was evaluated at 30 days after ROSC. Neurological outcome was dichotomized into poor (GOS of 1–2) or good outcome (GOS of 4 –5). Results: A total of 26 patients (mean age 67 y) were studied. The mean Glasgow coma scale value at ICU admission was 3.2, (comparable between good and poor outcomes). Mild hypothermia was performed on 12/26 patients,(comparable between good and poor outcomes). GOS of 1, 2, 3, 4, and 5 was evaluated in 15, 3, 0, 3, and 5 of 26 patients, respectively. ApEn, DFA, or MSE for poor outcome (n ⫽ 18) vs. good outcome (n ⫽ 8) was 0.899⫾0.696 (mean ⫾ SD) vs. 0.920⫾0.674 (P ⫽ 0.94), 0.628⫾0.12 vs. 0.891 ⫾ 0.17 (P ⫽ 0.03), or 18.3⫾14.5 vs. 23.9⫾15.9 (P ⫽ 0.37), respectively. AUC for ApEn, DFA, and MSE was 0.46 (P ⫽ 0.91), 0.88 (P ⫽ 0.003), and 0.61 (P ⫽ 0.37), respectively. Conclusions: Increasing value of DFA but not ApEn and MSE for RRI data based on a 6- hours- ECG recording within the first 24 hours after ROSC is associated with good neurological outcomes.

Introduction: Early study demonstrated that the cerebral microcirculation is significantly reduced after administration of epinephrine during CPR. However, whether the reduction of cerebral microcirculatory flow is the result of reduced cerebral macro flow remains to be confirmed. In this study, we investigated the effects of epinephrine on carotid blood flow (CBF) and coronary perfusion pressure (CPP) in a porcine model of cardiac arrest. Hypothesis: We hypothesized that after administration of epinephrine, CBF will be reduced regardless of increases in CPP. Methods: Ventricular fibrillation (VF) was induced in 30 male domestic pigs weighing between 34 and 36 kg. CPR was initiated after 7 min of untreated VF and continued for 5 min prior to defibrillation. Epinephrine (20 ␮g/kg) was injected intravenously at 2.5 min of CPR. CPP was calculated as the difference between aortic diastolic pressure and right atrial diastolic pressure. CBF was continuously measured with the aid of a transonic flow probe positioned around the right common carotid artery. Results: During CPR, CPP was significantly increased from 17.0⫾4.8 to 36.1⫾14.7 (p⬍0.001) 1 min after administration of epinephrine. However, CBF was significantly reduced from 50.2⫾16.5 to 28.2⫾12.0 (p⬍0.001) at the same time. Conclusions: During CPR, administration of epinephrine decreased CBF. This may explain the reduction of cerebral microcirculatory flow after administration of epinephrine.

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ADDRESSING BARRIERS TO ACTIVATING A RAPID RESPONSE TEAM

MANAGEMENT BASED ON INTERMITTENT THERMO-DILUTION MAY ERR:A COMPARISON OF 2014 CARDIAC INDEX MEASUREMENTS USING 2 METHODS IN 72 PATIENTS HAVING OPEN HEART SURGERY

Jennifer Elmer, Julie Schmidt, Joanna Enerson, Dorothy Gusa, Mayo Clinic Introduction: Rapid Response Teams (RRT) have been developed to provide early recognition and evaluation, stabilization, and transfer of deteriorating patients. The success of RRT lies in the detection system and activators (afferent arm), and is dependent upon knowledge and empowerment of frontline providers. The literature of the potential barriers to activation has not shown clear trends. Hypothesis: To identify and address barriers nurses face when activating RRT, using a baseline learning needs assessment (LNA), educational intervention and post assessment. Methods: The LNA was distributed to 2412 nurses before (2010) and after (2011) intervention. The LNA queried nurses’ knowledge, thoughts, and attitudes surrounding activation of RRT. Participants were assigned an on-line education module comprised of interactive teaching slides and video from institutional leaders, nursing peers and real patient family members, that addressed knowledge gaps and cultural barriers identified. An identical post assessment survey was conducted and analysis was performed with SAS software. Results: In 2010, 46% of 2412 eligible participants completed the survey compared to 50% of 2389 in 2011. In 2010, 90% knew the RRT calling criteria vs. 97% in 2011 (p⬍0.001). In 2010, 81% indicated RRT can be activated for a DNR/DNI patient, which increased to 98% in 2011 (p⬍0.001). 45% of participants correctly identified an RRT scenario in 2010 vs. 57% in 2011 (p⬍0.001). In 2010, 68% of participants have or would use an empowerment statement vs. 86% in 2011 (p⬍0.001). The results for changes in perceptions of cultural barriers to activating a RRT were mixed. Conclusions: The LNA identified key areas of knowledge deficits and cultural gaps. A mandatory web-based education module was associated with statistically significant improvements in all knowledge-based assessments about activation of RRT. Significant differences were identified in some cultural perceptions post intervention, while some of the cultural barriers identified remained unchanged, likely representing the true culture. Overall, a comprehensive educational intervention based on a LNA can be an effective means of identifying and addressing barriers to activating a RRT.


Stephen Woodford, Macquarie University Introduction: The reliability of thermodilution CO is based on replication of values repeated using a stndardised technique over a 3–5 minute measurement period.The accuracy of this data is generally considered robust. Hypothesis: The study hypothesized that bolus TDCO results in similar patient management to results based on Flotrac pulse contour analysis. Methods: 2014 cardiac output estimates were collected in 72 patients undergoing open heart surgery over 30 months (19F, 53 M; 17 AVR/AVR ⫽ CAG, 55 CAG). Values were collected in the OR and ICU, with simultaneous values from Flotrac (Edwards,Cal.). To assess implications for management, values were subdivided for both methods into 3 groups (1) CI ⬍2.2, representing a clear low CO state, (2) CI 2.2–2.5, representing a borderline low CO state, (3) CI ⬎ 2.5, representing normal or high flow. In every case, management was based only on Flotrac absolute and trended data. Results: Subdivision of data for TDCO was (1) CI ⬍2.2:356/2014 (18%) (2) CI .2–2.5 359/2014 (18%) and (3) CI ⬎2.5 1299/2014 (64%), and corresponding values for Flotrac were (1) CI ⬍2.2 119/2014 (6%), (2) CI 2.2–2.5 384/2014 (19%) and (3) CI⬎2.5 1511/2014 (75%). In 356 TDCI values less than 2.2, 223/356 (63%) had a Flotrac CI ⬎2.5. On 119/2014 occasions, Flotrac indicated a low CO state, but TDCI agreed in only 42/119 (35%).In 1299/2014 cases, TDCI indicated a normal or high CO state, but 48/1299 had a low CO state on Flotrac. There was subgroup agreement for the two methods in 58% of cases (1168/2014). Data was not analysed for differences related to gender, operation type or pre or post-surgery. Agreement between methods varied from near perfect agreement to gross disparity. Conclusions: If Flotrac is accurate, there were 119/2014 (6%) of occasions requiring active management of a low cardiac output state, but in 77/119 (65%), TDCI suggested a normal CO state or borderline low CO. On 1511/2014 occasions Flotrac indicated a normal or high CO state, but 223/1511 (14.7%) had a low CO state using the PAC. Failure to treat a low CO state requiring treatment or treating a low CO state where none exists may worsen outcomes.The 2 methods led to different treatment in a significant number of patients.

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CORRELATION OF CAROTID BLOOD FLOW AND THE RATE OF RESUSCITATION AFTER THE FIRST DEFIBRILLATION DURING CPR IN A PIG MODEL

CARDIOMYOCYTE CONTRACILITY IMPROVES IN NORMOTHERMIC REPERFUSION BENEFITS FROM ISCHEMIC COOLING

Xiaobo Wu, Weil Institue of Critical Care Medicine, Wei Chen, Weil Institute of Crit. Care Med., Yinlun Weng, Joe Bisera, Weil Institute of Critical Care Medicine, Shijie Sun, Wanchun Tang, Institute of Critical Care Medicine

Heng Li, Sun Yat-Sen Memorial hospitalHospital, Sun Yat-Sen University, Xiangshao Fang, Zhengfei Yang, Yue Fu, Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University, Tao Yu, Sun Yat-Sen Memorial Hospital, Sun YatSen University, Zitong Huang, Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University

Introduction: Coronary perfusion pressure (CPP) is recognized as a reliable indicator of resuscitation in both experimental and clinical settings. However, the relationship between carotid blood flow (CBF) and success of resuscitation during CPR has not been examined. In the present study, we investigated whether the CBF generated by chest compression during CPR is correlated with the rate of resuscitation after the first defibrillation in a pig model of CPR. Hypothesis: We hypothesized that CBF during CPR is highly correlated with the success of resuscitation. Methods: Thirty-two pigs weighing between 34 –38 kg were utilized in this study. CPR was started after 7 min of untreated ventricular fibrillation (VF), defibrillation was attempted after 5 min of CPR. If the animal was not resuscitated, CPR was continued for 2 min prior to another defibrillation attempt. The protocol was continued until return of spontaneous resuscitation (ROSC) or for a total of 15 min. CBF was directly measured with the transonic flow probe which was placed around the right carotid artery. Results: Fourteen animals were resuscitated after the first defibrillation, 13 animals required more than 1 electrical shock to achieve ROSC, while 5 animals were not resuscitated. CBF prior to defibrillation was significantly greater in those animals resuscitated after the first electrical shock when compared with those animals achieving ROSC after more than 1 electrical shock or not resuscitated (37.8⫾13.9 vs. 23.8⫾8.7, 10.5⫾6.8 ml/min, p⬍0.02). In addition, CBF was significantly greater in resuscitated animals than that in non-resuscitated animals (31.4⫾13.6 vs. 10.5⫾6.8 ml/min, p⬍0.01). Conclusions: Carotid blood flow was highly correlated with the rate of ROSC during CPR. The higher CBF indicated better resuscitation with CPR.

Introduction: Though an appropriate low temperature displays an optimistic alleviation of contractive failure in the ischemia/reperfusion myocardium, we still lack answers to many questions about its potential mechanism. Hypothesis: Our hypothesis is that a mild hypothermia (32°C) induced in ischemia can ease mitochondrial injury resulting in improvement of myocardial contractility even under the condition of a normothermic reperfusion. Methods: Fifty newly-born 1–2 days Sprague-Dawley rats were executed and the primary cardiomyocytes were obtained and cultivated in vitro. Myocytes were randomized into 3 groups and then subjected to ischemia either at 32°C or 37°C, prior to being reperfusion at 37°C. Contractility was presented as frequency and velosity. Ultrastructural alterations of cardiomyocytes and mitochondrion were under semi-quantitative analysis with TEM, and respiratory function of mitochondria was further assessed simutaneously. Results: During cooling ischemia and following reperfusion, though myocytes contracility was depressed in the initial time of perfusion, it can acquired a more immediate restoration to baseline level and had a significant difference with those normothermic ischemia. Furthermore, 32°C cooling exerted less deleterious effect on ultrastructure of myocyte and mitochondrion after ischemia. Furthermore, respiratory function of mitochondrion assessed in reperfusion differed significantly in cooled and uncooled group (P⬍0.05) results in a variation on contractile performance. Conclusions: Hypothermia in ischemia can improved myocyte contracility and mitochondrial respiratory function after normothermic reperfusion.


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CORE TEMPERATURE MEASUREMENT IN THERAPEUTIC HYPOTHERMIA: COMPARISON OF BLADDER, RECTAL, AND TYMPANIC VERSUS PULMONARY ARTERY METHOD

STAFF PERCEPTIONS OF A PEDIATRIC EARLY WARNING SCORE IN A TERTIARY CARE CHILDREN’S HOSPITAL

Jong Hwan Shin, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Jin Joo Kim, Gachon University Gill Hospital Introduction: Accurate measurement of core temperature is important in the therapeutic hypothermia. A trial was performed to compare the accuracy of bladder, rectal, tympanic temperatures with that of pulmonary artery (PA) core temperature measurements. Methods: A prospective observational cohort study was conducted comparing temperature of four different sites – bladder, rectum, tympanic membrane, PA - by using a bladder, rectal, tympanic digital thermometer, and Swan-Ganz catheter during mild therapeutic hypothermia which was controlled by surface cooling method(Arctic-Sun). Therapeutic hypothermia is divided to three periods – rapid cooling, maintenance, and rewarming period. The time from initiation of hypothermia to the body temperature reaches 33°C is considered as rapid cooling period. After rapid cooling period, body temperature is maintained at 33°C for 24 hours since initiation of hypothermia, which is the maintenance period. Rewarming period is followed after the maintenance period, till body temperature reaches 36.5°C. Each core temperatures were measured at half-hour intervals. Comparisons used a Bland and Altman method. Results: 21 patients admitted to our ED after out-of-hospital cardiac arrests were included in this study. In rapid cooling period, the mean differences between PA temperatures and those of the other methods studied were: bladder (-0.25⫾1.51°C), rectal (-0.65⫾1.38°C), tympanic (1.1⫾1.7°C). In maintenance period: bladder (0⫾0.87°C), rectal (-0.48⫾1.4°C), tympanic (0.7⫾1.5°C) and in rewarming period: bladder (0.15⫾0.82°C), rectal (-0.2⫾1.1°C), tympanic (1.27⫾1.43°C). In total period: bladder (0.04⫾0.89°C), rectal (-0.4⫾1.3°C), tympanic (1.2⫾1.4°C). Conclusions: Bladder thermometer is more reliable than the rectal and tympanic thermometer during therapeutic hypothermia. Tympanic thermometer is less reliable as a main core temperature. Rectal thermometer is comparatively reliable, but rectal temperature tends to be higher than temperature recorded by bladder thermometer or Swan-Ganz catheter during rapid cooling period. Cautious approach is warranted not to induce over-cooling when using rectal thermometer during the rapid cooling period.

Brandi McClain, Lauran Sevier, Whitney Browning, Randon Hall, Bradly Strohler, Monroe Carell Jr. Children’s Hospital at Vanderbilt Introduction: Pediatric Early Warning Scores (PEWS) were developed to help bedside providers recognize patients at risk for deterioration. Limitations to implementation include disruptions to nurse workflow and poor specificity that leads to unnecessary bedside evaluations by the physician team. Hypothesis: A simple, five-point PEWS can identify patients at risk for deterioration without creating extra work for the bedside nurse or physician team. Methods: Bedside nurses on a medical acute care floor in a tertiary care children’s hospital were trained to use the PEWS. The nurses recorded the duration of the assessment and answered a seven question survey after completing the score. The PEWS is a composite score with one category each for mental status and hemodynamics and three categories for the respiratory system. The score links to an algorithm provides decision support for escalation of support and frequency of reassessments. For the study, the nurses were given the algorithm but were not required to follow it. Results: The study captured 174 assessments for 45 patients. The mean time for completion of an assessment was 6:13 minutes. The mean score was 1.2 for dayshift and 2.2 for nightshift. Ten out of 140 responses (7%) felt the score did not accurately describe the acuity of the patient. The PEWS only prompted the nurse to involve the physician team when the nurse was not concerned about the patient in 1 out of 139 responses (⬍1%). The frequency of assessment assigned by the algorithm matched the nurses’ level of concern for 132 out of 139 responses (95%). Conclusions: The PEWS used in this study accurately describes the acuity of pediatric inpatients while adding little extra work for the bedside provider.

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CHEST COMPRESSIONS TARGETED TO 51 MM IMPROVE HEMODYNAMIC OUTCOMES DURING ASPHYXIA ASSOCIATED CARDIAC ARREST

THE INCIDENCE AND OUTCOME OF PEDIATRIC OUT-OFHOSPITAL CARDIAC ARREST FOLLOWING TRAUMA IN MELBOURNE, AUSTRALIA

Utpal Bhalala, Stuart Friess, Robert Sutton, Maryam Naim, Nathan Lear, Matthew Maltese, Dana Niles, George Bratinov, Vinay Nadkarni, Robert Berg, Children’s Hospital of Philadelphia

Conor Deasy, Monash University, Karen Smith, Janet Bray, Ambulance Victoria, Stephen Bernard, The Alfred Hospital, Peter Cameron, Monash University

Introduction: The American Heart Association (AHA) recommends that providers compress the chest ⱖ50 mm during cardiopulmonary resuscitation (CPR). Existing data suggests that providers achieve only about 33 mm during actual resuscitations. Hypothesis: Hemodynamic outcomes will improve when chest compressions (CCs) are targeted to a goal of 51 mm compared to 33 mm (usual care) during an asphyxial model of cardiac arrest. Methods: With IACUC approval, 8 female 3 month old pigs (30 ⫾ 1kg) were intubated, anesthetized with isoflurane and fentanyl, underwent 7 minutes of asphyxia, followed by induction of ventricular fibrillation (VF). Using a CPR recording defibrillator, manual CPR was performed (rate 100/min, ventilation rate 6/min, 100%FiO2) for 10 minutes before first defibrillation attempt. Arterial blood pressure and end tidal CO2 were measured continuously. Physiologic variables (arterial/venous blood gases) and cardiac outputs were recorded at baseline and 30s pre-VF. Animals were randomly assigned to 2 CPR strategies: 1) chest compressions (CCs) guided to a target of 33 mm with standard ACLS based epinephrine dosing (CC-33 (n ⫽ 5)); or 2) CCs guided to a target of 51 mm with standard ACLS epinephrine dosing (CC-51(n ⫽ 3)). Analysis was performed using generalized estimating equations to account for within subject correlation of 30s CPR epochs. The primary outcome variables were arterial blood pressure and end tidal CO2. Results: There were no differences between groups for physiologic variables/cardiac outputs at baseline or 30s pre-VF. Average delivered CC depths were: 30 mm (CC-33) and 47 mm (CC-51), significantly different between groups (p⬍0.01). Other CPR quality variables and epinephrine dosing were similar. Systolic blood pressure was significantly higher in CC-51 as compared to CC-33 (163 ⫾ 39 vs. 64 ⫾ 27 mmHg; p⬍0.01); diastolic and mean pressures were similar. End tidal CO2 was significantly higher in CC-51 as compared to CC-33 (36 ⫾ 7 vs. 25 ⫾ 7 mmHg; p ⫽ 0.01). Conclusions: Chest compressions targeted to 51 mm improve systolic arterial blood pressure and end tidal CO2 in an asphyxial model of porcine cardiac arrest.


Introduction: Traumatic out-of-hospital cardiac arrest (OHCA) in adults carries a poor prognosis but there is little data on traumatic OHCA in the pediatric population. This study aims to describe the characteristics and outcomes of pediatric traumatic OHCA in a large urban centre. Hypothesis: We hypothesized that pediatric traumatic OHCA would have a high mortality rate but that there may be some patients with good outcomes. Methods: The emergency medical service (EMS) provides advanced trauma life support for 4.5 M people in Melbourne, Australia. Data for all OHCA cases are included in the Victorian Ambulance Cardiac Arrest Registry. This data was searched for OHCA following trauma in pediatric patients (age less than 16 years) excluding hanging and burns. Results: Between 2000 –2009, the EMS attended 33,722 patients with OHCA of whom 538 (1.6%) were children. A traumatic cause of OHCA was identified in 64 children. The causes of the trauma were: pedestrian struck by a car (20), car occupant (11), struck by a train (8), cyclist (4), fall from a height (3), motorcycle pillion passenger (2), gunshot wound (2) and other (14). The median age (IQR) was 7 (4.5–13) years and 69% were male. Bystander CPR was performed in 22 patients (34.4%). The first cardiac rhythm was asystole in 42 (66%), pulseless electrical activity in 14 (22%) and ventricular fibrillation in 2 (3%). An initial cardiac output was present in 7 (11%) patients who subsequently had a cardiac arrest. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported to hospital. There was 1 (3%) patient who survived to hospital discharge with severe disability. There were 14 (40%) children who were transported with CPR but none survived to hospital discharge. The autopsy findings were multiple injuries in 47%, isolated head injury in 33%, head and neck injury in 10% and isolated chest injuries in 10%. Conclusions: Traumatic OHCA in children was associated with a very high mortality rate and the only survivor had a poor neurological outcome. Most patients had severe head injury. Strategies to decrease the high mortality rate of pediatric traumatic OHCA may need to focus on prevention of this devastating condition.

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USING IN SITU MOCK CODE TRAINING IN THE PEDIATRIC INTENSIVE CARE UNIT (PICU) TO IMPROVE MULTIDISCIPLINARY CODE TEAM RESPONSE

THE RELATIONSHIPS BETWEEN THE NUMBER OF DEFIBRILLATIONS AND POST RESUSCITATION VENTRICULAR TACHYCARDIA IN A RAT MODEL OF PROLONGED CARDIAC ARREST

Angela Wratney, Children’s National Medical Center, Janeane Walker, Childrens National Medical Center, Brett Russell, Elyse Tomanio, Tabatha Dragonberry, Elizabeth Marcello, Tracey Hamilton, Krista Cato, Children’s National Medical Center Introduction: Pediatric Intensive Care Unit (PICU) nurses have important roles in the code team. An individual nurse (RN) may vary code team roles within their ICU career. Mock code training allows for deliberate and repetitive practice of a code team role to gain confidence and proficiency with skills. Hypothesis: To evaluate self-reported confidence with resuscitation skills by RNs attending in situ mock code training. To determine which skills RNs report with high and low confidence. Methods: Multidisciplinary, monthly, in situ PICU mock codes. RNs (1–5) are relieved of clinical duty for participation to provide pre-assigned roles as bedside nurse, medication cart, nurse right and left, assist. Anonymous evaluations are completed at the end of scenario debriefing. Self-reported confidence in resuscitation skills for use of bag-mask ventilation, defibrillator, chest compressions, administration of epinephrine (EPI), code recorder, team participant, and communication using a Likert scale of 0 to 5 (0 ⫽ no confidence or knowledge; 3 ⫽ neutral level; 5 ⫽ complete confidence/sufficient to train others). Results: Our PICU nurses have a range of PICU experience 40.0% ⬍2 yrs; 24.6% 2–5 yrs; 23.0% 5–10 yrs; 11.9% ⬎10 yrs. Actual code experience reported ranged from an average of 4 codes to over 50 events. Variability in confidence level exists for all resuscitation skills and across all years of PICU experience. Confidence was highest for the skills for EPI (4.2⫾0.92); code team participant (3.8 ⫾1.18); and chest compressions (3.8 ⫾1.1). More frequent self-reported confidence level of ⱕ3, was associated with skills for use of defibrillator, code team recorder, and participant. Conclusions: Confidence for resuscitation skills varies across RNs. Ideally PICU nurses would have self-reported skill and knowledge ’sufficient to train others.’ Self-reported confidence is not a surrogate for performance proficiency. These data support AHA 2010 recommendation to support multidisciplinary team and skills training at frequent intervals. For the individual RN provider, we now offer increased frequency for exposure to in situ learning modalities to improve skill technique and to build confidence to train others.

Lingyan Lei, Yinlun Weng, Weil Institute of Critical Care Medicine, Xiaobo Wu, Weil Institue of Critical Care Medicine, Sen Ye, Weil Institute of Critical Care Medicine, Wei Chen, Weil Institute of Crit. Care Med., katherine tang, Max Weil, Shijie Sun, Weil Institute of Critical Care Medicine Introduction: Earlier studies have demonstrated that high-energy defibrillation (DF) increases the severity of post resuscitation myocardial dysfunction, including myocardial contractility and ventricular arrhythmias. In the present study, we investigated the relationships between the number of DF and the incidence of ventricular tachycardia in a rat model of prolonged cardiac arrest. Hypothesis: The lesser number of DF during CPR would decrease the severity of post resuscitation ventricular tachycardia. Methods: Ventricular fibrillation was electrically induced and untreated for 8 minutes in 20 SD rats, weighing between 450 –500 g. Animals were randomized into 2 groups prior to CPR: 1) chest compression was performed continuously and the defibrillation was not delivered until the amplitude spectrum analysis (AMSA) value reached to or was more than the threshold of 10 mV䡠Hz. (AMSA guided); 2) defibrillation was attempted after every 2 minutes of CPR as recommended by the current guidelines (GL based). Resuscitated animals were observed for 4 hours after return of spontaneous circulation (ROSC). Post resuscitation ventricular tachycardia was measured as the total incidence of continuous ventricular tachycardia for 30 minutes after ROSC. Results: A significantly fewer number of defibrillations required to achieve ROSC was observed in the AMSA guided group when compared with the GL based group (1.5⫾1.2 vs 3.1⫾0.76, p⬍0.01). This was associated with significantly fewer incidences of post resuscitation ventricular tachycardia (13⫾19 vs 237⫾192, p⬍0.02). The number of DF and the incidence of continuous ventricular arrhythmia was significantly correlated (r ⫽ -0.561, p⬍0.016). Conclusions: The number of defibrillations required for resuscitation during CPR highly corresponded with the incidence of post resuscitation ventricular arrhythmias in this rat model of CPR.

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OUTCOMES OF CARDIAC ARREST IN NON-INTENSIVE CARE UNIT HOSPITALIZED HEMODIALYSIS PATIENTS

IMPACT OF A TASK FOCUSING STRATEGY ON STRESS LEVELS AND PERFORMANCE DURING A SIMULATED CARDIOPULMONARY RESUSCITATION: A RANDOMIZED CONTROLLED TRIAL

Jayanth Vedre, Mayo Foundation For Medical Education and Research, Vicki Loeslie, Jeffrey Rabatin, Mayo Clinic Introduction: Patients on hemodialysis are believed to have a poor survival rate after cardiopulmonary resuscitation (CPR). There is limited information about the short and long term outcomes of non-intensive care unit (ICU) hospitalized hemodialysis patients after cardiac arrest to assist them in informed decision making regarding CPR. Methods: A retrospective electronic chart review was performed among non-ICU hospitalized patients who had cardiac arrest (absence of pulse or non perfusing rhythm) requiring CPR at a tertiary care academic medical center between January 2005 and December 2009. Data was abstracted and summarized using appropriate statistical methods Results: A total of 367 non-ICU hospitalized patients had a cardiac arrest during the specified time period. 45/367(12.2%) were hemodialysis patients and 322/367 (87%) were non-hemodialysis patients. 31/45(68.8%) patients undergoing treatment with hemodialysis had return of spontaneous circulation after resuscitation. 22/45 (48%) survived to hospital discharge, 13/45(28%) were alive at three months and 9/45(20%) were alive at one year.Among the non-hemodialysis patients, 197/ 322(61%) had return of spontaneous circulation after resuscitation. This was not statistically significantly different compared to the hemodialysis patients with an odds ratio of 0.71(95% confidence interval of 0.3–1.3). 142/322 (45%) survived to hospital discharge, 91/322 (28%) were alive at three months and 73/322 (22%) were alive at one year. Conclusions: Despite considerable efforts to improve the outcomes of cardiac arrest of non-ICU hospitalized hemodialysis patients (dedicated CODE teams, rapid response times, access to AEDs) patients have poor outcomes. The overall three month and one year survival in our study was comparable to that of non-hemodialysis patients with a relative risk (RR) of 0.99 and 0.91 respectively. In discussion about preferences for attempts at resuscitation/CPR with dialysis patients, Hospitalists and Nephrologists can describe the overall likelihood of surviving three months as 1 in 4 and surviving one year as 1 in 5. To improve patient outcomes, additional identification of risk factors associated with survival are necessary.

Sabina Hunziker, Beth Israel Deaconess Medical Center, Stephan Marsch, University Hospital Basel Introduction: Cardiopulmonary resuscitation (CPR) results in significant stress, which may causer deficiencies in attention and increase distractibility. This may lead to misjudgements of priorities and delays in CPR performance, which further increase mental stress. Interventions to stop this vicious cycle by reducing stress and its negative consequences are largely lacking. Hypothesis: We hypothesized that a task focusing strategy would lower perceived stress levels of rescuers and thereby improve performance during a simulated CPR scenario. Methods: This prospective, randomized-controlled trial was conducted at the simulator center of the University Hospital Basel, Switzerland. A total of 124 volunteer medical students were randomized to receive instructions about focusing on relevant tasks by posing two task focusing questions (“what is the patient’s condition?”, “what immediate action is needed?”) when feeling overwhelmed by stress (intervention group) or a control group without a similar instruction.The primary outcome was the perceived levels of stress and feeling overwhelmed (stress/overload) during the simulated resuscitation. Secondary outcomes were amount of hands-on time in the first 120 seconds after the onset of the cardiac arrest, time to start CPR and number of leadership statements. Results: Participants in the intervention group reported significantly less perceived stress/overload levels compared to the control group (mean difference: -0.6 (95%CI -1.3, -0.1), p ⫽ 0.04). No significant difference was found in regard to hands-on time (difference 5.5 (95%CI -3.1, 14.2), p ⫽ 0.2) and time to start CPR (difference -1.4 (95%CI -8.4, 5.7), p ⫽ 0.71). Conclusions: A brief task focusing strategy decreased perceived stress without, however, significantly affecting performance of rescuers in a simulated CPR scenario. Further studies into the effect of stress and stress reducing strategies are warranted.


433 ADMISSION SERUM PH LEVEL PREDICTS NEUROLOGICAL OUTCOME OF OUT-OF-HOSPITAL CARDIAC ARREST Naofumi Bunya, Yoshihiro Takeyama, Hakodate municipal hospital, Kunihiko Maekawa, Kohei Kato, Sapporo Medical University, Takehiko Kasai, Toshihiro Tawara, Hiroyuki Inoue, Hiroyuki Okamoto, Hakodate Municipal Hospital, Yasufumi Asai, Sapporo Medical University Introduction: Almost all patients with refractory out-of-hospital cardiac arrest (OHCA) had no hope of intact survival, however, we would continue to do resuscitative efforts in the emergency department (ED) and the intensive care unit. Identifying these patients could enhance utilization of scarce health care resources. Serum pH is measurable easily in most hospitals and we don’t know whether serum pH can identify patients with poor neurological outcome of OHCA. Hypothesis: Serum pH on ED arrival can predict poor neurological outcome of OHCA. Methods: We conducted a single center retrospective cohort study between January 2006 and June 2011. All adults patients with witnessed OHCA of presumed cardiac origin were eligible for inclusion. Data were abstracted from the charts including demographic, presence/absence of bystander CPR, initial electorical rhythm, down time interval, levels of serum lactate and pH on ED arrival and the use of therapeutic hypothermia (TH). Primary endpoint was the neurological outcome (the cerebral performance category (CPC)) at hospital discharge. Results: A total of 290 patients were enrolled, 274 (94.4%) had poor outcome (CPC 3–5) and 26 (9.0%) had favorable outcome (CPC 1–2). Compared to patients with favorable outcome, patient with poor outcome were older (75[64- 83] vs. 59[53- 65]yr), had more often non-shockable rhythm (72.7% vs. 11.5%), longer low-flow time (30[25– 40] vs. 16[8.3–20]min), higher level of serum lactate (11.1[8.7–14.6] vs. 9.3[7.4 –10.9]mmol/L), lower level of pH (6.980[6.876 –7.090] vs. 7.184[6.988 –7.253]) and less often underwent TH (4.5% vs. 61.5%). Multivariable logistic regression analysis identified serum pH and low-flow time as independent predictors of poor outcome (adjusted OR; 2.02 [95% CI; 1.06 –3.85], 4.8 [2.02–11.42], respectively). ROC analysis showed an AUC was 0.744 and identified serum pH ⬍6.883 as an optimal cut-off point identifying poor neurological outcome, with a sensitivity of 27.0%, a specificity of 100%, positive predictive value of 100% and negative predictive value of 11.3%. Conclusions: Serum pH on ED arrival was independent predictor of OHCA. We might be able to terminate more resuscitative efforts against OHCA patients with serum pH below 6.883.


Posters: CPR/Resuscitation-4 434

435

PERFUSION INDEX (PI) CORRELATES TO TRANSCUTANEOUS PRESSURE OF OXYGEN (PTCO2) TEST AND MAY PROVIDE A NONINVASIVE METHOD OF TISSUE PERFUSION

IN-HOSPITAL CARDIAC ARREST: IMPLICATION OF MONITORED VERSUS UNMONITORED CARDIAC ARREST

Michael Hu, Uy Vu, Sho Furuta, Maimona Ghows, Keilla Schmidt, Erin Suydam, David Inouye, Michael Hayashi, Danny Takanishi, Mihae Yu, University of Hawaii

Shikha Sharma, Antoine Trammell, Emory School of Medicine, Prasad Abraham, Vivian Liao, Tara Holt, Grady Health Systems, Maziar Zafari, Emory School of Medicine

Introduction: The early detection and treatment of occult shock is anongoing challenge in critical care. In shock states, the skin is the firsttissue bed to vasoconstrict. Transcutaneous pressure of oxygen (PtcO2) changeswith PaO2 when perfusion is adequate, but during times of shock andvasoconstriction, PtcO2 does not change with increasing FiO2 and increasing PaO2.The change in response of PtcO2 to a FiO2 of 1.0 has been called the oxygenchallenge test (OCT) and minimum increase in PtcO2 has been shown to be anearly marker of shock as well as an endpoint of resuscitation with decreasedmortality (1). The perfusion index (PI) is an assessment of the pulsatilestrength calculated via pulse oximetry, derived from the amount of infrared(940 nm) light absorbed (Masimo Radical-7, Irvine, CA). It is a noninvasive andcontinuous measure of peripheral perfusion. Hypothesis: PI correlates with OCT values and is a marker of tissuehypoperfusion. Methods: Critically ill intubated patients in the surgical intensivecare unit had measurements of PtcO2 and PI. PtcO2 was measured usingtranscutaneous sensors (TCM3 Transcutaneous Oxygen/Carbon Dioxide MonitoringSystem, Radiometer, Copenhagen, Denmark). The sensors were attached to thepatients’ upper chest. Measurements of PtcO2 were recorded immediately prior toand after increasing FiO2 to 1.0 for 5 minutes. The value for the OCT wasdefined as the baseline PtcO2 subtracted from the new PtcO2 after increasingthe FiO2 to 1.0 for 5 minutes. Correlation and regression analysis was donebetween PI and OCT values. Results: Six patients contributed nine data points with the followingdemographics: age 60⫾9years, male:female 3:3, APACHE II ⫽ 22⫾8.Diagnoses included: severe sepsis/septic shock (n ⫽ 4) and ALI/ARDS (n ⫽ 2).Analysis showed a significant correlation between DPtcO2 (OCT) and PI (r ⫽ 0.70,p⬍0.05). DPtcO2range was 8 to 97 with mean 45⫾29.1.PI range was 0.24 to 5 with mean 1.87⫾1.51 (normal is ⬎0.70). Conclusions: Preliminary data shows the PI correlates with DPtcO2in the oxygen challenge test, a method of assessing tissue perfusion. Furtherstudies may prove PI to be another noninvasive tool for the early detection ofshock. Reference:1)Yu,M et al, Shock 2007;27:615

Introduction: Early recognition of arrest and initiation of resuscitation is critical for the survival. The cardiac monitoring may improve the outcome of arrest patients by early identification. To assess the role of monitoring on the survival, we evaluate the survival rates of adult in-hospital cardiac arrest based on whether the arrest was monitored or unmonitored. Hypothesis: Monitored patients have better survival outcome compared to non-monitored patients at the onset of the arrest. Methods: This is a retrospective chart review done at Grady Memorial Hospital. We identified 192 cardiac arrests at all locations including intensive care units (medical/surgical), emergency room, step-down units and floor (medical/ surgical) from July 2010 to May 2011. After excluding the patient who was brought in after successful resuscitation by the EMS; 191 code sheets and charts were reviewed to determine the code details and outcome at discharge. Results: 157 patients (mean age 57 ⫾16 years, male 58%, mean charleson comorbidity index 4.05 ⫾0.22) experienced 191 cardiac arrest. The rate of successful return of spontaneous circulation noted in 66% of patients whereas only 15% were discharged alive from the hospital.Notably 85% of cardiac arrests were monitored. The monitored arrest occurred in younger patients (55⫾14 vs. 63⫾18 years, p⬍0.02) predominantly at intensive care settings (58% vs 4%, p⬍0.001) compared to unmonitored arrest.Time to cardiac pulmonary resuscitation (48⫾13 vs. 83⫾4 seconds, p⬍0.01) and duration of arrest (18⫹11 vs. 16 11 minutes, p ⫽ 0.3) was significantly less in monitored patients compare to non-monitored patients. The rate of successful return of spontaneous circulation (57% vs. 12%) and survival rate at discharge (12% vs 3%) was better in monitored group than in non-monitored group. Conclusions: The survival rate after In-hospital cardiac arrest is very poor and underscores the need to identify and evaluate the factors leading to the poor patient outcome. Monitored cardiac arrest reduces time to CPR which translates into better rate of ROSC and survival at discharge. Further reforms including mock drills and dedicated code team are needed to improve the in-hospital arrest outcome.

436

437

EVEN FOUR MINUTES POOR QUALITY OF CPR COMPROMISES THE OUTCOME IN A PORCINE MODEL OF PROLONGED CARDIAC ARREST

OUTCOMES OF ADDING ACUTE CARE NURSE PRACTITIONERS (ACNP) TO MEDICAL AND SURGICAL RAPID RESPONSE TEAMS (RRTS)

Zhengfei Yang, Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University, Heng Li, Sun Yat-Sen Memorial hospital, Sun Yat-Sen University, Zitong Huang, Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University, Tao Yu, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University

April Kapu, Vanderbilt University Hospital, Laurie Ford, Vanderbilt University, Susan Hellervik, Vanderbilt Medical Center, Arthur Wheeler, Vanderbilt University Medical Center

Introduction: The new guidelines emphasized the quality of CPR, however, untrained layperson usually cannot deliver optimal chest compression to victim suffered from cardiac arrest in out of hospital settings. Although early defibrillation had been feasible, high quality chest compression may be delayed until EMTs arrive. We therefore sought to investigate resuscitation outcome and hemodynamic in those received suboptimal quality of CPR in first four minutes compared to good CPR originally. Hypothesis: We hypothesized that even four minutes of poor quality of CPR compromises the outcome in a porcine model of prolonged cardiac arrest. Methods: Fourteen Yorkshire pigs weighted 30⫾5kg were randomized into good CPR and poor CPR groups. Ventricular fibrillation was electrically induced and untreated for 6 mins. In Good CPR group, animals received enough depth (20% of animal’s anterior posterior thoracic diameter) of manual chest compressions in the first two minutes of CPR compared with 70% of good CPR depth in poor group. For both groups, compression rate maintained 100 bpm. After 2 mins of chest compression, a 150-J biphasic shock was delivered. If the animal didn’t acquire ROSC, another 2 minutes of CPR and shock continues. After 4 min of CPR, both groups received optimal CPR until total 10 min of CPR has been finished. Results: All the seven animals of good CPR group were resuscitated compared that only 2 in poor CPR group (P⬍0.05). In the 5 nonsurvival animals, after four minutes of poor CPR, coronary perfusion pressure maintained a lower level, even the delayed good CPR failed to improve the CPP level significantly and the outcome. Conclusions: In this model, even four minutes of poor quality of CPR compromises the outcome in a porcine model of prolonged cardiac arrest.

Introduction: In 2005, Vanderbilt began using RRTs comprised of an ICU charge nurse (CN) and a respiratory therapist. A problem identified was the absence of a provider that could diagnose, treat, facilitate communication and expedite ICU transfer. In late 2010, we added ACNPs to the MICU and SICU RRTs. Hypothesis: We hypothesized adding ACNPs to the RRT would improve team satisfaction while identifying system- problems. Data collected allowed comparisons of diagnoses, interventions, outcomes and problems between teams. Methods: We compared these variables on all daytime (0700 –1900) MRRT and SRRT ACNP-led calls between Jan-July 2011, using a RedCap QI database. We anonymously surveyed CN’s opinions about the addition of ACNPs. Data shown as proportions or mean⫹/⫺ std. Results: There were 186 MRRT and 127 SRRT calls of an average duration of 30 ⫾16 and 35⫾20 min. Critical care billing occurred for (29%) of MRRT and (55%) of SRRT calls. The most common triggers were respiratory (29%) for MRRT and changes in heart rate (24%) for SRRT. Most frequent diagnosis for the MRRT was respiratory distress (27%) and for the SRRT, pain (19%). MRRT and SRRT calls resulted in 31% and 33% of subjects moving to an ICU respectively. ACNPs ordered labs on (23% vs. 61%), x-rays on (16% vs. 53%), ECGs on (17% vs. 50x %) and medications on (41% vs. 57%) of MRRT and SRRT calls respectively. Problems contacting the primary team (7 vs. 5%) obtaining ECGs (5 vs. 2%), and delayed ICU bed availability (4 vs. 4%) were identified. Of responding CNs 96% felt that having ACNPs on the RRT was beneficial, with the primary reason being ACNPs could place orders (93%), followed by support of nurses (82%) and team collaboration (78%). Conclusions: We conclude triggers for and interventions during MRRT and SRRT calls differ. We speculate these differences are due to surgical and nonsurgical complications. A high satisfaction level was expressed by CNs regarding ACNPs on the RRT. Problems identified by the ACNPs have resulted in process improvements.


438

439

DISTINGUISHING ESOPHAGEAL AND ENDOTRACHEAL INTUBATION BY MEASURING CUFF PRESSURE

PERCEPTIONS OF TEAMWORK AMONGST CODE TEAM MEMBERS

Brian Goentzel, Eric Larsen, Nicholas Shelburne, Darius Tolbert, William Culp, William Johnston, Texas A&M University College of Medicine, Scott and White Hospital

Sarah Frewin, Tara Mahramus, Orlando Health, Elizabeth Aragon Penoyer, Orlando Regional Medical Center, Mary Sole, University of Central Florida

Introduction: Inadvertent esophageal intubation leads to serious and potentially lethal complications if undetected. Whether measuring cuff pressure can accurately differentiate esophageal from tracheal intubation is unknown. Studies using a live porcine model found a difference in cuff pressure between the esophagus and the trachea but a human cadaveric study did not support this finding. This study was designed to resolve this conflict using live human subjects to determine whether proper placement of the endotracheal tube could be confirmed through measurement of cuff pressure. Hypothesis: Due to structural differences between the esophagus and trachea, we expect cuff pressure to initially be higher in the esophagus but to increase more rapidly in the trachea as the cuff is inflated against the cartilaginous rings of the airway. At high cuff volumes, tracheal cuff pressure should exceed esophageal cuff pressure. Methods: 34 female and 35 male patients undergoing elective surgery were intubated with 7.0 and 8.0 mm cuffed tubes, respectively, both esophageally then tracheally. Cuff pressure was recorded after each one mL of inflation until a volume of 10 mL was reached or cuff pressure exceeded 250 mmHg. Esophageal and tracheal cuff pressures were compared using the Wilcoxon signed rank test. Results: In females, tracheal cuff pressure was significantly higher than esophageal cuff pressure at volumes between 3 and 10 mL (p⬍0.05). The pressure difference was greatest at 9 mL, where tracheal cuff pressure averaged 70 mmHg higher (SD 63 mmHg, p⬍0.0001) than the esophageal cuff pressure. In contrast, in males, esophageal cuff pressure was significantly higher at volumes less than 4 mL. The pressure difference (10 mmHg, SD 48 mmHg, p 0.15) was greatest at 7 mL, though this did not reach statistical significance. Conclusions: At greater cuff volumes, tracheal cuff pressure was found to be higher than esophageal cuff pressure in females but not in males. However, the high degree of variability between patients limits the clinical usefulness of this measurement as a method to confirm proper placement of an endotracheal tube.

Introduction: Research about teamwork on code teams is limited.The purpose of this study was to explore perceptions of teamwork during cardiac resuscitation amongst and between core team members: medical residents(MD), nurses(RN), and respiratory therapists(RT). Hypothesis: Teamwork perceptions would be less than optimal and a difference of perceptions would exist between disciplines. Methods: A descriptive study using an online survey design was used to measure teamwork perceptions. The survey tool was adapted from 2 tools from the literature measuring teamwork (TEAM; MTMA) and information gained from a focus study group and direct observations of codes. The tool included 30 items ranked on a Likert scale of 0 – 4, one overall rating scale of teamwork from 1–10, and an open-ended comment. Content analysis was used to analyze comments. Results: Sixty-six code team members participated: 22 MDs, 26 RTs, 18 RNs, with experience ranging from ⬍2 to ⬎10 years. Overall teamwork rating averaged 6.92 on a 10 point scale. Total mean scores were 80 out of a total 128 points. Overall total scores were not significantly different between disciplines. However, subjects with ⬍2 years of experience on the code team ranked teamwork higher than those with more experience (p ⫽ 0.013). Post hoc analysis revealed significant differences in scores by group: MD’s rated perception of leadership significantly higher than other disciplines (p ⫽ ⬍0.001), RT’s were significantly more confident in their responsibilities during a code (p ⫽ 0.008), and RTs and RNs felt significantly better trained to participate as code team member as compared to physicians (p ⫽ 0.028). Themes generated by open ended comments were chaotic room environment, unprofessional behavior, variable quality of code processes, inconsistent leadership and role expectations. Reliability of the survey tool revealed a Cronbach alpha of 0.91. Conclusions: Overall impressions from the findings indicate the code team members perceive teamwork to be less than optimal. Ideal teamwork perceptions would show that good teamwork was realized often or always. In our study, average total scores did not illustrate ideal teamwork perception. The survey tool was a reliable measure of teamwork perception.

440

441

IS THE ATTENDING PHYSICIAN NECESSARY AT RAPID RESPONSE ACTIVATIONS?

PROGRESSIVE REDUCTION IN CENTRAL BLOOD VOLUME IS NOT DETECTED BY SUBLINGUAL CAPNOGRAPHY

David Morris, Hospital of The University of Pennsylvania, William Schweickert, University of Pennsylvania, Robert Handzel, SUNY Upstate Medical University, Daniel Holena, Carrie Sims, Jose Pascual, Hospital of The University of Pennsylvania, Babak Sarani, Trauma Center At Penn

Kevin Chung, Kathy Ryan, United States Army Institute of Surgical Research, Caroline Rickards, University of Texas at San Antonio, Carmen HinojosaLaborde, United States Army Institute of Surgical Research, Jeremy Pamplin, Shimul Patel, Thomas Herold, San Antonio Military Medical Center, Victor Convertino, United States Army Institute of Surgical Research

Introduction: Although medical emergency teams (MET) have been shown to decrease the incidence of cardiac arrest (CA), there are no studies evaluating optimal staffing. There are significant resource implications in mandating attending physician response. Hypothesis: We hypothesize that there are no outcome differences between ICU physician and senior resident led events. Methods: A retrospective study of the MET database at a single, academic hospital was performed from July 1, 2006 to May 31, 2010. In addition to the physician-responder, the MET includes an ICU trained nurse coordinator, respiratory therapist, and pharmacist. Day (D) was defined as 7am-5pm, and weekends were defined as 5pm on Friday to 6:59am on Monday. D events on non-surgical patients are led by an ICU attending whereas night/weekend (NW) events are led by residents. Non-hospitalized and ICU patients were excluded. Patients admitted to a surgical service (general, vascular, urologic, orthopedic, neurologic, cardiothoracic, plastic surgery, ENT and OB/GYN) were excluded due to variability in the training level of the physician-responder. NW events were compared against D events using chi square testing. Significance was defined as p⬍0.05. Results: A total of 1642 events were reviewed with 627 (38%) occurring during D and 1015 (62%) occurring during NW. A respiratory trigger was more likely during NW compared to D (50 % v 39%, p⬍0.001) as were staff concerns (46% v 34%, p⬍0.001). No difference was noted in the incidence of CA, ICU transfer, or mortality between the 2 groups. Use of diuretics, bronchodilators, chest x-ray, and central line insertion were more likely during resident led events. This difference persisted after controlling for the higher incidence of respiratory triggers in the NW group. Conclusions: Rapid response events are more common afterhours, but there is no difference in outcomes between attending intensivist and senior resident led events. The absence of an ICU physician did not have an impact on outcome but resulted in more interventions. With proper training, resident-led MET may enable more efficient use of attending physician time and resources.


Introduction: Early detection and management of shock is important in optimizing clinical outcomes. One regional marker, sublingual capnography, is particularly appealing as redistribution of blood flow away from the sublingual mucosa can happen very early in the compensatory phase of hypovolemic shock. Hypothesis: The present study was conducted to determine if sublingual capnography could be useful in detecting early hypovolemia in a human laboratory model. Methods: Utilizing a human model of central hypovolemia produced by progressive lower body negative pressure (LBNP), various physiologic parameters were measured continuously until onset of cardiovascular collapse. The LBNP protocol consisted of a 5-min rest period (0 mmHg) followed by 5 min of chamber decompression (applied to the lower body) to -15, -30, -45, and -60 mmHg, and additional increments of -10 mmHg every 5 min until the onset of cardiovascular collapse. For each subject, a probe was placed under the tongue for continuous measurement of sublingual PCO2 (SLCO2) using a modification of the MicroStatTM system (ExoStat Medical, Prior Lake, MN). Results: Eighteen healthy nonsmoking subjects (10 males, 8 females) with mean ⫾ SD age of 28 ⫾ 8 yrs, body weight of 72 ⫾ 13 kg, and height of 172 ⫾ 9 cm were recruited to participate, of which 17 completed the experiment. Average time to presyncope was 1579 ⫾ 72 sec (subject numbers at presyncope: -45 (1), -60 (6), -70 (7), -80 (1), -90 (2). Time to presyncope above includes a 300-sec baseline; thus LBNP was applied for an average of 1279 sec (approx 21 min). At the time of cardiovascular collapse, LBNP altered (p ⬍0.001) systolic blood pressure (130 ⫾ 3 vs. 98 ⫾ 2 mmHg, mean ⫾ SE), pulse pressure (58 ⫾ 2 vs. 33 ⫾ 2 mmHg) and heart rate (63 ⫾ 3 vs. 102 ⫾ 6 beats per minute) when compared to baseline while SLCO2 did not change (49.1 ⫾ 1.5 vs. 48.6 ⫾ 1.5 mmHg, p ⫽ 0.624). Conclusions: In a model of progressive hypovolemia in humans, we did not detect metabolic derangements in the sublingual mucosa, as measured by SLCO2.

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443

EFFECT OF SODIUM BICARBONATE ON IN-HOSPITAL CARDIAC ARREST SURVIVAL

USE OF A CLINICAL NURSE SPECIALIST TO DECREASE CODE CALLS: EVALUATION AND OUTCOME

T. Vivian Liao, University of Georgia, Prasad Abraham, Tara Holt, Grady Health System, Antoine Trammell, Emory University

Robin Proffitt, Mountain States Health Alliance

Introduction: Existing studies evaluating the use of sodium bicarbonate have produced conflicting results based on indirect measures on outcome and predominately focusing on out-of-hospital arrests. The primary objective of this study was to evaluate the effect of sodium bicarbonate on survival for an in-hospital cardiac arrest event. Hypothesis: We hypothesized that the use of bicarbonate is associated with decreased survival. Methods: This study was designed as a retrospective, observational study at Grady Health System, an urban, academic hospital. In-hospital code sheets from July 2010 through June 2011 were reviewed. The primary outcome was survival, using chi-square to test for an association between the number of ampoules of sodium bicarbonate administered and a dichotomous survival outcome. Results: A total of 192 in-hospital cardiac arrest codes occurred during the study period. Median age was 57 years (IQR 49 to 68). For the primary outcome, there was an association between decreased survival and the use of sodium bicarbonate (?2(10) ⫽ 28.61, p ⫽ 0.001). No association was found between gender and survival (?2(4) ⫽ 0.391, p ⫽ 0.531). No association was found between initial rhythm and survival (?2(5) ⫽ 6.327, p ⫽ 0.275). The median time to CPR was 0 minutes, meaning that CPR began immediately (IQR 0 - 2). Median duration of resuscitation efforts was 18 minutes (IQR 10 – 26). Conclusions: The number of persons surviving an in-hospital cardiac arrest event increases as the number of ampoules of sodium bicarbonate decreases, with the greatest number of survivors (n ⫽ 53) being those who did not receive any sodium bicarbonate.

Introduction: The Institute for Healthcare Improvement advocates the use of Rapid Response Teams to reduce the number of codes. We evaluated the use and effectiveness of an existing rapid response team before and after involvement of a dedicated Clinical Nurse Specialist (CNS). Hypothesis: A CNS reviewing monthly code and rapid response calls, identifying missed opportunities, and giving feedback to clinical staff, would lead to a reduction in total codes and an increase in rapid response calls. Methods: A rapid response team was established in 2006 at our 460 bed tertiary care hospital. Starting January 2010 a CNS was tasked with reviewing all records of rapid response calls and code calls. Retrospective review of 336 rapid response calls and 250 code calls in the adult inpatient setting from July 2009 to June 2010 was conducted. Review included patient’s clinical condition, vital signs, and treatments prior to the calls and subsequent outcomes. In February 2010 results of that review revealed missed opportunities. Possible earlier interventions were presented and feedback given to clinical staff, nursing and medical leadership. We continuously reviewed 172 code calls and 363 rapid response calls from July 2010 to June 2011. Calculations of both total codes and rapid response calls per 1000 patient discharges were examined. Results: In the retrospective analysis, rates of code calls and rapid response calls were measured. Comparing the 5 year period from July 2006 to June 2010 to the period from June 2010 to July 2011 after the introduction of a CNS, code blue calls decreased from 8.54 to 7.67 per 1000 patient discharges, and rapid response calls increased from 10.93 to 16.09 per 1000 patient discharges. Conclusions: The introduction of a CNS was associated with a progressive decline in code calls, and a steady increase in rapid response calls.


Posters: Education-1 444

445

IMPACT OF A NOVEL SURGICAL SKILLS TRAINING COURSE ON CRITICAL CARE MEDICINE FELLOWSHIP EDUCATION

EFFECTS OF CLINICAL EXPERIENCES ON SUCCESSFUL TRACHEAL INTUBATION USING AIRWAY SCOPE, A RIGID TYPE VIDEO-LARYNGOSCOPE

Dennis Kim, University of California San Diego Medical Center, Rakesh Patel, The Ottawa Hospital

Kohei Ota, Hiroshima University, Koichi Tanigawa, Grad. School Of Biomed. Sci., Hiroshima Univ., Takuma Sadamori, Shinji Kusunoki, Tomoko Tamura, Tadatsugu Otani, Hiroshima University, Yoshiko Kida, Hioshima University, Shinichiro Ohshimo, Grad. School Of Biomed. Sci., Hiroshima Univ., Yasumasa Iwasaki, Hiroshima University Hospital, Nobuyuki Hirohashi, Department of Emergency and Critical Medicine,Hiroshima University

Introduction: Increased calls for the delivery of improved patient safety and the availability of alternative modes of skills training have resulted in more emphasis being placed upon the educational curriculum to provide trainees with opportunities for developing the cognitive, psychomotor, and attitudinal skills required to perform various lifesaving procedures. Hypothesis: The purpose of this study was to determine the effectiveness of a surgical skills training course in improving trainee knowledge and confidence in the performance of a variety of invasive procedures. Methods: This observational study was performed on a prospective basis over a two year period. Trainees were administered a pre- and post-course questionnaire designed to determine their previous experience, confidence, and knowledge performing 5 procedures: chest tube and needle thoracostomy; pericardiocentesis; needle and surgical cricothyroidotomy. The confidence questionnaire utilized a 5 point Likert scale. Knowledge was assessed using multiple choice questions (MCQs) and case based scenarios. The skills course involved a 3 hour practical session proctored by 2 general surgeons using a cadaveric adult swine model in accordance with institutional policies. Pre- and post-course data was analyzed using the Wilcoxon-signed rank test for nonparametric data. Results: 13 fellows (8 first year and 5 second year) from 4 specialties (8 internal medicine; 2 anesthesia; 2 general surgery; 1 emergency medicine) underwent training. First and second year trainees demonstrated a significant improvement in pre- and post-course confidence levels (2.4 ⫹/⫺ 0.6 vs. 4.1 ⫹/⫺ 0.2, p ⬍0.005) both overall and for each individual procedure (p⬍0.05). Knowledge also increased between the pre- and post-tests on both the MCQs and short case based scenarios from 72% to 81% (14.2 ⫹/⫺ 1.8 vs. 16.2 ⫹/⫺ 0.9, p ⬍0.004). However, the improvement in knowledge among second year fellows did not reach statistical significance. Conclusions: A surgical skills training course can improve critical care medicine fellows’ confidence and knowledge in the performance of potentially life-saving invasive procedures. Further study is required to determine sustainability of these improvements.

Introduction: Appropriate skills for conventional tracheal intubation using Macintosh laryngoscope require substantial clinical training and experiences. The Airway Scope (AWS) is a video-laryngoscopes designed to facilitate effective and safe tracheal intubation. Studies have shown that AWS required less operator skills for tracheal intubation. Hypothesis: Few studies have reported clinical training or experiences required for appropriate skills for use of AWS. The objective was to examine effects of clinical training or experiences on success rates and times to intubation using AWS. Methods: Fifteen paramedics, 10 of them had no prior clinical training or experiences of tracheal intubation (group A) and 5 experienced with conventional tracheal intubation (group B, n ⫽ 5), were enrolled. Before the study, all paramedics had finished the same training program using audio-visual materials and manikin practice. They attempted tracheal intubation using AWS for surgical patients in OR. During intubation attempts, no advice was provided by the supervisors unless the study protocol was violated. Success rates for tracheal intubation, and the time required for visualization of the glottis (T1), tracheal intubation (T2), and inflationofthelungs(T3)wereanalyzed. Results:Paramedicsattemptedintubationfor93 patients (group A: n ⫽ 67, group B: n ⫽ 26). Success rate of intubation was 97% (65/67, 2 attempts failed) in group A, whereas 100% (26/26) in group B. In group A, 97% (63/65) of intubations were achieved on the first attempt (*p⬍0.05, vs. group B), 3% (2/65) were on the second attempt. In group B, 50% (13/26) were intubated on the first attempt, 42% (11/26) were on the second attempt, and 2 intubations required 3 attempts. Regarding times required for intubation, T1, T2 and T3 were 22.6 ⫾ 17.9, 36.6 ⫾ 25.5*, and 63.5 ⫾ 30.1 second respectively in group A (* p⬍0.05, vs. group B). In group B, T1, T2 and T3 were 33.6 ⫾ 24.9, 53.4 ⫾ 25.4, and 69.0 ⫾ 22.7 second respectively. No complications were encountered in both groups. Conclusions: These results suggest that AWS may be a useful device for those who have no clinical training or experiences of tracheal intubation.

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DOES A PEDIATRIC AIRWAY PROGRAM LEAD TO SUSTAINED IMPROVEMENT IN PEDIATRIC RESIDENT AIRWAY SKILLS?

AN OBSERVATIONAL STUDY OF COST-EFFECTIVENESS ANALYSIS OF FLEXIBLE OPTICAL REUSABLE SCOPES WITH AND WITHOUT ENDOSHEATH® TECHNOLOGY: AN EFFECT OF TURNOVER TIME ON COSTS

Richard Mink, Nicole Baier, Harbor-UCLA Medical Center & LABioMed, Christopher Babbitt, Miller Children’s Hospital, Khanh-Van Le-Bucklin, University California, Irvine & Miller Children’s Hospital, Esther An, Harbor-UCLA Medical Center, Tom Kallay, Harbor-UCLA Medical Center & LABioMed Introduction: By the end of their training, pediatric residents are expected to be competent in airway skills, including endotracheal intubation (ET). However, studies indicate that this is not so. To improve airway proficiency, we created a program comprised of didactic sessions, simulation, an anesthesia rotation with patient encounters and a test to reinforce knowledge. Hypothesis: The purpose of this study was to determine whether this program was effective in increasing trainee airway knowledge, skill and attitude and if so, were these improvements sustained. Methods: Pediatric interns from 2 different pediatric residencies were evaluated. One group (n ⫽ 9) was exposed to the program, the other was not (n ⫽ 12). Knowledge, skills and attitude were assessed in both groups in the middle of the 1st year of training (pre-course; PRE), at the start of the 2nd year (post-course; POST) and 6 months later (6POST). Previously validated tools included tests of airway knowledge (multiple-choice [MCQ] and case-based questions; % correct), evaluation of bag-mask ventilation and ET performance (checklists; % correct), and a confidence questionnaire (5-point Likert scale). Analyses used repeated measures ANOVA and Fisher’s LSD. Data are mean⫾SD. Results: The groups were similar (p⬎0.05) in all baseline assessments except those who did not take the course scored slightly better (p⬍0.05) in MCQ than those who did. Program participants showed a greater improvement (p⬍0.05) in MCQ (POST-PRE: 19.3%⫾12.2 vs. -2.2%⫾26.7), ET (POST-PRE: 34.4%⫾13.5 vs. -5.3%⫾19.2; 6POST-PRE: 30.3%⫾24.5 vs. -4.6%⫾ 23.4%) and greater airway confidence (POST-PRE: 1.1⫾0.3 vs. -0.2⫾0.7; 6POST-PRE: 1.5⫾0.4 vs. 0.5⫾0.5). Compared with PRE, both groups showed increases (p⬍0.05) in MCQ and confidence at 6POST. The effect size (Cohen’s D) for all improvements was large. Conclusions: An airway skills program that uses multiple teaching methods can lead to a sustained improvement in pediatric trainee airway knowledge, skills and attitude. Without formal training, pediatric residents showed an increase in knowledge and greater confidence but this was not associated with improved ET performance as seen in participants, potentially contributing to a false sense of competency.


Deepak Gupta, Harper University Hospital, Dept. of Anesthesiology, Arvind Srirajakalidindi, Peter Panagopoulos, Romeo Kaddoum, Michael Okumura, Yaseer Al-Baghdadi, Hong Wang, Wayne State University/Detroit Medical Center Introduction: Flexible fiberoptic scopes’ use have cost-limitations secondary to their high costs of purchase and maintenance, and tedious and costly sterilization processes to contain cross-infection with cost-ineffective high turnover times between the cases. Hypothesis: The hypothesis for this observational study was that EndoSheath Technology, a single-use disposable sheath covering the specifically designed Vision-Sciences, Inc. reusable scope, will be cost effective in terms of cost-per-procedure secondary to the improved turnover time as compared to the traditional Olympus Inc. reusable scope. Methods: After institutional review board approval for waived consent, the Vision-Sciences Inc. reusable bronchoscope with single use disposable sheath called EndoSheath Technology was used for 75 airway procedures including fiberoptic tracheal intubations (sleep as well as awake fiberoptic intubations), assisting Glidescope intubations, double lumen endobronchial tube placements and fiberoptic bronchoscopies in the operating room environments. The data was collected in regards to the turnover times from the completion of use of scope until its readiness again for the next use. The cost-per-procedure was ascertained based on the purchase costs, repair costs, maintenance costs and labor costs for the EndoSheath Technology. This data was then compared with the historical data of the cost-per-procedure in regards to the traditional use of the Olympus Inc. fiberoptic bronchoscope at our institution. Results: As compared to the cost-per-procedure with Olympus fiberscope that was $119.75 which included $20.15 (purchasing), $53.48 (repair), $33.16 (maintenance), and $12.96 (labor), the cost-per-procedure with EndoSheath Technology was $84.91 which included $9.36 (purchasing), $28.92 (repair), $42.39 (maintenance), and $4.24 (labor) (P ⫽ 0.01). The turnover time was 5.44 minutes with EndoSheath Technology as compared to 30 minutes with Olympus fiberscope (P ⫽ 0.001). Conclusions: The EndoSheath Technology is significantly cost-effective than the traditional fiberscope technology with significantly improved turnover times for the airway related procedures. The present study was partially funded by Vision-Sciences, Inc. Orangeburg, NY.

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NON-INFERIORITY OF WEB-BASED TRAINING VS CLASSROOM-BASED INSTRUCTIONS FOR US-GUIDED CENTRAL VENOUS CATHETER (CVC) PLACEMENT–A SCALABLE TRAINING SYSTEM

ENHANCED TEACHING OF EVIDENCE-BASED GUIDELINES IN CRITICAL CARE MEDICINE USING ONLINE TESTING, FILE-SHARING, AND INTERACTIVE CASE-BASED TEACHING SESSIONS.

Gyorgy Frendl, Kimberly Matzie, Lauren Philbrook, Aya Mitani, Annette Mizuguchi, Rebecca Gersten, Brian Gelfand, Marie Gerhard-Herman, Charles Pozner, Brigham and Women’s Hospital

Adam Keene, Ariel Shiloh, Ronen Dudaie, Lewis Eisen, Richard Savel, Montefiore Medical Center

Introduction: US guidance reduces CVC related complications. The lack of scalable, structured training programs and standardized competency testing hinders its broad implementation. Hypothesis: Structured US guidance educational programs, if proven effective, could train and test the competency of hundreds of operators prior to patient encounter. Methods: 133 participants wererandomized via computer to either classroom (class:65) or web-based (web:68) group (with identical content), stratified by medical specialty and training level. They completed an online knowledge test, and were subjected to a 1-hour, simulator-based, US-guided CVC placement test on a Blue PhantomTM mannequin. Knowledge and procedural competency was compared using non-inferiority t-tests (scores⫹SD were scaled to 100 for all but the time and the image quality analysis). Results: The knowledge score of the participants (Web:74.4 ⫹12.13; Class:72.66⫹10.9; p⬍0.011, power 74.4%) did not reach the difference of 3 points we predicted in our null hypothesis, proving that the web-based learning is equally effective. With regards to the competencies acquired, the one-sided non-inferiority t-test confirmed web-based training is not inferior to classroom training in teaching how to archive data into the US machine (Web:71.50⫹9.47 vs. Class:73.38⫹11.76; P⬍0.05); US imaging and guidance of needle (Web:83.85⫹11.29 vs. Class:82.30⫹11.1; P⬍0.001; 5 point difference hypothesized for all); or in the quality of images they obtained (Web:11.32⫹1.73 vs. Class:11.18⫹1.51 [scale of 15; 2 point difference hypothesized]; P⬍0.001) and time to completion (Web:11.85⫹6.25 vs. Class:11.35⫹5.03 min; P⬍0.007; 2 min difference hypothesized). There was also no significant difference between the trainings; participants were not less competent in any of the following areas: sterile technique (Web:93.21⫹7.2 vs. Class:92.78⫹8.76; P⬍0.001); or in the number of attempts made (P⬍0.274, using Cochran-Armitage Trend Test). Conclusions: Our scalable Web-based US training program is not inferior to classroom-based instructions in delivering the knowledge content or to teach skills for US-guided CVC placement. We also demonstrated that simulation is a viable way to measure procedural competency.

Introduction: The purpose of this project was to document successful teaching of evidence-based guidelines in critical care medicine using online testing, file-sharing, and interactive case-base teaching sessions. Hypothesis: We hypothesized that this novel teaching method would lead to improved knowledge of evidencebased guidelines in critical care medicine and would be well received. Methods: We used a free, internet-based document collaboration system (GoogleDocs, http://docs.google.com) to develop and share online tests and teaching files as part of our critical care curriculum. Pre-tests were reviewed and completed by critical care fellows a week before each teaching session. Forms were created using GoogleDocs, and the results automatically populated a GoogleDocs spreadsheet. All teaching files and tests were distributed electronically. At the sessions, the pre-tests were reviewed interactively, and additional case-based questions were asked. One week after the session, the fellows were sent a post-test (identical to the pre-test) and a post-session survey. Results: 8 teaching sessions were held. The topics reviewed included vasopressors and inotropes, mechanical ventilation modes, salvage modalities for ARDS, nutrition in the ICU, antibiotics for septic shock, intracerebral hemorrhage, post cardiac arrest brain injury, and erythrocyte transfusion in the ICU. Overall, 220/405 questions were answered correctly on the pre-tests and 164/185 questions were answered correctly on the post-tests (54.3 vs 88.6%, p⬍0.001). On a scale of 1–10, the average ratings given by the fellows were 9.3 for utility of the teaching session, 9.1 for utility of the test questions, and 9.6 for utility of the teaching files. Conclusions: Evidence-based guidelines in critical care medicine can be successfully taught to critical care fellows using online testing, file-sharing, and interactive case-based teaching sessions.

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A US SURVEY OF AIRWAY MANAGEMENT TRAINING IN INTERNAL MEDICINE-BASED CRITICAL CARE FELLOWSHIPS

CARDIOVASCULAR CRITICAL CARE: A PERCEIVED DEFICIENCY AMONG CURRENT US FELLOWSHIP TRAINEES

Aaron Joffe, University of Washington, Harborview Medical Center, Elaine Liew, University of Southern California, Keck School of Medicine, Hernando Olivar, Miriam Treggiari, University of Washington, Harborview Medical Center

Jason Katz, University of North Carolina School of Medicine, Terence Hill, Johns Hopkins, Timir Paul, University of North Carolina School of Medicine, Loretta Que, Duke University Medical Center

Introduction: Intensivists may be primarily responsible for airway management in non-operating room locations. Little is know of airway management training provided during fellowship. Our aim was to describe the current state of airway education of internal medicine-based critical care fellowships. Hypothesis: The number of supervised airway procedures that fellows perform prior to graduation, on average, will vary widely and may be fewer than program directors believe is necessary to attain proficiency. Methods: From February to May, 2011, program directors of all three-year combined pulmonary/critical care and two-year multidisciplinary critical care medicine programs in the United States were invited to complete an online survey. Contact information was obtained via FRIEDA® online. Non-responders were contacted by email or telephone. Results: The overall response was 66% (111/168 programs). Sixty-four (58%) programs reported a designated airway rotation, chiefly occurring for 1 month during the first year of training. Thirty-five programs (32%) reported having a director of airway education and 78 (70%) reported incorporating simulation-based airway education. Nearly all programs (95%) reported provision of supervised airway experience during fellowship. Commonly used airway management devices including traditional and video laryngoscopes, intubating stylets, supraglottic airway devices, and fiberoptic bronchoscopes were reportedly available to trainees. However, 77% reported ⱕ10 uses of a supraglottic airway device, 65% ⱕ25 uses of intubating stylets , 77% ⱕ30 uses of a video laryngoscope, and 65% reported ⱕ10 flexible fiberoptic intubations. Estimates of the required number of procedures to ensure competence varied widely. Conclusions: The majority of programs have a formal airway management program incorporating a variety of techniques. Experience varies widely and it is unclear if competence is achieved, however

Introduction: Acute and chronic cardiovascular (CV) diseases commonly complicate the care of ICU patients. When present, they result in higher morbidity and mortality. Despite increasing awareness and a deliberate focus on CV care by the US critical care boards, it is not clear whether fellowship programs are currently meeting the educational needs of their trainees. Hypothesis: Trainees will identify multiple deficiencies in their ability to manage patients with comorbid CV disease. Methods: We designed and piloted a 19-item electronic survey sent to all trainees in ACGME-accredited critical care programs. Questions were designed to assess confidence, ranging from 1 (not confident) to 5 (very confident), and focused predominantly on CV disease management and procedural skills. Descriptive stats were performed and non-parametric Spearman’s rank correlation was used to identify associations between training program or year and confidence. Results: 134 surveys were collected, representing pulmonary/CC (n ⫽ 70), surgical/CC (n ⫽ 38), anesthesiology/CC (n ⫽ 13), and stand-alone CC (n ⫽ 13) programs. Most participants were in their 1st year of training (58%). In aggregate, those surveyed had greater mean confidence in their ability to identify and manage non-CV diseases (4.6 vs. 4.0), as well as their ability to perform non-CV critical care procedures compared to traditional CV ones (4.5 vs. 2.9). With many topics, including cardiogenic shock, aortic dissection and aneurysm, valvular disease, pacer troubleshooting, PA cath placement, and echo (all p⬍0.05), trainees within pulm/CC programs were less confident than others. Additional deficiencies included congenital heart disease and circulatory support. The majority of respondants reported that both CV didactics and dedicated cardiac ICU training were infrequently part of their curriculum, but that they would benefit from their inclusion. Conclusions: Despite its growing influence on outcomes, there appears to be a disparity between need and support for CV critical care training within US fellowship programs. Future direction should focus on creating standardized curricula for education and skills acquisition in order to improve the care of an increasingly complex patient population.


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ABILITY OF ANESTHESIOLOGISTS TO DETECT PNEUMOTHORAX ON ULTRASOUND

PEDIATRIC CRITICAL CARE SIMULATION IDENTIFIES AREAS NEEDING FURTHER EDUCATION

Sundar Krishnan, Taften Kuhl, Kenichi Ueda, Waseemuddin Ahmed, University of Iowa Hospitals and Clinics

Courtney Rowan, William Ma, Alvaro Tori, Richard Speicher, Riley Hospital For Children

Introduction: Portability, lack of radiation, and a high negative predictive value make ultrasound an attractive tool to rule out pneumothorax. To achieve widespread use, new learners have to easily acquire this skill. Hypothesis: We hypothesized that after basic training, anesthesia residents and faculty can rule out pneumothorax on an ultrasound image of the chest with a high degree of sensitivity and specificity. Methods: After Institutional Review Board-approval, ultrasound video images with and without pneumothorax were compiled in a library by the study investigators from 53 patients undergoing elective thoracic surgery. Ninetynine videos were compiled in a library. Forty-eight anesthesia residents and 57 anesthesia faculty members were invited to view a 5-minute tutorial and then take a quiz with 20 ultrasound videos randomly selected from the library. Sensitivity and specificity were calculated for overall performance, and multivariate logistic regression was performed to identify significant independent covariates affecting performance. Residents and faculty who took the quiz were asked to retake the quiz six months later, to test for retention of knowledge. Results: Seventy-nine (75.2%) of the invited residents and faculty members took part in the study. The overall sensitivity and specificity for ruling out pneumothorax was 87.4% and 85.6%, respectively. On multivariate analysis, factors that significantly reduced the ability of participants to correctly rule out pneumothorax on ultrasound were presence of heart beat (OR 3.7, 95% CI 2.4 –5.8) and probe movement (OR 2.6, 95% CI 1.4 – 4.7) on the ultrasound video. Years of experience in anesthesia, prior training with ultrasound and frequency of use of ultrasound did not alter participant performance. In a preliminary analysis of the retest taken after six months, anesthesiologists chose the correct answer 80% of the time. Conclusions: After basic training, anesthesia residents and faculty members can rule out pneumothorax on ultrasound with high reliability. Imaging characteristics, like probe movement or heart beat, may affect this ability. Anesthesiologists exhibited good retention of this knowledge six months after the initial training.

Introduction: Simulation can enhance medical education by applying real-life clinical scenarios in a controlled environment, allow the learners to practice clinical skills at varying levels of difficulty, and to progress at their own pace. It is a unique way to practice seldom used but important life-saving techniques, particularly in a critical care setting. Previous realistic practice of emergency skills with simulation may improve patient outcomes in the intensive care unit. Hypothesis: A well designed simulation program can identify areas that need further education, while improving resident confidence when faced with similar real life acute clinical scenarios. Methods: This is a prospective, observational study of pediatric residents describing the experience implementing a new pediatric critical care simulation education program. Residents underwent 2 videotaped scenarios and debriefing sessions. Pre and post self assessment confidence tests were administered. The videotapes were reviewed by a team of experts using a checklist of expected performance skills to identify areas of education deficiencies. Results: Nine sessions with a total of 30 residents were completed. Education deficiencies were identified with intubation, modified rapid sequence intubation, needle decompression, ordering a chest radiograph at the appropriate time, choosing endotracheal tube size, starting vasopressors, and treatment of ventricular tachycardia. There was a statistical improvement (p⬍0.05) in confidence in running and participating in a code, knowing the roles of the team, deciding on intravenous access, placing an intraosseous line, starting vasopressors, and overall confidence score. There was a trend toward improved confidence (p ⫽ 0.06) in using a defibrillator and intubation. Conclusions: Simulation can identify clinical areas in need of further education. This data can be applied to the design of a more formal critical care education program for pediatric residents. It also improves self-measured confidence among pediatric residents.

454 TWO POINT COMPRESSION ULTRASOUND IS SUBOPTIMAL IN THE CRITICALLY ILL Jonathan Caronia, Adrian Sarzynski, Raghukumar Thirumala, Babak Tofighi, Georgia Panagopoulos, Bushra Mina, Lenox Hill Hospital Introduction: Two point compression ultrasonography (CUS) is often used by critical care and emergency physicians for rapid diagnosis of DVT. This method involves compression at the the common femoral and popliteal veins and excludes evaluation of the superficial femoral vein. The utility of this method in the critically ill is unknown. We performed a subset analysis of concurrently submitted data analyzing accuracy of CUS performed by trained internal medicine residents (IMR) for all clinically relevant DVT, including those involving the superficial femoral vein. Hypothesis: IMR may detect DVT using two point CUS in critically ill patients. Methods: We performed a prospective study of two-point CUS by IMR in critically ill patients at a tertiary teaching hospital. Attending radiologist official findings were used as the reference standard. All residents received a 2-hour standardized training course in focused vascular ultrasonography, which included instruction in visualization and compression of the common femoral and popliteal veins. The superficial femoral vein was excluded. Results: Forty three patients were included in the study. Prevalence of DVT in our cohort was 11.6%. Three patients (7%) had DVT in the superficial femoral vein, two of whom had preserved compressibility in the common femoral vein. One patient with superficial femoral vein thrombosis had DVT in the common femoral vein as well and lacked compressibility there. When compared with the reference standard specificity was 92%, negative predictive value was 95%, sensitivity was 60% and positive predictive value was 50%. The kappa coefficient was 0.48 and diagnostic accuracy was 88.3%. Conclusions: Two point CUS had a low sensitivity for all DVT in our cohort, missing two superficial femoral DVT. This method is inadequate for diagnosis of DVT in critically ill patients. We recommend a ‘three-point‘ compression study in order to improve sensitivity in future IMR CUS training.



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ALGORITHM-BASED PROACTIVE RAPID RESPONSE TEAM ROUNDS: DEVELOPING A SAFETY NET FOR PATIENTS AND NURSES

AIRWAY MANAGEMENT SKILLS FOR PEDIATRIC CRITICAL CARE NURSE PRACTITIONERS: A SIMULATION-BASED TRAINING PROGRAM

Valerie Danesh, Orlando Health, Edgar Jimenez, Orlando Regional Medical Center

Allison Thompson, Sharon Irving, Akira Nishisaki, Roberta Hales, Vinay Nadkarni, Robert Berg, Children’s Hospital of Philadelphia

Introduction: The future of Rapid Response Teams (RRT) is to move from reactive calls to proactive surveillance. The Electronic Medical Record can be optimized to promote nurse-to-nurse education while providing a safety net for the management of hospitalized patients. Hypothesis: The use of algorithms within the EMR for Early Warning Scores (EWS) can increase anticipatory nursing interventions for patients at risk for deterioration. Methods: The Rothman Severity of Illness Index (RI) is a graphic display of an algorithm based on 26 variables that provides a timeline of the patient’s condition throughout hospitalization to support the clinical evaluation of patients to help identify critical changes or slow deteriorations that may be difficult to detect. The RI was implemented in all inpatient areas of a 210-bed teaching hospital in Florida in 2011 to drive proactive ‘surveillance‘ rounding by Rapid Response Team nurses (RRT RN). The RRT RN identifies relevant cases and rounds on 2– 4 patients while delegating additional patients to the charge nurse for follow-up and report back to the RRT RN. The reasons and interventions for each patient visit were recorded. Results: 206 patient graphs were inspected by RRT RNs over 3 weeks. Surveillance visits were conducted on 162 occasions (average 3.9 visits/12h) and represented a 1013% increase in patient encounters compared with traditional reactive RRT calls (N ⫽ 16) during the same period in 2010. Nursing-driven interventions and/or nurse-to-nurse coaching was implemented 89 times (average 2.1 visits/12h) and demonstrated anticipatory nursing care such as prompting calls to providers for relevant assessment findings and lab results (19%, N ⫽ 17) and nurse-to-nurse mentorship (59.6%, N ⫽ 53) including code status dialogue, documentation inconsistencies, and sepsis screen coaching. Conclusions: The use of ‘smart‘ algorithms combined with the clinical experience of RRT RNs effectively increased anticipatory nursing care for patients at risk for deterioration while promoting expertise-sharing among nurses. Further study of the patient safety and quality implications of data-driven proactive rounds is warranted.

Introduction: Airway management skills are essential for pediatric critical care nurse practitioners (NP). Our objective was to develop and implement a simulation-based training program to better prepare our critical care NPs for airway management. Hypothesis: We hypothesized that tracheal intubation performed by NPs in a pediatric ICU is more successful compared to those by pediatric residents, as determined by first-attempt intubation success rates. Methods: The NP airway training program was developed by pediatric critical care NPs and attending physicians specifically trained in simulation-based education. The program was implemented in FY2011 and consisted of a 4-hour structured airway management skills training with a didactic discussion and one-to one hands-on training with partial task trainers and whole body simulators, followed by one week of airway management training in the operation room. The instructors were critical care medicine attendings/ senior fellows. The first attempt success of tracheal intubation was measured using local airway database (NEAR4KIDS) during FY2009 –11. This was compared to the performance by residents. Fisher’s exact test with p⬍0.05 as significant. Results: Thirteen NPs (81 %) completed the training in FY2011. NPs were the first laryngoscopist in 39/566 (6.9%) of all ICU oral primary intubations (3.3% in FY2009, 8.5% in FY2010, 7.9% in FY2011). This increase was not significant over years (p ⫽ 0.11). First attempt success rate was not different when compared to Residents (NP: 25/39 (64%) vs. Residents: 83/171 (49%), p ⫽ 0.11). This finding was similar when analyzed for each academic year (p⬎0.1 for all FYs). NPs were successful in 4/5 (80%) in FY2009, 9/14 (64%) in FY 2010, and 12/20 (60%) in FY 2011. This NP first attempt success rate, however, did not change over the time (p ⫽ 0.89). Conclusions: The simulation-based airway training program for pediatric critical care NPs was successfully implemented and performance was tracked by a local NEAR4KIDS database. NPs performance measured by first attempt success was not different from the Residents and did not improve during the observation period. Further follow-up is warranted to evaluate training effectiveness and mitigation if necessary.

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EDUCATIONAL LEVEL OF EMERGENCY PHYSICIANS IS ASSOCIATED WITH PROLONGED SCENE TIME IN HELICOPTER EMERGENCY MEDICAL SERVICES (DOCTOR-HELICOPTER) IN JAPAN

ORGANIZATIONAL COMMUNICATION EFFORTS FOR PREVENTING CATHETER RELATED BLOOD STREAM INFECTIONS (CRBSIS) IN A MEDICAL INTENSIVE CARE UNIT

Eiji Sakawaki, Wakiko Aisaka, Hirotoshi Mizuno, RYOKO KYAN, Keigo Sawamoto, Kunihiko Maekawa, Katsutoshi Tanno, Kazuhisa Mori, Yasufumi Asai, Sapporo Medical University Introduction: It is advocated that pre-hospital time from scene to admission should be kept as short as possible in severe disease such as trauma, acute myocardial infarction and acute ischemic stroke. In Japan, emergency physicians (EPs)-staffed helicopter emergency medical service (HEMS), called as “DoctorHelicopter”, is prevailing now, but it is unknown about the impact of educational level of EPs on pre-hospital scene time. Hypothesis: Educational level of EPs may be associated with prolonged scene time in EPs-staffed HEMS. Methods: We performed a retrospective cohort study on 12 months. All patients were included if they were referred directly from scene to hospital by EPs-staffed HEMS. The dispatch of HEMS was decided according to our local protocol. Data were abstracted including demographics, diagnosis, physical status on HEMS arrival, scene time and interventions by EPs. EPs were stratified according to their educational level into 2 groups, junior doctors (with 4 –5 years of ongoing emergency medicine experience) and senior doctors (with 6 –10 years of experience). Outcome measure was prolonged scene time (PST), defined as ⬎⫽ 15 minutes. Logistic regression model was used to evaluate the association between educational level and outcome. Results: Of 61 consecutive patients, 33 were enrolled into PST group and 28 were enrolled into non-PST group. 2 junior doctors and 4 senior doctors attended our HEMS. Compared to non-PST group, PST group had significantly more women (42.4% vs. 21.4%, p ⫽ 0.082), less cardiac arrest patients and more trauma patients (3.0% vs.25.0%, 51.5% vs. 42.9%, respectively, p ⫽ 0.034), less hypotension (systolic blood pressure ⫽ ⬍75 mmHg) (15.2% vs. 32.1%, p ⫽ 0.014), less bradypnea (respiratory rate ⫽ ⬍9/minute) (9.1% vs. 32.1%, p ⫽ 0.049) and more often treated by junior doctors (48.5% vs. 25.0%, p ⫽ 0.059). Multivariate logistic regression analysis showed that treatment by junior doctors only was significantly associated with PST (adjusted odds ratio 4.11, 95%CI 1.01–16.61, p ⫽ 0.047). Conclusions: Educational level of EPs was associated with prolonged scene time in EPs-staffed HEMS. Educational effects on junior doctors need to be determined in further studies.

Harigopal Reddy, Amy Blanchard, William Davis, Thomas Dillard, Sandra Clay, Sarah Perry, Michelle Sweat, Donna Goins, Wanda Gillespie, Pavani Rangachari, Georgia Health Sciences University Introduction: CRBSIs are a significant source of mortality. Substantial evidence shows that successful implementation of the “central line bundle (CLB)” can significantly reduce CRBSIs. The CLB consists of five practices: hand hygiene; CHG skin antisepsis; maximal barrier precautions; optimal site selection; and daily review of line need. We previously showed that low compliance with CLB in MICU was associated with the absence of an organizational communication network related to CLB. This prospective study seeks to improve implementation of the CLB in the MICU and also examine communication dynamics underlying successful implementation of CLB. Hypothesis: Our aim is to improve implementation of CLB in MICU through periodic quality improvement (QI) interventions over a 52-week period, and also: 1)Examine dynamics (direction, frequency, and content) of communication related to CLB in the MICU through weekly communication logs from RNs and MDs; and2)Examine bedside compliance with CLB in the MICU through weekly chart review. Methods: The institution initiated the study (Grant R03HS019785 from AHRQ) in Jan 2011 and has so far compiled data for 26 weeks. QI interventions include 1) feedback of CLB compliance data to MICU staff, and 2) education on how CLB prevents CRBSIs. Results: MICU compliance with “catheter certification,” i.e. hospital protocols of having the catheter insertion process observed by a member of vascular team (to ensure adherence to first four CLB practices) rose from 30% at baseline, to 100%. Additionally, MICU launched a system for “catheter maintenance,” i.e., daily review of line need (to ensure adherence to fifth CLB practice). The system addresses need for central lines during morning rounds. Concurrently, MICU CRBSI rate declined from 3.6 to 0.8 per 1000 catheter days (p⬍0.05). These process improvements are concurrent with increased communication among RNs and MDs, on CLB processes, as well as increased engagement related to catheter safety (i.e., a culture of safety). Conclusions: The study suggests that the combination of process, communication, and culture changes has helped MICU significantly reduce its CRBSI rate, and we hope that they will also help MICU sustain the reduction.


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ENDOSCOPICALLY DIRECTED MIDDLE MEATAL CULTURES VERSUS CT SCANS IN THE DIAGNOSIS OF BACTERIAL SINUSITIS IN INTENSIVE CARE UNITS

IMPACT OF AN ICU DELIRIUM EDUCATIONAL SERIES ON NURSES’ PERCEPTION OF DELIRIUM

Ehab El Reweny, Faculty of Medicine Alexandria Univeristy Introduction: Patients admitted to the intensive care units are likely to develop fever at some point of their stay there. It could be due to well recognized hospital acquired infection such as ventilator-associated pneumonia . 1 However, the potential role of sinusitis as a source of hospital-acquired infection has been much less well studied. Hypothesis: The objective of the study was to evaluate the accuracy of endoscopically directed middle meatal cultures (EDMMC) in the diagnosis of bacterial sinusitis in intensive care unit (ICU) patients in comparison with CT scans. Methods: The study was conducted at Alexandria University Hospitals on 51 ICU patients with occult fever and clinical signs of sinusitis. Sinus CT scans were done for all patients, and Calgi swabs were obtained from the middle meatus bilaterally under endoscopic vision using sterile endoscopes. The results of EDMMC were compared with the results of CT scans. Results: CT signs of sinusitis were bilateral in 10 patients (19.6%), unilateral in 31 patients (60.8%), and negative in 10 patients (19.6%). EDMMC yielded positive cultures on both sides in 13 patients (25.5%), and on one side in 27 patients (52.9%). On the other hand, the cultures were negative in 11 patients (21.6%). EDMMC had a sensitivity of 92.8%, a specificity of 80.0%, and an accuracy of 90.2% in comparison with CT scans. Polymicrobial colonization was more frequent than monomicrobial colonization. The organisms isolated most frequently were coagulase negative staphylococci, S. aureus, and pseudomonas aeurginosa. Conclusions: EDMMC had high sensitivity in diagnosis of bacterial sinusitis and identified the causative bacteria in comparison to CT scans. The procedure is simple, non-invasive, and can be easily performed at the bedside .The procedure can be considered as a trustworthy substitute to sinus CT scans in ICU patients especially when it is difficult to transport the patients for imaging. CT scans can be , therefore, reserved for patients who do not respond to culture specific antibiotherapy.A further advantage of this approach is avoidance of the cumulative effect of unnecessary radiation.

Jeffrey Gonzales, University of Maryland School of Pharmacy, Kathleen Morneau, Methodist University Hospital, Siu Yan Yeung, University of Maryland Medical Center Introduction: ICU delirium increases morbidity and mortality and is often under-recognized due to the lack of awareness and the use of informal assessments. The purpose of this survey study was to assess the impact of an ICU delirium educational series on nurses’ perception of delirium. Hypothesis: We hypothesized that ICU nurses perception of ICU delirium will change after education. Methods: This is a single center, pre-/post-educational survey. Inclusion criteria were all MICU nurses. There were no exclusion criteria. The pre-educational survey (pre-ES) was distributed to the nurses in 8/2009. Education on ICU delirium was then initiated, which included in-services, web-based training, and poster boards. The post-educational survey (post-ES) was distributed in 4/2010. Data collected included: demographic data, awareness of ICU delirium guidelines, use of delirium assessment, frequency of delirium assessment, interventions for delirium, and understanding of delirium. Results: 82 nurses completed the pre-ES and 61 nurses completed the post-ES. Pre-ES and Post-ES demographic data were: mean age, 35⫾8.4 yr vs. 35.4⫾9.8 yr; MICU service, 4.4 yr vs. 3.6 yr; day shift, 51.1% vs. 51%. 90% of the pre-ES group were aware of the MICU sedation guidelines, whereas 32.9% were aware of the MICU delirium guidelines. 66.3% of the pre-ES group used either a neurologic exam or did not assess for delirium. 60.3% of the pre-ES group had no prior education on delirium. Frequency of delirium assessment between groups (pre-ES vs. post-ES) was: 65.5% reported none or only when agitated vs. 89.8% used the CAM-ICU every 4 hours. 54.9% of the pre-ES group thought that environmental modification was useful compared to 78.3% of the post-ES group. Both groups thought that delirium was under-diagnosed (⬎90%). 73.2% of the post-ES group had a satisfactory understanding of ICU delirium. 74.6% of the post-ES group were confident in their ability to administer the CAM-ICU. Conclusions: An ICU delirium educational series was beneficial to the nursing staff. The nurses increased their understanding of ICU delirium and their confidence in administering the CAM-ICU. The lack of baseline education on delirium underscores the importance of continued education.

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JUST SAY NO TO ICU STARVATION: A NUTRITION EDUCATION PROGRAM FOR SURGERY RESIDENTS

IMPACT OF HIGH-FIDELITY SIMULATION TRAINING ON PHARMACIST COMPETENCY IN ADVANCED CARDIOVASCULAR LIFE SUPPORT

Shawn Spear, The Methodist Hospital, S. Todd, NYU Langone Medical Center Introduction: Nutrition education of residents is inadequate. At the same time, current research supports the importance of targeted nutritional therapy in the ICU. In 2009, SCCM and the American Society for Parenteral and Enteral Nutrition (ASPEN) published “Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient”. To improve our surgery residents’ understanding of ICU nutrition, we developed a Nutrition Education Program based on these guidelines. Hypothesis: The purpose of this study was to assess its’ effectiveness. We hypothesized that our Nutrition Education Program would improve our residents’ knowledge of ICU nutrition. Methods: This was a prospective observational pilot study performed in the Surgical ICU (SICU) at an academic medical center. Based on the SCCM/ASPEN nutrition guidelines, we developed a Nutrition Education Program. All surgery residents rotating through the SICU were required to attend 2 one-hour lectures covering selected guidelines and to participate in interactive case studies. Pre- and post-testing were performed to assess short-term comprehension. Long-term retention was assessed 3 months after the initial educational program. The primary outcome measure was the change in knowledge about ICU nutrition. A one-way ANOVA analysis was performed with significance set at a p ⬍0.05. Results: Over 12 months ending June 2010, 8 surgery residents completed the Nutrition Education Program. Their mean age was 27.8⫾1.2 years and 50% were male. The mean test scores were: pre-test, 45⫾9%; post-test, 81⫾5%; and 3-month test, 65⫾8%. The differences between the pre-test and both the post-test and 3-month test scores were significant, p⬍0.01. Conclusions: Residents have little understanding of ICU nutrition. This is confirmed by the pre-test results of the current study. Our Nutrition Education Program improved not only the shortterm ICU nutrition knowledge of our surgery residents, but the long-term as well. Future studies should evaluate the effect such education has on the clinical outcomes of our SICU patients.


Amy Eng, Jennifer Namba, Kevin Box, James Lane, Dennis Kim, Daniel Davis, Raul Coimbra, Jay Doucet, University of California San Diego Medical Center Introduction: High-fidelity simulation is a mode of education that can support the real-time application of skill sets and has impacted medical training through the emphasis of critical thinking, communication, and inter-professional teamwork skills. Hypothesis: We hypothesize that human patient simulation can improve pharmacist knowledge, confidence, and competency with Advanced Cardiovascular Life Support (ACLS) algorithms and interventions. Methods: Twelve acute care pharmacist residents at the University of California San Diego Medical Center (UCSDMC) participated in an ACLS simulation training session using a high-fidelity mannequin. The course involved an overview of the 2010 American Heart Association guidelines, a review of pertinent medications and calculations, and participation in 3 simulated clinical scenarios. The first simulated case was demonstrated by 2 code-competent intensive care unit pharmacists and the remaining scenarios were managed by a group of 4 pharmacist residents. Each resident was given the opportunity to participate as the primary pharmacist in the simulated code team. Instructor debriefing and resident feedback was provided after each case. Results: Following human patient simulation, knowledge increased from 65% to 88% (p ⫽ 0.001) and confidence scores rose from 3.2 to 4.0 (p ⫽ 0.001) based on a 5-point Likert scale. Overall competency with ACLS algorithms and techniques also improved from 64% to 77% (p ⫽ 0.009) through an evaluation from a comprehensive intervention checklist. Conclusions: High-fidelity simulation training facilitated a notable improvement of pharmacist resident knowledge, confidence, and competency with practical ACLS skills. In addition, pharmacist residents demonstrated significantly higher levels of performance, including skills requiring advanced competency and proactive interactions with the code team. The outcomes of this study may be used to guide further use of simulation for ACLS education and training.

463 MULTI-DISCIPLINARY QUALITY IMPROVEMENT PROACH ON HYPOGLYCEMIA IN A SURGICAL ICU

464 AP-

Anthony Gerlach, Ohio State University Medical Center, Jennifer MacDermott, The Ohio State University Medical Center, Cheryl Newton, Ohio State University Medical Center, Charles Cook, Ohio State University Hospitals, Claire Murphy, The Ohio State University Medical Center Introduction: Both hyperglycemia and hypoglycemia can significantly impact on outcomes in critically ill patients. In the intensive care unit (ICU), hypoglycemia is often the result of intensive insulin therapy used to counteract the negative effects of hyperglycemia. Hypothesis: The purpose of this study is to compare rates of hyperglycemia using a multi-disciplinary quality improvement approach with targeted education and real time follow-up in a surgical ICU. Methods: Using a daily report, a clinical pharmacist reviewed all cases of hypoglycemia (glucose ⬍74 mg/dL) for the previous day from 3/16/10 through 3/15/11. For cases of hypoglycemia related to insulin infusions and non-adherence to the institutional guideline, the pharmacist spoke with a clinical nurse specialist who provided targeted education to the bedside nurse involved. In August 2010, nursing education and feedback was conducted on glycemic control and the insulin infusion guideline. Causes of hypoglycemic events were compared before and after this education and feedback was completed. Results: Four hundred twenty nine hypogylcemic events (188 patients) occurred in 2233 patient admissions. Most of the events involved administration of insulin (40%), including 106 (25%) involving insulin infusions and 59 (14%) associated with sliding scale insulin administration. Prior to unit feedback, 47% of hypoglycemic events involving insulin infusions were associated with guideline non-compliance. Education and feedback significantly reduced the percentage of hypoglycemic events due to non-compliance (17%, p ⫽ 0.002). Conclusions: Education and unit feedback with follow-up to staff in real time was associated with increased compliance of insulin infusion guidelines. Targets for improvement have been identified.

HOW ARE COMMUNICATION AND PROFESSIONALISM TAUGHT AND EVALUATED ACROSS THE CONTINUUM OF PEDIATRIC CRITICAL CARE MEDICINE FELLOWSHIPS? David Turner, Duke University Medical Center, Richard Mink, Harbor UCLA Medical Center, Margaret Winkler, The Children’s Hospital of Alabama, K Lee, Medical College of Wisconsin, Sara Ross, Montefiore Medical Center, Jennifer Schuette, Children’s National Medical Center, Katherine Mason, Rainbow Babies and Children’s Hospital, Katherine Biagas, Columbia University, College of Physicians and Surgeons, Stephanie Storgion, University of Tennessee Health Science Center, Denise Goodman, Children’s Memorial Hospital, for the Education in Pediatric Intensive Care (EPIC) Investigators Introduction: Communication and professionalism are crucial elements of graduate medical education, but teaching and evaluating these two areas are often challenging. Despite their importance, little is known regarding the teaching and evaluation modalities utilized by pediatric critical care medicine (PCCM) training programs. Hypothesis: We hypothesized that teaching and evaluation techniques for communication and professionalism are diverse among PCCM training programs. Methods: The Education in Pediatric Intensive Care (EPIC) Investigators developed a survey based on the training requirements of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics. After development and piloting, surveys were sent to the 66 program directors (PDs) of accredited PCCM fellowships. Results: 67% of PDs responded, representing educators for 73% of current PCCM fellows. Respondents had a median of 4 years of experience and a median of 36 ICU beds, 7 fellows, and 12 teaching faculty in their programs. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication, and 54% of PDs indicated that these were most important. Faculty role modeling was also the most commonly used technique to teach professionalism in 7 out of 16 content areas and was judged by 59% of PDs to be most important. For 7 other professionalism content areas, didactics were most common, but only 19% of PDs reported didactics as most important. Evaluations by members of the multidisciplinary team were used most commonly for assessment of both communication and professionalism. The use of a specific teaching technique was not related to program size, PD experience, participation in an ACGME review, or availability of faculty with training in medical education. Conclusions: A wide range of modalities are used to teach communication and professionalism, but PCCM programs primarily use faculty role modeling and direct observation for communication, and faculty role modeling and didactics for professionalism. Opportunities exist to expand the use of other techniques and determine the optimal methods to enhance fellow education in these areas.

465 DO PEDIATRIC CRITICAL CARE MEDICINE FELLOWSHIPS MEET THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION REQUIREMENTS TO TEACH COMMUNICATION AND PROFESSIONALISM? David Turner, Duke University Medical Center, Richard Mink, Harbor UCLA Medical Center, Margaret Winkler, The Children’s Hospital of Alabama, K Lee, Medical College of Wisconsin, Sara Ross, Montefiore Medical Center, Jennifer Schuette, Children’s National Medical Center, Katherine Mason, Rainbow Babies and Children’s Hospital, Katherine Biagas, Columbia University, College of Physicians and Surgeons, Stephanie Storgion, University of Tennessee Health Science Center, Denise Goodman, Children’s Memorial Hospital, for the Education in Pediatric Intensive Care (EPIC) Investigators Introduction: Communication and professionalism are key educational competencies established by the Accreditation Council on Graduate Medical Education (ACGME) that include a number of required content areas. These competencies are often difficult to teach, and little data exist regarding whether pediatric critical care medicine (PCCM) training programs provide formal instruction in all mandatory areas. Hypothesis: We hypothesized that many PCCM programs lack a structured method to teach important required elements of communication and professionalism. Methods: The Education in Pediatric Intensive Care (EPIC) Investigators developed a survey based on the training requirements of the ACGME and the American Board of Pediatrics. After development and piloting, the surveys were sent to the 66 program directors (PDs) of accredited PCCM fellowships. Results: Survey response rate was 67%. PD respondents had a median experience of 4 years, 66% had participated in an ACGME review, and their programs had a median of 7 fellows and 12 teaching faculty. 32% of programs had no mechanism to teach communication and how to work effectively within a non-clinical group, and 18% did not teach communication through medical records. In one quarter of programs, there was no method to teach fellows communication via consultation outside of the ICU and no formal mechanism to teach the maintenance of professional standards. 18% had no method to teach peer review. There was no system to help fellows learn the impact of grief and loss on themselves in 16% of programs, and 14% did not formally teach trainees professional boundaries. Deficiencies were unrelated to program size, PD experience, participation in an ACGME review, or the presence of faculty with advanced medical education training. Conclusions: Within PCCM, a structured mechanism does not exist to teach required components of the ACGME competencies of communication and professionalism. Deficiencies of this nature likely exist broadly within GME given the traditional difficulties teaching and evaluating these important competencies. These areas represent opportunities to develop and implement novel educational techniques to improve GME.



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INTERNAL MEDICINE RESIDENTS DETECTING HYDRONEPHROSIS USING FOCUSED RENAL ULTRASONOGRAPHY

IMPROVING TEAMWORK, CONFIDENCE AND COLLABORATION AMONG A PEDIATRIC CARDIOVASCULAR INTENSIVE CARE MULTIDISCIPLINARY TEAM USING SIMULATION

Jonathan Caronia, Babak Tofighi, Maria DeVita, Alexander Bershadsky, Georgia Panagopoulos, Gina Frumkin, Bushra Mina, Lenox Hill Hospital Introduction: Despite considerable advances in the management of patients with acute kidney injury (AKI), mortality rates continue to remain high. In response, the 2011 Renal Association Guidelines recommended the use of renal ultrasound (US) within 24 hours of detecting AKI. The prospects for quickly diagnosing an etiology for AKI may be improved with the increased availability of bedside US, especially when performed by Internal Medicine residents (IMR) in intensive care units (ICU). Key components included kidney size, echogenicity, cortical thickness, and presence of hydronephrosis (HN). We report our initial findings. Hypothesis: IMR findings on US will correlate with official radiological studies in detecting HN as an etiology of AKI. Methods: A blinded prospective study was done with IMR performing focused renal sonography in patients presenting with AKI within 24 hours of diagnosis in the ICU, intermediate units, and Regional Medical floors. Patients were studied for HN, echogenicity, length, and cortical thickness. Residents were given a standardized 2 hour course accompanied with bedside training for the detection of HN. Results were then compared with official Radiology findings. We now report our HN findings. Results: There were a total of 10 IMR performing 40 studies over a five month period. Seventy-seven kidneys were evaluated, 16 studies revealed HN by IMR. When compared to official radiology findings, 9 were confirmed as true-positives, 7 were not confirmed (false positive), and 1 case was not detected by IMR (false negative) yielding a sensitivity of 90%, specificity of 89.6%, NPV of 98.3%, PPV of 56.3% and Kappa of 0.634. Of note the one false negative was on the left side, which is more difficult to evaluate. Conclusions: IMR are proficient in detecting hydronephrosis allowing for earlier diagnosis and treatment of AKI. IMR are now being assessed for accuracy in detecting cortical thickness, echogenicity, and length as another tool in the management of AKI.

Whitney Smith, Lebonheur Children’s Hospital, Samir Shah, Le Bonheur Children’s Medical Hospital, Deborah Esmon, LeBonheur Childrens Hospital, Robert Sepanski, LeBonheur Children’s Hospital, Mayte Figueroa, Le Bonheur Children’s Hospital Introduction: The purpose of the study was to evaluate the effectiveness of cardiac simulation training on improving teamwork, confidence and collaboration amongst multidisciplinary team members of a Pediatric Cardiovascular Intensive Care Unit(PCICU). Hypothesis: We hypothesized that implementation of a simulation workshop focused on common pediatric postoperative cardiac surgical emergencies would aid in improving teamwork, confidence and communication during these events. Methods: The leadership team of the PCICU chose to use simulation based training to implement a Post Pediatric Cardiac Surgery arrest(PPCS-CA) management algorithm as well as Team STEPPS in the PCICU. Predetermined critical performance criteria for each scenario were used to evaluate participants and shared during debriefing. Electronic surveys were performed prior to, immediately after and at 3 months to capture perception of skill, knowledge and confidence. Participants were asked to rate their level of skill and confidence in performing specific roles in a team resuscitation. They also rated the team on overall skill, collaboration and communication (Team STEPPS) . Results: There were a total of 37 participants: 23 nurses, 5 Cardiology/ Critical Care trainees (1 Pediatric Critical Care and 4 Pediatric Cardiology fellows), 5 respiratory therapists, and 4 not categorized. Statistical analyses were performed on survey results using Wilcoxon signed-rank tests and a Holm (Stepdown Bonferroni) multiple testing correction. When analyzing the overall team responses, respondents reported a statistically significant (p ⬍or ⫽ 0.05) increase in confidence and skill immediately after and 3 months post training in the following roles: Team Leader, advanced airway management and cardioversion/defibrillation. There was also a statistically significant (p ⬍or ⫽ 0.05) increase in the practice of Team STEPPS concepts immediately after and 3 months post training. Conclusions: Simulation based training is an effective way of improving communication and increasing confidence amongst members of a multidisciplinary team. Simulation may provide an alternative tool for maintaining critical skills as well as implementing new processes and quality initiatives in the CVICU.

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THE ROLE OF QT INTERVAL DISPERSION AS A PREDICTOR OF THE FUNCTIONAL OUTCOME IN PATIENTS WITH ACUTE CEREBROVASCULAR STROKE

THE EFFICACY OF AIRWAYSCOPE (PENTAX-AWS) ON THE EDUCATION OF THE RESIDENTS AND FELLOWS IN TERMS OF THE PEDIATRIC INTUBATION

Ehab El Reweny, Faculty of Medicine Alexandria Univeristy

Yoshio Sakurai, Saitama Medical Center, Saitama Medical University

Introduction: QT dispersion (QTD) could be used as a predictor of adverse outcomes in various cardiac diseases. Prolonged QTD could be found in patients with myocardial infarction, left ventricular hypertrophy, heart failure, and diabetes mellitus. However, the relation between prolonged QTD and functional outcomes in patients with acute cerebrovascular stroke (CVS) has been much less well studied. Hypothesis: Estimate the incidence of QT dispersion in patients with acute CVS and find any correlation between it and the functional outcome. Methods: The study was conducted at Alexandria University Hospitals on 100 adult patients diagnosed as acute CVS and they were admitted to the Intensive Care Unit (ICU). All patients were followed up till the discharge from the ICU and up to 3 months later. Results: Patients included in the present study were divided into two groups according to the mean length of QTD; group I (normal QTD ⬍71 msec) include: 67 patients (67%) and group II (prolonged QTD ⬎71 msec) include: 33 patients (33%). Glasgow coma scale (GCS) was worse in prolonged QTD group than normal QTD group. Glasgow Outcome Scale (GOS) was associated with high mortality and morbidity in prolonged QTD group than normal one. Conclusions: QT dispersion should be taken as a predictor of the functional outcome in patients with acute cerebrovascular stroke.

Introduction: The efficacy of AirwayScope (Pentax-AWS) on the education of the residents and fellows in terms of the pediatric intubation was evaluated by using the pediatric simulators. Hypothesis: Compared with Miller type, PentaxAWS could make the intubation easier and safer for the children. Methods: 1) 32 residents and fellows who had finished the anesthesia rotation were enrolled. 2) After the practice of AirwayScope was done, the respiration of Baby SIM(METI) was stopped and the trial of intubation started. If SpO2 got down to 90% during intubation, the manipulation stopped and the mask bagging started and continued until SpO2 got up to 95%. Then the intubation restarted. After finishing the intubation, the time of intubation and the frequency of SpO2⬍90% were compared between the miller type laryngoscope and AirwayScope. 4) Secondary, ALS Baby(Laerdal) was used to compare the time of intubation and the frequency of failure in intubation within 60 sec between the above two groups. The intubation of ALS Baby is more difficult than that of Baby SIM. 5) T-test was used for the statistical evaluation. Results: 1) In terms of Baby SIM, the time of intubation was significantly shorter with AWS than by Miller type (19⫹18sec v.s. 33⫹29sec, p⬍0.05 )and the frequency of desaturation during intubation was significantly less by AWS than by Miller type(2 times v.s. 9times, p⬍0.05).2) In terms of ALS Baby, the time of intubation was significantly shorter with AWS than by Miller type (27⫹17 sec v.s. 40⫹17 sec, p⬍0.05 )and the frequency of failure in intubation was significantly less by AWS than by Miller type(2 times v.s. 9times, p⬍0.05). Conclusions: Pentax–AWS could not only shorten the time of intubation but also make intubation safer for the children to reduce the frequency of desaturation and failure of intubation.


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EVALUATION OF PROFICIENCY IN FOCUSED TRANSTHORACIC ECHOCARDIOGRAPHY IN GRADUATING CRITICAL CARE FELLOWS

THE INSTITUTION OF A FORMALIZED NOVEL MULTI-DISCIPLINARY EMERGENCY MEDICINE CRITICAL CARE (MDEM/CC) FELLOWSHIP TRAINING CURRICULUM

Anne-Sophie Beraud, Sukhvinder Nagi, Norman Rizk, Ronald Pearl, Andrew Patterson, Stanford University

Brian Wessman, Walter Boyle, Washington University in Saint Louis School of Medicine

Introduction: Ultrasound is an important skill for Intensivists, but guidelines for training and evaluation of proficiency are lacking. Hypothesis: We hypothesized that critical care medicine fellows could develop proficiency in transthoracic ultrasound one year after formal instruction. Methods: We implemented a standardized transthoracic echocardiography training program in a critical care fellowship, and assessed proficiency in scanning and interpreting examinations at the end of the academic year. The training consisted in eight hours of didactic lectures and 10 –18 hours of individual bedside scanning instruction by a cardiologist. Fellows were encouraged to perform independent examinations throughout the year, which were recorded for review. Evaluation of proficiency consisted of three parts: assessment of image quality obtained in three random critically ill patients, interpretation of pre-recorded images representing commonly encountered pathologies, and synthesis of scanning and interpretation skills on an echocardiography simulator. Results: Beginning in August 2010, eight critical care fellows from backgrounds including internal medicine (4), emergency medicine (3) and anesthesia (1) participated in this study. Previous exposure to ultrasound ranged from none to proficiency in FAST exam. Each fellow performed an average of 38 scans independently during the year.At the end of the year (July 2011), all fellows were able to obtain adequate transthoracic images in three patients and interpret online images with ⬎80% accuracy. The five simulation scenarii were diagnosed promptly: asystole (average diagnosis time 10s), biventricular dysfunction (59s), right ventricular strain (140s), large pericardial effusion (18s), and a normal heart in a patient with poor transthoracic windows (236s). Specific windows were obtained in the following average times: parasternal long axis (19s), parasternal short axis (18s), apical 4 chamber (16s), subcostal 4 chamber (14s), and IVC views (10s). Conclusions: A standardized curriculum can be successfully integrated into an academic critical care program such that graduating fellows achieve proficiency in performance and interpretation of focused transthoracic echocardiography.

Introduction: The president of SCCM, during her initial 2011 conference remarks, expressed support for the inclusion of EM Intensivists and the urgent need to solidify a formalized certification process. We have created a novel 2-year multi-disciplinary CC training tract for an EM trainee that meets all of the current RRC requirements for CC fellowship training in Medicine, Anesthesiology, and Surgery. Hypothesis: This proposed curriculum would provide EM trainees with a sufficient CC knowledge base to equate them with trainees from the current training regimes used by the existing CC Fellowship training programs. We will also foster Multi-disciplinary CC growth at our Institution. Methods: Our novel MDEM/CC fellowship consists of 24 mos of full-time training (divided into: 6 mos MICU, 1 mo coronary ICU, 9 mos SICU, 1 mo neuro ICU). The remaining time is spent completing required “selectives” (topics include Nutrition, Bronchoscopy, Research, etc) and “electives” (Radiology, Renal, Infectious Disease, etc). The Fellows also complete a scholarly project and present 4 lectures.We reviewed in-training exam scores from the annual SCCM Multi-disciplinary Critical Care Knowledge Assessment Program (MCCKAP) and compared our EM/CC trainee scores with those from other critical care disciplines as well as against national reported standard deviations. Results: No EM/CC trainee MCCKAP score was found to be less than one standard deviation below the average of the other CC Fellows either locally or at a national level. Development of this curriculum stimulated the creation of a weekly Multi-disciplinary CC Lecture Series (MDCCLS) . The goal of the MDCCLS is to have Attending-level Intensivists from various specialties provide discussion points regarding areas of their expertise. Conclusions: We have created a novel, 2-year Multi-disciplinary CC Fellowship to provide training to EM residency graduates. Our MDEM/CC Fellowship tract provides our trainees with the breadth of knowledge that is reflected on the SCCM MCCKP assessment exam. We propose that a 2-year curriculum that embraces this type of Multi-disciplinary CC training become the accepted national standard model for training EM/CC Intensivists.

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IMPACT OF THE FUNDAMENTAL CRITICAL CARE SUPPORT (FCCS) AND PEDIATRIC FUNDAMENTAL CRITICAL CARE SUPPORT (PFCCS) FOR CRITICAL CARE MEDICINE IN JAPAN

THE SIMULATION TRAINING OF MEDICAL EMERGENCY TEAM FOR DISSEMINATING RAPID RESPONSE SYSTEM IN JAPAN

Kazuaki Atagi, Osaka City General Hospital, Shigeki Fujitani, St.Marianna University school of medicine, Takamitsu Kodama, St. Marianna University, Ikuya Ueta, Shizuoka Children’s Hospital, Junya Ishikawa, Yokohama City University, School of Medicine, Rikimaru Kogawa, Nihon University, School of Medicine, Hiroshisa Shimizu, Saitama Seikeikai Hospital, Hiroshi Imai, Mie University, Hideki Shimaoka, Osaka City General Hospital, Shinichi Nishi, Hyogo College of Medicine

Takamitsu Kodama, Shigeki Fujitani, Eiji Kawamoto, St. Marianna University School of Medicine, Kazuaki Atagi, Osaka City General Hospital

Introduction: With regard to the intensive care of critical ill patients, the uniformity and consistency of medical treatment is important; therefore, it is necessary to provide medical intervention by combining “standard treatment” with treatment by specialists in each medical field. In Japan, at present, there is neither a guideline for “standard treatment” nor a training system, which forms the basis of intensive care, and as such it is currently left to the guidance by senior physicians of respective medical institutions. We have studied the importance of courses on FCCS in Japan from the survey conducted then. Hypothesis: The course on FCCS is also important in Japan as the basis of critical care medicine. Methods: Courses on FCCS or PFCCS have been held 24 times in Japan from 2009 to the present. After the course had ended, we conducted a survey to study the ratio of residents among the participants and those hoping to participate, the motive of attending the course, and the satisfaction level of each lecture and skills stations. Results: Approximately 1/3 of the participants were those of leader class in respective medical institutions; approximately the other 2/3 were those of resident class, nurses, and clinical engineers. Recently, the number of resident and nurse has increased.With regard to the motive for participation, several leader class participants had expressed their hope for standardization in the guidance of trainee doctors; on the other hand, several resident class participants had raised questions with regard to managing seriously ill patients and expressed their dissatisfaction with the management, which varies from one advising doctor to another. In the evaluation of lectures and skills stations, almost all the participants had answered that they were satisfied; particularly, the satisfaction rating of skills stations for the Mechanical Ventilation was high. Conclusions: Also in Japan, those of the leader class and resident class at the site of intensive care hope for the making of a guideline of “standard treatment,” for which the course on FCCS and PFCCS is considered to be useful.

Introduction: The interest in safety of in-patients has been growing in Japan. The ‘100,000 Lives Campaign’ was introduced under the Japanese Patient Safety Act in 2008. In this campaign, the Rapid Response System (RRS) was one of the mainstreams to improve in-patient care. However, many Japanese healthcare providers did not have enough knowledge regarding the RRS. To fill this gap, a new Medical Emergency Team (MET) training program has been developed. Hypothesis: Trainees would acknowledge the effectiveness of the RRS by entertaining MET simulation training. Methods: The educational programs include lecture series, followed by introduction of the high-fidelity mannequin for simulation training, and first scenario drill by MET members, then debriefing, and lastly a second drill. Evaluation was made by surveillance questionnaires to 444 participants. The questionnaires are : A. Does the RRS decrease the unexpected death?, B. Does the RRS decrease the psychological burden?, C. Is the RRS useful for patient safety?, D. Did the training contribute to improve your action for patient safety?, and E. How do you impress on the training? Results: All trainees answered the questionnaire. The numbers of trainees who scored more than three points out of five points before a course, after lecture and after simulation training were as follows. A. 354, 364 and 378. B. 213, 260 and 281. In A, there was significant difference in numbers of before lecture and after simulation training, which was also true in B. And in B, there was significant difference also in after lecture and after simulation training (p ⬍0.05). And the number of trainees who scored more than three points after simulation training was 395 (89.0%) in C and 384 (86.5%) in D. In E, many trainees were expected to hold this course. Listening to lectures or reading textbooks might not be sufficient to understand the RRS. Trainees learned team building and crew resource management through simulation. Namely new training deepened the understanding the effectiveness of the RRS appropriately. Many trainees appreciated the educational value of the course. Conclusions: New MET training program may promote to disseminate the RRS in Japan.


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ABDOMINAL PATHOLOGY IN PATIENTS WITH DIABETES KETOACIDOSIS

BOOT CAMP FOR PARAMEDICS IN PRE-HOSPITAL MANAGEMENT OF CHILDREN: AN EDUCATIONAL CURRICULUM WITH EMPHASIS ON AIRWAY SKILLS, INTRAVENOUS ACCESS AND FLUID RESUSCITATION

Nicole Pant, University of Tennessee, HSC, Dipen Kadaria, University of Tennessee Health Science Center College of Medicine, Luis Murillo, Univ. of Tennessee - Pulmonary/Critical Care Medicine/Sleep Medicine, Jose Yataco, University of Tennessee, Arthur Headley, Univ. of Tennessee Medical Group, Amado Freire, University of Tennessee Health Science Center Introduction: Abdominal pain is a common presenting symptom in patients with Diabetes Ketoacidosis (DKA). It is presumed to be associated with the metabolic acidosis and is expected to resolve with its correction. However, abdominal pain on occasions can be due to an intercurrent medical process like acute pancreatitis, acute cholecystitis, or appendicitis. This study aims to describe the incidence and nature of significant abdominal pathologies in patients with DKA and abdominal pain. Hypothesis: Patients with DKA having abdominal pain and significant elevation of pancreatic enzymes need further evaluation. Methods: Retrospective review (N ⫽ 86) of patients with DKA from January 1, 2005 to January 31, 2010 was performed. Data included demographics, comorbidities, compliance, chief complaints and physical findings, blood count, metabolic profile, lactic acid, glycosylated hemoglobin (HbA1C), amylase, lipase, anion gap, arterial blood gases, imaging and final diagnosis. Continuous variables were described as mean ⫹ SD and compared with the student’s t test. Categorical variables were expressed as percents (%) and compared with the Mantel-Haenszel ␹2 test. Univariate analysis was conducted among patients with and without significant abdominal pain and also with and without significant abdominal pathology. Two lipase strata were created at 400 Units. Multivariate model to identify limits (CI) of the estimated risk imposed by the predictor found significant in univariate analysis. A p value of ⬍0.05 was considered significant. Stat View 5.0 (SAS Institute, Cary, NC) was used for the statistical analysis. Results: In patients with abdominal pain, 17 % had significant abdominal pathology mainly acute pancreatitis. Serum amylase and lipase level were found to be significant indicator of significant underlying pathology (both p-value ⬍0.001). Logistic model created showed that patients with lipase level ⬎400 Unit have a 7 % increased risk of having acute pancreatitis with CI of (0.01— 0.6). Conclusions: Patients with DKA and abdominal pain with lipase ⬎400 U, have increased risk of significant underlying abdominal pathology (acute pancreatitis).

Arsenia Asuncion, The Children’s Regional Hosp.-Cooper Introduction: A retrospective study review of trauma registry from a University Hospital (2004 –2006)revealed significant problem with airway management (69% vs. 21%), vascular access success (85% vs. 65%) and fluid resuscitation(25.5% vs. 9.1%) management of children vs adult patient. An educational curriculum was designed to educate paramedics of above skills to improve patients’ outcome. Hypothesis: Significantly improved the proficiency of paramedics in airway management , vascualr access and early rersuscitation of children Methods: An educational curriculum was designed as non –randomized trial, recruittment through the EMS (emergency medical office) . The sessions divided into : 1) didactic lecture on airway, vascular access and shock 2) Three station hands on : airway, vascular access and shock station with the use of simulators. Evaluations composed of pre and post test for knowledge; pre-and post survey questionnaires for attitude . Paired t-test to compare the pre vs. the post curriculum data of the evaluation. For skill evaluation, two scenarios created for subjects as objective structured clinical evaluation (OSCE) of simulation scenarios , with two evaluators and checklist adopted from the PALS (pediatric advanced life support) – with feedback and debriefing . One way Anova used for analysis. Results: Seventeen subjects were enrolled so far. Three subjects have 3–5 years of experience as paramedics and fourteen subjects have more than five years of clinical experience . Pre and post –test, there was a significant difference in the mean value of the total score 6.19 vs. 8.0 (p value ⬍0.01.)Pre-survey and post survey questionnaires showed a significant difference in the attitude and skills of the paramedics after the curriculum 44.29 vs 51.47 p value⬍0.01 Conclusions: The curriculum will have significant impact in the proficiency of paramedics on airway skills, vascular access and shock recognition in the pre-hospital management of children

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DEVELOPMENT AND CONTENT VALIDATION OF A HEALTH–LITERACY FOCUSED PARENT-PROVIDER COMMUNICATION SCENARIO FOR USE IN A VIRTUAL PATIENT TRAINING INTERVENTION

WEANING’S MATHEMATICS - PLACE NUMBERS AND REMOVE YOUR PATIENT FROM MECHANICAL VENTILATION

Renuka Mehta, Medical College of Georgia, Meghana Bhatta, Aanme Shalabi, Georgia Health Science University, Elyceia Dortch, Geogia Health Sceinces University, Joan Johnson, Christie Palladino, Georgia Health Science University

Introduction: The use of weaning protocols has shown favorable results, although the professionals involved in its implementation have not yet practical formula to observe and verify, at the bedside,if structured guides are being used and the response of the patient easily, which, in the end, difficult the implementation of the weaning protocol itself in the department. Hypothesis: The purpose of the study was to evaluate whether a weaning protocol based on easy numbers to remember and evaluate whether its use makes a difference in adherence of the professionals involved. Methods: In the study were included 50 ICU patients who used invasive mechanical ventilation and initially identified as suitable for weaning. Two groups were formed. There were no differences between groups with regard to the causes of ARF patients that led to the VM, age and severity score. In 25 patients, we applied the 0/5/10/30/40/60/90 guide, where each number has a meaning as follows: 0 - no sedation, 5 - Peep ⱕ5 cmH2O, 10 - 10 cmH2O PSV, 30 - FR ⱕ30 bpm, 40 - FiO2 ⱕ0.4, 60 to 60 minutes for observation/evaluation of patient response during process/ready for extubation, 90 SpO2 ⱖ90% throughout the period. In 25 patients we used the usual practice in the department, left to the discretion of the assistant physician and physical therapist to decide the entire process without following a written protocol. Results: The weaning protocol with numbers was successful in 20/25 patients compared with 17/25 patients in the group’s usual practice. The length of time to extubation was shorter with intervention strategy (2 ⫾ 1.7 days) than with usual practice (4 ⫾ 2.2 days). We found no significant differences between groups in adverse events. Conclusions: The application of a written protocol that includes memorable numbers, identifying and describing all stages of the process has shown positive results. The authors conclude that the use of numbers 0 –5–10 – 30 – 40 – 60 –90 can facilitate the weaning of patients, making it friendlier to use as a protocol.

Introduction: Our study aimed to identify the differences and similarities in the preferences of parents of pediatric patients and healthcare providers for degree of complexity and empathy in clinical interactions. The goal is to improve the transmission of clinical information between parents of different educational background and providers, hopefully to improve patient outcome ultimately. Hypothesis: There would not be a statistically significant difference between parent and expert preferences in level of complexity and empathy in clinical communication. Methods: We devised a scenario modeling a conversation between a patient’s father and doctor, which contained a series of questions/statements posed by the father, each followed by several responses from the doctor that varied in complexity or empathy. The scenario was distributed to 25 providers and 45 parents of pediatric patients, who were asked to select their most and/or least favored answer. Response choices were assigned a rating ofcomplexity level using the SMOG readability test. They were also given the Rapid Estimateof Adult Literacy in Medicine (REALM) test to quantify their health literacy level. Results: For the majority of questions, parents and experts did not significantly differ on their preference. However, for three questions, there was a significant difference in the preferences of parents and experts; so, complexity level preference was dependent on the identity of the subject and literacy level. Furthermore, parents preferred more detailed answers with more technical terminology than the experts selected. Conclusions: Parents choice for majority of the survey did not depend on literacylevel. Providers may oversimplify their communication with parents. Since parents may be hesitant to ask for more details and more precision about their child’s condition, it is imperative for providers to communicate with the appropriate level of complexity from the start. This serves to ensure that the parent maximally understands the situation and will provide optimal care for his/her child. This information will be used to design a sample interaction approved by both parents and providers to be incorporated into a virtual patient training tool.


Afonso Soares, HFAG, UFRJ, Lilian Acha, Clara Soares, Debora Soares, HFAG

478 NOVEL TRAINING IMPROVES ACQUISITION AND RETENTION OF LIFE SUPPORT SKILLS IN RESOURCE LIMITED SETTINGS Peter Meaney, Children’s Hospital of Philadelphia, Billy Tsima, Princess Marina Hospital, Robert Sutton, Children’s Hospital of Philadelphia, Andrew Steenhoff, University of Pennsylvania, Andrew Kestler, University of Botswana, Sharon Irving, University of Pennsylvania School of Nursing, Kasey Church, Dana Niles, Children’S Hospital of Philadelphia, Loeto Mazhani, University of Botswana School of Medicine, Vinay Nadkarni, Children’s Hospital of Philadelphia Introduction: Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. Hypothesis: Both existing and novel training programs significantly impact CPR skills of hospital-based providers in Botswana. Methods: Participants were prospectively randomized to: American Heart Association (AHA) Basic Life Support (2005), BLS with limited instructor and manikin feedback, or self-directed learning (HeartCode). Demographics, knowledge and skill data were collected at baseline, after training, and at 3 and 6 months. Knowledge was measured by standard AHA BLS multiple choice testing. Excellent CPR was defined as having at least 4 of 5 characteristics: compression depth (ⱖ23 mm for infant, ⱖ38 mm for adult), rate (ⱖ90 and ⱕ120/min), ⱕ20% incomplete release (⬍5 mm), no flow fraction ⱕ0.40, and ventilation rate (ⱖ2 and ⱕ10/min). GEE was performed to account for within subject correlation. Results: Of 214 participants, 40% perform resuscitation ⱖ1/month, 31% work in high acuity areas, and only 28% had previous CPR training. Median cognitive score rose after training (63 vs. 84%, ⬍0.01), and remained elevated from baseline (75%, 74% respectively, each p⬍0.01). Excellent CPR increased immediately after training (infant adjOR: 3.4, 95%CI 2.2–5.4; adult adjOR: 2.1, 95%CI 1.3–3.5) and at 3 months (infant adjOR: 3.8, 95%CI 2.3– 6.5; adult adjOR: 2.1, 95%CI 1.3–3.5). At 6 months, rates of Excellent CPR remained above baseline for the infant but not adult scenario (infant adjOR: 3.6, 95%CI 2.1– 6.3; Adult adjOR: 1.4, 95%CI 0.8 –2.5). 65% of participants required skill remediation to meet criteria for AHA certification. There were no significant differences among type of instruction method. Conclusions: Hospital providers in resource-limited settings resuscitate frequently and can significantly acquire and retain CPR skills using existing training, yet they often require remediation. Novel techniques with increased student: instructor ratio and self-directed training combined with automated feedback manikins similarly impact skills acquisition and retention at 6 months. Supported by Laerdal Foundation for Acute Medicine.


Posters: Epidemiology/Outcomes (Predictors, Quality of Life, Safety)-1 479

480

CAN THE MEMORIAL DELIRIUM ASSESSMENT SCALE BE UTILIZED FOR EARLY IDENTIFICATION OF DELIRIUM ONSET?

THE ROLE OF ENDOTHELIAL HEALTH IN PREVENTION OF ICU BRAIN DYSFUNCTION

Leif Saager, Jing You, Andrea Kurz, Alparslan Turan, Cleveland Clinic Introduction: Postoperative delirium (PD) is associated with subsequent cognitive decline, prolonged critical care and hospital length-of-stay, and increased mortality. The Confusion Assessment Method (CAM) is a frequently used tool to identify delirious patients and testing results in a dichotomous outcome. The Memorial Delirium Assessment Scale (MDAS) is less commonly used to rate severity of PD, but results in a continuous scale. Early identification and treatment of delirium can reduce medication use and adverse outcomes. Hypothesis: We sought to investigate if a positive screening for PD with the CAM is preceded by increasing MDAS ratings, possibly indicating an increasing severity of symptoms and subsyndromal delirium. Methods: With approval of the Institutional Review Board and after obtaining written consent, we enrolled patients between 18 –90 years old, scheduled for on-pump coronary artery bypass grafting (CABG), valve replacement, or a combination of the two. Patients were assessed for delirium using the CAM and the MDAS preoperatively, and each morning and evening for a maximum of five days while hospitalized. SAS software version 9.2 (SAS Institute, Cary, NC, USA) and R software version 2.12.0 (The R Foundation for Statistical Computing, Vienna, Austria) were used for all statistical analyses and graphics. Results: We enrolled a total of 198 patients. The incidence of PD was 21% (95% CI: 15%, 26%). MDAS scores were positively correlated with the number of fulfilled CAM criteria (Pearson correlation, 95% CI: 0.81, 0.77– 0.84; P ⬍0.001, Fig 1). The observed median (Q1, Q3) MDAS score was 3 (1, 5) among all the assessments before delirium was diagnosed, however when the patients tested positive on the CAM, MDAS scored 8.8 times (95% CI: 4.1, 13.5) higher than at the assessment right before (P ⫽ 0.002, Fig 2). Conclusions: Positive screening for delirium with the CAM is not preceded by increasing MDAS scores in previous testing. The fluctuating nature of PD allows for rapid changes in cognitive function and this seems to be represented by a sudden steep increase in MDAS score with the first positive CAM assessment.

Christopher Hughes, Alessandro Morandi, Jennifer Thompson, Timothy Girard, E. Ely, Pratik Pandharipande, Vanderbilt University School of Medicine Introduction: Endothelial dysfunction is associated with increased morbidity and mortality and is exacerbated by critical illness and sepsis. Endothelial dysfunction may lead to alterations in blood brain barrier permeability, a leading hypothesis implicated in critical illness brain dysfunction (delirium and coma), itself a prevalent and costly syndrome associated with poor outcomes. Hypothesis: We hypothesized that ICU patients with better endothelial function would have more days alive and free of brain dysfunction. Methods: We prospectively enrolled adult medical or surgical ICU patients in shock and/or respiratory failure. Endothelial function was assessed at enrollment using the validated Endo_PAT device to determine reactive hyperemia index (RHI). A lower RHI is indicative of worse endothelial function, with a value of less than 1.67 representing endothelial dysfunction. Brain dysfunction was assessed daily using the RASS and CAM-ICU. Linear regression was used to study the association between endothelial function and 1) days alive and free of brain dysfunction over the first 14 study days and 2) delirium duration in survivors, while adjusting for potential confounders including age, severity of illness, baseline cognitive impairment, statin use, and sepsis. Results: Endothelial function was measured in 134 patients, 30% of whom were admitted with severe sepsis. Our study population had a median RHI of 1.5 (IQR 1.32–1.81), median age of 57 years, and median APACHE II score of 26. Median length of ICU stay was 4.8 days, and median duration of brain dysfunction was 3 days. Better endothelial function was associated with more days alive and free of coma or delirium, such that a patient with a RHI of 1.81 (75th percentile, reflecting better endothelial function) vs. 1.32 (25th percentile, reflecting worse endothelial function) had 0.83 more days free of brain dysfunction after adjusting for covariates [95% CI: (0.12, 1.54); p ⫽ 0.02]. Better endothelial function was also predictive of decreased duration of delirium in survivors [-0.43 days; 95% CI: (-0.86, 0.00); p ⫽ 0.05]. Conclusions: Our data support the association between endothelial dysfunction and brain dysfunction in critically ill patients.

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THE ASSOCIATION OF ELEVATED CARDIAC TROPONIN AND DEATH IN THE EARLY POST-OPERATIVE PERIOD FOLLOWING RUPTURED ABDOMINAL AORTIC ANEURYSM

HYPOGLYCEMIA ADVERSE EVENTS IN THE PEDIATRIC AND CARDIAC INTENSIVE CARE UNITS: DIFFERENTIATING PREVENTABLE AND NONPREVENTABLE EVENTS

Ilana Kopolovic, University of Alberta, Kimberley Simmonds, Alberta Health Services, Shelly Duggan, Mark Ewanchuk, Daniel Stollery, Sean Bagshaw, University Of Alberta Introduction: Cardiac complications are potentially life-threatening following emergent repair of ruptured abdominal aortic aneuryms (rAAA). Our objectives were to describe the incidence, risk factors, cardiac outcomes and mortality associated with elevated cardiac-specific troponin (cTnI) following repair of rAAA. Hypothesis: We hypothesized that in rAAA patients, early post-operative troponin elevation would identify a high- risk subgroup with a high rate of cardiovascular complications and would be associated with a worse clinical outcome. Methods: Retrospective population-based cohort study of all referrals for emergency repair of rAAA in Northern Alberta, from January 1, 2002 to December 31 2009. Demographic, comorbidity, physiologic and laboratory data, along with cTnI measurements for 72 hours following rAAA repair and documented cardiacspecific investigations (electrocardiography (ECG), echocardiography) were captured. Results: In total, 54.6% of patients (n ⫽ 77/141) had elevated cTnI (⬎0.15 ng/mL), of which 12% (n ⫽ 9) had ST segment elevation, 21% (n ⫽ 16) had ST segment depression, 6% (n ⫽ 5) had other dynamic ECG changes, and 61% (n ⫽ 47) had no diagnostic ECG changes. Those with positive cTnI were more likely to have a history of coronary artery disease (45.5% vs. 23.4%, p ⫽ 0.010) and higher Acute Physiology and Chronic Health Evaluation II scores (24.9 vs. 21.4%, n ⫽ 0.016). cTnI positive patients were more likely to be supported by vasoactive medications (58.4% vs. 14.1%, p⬍0.001), had longer ICU length of stay (8 [3–11] vs. 4 [2–9] days, p ⫽ 0.021) and higher crude mortality (37.7% vs. 14.1%, odds ratio (OR) 4.0; 95% CI, 1.7–9.1, p ⫽ 0.003). Those adjudicated as having acute myocardial infarction (AMI) had higher rates of post-operative cardiogenic shock and death. Alternatively, in those with isolated elevated cTnI without AMI, hospital mortality was similar to those with no elevation in cTnI. Conclusions: Elevated cTnI early after rAAA repair is a strong prognostic marker for post-operative hemodynamic compromise and death.


Paul Shea, Michael Spaeder, Children’s National Medical Center, Puneet Sayal, George Washington University School of Medicine, Brian Jacobs, David Stockwell, Children’s National Medical Center Introduction: Hypoglycemia adverse events (AE) are common and can expose children to significant morbidity and mortality especially in critically ill patients in a PICU and CICU. However, the occurrence of preventable and nonpreventable hypoglycemia AEs in the PICU and CICU and the characteristic differences of each population have yet to be described. Hypothesis: The use of an automated AE detection system to detect and categorize hypoglycemia-related AEs in pediatric ICUs can identify events that are preventable and target areas for improvement. Methods: A retrospective observational study of all hypoglycemia triggers generated by an electronic health record-driven surveillance system was conducted at a large urban children’s hospital’s PICU and CICU during a three year period. All hypoglycemia triggers were investigated to determine if they represented a true AE and if that event was preventable or nonpreventable. Clinical and demographic variables were analyzed to identify characteristics of patients who developed a preventable or nonpreventable AE. Results: There were 197 AEs of hypoglycemia in 90 patients. Of the AEs, the PICU had 29% and the CICU had 36% preventable events. Preventable events were more likely to occur at nighttime (p ⫽ 0.006), during weekends/holidays (p ⫽ 0.02), and in patients only receiving parenteral nutrition (p ⫽ 0.005). There was no significant difference between those patients who experienced a nonpreventable AE vs a preventable AE in regards to mechanical ventilation (82% vs 75%), vasoactive requirement (52% vs 54%) or insulin infusion (50% vs 49%). Adjusting for nighttime, weekend/holiday and parenteral nutrition, logistic regression analysis demonstrated that each of these three variables independently increased the odds of an AE being preventable: Nighttime odds ratio (OR) ⫽ 3.12 (p ⫽ 0.001); Weekend/Holiday OR ⫽ 2.38 (p ⫽ 0.013); Parenteral Nutrition OR ⫽ 3.74 (p ⫽ 0.002). Conclusions: Preventable hypoglycemia AEs are an area that can be targeted for improvement. Nighttime and weekend/holiday times as well as parenteral sources of nutrition put patients at an increased risk of preventable hypoglycemic AEs.

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RELIABILITY WITHIN INTENSIVE CARE UNITS OF A NEW SCALE TO MEASURE LEVEL OF CONSCIOUSNESS: THE FOUR SCORE

EVALUATION OF PICU ATTENDING COVERAGE MODEL AND PATIENT MORTALITY

Andrew Kramer, Cerner Corporation, Eelco Wijdicks, Mayo Clinic, Jessica Dunivan, Memorial Health University Medical Center, Linda Smitz Naranjo, University of Maryland Medical Center, Sue Hanna, Borgess Medical Center, Stacy Dickess, St. Mary’s Medical Center, Vicki Snavely, Cerner Corporation Introduction: Measuring level of consciousness (LOC) is traditionally done using the Glasgow Coma Score (GCS). Since one of its components involves verbal response, its use in the ICU might be problematic given the large percentage of patients on mechanical ventilation. A relatively new measure, the Full Outline of Unresponsiveness (FOUR) score incorporates eye opening and eye movements, brainstem reflexes, respiration patterns, several motor responses and specific ways to assess comprehension to a command. Thus it might be better suited than the GCS to measure LOC in critically ill patients. Hypothesis: The FOUR Score can be reliably measured within and across ICUs. Methods: Patients admitted to ICUs at five U.S. hospitals during the latter part of 2010 had their FOUR Score assessed by two nurses during the first day after admission. Each nurse evaluating a patient was blinded to the other nurse’s score. In total 907 patients were scored in this study. Since the FOUR Score ranges from 0 to 16, weighted Kappas were calculated for the agreement of the two nurse evaluators at each site. The weighted Kappas were further analyzed for heterogeneity across hospitals. Results: The overall weighted Kappa was 0.92 (95% C.I. ⫽ 0.88 – 0.94). While 48% of the FOUR score measurements were 16 (the highest value, i.e. normal), the remainder of the values had good dispersion along the FOUR Score’s range. There was no significant difference in weighted Kappa values among hospitals (p ⫽ 0.76). Further, for the 59% of patients on a mechanical ventilator the weighted Kappa did not differ from the value for the 41% of patients not on a ventilator. Conclusions: The FOUR Score showed excellent inter-rater reliability, which did not differ by sites and whether or not a patient was ventilated. Pending its ability to predict outcomes, the FOUR Score may prove to be an adequate replacement for the GCS when measuring LOC in critically ill patients.

Paras Khandhar, The Medical College of Wisconsin, Evelyn Kuhn, Children’s Hospital of Wisconsin, Kathleen Murkowski, Matthew Scanlon, Medical College of Wisconsin Introduction: The presence of an attending critical care physician in adult intensive care units 24 hours a day, 7 days a week (24/7) is associated with improved outcomes, prompting national groups to propose minimum staffing models. In pediatric ICUs (PICUs), mid-level providers are associated with improved outcomes. Whether 24/7 staffing of PICU attendings are associated with improved outcomes remains unknown. Hypothesis: PICUs with 24/7 attending coverage will have improved outcomes as measured by lower standardized mortality ratios (SMR) compared to PICUs without such coverage. Methods: Retrospective study using the VPS, a multi-institutional PICU database. All patients less than 18 years of age discharged between 1/1/06 and 12/31/08 were included. Abstracted patient and hospital data elements included PICU attending coverage model, pediatric index of mortality (PIM2) scores, diagnoses, and outcomes. Analysis included descriptive statistics, logistic and multiple regression modeling. Results: Data included 155, 793 patient discharges from 66 participating VPS institutions. Patient demographics were similar between units with and without 24/7 PICU attending coverage. When stratified for unit size, 24/7 PICU attending coverage was associated with lower PIM2 scores with no statistical difference in the odds ratio for mortality between coverage models. Using stepwise and backward stepwise multiple regression models, the relationship between SMR and 24/7 PICU attending coverage was not statistically significant (p ⫽ 0.9383). Using the same models, a larger PICU unit size was related to higher SMR (p ⫽ 0.0009). Conclusions: Unlike adult ICUs, there appears to be no relationship between 24/7 PICU attending coverage and improved mortality. A relationship exists between PICU unit size and increased mortality. Next steps include measuring association of staffing models with indicators of morbidity as defined by risk-adjusted medical length of stay and duration of mechanical ventilation.

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A PROSPECTIVE STUDY OF VITAMIN D DEFICIENCY AND PLASMA IL-18 LEVELS IN CRITICAL ILLNESS

IMPACT OF INTENSIVIST-DIRECTED MULTIDISCIPLINARY ICU CARE AND PERIOPERATIVE PROTOCOLS IN ORTHOTOPIC LIVER TRANSPLANT (OLT) RISK-ADJUSTED OUTCOMES

Augusto Litonjua, Brigham & Women’s Hospital, Tamas Dolinay, University of Tennessee College of Medicine, Lee Gazourian, Andrea Braun, Brigham and Women’s Hospital, Edward Giovannucci, Harvard School of Public Health, Augustine Choi, Brigham and Women’s Hospital, Pulmonary Division, Kenneth Christopher, Brigham and Women’s Hospital Introduction: Activated vitamin D stimulates innate immunity, promotes induction of T Regulatory cells and has a therapeutic effect on pro-inflammatory cytokine profiles. Hypothesis: We hypothesized that 25(OH)D deficiency is associated with bloodstream infection, mortality and IL-18 levels in the critically ill. Methods: We performed a prospective cohort study on 97 patients, age ⱖ18 years, who received critical care between 2008 and 2010 in a Medical Intensive Care Unit in Boston. The exposure of interest was plasma 25(OH)D deficiency and categorized a priori as 25(OH)D ⱕ15ng/mL. The primary endpoint was bloodstream infection 48 hours prior to critical care to 48 hours after critical care initiation. The secondary endpoints were 30-day mortality and in-hospital mortality. We also determined the correlation of plasma 25(OH)D and IL-18 a marker of inflammation. Associations were estimated through logistic regression models. Adjustment included age or APACHE II score. Results: In the cohort, 78.4% had SIRS, 43.3% had sepsis and 14.4% had ARDS. The 30-day mortality was 27.8%. APACHE II mean (SD) was 24.2 (8.0). 25(OH)D deficiency was associated with a significant increase in bloodstream infection risk (APACHE II adjusted OR 8.73; 95%CI 1.09 –70.24, p ⫽ 0.04). 25(OH)D was a non-significant predictor of all cause mortality 30 days following critical care initiation (APACHE II adjusted OR 1.79; 95%CI 0.62–5.22, p ⫽ 0.3). In patients with 25(OH)D deficiency, there is a strong negative correlation between plasma IL-18 and plasma 25(OH)D levels (r ⫽ -0.66;p⬍0.001). Plasma IL-18 ⬎500 pg/ml was a significant predictor of all cause mortality 30 days following critical care initiation and associated with a significant increase in bloodstream infection risk. Conclusions: Although underpowered to detect differences in mortality, this study shows that in the critically ill, plasma 25(OH)D is a significant predictor of bloodstream infections and is a non-significant predictor of 30-day mortality. In patients with 25(OH)D deficiency, 25(OH)D was strongly negatively correlated with plasma IL-18. Our findings suggest that 25(OH)D deficiency is associated with increased inflammation in critical illness as reflected by IL-18 levels.

Jeremy Heffner, Shan Pelletier, Chris Sonnenday, Paul Picton, Jeffrey Punch, Pauline Park, University of Michigan Hospitals, Krishnan Raghavendran, University of Michign Hospitals, Lena Napolitano, University of Michigan School of Medicine Introduction: Optimal critical care and postoperative management of the OLT patient is necessary for successful outcomes. No data, to our knowledge, are available regarding the impact of the intensivist-directed multidisciplinary ICU collaborative care model and standardized perioperative care protocols in OLT patient outcomes. Hypothesis: Implementation of an intensivist-directed ICU collaborative model of care and comprehensive perioperative care protocols in OLT patients improves ICU and hospital mortality. Methods: Prospective data were collected by one APACHE Coordinator for all OLT patients (n ⫽ 671) admitted to ICU for 10 years (2000 – 2010). Baseline data [2000 –2005, Group 1(G1), n ⫽ 366] were compared to protocolized ICU care [2006 –2010, Group 2 (G2), n ⫽ 304]. Intensivist-directed ICU care started in 2006 with evidence-based ICU protocols for OLT patients developed by transplant surgery, anesthesia and critical care. Postoperatively patients were stratified into 1 of 2 ICU protocols based on hemodynamic stability, intraoperative course, transfusion requirements and allograft function and were used to guide vasopressor use, extubation, nutrition, transfusions, labs, and DVT prophylaxis. Results: No differences in admission characteristics were noted between Groups for mean age (G1 49.9, G2 51.7), gender (G1 67% male, G2 56% male), ICU admission APACHE III score (G1 63.17, G2 65.70), or ICU admission APS score (G1 58.55, G2 59.69). ICU mortality decreased from 5.3% in G1 to 1.8% in G2. SMR for ICU mortality decreased from 0.98 in G1 to 0.35 in G2, representing a 66% reduction in ICU mortality in the protocolized ICU group. Hospital mortality decreased from 5.8% in G1 to 3.2% in G2. SMR for hospital mortality decreased from 1.12 in G1 to 0.52 in G2, representing a 45% reduction in hospital mortality in the protocolized ICU care group. ICU (6.62 vs. 5.53 days) and hospital (18.02 vs. 20.37 days) were no different between groups. Conclusions: Intensivist-directed multidisciplinary ICU management with standardized evidence-based perioperative ICU protocols for OLT patients significantly reduced ICU and hospital mortality compared to our baseline institutional outcomes and benchmarked with national risk-adjusted outcomes.


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488

HEMOGLOBIN A1C AND RISK OF BLOODSTREAM INFECTION IN THE CRITICALLY ILL

CARDIAC ANESTHESIA RISK EVALUATION (CARE) SCORE VERSUS EUROSCORE FOR MORBIDITY PREDICTION IN THE INTENSIVE CARE UNIT AFTER CARDIAC SURGERY

Takuhiro Moromizato, Brigham and Women’s Hospital, Melina Marmarelis, Harvard Medical School, Fiona Gibbons, Massachusetts General Hospital, Kenneth Christopher, Brigham and Women’s Hospital Introduction: An association between chronic hyperglycemia and infection has been postulated but the evidence to support such an association is not strong. Hypothesis: We hypothesized that preadmission Hemoglobin A1c (HbA1c) is associated with bloodstream infection at the time of critical care initiation and all cause mortality. Methods: We performed an observational cohort study on 11,158 patients age ⱖ18 years, admitted to an ICU in two teaching hospitals in Boston between 1998 and 2009. The exposure of interest was HbA1c measured within 1 year prior to hospital admission and categorized a priori as ⱕ6.4%, 6.4 –7.1%, 7.1–7.8%, 7.8 –9.0%, or ⬎9.0%. Bloodstream infection was determined by blood cultures obtained 48 hours prior to and 48 hours following critical care initiation. Vital status for the cohort was obtained from the Social Security Administration Master Death File. The primary endpoint was bloodstream infection. The secondary endpoint was 30-day mortality. Logistic regression examined bloodstream infection and death by day 30 post-critical care initiation. Adjusted odds ratios were estimated by multivariable logistic regression models. Results: HbA1c is poor predictor of bloodstream infection. The risk of bloodstream infection was not significantly higher in patients in any HbA1c group (6.4 –7.1%, 7.1–7.8%, 7.8 –9.0%, or ⬎9.0%) compared with those with HbA1c ⱕ6.4%. HbA1c in the cohort remains a poor predictor of bloodstream infection following adjustment for age, gender, race, patient type (medical/surgical), Deyo-Charlson comorbidity index, hematocrit, white blood count, transfusion and creatinine. This absence of a relationship between HbA1c and bloodstream infections does not change according to the presence or absence of diabetes, sepsis, or the time of HbA1c measurement relative to hospital admission. Following multivariable adjustment including sepsis, the risk of 30 day mortality was not significantly different in any HbA1c group when compared to those with HbA1c ⱕ6.4%. Conclusions: In a cohort with sufficient power, we are unable to demonstrate that chronic glycemic control is associated with bloodstream infections at the time of critical care initiation or associated with 30-day mortality.

489 REDUCTION OF CATHETER ASSOCIATED URINARY TRACT INFECTIONS (UTI) AMONG NEUROICU PATIENTS: A SINGLE INSTITUTION’S SUCCESS W. Titsworth, University of Florida College of Medicine, Abraham Layon, University of Florida, Lennox Archibald, University of Florida College of Medicine, Thomas Correia, Peggy Guin, Jeannette Hester, Richard Reed, Miranda Williams, Shands Hospital at the University of Florida, J. Mocco, University of Florida College of Medicine Introduction: UTI account for ⬃ 40% of hospital-acquired infections (HAI) yearly. UTI are the 3rd commonest ICU-infection, about 23% of adult ICU-HAIs in the US (1); 80% of HA-UTI due to urethral catheters (2,3). In Nov. 2007 we launched a 30-month campaign to decrease CA-UTI below the NHSN mean. Hypothesis: An ICU team-led UTI-prevention bundle will decrease CA-UTIs. Methods: Study population was all consecutive Pts admitted between Aug 2008 - Dec 2010to the 30-bed NeuroICU. Pts with CA-UTI occurring ⬍48 hrs after admission were excluded. After 2 1-mo pre-intervention periods, a 30-mo prospective phase (Aug 1, 2008 - Dec 31, 2010) began. Catheter insertion was a physicians decision. CA-UTI was defined per NHSN criteria (4). Rate was number of Pts with CA-UTI divided by number of indwelling urinary catheter days X 1,000. Catheter Utilization was total number of catheter days divided by the total number of patient days X 100. Pressure ulcers were counted using National PU Advisory Panel stds. UTI bundle was: avoidance of catheter insertion, product standardization, maintenance of catheter sterility, and timely removal. Pearson product moment correlation was used to assess correlation between quarterly catheter utilization, rate of CA-UTI, & pressure ulcer incidence. P value ⬍0.05 was significant. Results: During study period mean number of catheters/day decreased from 25.8 to 18.5; initially 100% of Pts had urinary catheters. 6 mo after initiation of UTI bundle, utilization rate fell to 92% and then to 75% at 15 months (r2 ⫽ 0.794, p ⬍0.0001); below NHSN utilization 25th %’ile (5). Total UTIs & UTI-rate decreased significantly following intervention (r2 ⫽ 0.695, p ⬍0.001): total UTIs/quarter fell from a high of 32 to 7 infections/quarter over a 2-year period. UTI rates fell from high of 13.3 to current/sustained of 4 infections/ 1,000 catheter days; NHSN 25%’ile ⫽ 4.4 (5). Quarterly catheter utilization rate & CA-UTI correlated strongly (r2 ⫽ 0.79, p ⬍0.0001). No increase in PU prevalence during study period was seen (p ⫽ 0.95); there was no correlation between sacral decubitus ulcers and the UTI utilization rate. Conclusions: A Team-led CQI group can decrease CA-UTI and utilization rates & change Unit culture.


Jean-Yves Dupuis, Diem T Tran, Bernard McDonald, University of Ottawa Heart Institute Introduction: The CARE score is a simple risk prediction model for cardiac surgery. With a design resembling the physical status classification of the American Society of Anesthesiologists, it combines clinical judgment and the recognition of three risk factors: comorbid conditions categorized as controlled or uncontrolled, surgical complexity and urgency of the procedure. Known to predict mortality as well as most multifactorial indices, the CARE score is compared to the EuroSCORE in this study for prediction of major postoperative morbidity in a specialized cardiac surgical intensive care unit (CSICU). Hypothesis: The CARE score and the EuroSCORE are comparable for prediction of postoperative morbidity in our CSICU. Methods: With Research Ethics Board approval, patients admitted to our CSICU between April 2006 and March 2009 were randomly divided in a derivation (n ⫽ 2000) and validation group (n ⫽ 1802). Morbidity was defined as any major cardiac, respiratory, renal, gastro-intestinal, neurological or infectious complications that were life-threatening and/or prolonged CSICU length of stay. To estimate the morbidity probabilities, logistic regression models were developed using the CARE score or the EuroSCORE as a single covariable for prediction of morbidity in the derivation set. Model discrimination was obtained using the area under the receiver operating characteristics (ROC) curve. Calibration, or comparison of the observed with the predicted morbidity, was tested in the validation set with each model, using a chi-square goodness-of-fit test. Results: The overall CSICU morbidity was 15.3%. The area under the ROC curve is 0.76 (95% CI: 0.73 – 0.79) with the CARE score and 0.77 (95% CI: 0.74 – 0.80) with the EuroSCORE (p ⫽ 0.65). Both models have good calibration for morbidity prediction in the validation set: chi-square ⫽ 9.18 (p ⫽ 0.21) with the CARE score and chi-square ⫽ 6.56 (p ⫽ 0.68) with the EuroSCORE. Conclusions: The CARE score and the EuroSCORE are comparable for prediction of major morbidity in our CSICU. Although primarily developed as preoperative risk predictors of mortality, both models have predictive characteristics which make them suitable for risk-adjusted analysis of morbidity in our CSICU.


492

FUNCTIONAL OUTCOMES IN PEDIATRIC SEVERE SEPSIS: FURTHER ANALYSIS OF THE RESOLVE TRIAL

SCOTTISH INTENSIVE CARE AND MORTALITY–SHEDDING LIGHT ON OUT OF HOURS ADMISSIONS

Reid Farris, Children’s Hospital & Regional Medical Center, Jerry Zimmerman, Children’s Hospital Regional Medical Center

Alistair Meikle, Southern General Hospital, David Young, University of Strathclyde, Antony Vassalos, Department of Anaesthesia, Royal Alexandra Hospital

Introduction: Sepsis is an infection-mediated syndrome that can progress to shock, multiple organ dysfunction and death. The rarity of severe pediatric disease and subsequent mortality in the developed world makes outcomes research challenging. Functional status represents a meaningful outcome that has been little explored in pediatric sepsis. Hypothesis: The objective is to report the 28-day functional outcomes of pediatric patients with severe sepsis and to explore and describe the risk factors for poor functional outcome. Methods: Retrospective cohort study analyzing data from the RESOLVE trial of activated protein C for pediatric severe sepsis. Poor functional outcome is defined as a Pediatric Overall Performance Category score ⱖ3 AND a change from baseline when measured 28 days after trial enrollment. Univariate and multivariate analyses were performed to assess the relationship between patient characteristics and functional outcome at 28 days. Corrected odds ratios provide improved estimates of relative risk. Results: 32% of patients had a poor functional outcome at 28 days. Characteristics that increased risk include: Age 1 month to ⬍1 year vs. the 1–5 year referent group, Relative Risk (RR) ⫽ 1.6 [95%Confidence Interval(CI) 1.1, 2.2] and Hispanic ethnicity RR ⫽ 1.6 (95%CI 1.2, 2.1). Clinical factors that increased risk include: immune dysfunction RR ⫽ 1.6 (95%CI 1.0, 2.2), receipt of cardiopulmonary resuscitation RR ⫽ 2.7 (95%CI 1.2, 3.2), Pediatric Risk of Mortality III score ⱖ20 and ⱖ3 dysfunctional organ systems at enrollment. Protective factors include: female gender RR ⫽ 0.7 (95%CI 0.5, 1.0), presence of a congenital anomaly RR ⫽ 0.5 (95%CI 0.3, 0.9) and a blood infection source RR ⫽ 0.6 (95%CI 0.4, 1.0) vs. the referent lung source. Conclusions: Poor functional outcome 28 days after an episode of severe pediatric sepsis is a frequent and clinically meaningful event. This analysis demonstrates that patient characteristics and aspects of their clinical course can be implicated as risk factors for poor functional outcome 28 days from onset of severe pediatric sepsis. These characteristics suggest opportunities for further study and ultimately intervention to improve functional outcomes among children with severe sepsis.

Introduction: Critically ill patients can present to the intensive care unit (ICU) at any time of day despite variations in staffing levels, treatment and diagnostic resources. Several cohort studies have considered the impact of admission time on patient outcome with conflicting results. Hypothesis: We investigated whether ICU admission time affects mortality and hospital stay. Methods: A retrospective cohort analysis of adult ICU admissions within Greater Glasgow and Clyde NHS Health Board from January 2007 to 2011 was performed. Demographic (age, sex), admission (specialty, time, APACHE II) and outcome data (ICU/hospital mortality and stay) were extracted from the Scottish Intensive Care Society Audit Database. Admission time was categorised into day (07:45–19:45), night (19:45– 07:45) and weekend (19:45 Friday – 07:45 Monday).Univariate analyses of quantitative and qualitative variables with mortality were performed using MannWhitney or Kruskal-Wallis and chi-squared tests respectively according to Anderson-Darling test for normality. Variables univariately associated with mortality entered a logistic regression analysis to identify independent risk factors. All analyses performed using Minitab 16 at a significance level of 5%. Results: In total, 7912 patients (57(17)yrs, APACHE II 17(11–23[0 –53])) were admitted to ICU during this period (day 3091(39.1%), night 2314(29.2%), weekend 2507(31.7%)). ICU mortality (day 598(19.3%), night 491(21.2%), weekend 566(22.6%)) was significantly associated with age (p⬍0.001), APACHE II (p⬍0.001) and admitting specialty (p⬍0.001). Weekend admissions had significantly higher adjusted ICU mortality (odds ratio (OR),1.26[95%CI 1.10, 1.45]; p ⫽ 0.001) but not night (OR,1.13[95%CI 0.98, 1.3]; p ⫽ 0.089). Hospital stay of survivors admitted during the day was significantly longer than out of hours (night and weekend) admissions (14(6 –28[0 –341]) vs. 12(5–27[0 –341]), p ⫽ 0.001). Conclusions: Patients admitted during the weekend to ICU in the west of Scotland have an increased risk of death compared to those admitted through the week. Similarities in age and acute physiology severity scores across all time periods implicates other patient, organisational, physician or nurse related factors.

493 OBESITY AND PEDIATRIC CRITICAL CARE Colin Widener, University of Alabama At Birmingham Children’s Hospital, James Gladden, University of Alabama, Birmingham, Margaret Winkler, The Children’s Hospital of Alabama Introduction: Obesity in the adult population has been well characterized. The prevalence of obesity in children and adolescents has almost tripled from 1980 to 2008, approaching 20%. The effect of obesity on morbidity and mortality in the pediatric acute care setting has not been well studied. This retrospective analysis of recent pediatric intensive care unit admissions (PICU) investigates the effect of obesity on pediatric critical care. Hypothesis: Obesity is associated with increased morbidity in acute pediatric critical care. Methods: This retrospective review at the Children’s Hospital of Alabama, Birmingham included all pediatric intensive care admissions ages 2–19. Body mass index (BMI) (kg/m2) was calculated for each patient. BMI percentiles were formulated and divided into four categories: underweight (BMI ⬍5%), normal weight (BMI 5% to ⫾ standard error. Appropriate statistical analysis was performed and p⬍0.05 was considered statistically significant. Results: There were 2765 medical/surgical admissions,1846 met inclusion criteria. These patients were placed into there BMI groups; underweight (n ⫽ 197), normal (n ⫽ 907), overweight (n ⫽ 291), and obese (n ⫽ 451). Demographics between groups were similar and there was no statistical difference between Pediatric Risk of Mortality III (PRISM) scores and overall mortality. There was a significant increase in length of PICU stay in obese patients compared to normal weight patients (2.9⫾0.23 vs. 2.3⫾0.16 days, p⬍0.05). Of patients in the obese group, 20% had central lines vs. 9.7% in normal weight group (p⬍0.05). BiPAP was used in 10.2% of the obese group vs. 6.5% of the normal group (p⬍0.05). There was no difference in duration of mechanical ventilation and the extubation failure rates. Creatinine and systolic blood pressure was higher in obese group vs. normal (1.03⫾0.1 vs. 0.76⫾0.043, p⬍0.05) and (139⫾1.1 vs. 133.8⫾0.64 p⬍0.05), respectively. Conclusions: Obesity in pediatric critical care increases morbidity. There are more invasive procedures and support despite no difference in PRISM-III scores. Obesity increases length of stay and cost to patients.

494 EPIDEMIOLOGY AND OUTCOMES FOR EXTRACORPOREAL MEMBRANE OXYGENATION IN ADULTS WITH HEART DISEASE Charlotte Briar, Cindy Barrett, Satish Rajagopal, Sitaram Emani, Francis FynnThompson, Ravi Thiagarajan, Children’s Hospital Boston Introduction: We sought to evaluate the demographic and clinical characteristics of adult cardiac patients recorded in the Extracorporeal Life Support Organization (ELSO) registry, and to determine predictors of mortality in adult patients with heart disease supported with extracorporeal membrane oxygenation (ECMO) for cardio-respiratory failure. Hypothesis: We hypothesized that increased age and severity of illness prior to initiation of ECMO would raise the odds of mortality in adult cardiac patients. Methods: Retrospective cohort review of adult cardiac patients supported with ECMO during 2000 –2009. Logistic regression was used to determine predictors of mortality. Results: Of 1096 adults aged 18 –90 years (median 51) included, 39% survived to discharge. Most patients (93%) were supported with veno-arterial ECMO. Mortality varied widely by pre-ECMO diagnosis with cardiomyopathy having the lowest mortality (48%), compared to ischemic heart disease (63%), heart failure (67%), pulmonary hypertension (78%), congenital heart disease (67%) and aortic surgeries (81%). Using a multivariable logistic regression model adjusted for diagnostic category, pre-ECMO factors associated with increased odds of mortality included: age ⬎62 yr (OR 2.0 (95% CI 1.3–3.1), severity of illness prior to ECMO, as expressed by longer duration of mechanical ventilation (OR 2.1 (1.4 –3.3) for ⬎10.5h), pre-ECMO arrest (OR 2.0 (1.5–2.8)), vasopressor dependence (OR 2.0 (1.5–2.7)), inhaled nitric oxide requirement (OR 1.7 (1.1–3.0)), and evidence of pre-ECMO infection (OR 2.7 (1.6 – 4.6)). Complications were consistently greater in non-survivors, with CNS injury (OR 6.7 (3.6 –12.4)) and renal failure (OR 2.9 (2.2–3.9)) being most strongly associated with odds of mortality. Conclusions: Mortality amongst this cohort of adults supported with ECMO for heart disease was high at 61%. Pre-ECMO diagnosis had a significant impact on survival. Advancing patient age, severity of illness, and infection were all significantly associated with mortality. Complications of ECMO support, particularly brain injury, were higher in non-survivors. Careful patient selection, early ECMO deployment, and clear guidelines for management on ECMO may improve outcomes.


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THE TURN TEAM: A NOVEL STRATEGY FOR REDUCING UNIT ACQUIRED PRESSURE ULCERS IN THE ICU

COMBINATION OF N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE AND PNEUMONIA SEVERITY INDEX (PSI)/CURB65 SCORE CAN PREDICT 30-DAY MORTALITY IN HOSPITALIZED PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA

Mary Still, Linda Cross, Emory University Hospital, David Carpenter, Timothy Buchman, Craig Coopersmith, Emory Center for Critical Care Introduction: Unit acquired pressure ulcers (UAPU) are a major source of morbidity in the ICU. Several strategies have been suggested for preventing UAPU, including repositioning and frequent turning of patients. Hypothesis: Implementation of a dedicated turn team will reduce the rate of UAPU in the ICU. Methods: UAPU data was collected in a 20 bed SICU in an academic hospital using a point prevalence strategy from 12/08 –3/10. During this time period, frequent turning was encouraged by the bedside nurse; however, there was no uniform standard regarding frequency of turning and repositioning of patient. In 3/10, a turn team consisting of two patient care assistants on each shift was implemented who were responsible for turning all patients every 2 hours. After development of the turn team, data was collected by the same auditors using a similar point prevalence strategy (weekly audits) from 4/10 –9/10. Results: Prior to the intervention, there were a total of 42 UAPU identified in 278 patients (average 2.8/week, range 0 –7). After initiation of the turn team, there were a total of 12 UAPA identified in 229 patients (average .87/week, range 0 –2, p⬍0.0001). The pre-intervention group included 7 stage 1 ulcers, 27 stage 2 ulcers, 1 stage 3 ulcer, 4 deep tissue injury (DTI) and 2 unstageable ulcers. By comparison, after the turn team, there were 2 stage 1 ulcers, 5 stage 2 ulcers, 2 stage 4 ulcers, 3 DTI and 1 unstageable ulcer. A total of 30 of 42 (71%) patients with UAPU were on pressors in the pre-group compared to 12 of 12 (100%) in the post group (p ⫽ .049). The average Braden score was 17 in the pre-group and 12 in the post-group (p ⫽ 0.006) suggesting that UAPA were occurring in higher risk patients after initiation of the turn team. Patients with ulcers had similar lengths of stay (36 vs. 48 days, p ⫽ 0.29) and had a similar risk of being on mechanical ventilation (86% vs. 83%, p ⫽ 1.0) in both pre- and post-intervention groups. Conclusions: The formation of a team dedicated to turning ICU patients every 2 hours induced a dramatic decrease in pressure ulcer incidence. The vast majority of stage 1 and 2 ulcers in lower risk patients appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention.

Ki Young Jeong, Seoul National University Hospital, Kyuseok Kim, Tae Yun Kim, Joong Eui Rhee, You Hwan Jo, Seoul National University Bundang Hospital, Gil Joon Suh, Seoul National University Hospital Introduction: Our aim was to investigate whether N-terminal pro-brain natriuretic peptide (NT-proBNP) plus pneumonia severity index (PSI) and NTproBNP plus CURB65 score are more effective in predicting 30-day mortality than PSI and CURB65 score in hospitalized community-acquired pneumonia (CAP) patients. Hypothesis: We hypothesized that the combination of serum NT-proBNP and PSI/CURB65 score can more effective in predicting 30-day mortality of the patients than PSI/CURB score alone. Methods: This was a prospective observational study conducted in an emergency department (ED) of a tertiary academic hospital. We enrolled hospitalized patients with a diagnosis of CAP from April 2008 to December 2010. We collected data with respect to demographic findings, initial serum NT-proBNP level, PSI, and CURB65 score of the patients. Receiver operating characteristic (ROC) analysis was used to identify the predictive value of NT-proBNP, PSI, CURB65 score, NT-proBNP plus PSI, and NT-proBNP plus CURB65 score for 30-day mortality. Results: Among 471 enrolled patients, 396 were survivors and 75 were non-survivors on day 30. High NT-proBNP was independently associated with 30-day mortality (adjusted OR 1.40; 95% CI 1.14 - 1.71, p ⫽ 0.001). The AUC of NT-proBNP, PSI, and CURB65 score for 30-day mortality were 0.719 (95% CI, 0.661 0.776), 0.699 (95% CI, 0.638 – 0.761) and 0.580 (95% CI, 0.508 – 0.652), respectively. The AUC of NT-proBNP plus PSI (0.744, 95% CI, 0.687 - 0.801) and NT-proBNP plus CURB65 score (0.719, 95% CI, 0.661 - 0.776) were higher than that of PSI and CURB65 score, respectively (p ⫽ 0.037 and ⬍0.001, respectively). Conclusions: In conclusion, NT-proBNP plus PSI and NTproBNP plus CURB65 score are more effective in predicting 30-day mortality in hospitalized community-acquired pneumonia (CAP) patients than PSI and CURB65 alone.

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MAINTAINING AN AIR LEAK WHEN USING CUFFED ENDOTRACHEAL TUBES DECREASES POST EXTUBATION STRIDOR IN CHILDREN

SURVIVAL OF CHILDREN AFTER CARDIOPULMONARY RESUSCITATION DURING INTERFACILITY TRANSPORT BY A SPECIALIZED TRANSPORT TEAM

James Schneider, Unami Mulale, Stephanie Andrus, Sharon Pollard, Cohen Children’s Medical Center of New York

Frank Casey, Children’s Hospital of Pittsburgh of UPMC, Bradley Kuch, Children’s Hospital of Pittsburgh, Patrick Kochanek, University of Pittsburgh Medical Center, Andrea Beach, Richard Orr, Kathryn Felmet, Ericka Fink, Children’s Hospital of Pittsburgh

Introduction: The use of endotracheal tubes (ETT) for the provision of mechanical ventilation (MV) is very common in pediatric intensive care unit (PICU) patients. The development of post extubation stridor (PES) is an important risk factor for patient outcome. The use of a cuffed ETT has historically been avoided in children because of its risk of developing airway edema and PES, particularly if over inflated. We sought to determine if implementing a protocol of measuring and maintaining cuff leak pressures at ⬍/⫽ 25cm H2O or peak inspiratory pressure, if greater, during MV would decrease the rate of post extubation stridor. Hypothesis: Maintaining an appropriate air leak pressure throughout the course of MV will decrease the incidence of PES. Methods: Data was gathered prospectively in a tertiary PICU for every patient receiving MV through a cuffed ETT from 10/09 through 10/10. Subsequently, a protocol was introduced whereby upon placement of a cuffed ETT, enough air was instilled to maintain an audible air leak by 25cm H2O pressure or peak inspiratory pressure, if greater. Respiratory therapists monitored and adjusted cuff volumes to maintain air leaks every 6 hours. Subsequently, data was collected on all patients requiring MV through cuffed ETT from 11/10 through 5/11. Patients who received nebulized racemic epinephrine due to the presence of stridor at the time of extubation were characterized as having PES. Results: All patients receiving MV were screened. Patients were excluded if they had a history of upper airway anomaly, died while on MV, received a tracheostomy before extubation, and were transferred from the PICU with the ETT in place. During the baseline period, 112 patients received cuffed ETTs, with 53 (47%) having an audible air leak at the time of extubation. Upon extubation, 24 patients (21.4%) developed PES. During the intervention phase, 98 patients with cuffed ETTs were included. 75 (76%) of these patients maintained an audible air leak throughout MV (p ⬍0.0001). 11 (11.2%) developed PES, a 47.7% reduction (p ⫽ 0.04). Conclusions: Maintaining an appropriate air leak throughout the course of MV using a cuffed ETT can decrease the rate of PES in children.


Introduction: Children with in-and out-of-hospital cardiac arrest (CA) have survival to hospital discharge (HD) of 27% and 8% respectively. Complex challenges in the management of crises in the transport setting could potentially contribute to poor outcome. To date, no studies have examined the epidemiology and outcomes of pediatric cardiopulmonary resuscitation (CPR) on transport. Hypothesis: Outcomes after CPR on pediatric transport will be better than out-of-hospital CA, but poorer than in-hospital CA. Methods: We performed a single center, retrospective analysis of children who received CPR by our transport team between 11/1997–12/2010. Group 1 included children who received CPR from the transport team at the referring hospital but not on transport and Group 2 were children who received CPR after departure from the referring hospital. We collected data on patient characteristics, resuscitation interventions, transport intervals and patient outcomes. Results: Sixty-seven (0.38%) out of 17,446 children transported required CPR with 13 occurring during transport. The median age was 2 (range .03–207) mos, 18 (27%) were premature newborns, and 14 (26%) children arrested peri-intubation. Children received a median of 4 (0 –20) doses of epinephrine and 14% were defibrillated during CPR. The most common initial rhythms were bradycardia (56%) and asystole (28%) and the median duration of CPR was 15 (0.2–240) minutes. Forty (68%) children had return of spontaneous circulation (61% Group 1 vs. 92% Group 2, p ⫽ .04) and 22 (33%) survived to hospital discharge (29% Group 1 vs. 46% Group 2, p ⫽ 0.32). Children received 6 (1–12) medications and underwent 2.4 (1–5) procedures by the transport team. There was no effect of fellow presence, total transport, response, or scene time on survival but more children survived when the transport team traveled by fixed wing or helicopter vs. ambulance (p ⫽ 0.03). Conclusions: Children requiring CPR during interfacility transport by a specialized pediatric team had outcomes that were comparable and possibly even more favorable than those seen during in-hospital CA. The period surrounding airway intubation represents an opportunity for prevention of cardiopulmonary instability.

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DEVELOPING A PREDICTIVE MODEL FOR ASSESSING PAO2/ FIO2 USING SAO2/FIO2 IN CRITICALLY ILL PATIENTS

PD2I AS PROGNOSTIC SCORE OF MORTALITY IN THE INTENSIVE CARE UNIT

Asmitha Sathiyakumar, Vanderbilt School of Medicine, Melissa Pitrowsky, Instituto Nacional de C␮er - INCA, Mario Davidson, Vanderbilt University, Jorge Salluh, D’Or Institute for Research and Education, Todd Rice, Vanderbilt University, Raeanna Adams, Vanderbilt University Medical Center, Lorraine Ware, Vanderbilt University School Of Medicine, Gordon Bernard, E. Ely, Pratik Pandharipande, Vanderbilt University Medical Center

Miguel Llano, Hospital General de las Fuerzas Armadas, Andres Suarez, Universidad San Francisco de Quito, Gustavo del Pozo, Hospital General de las Fuerzas Armadas, Michelle Grunauer, Universidad San Francisco de Quito

Introduction: Retrospective studies have shown a strong correlation between SpO2/FiO2 (SF) and PaO2/FiO2 (PF) ratios in critically ill patients. This has led to the identification of SF correlates for PF levels of 100, 200, 300 and 400 that are useful in the diagnosis of lung injury, and for severity of illness scoring systems. Hypothesis: In addition to the SF, PEEP, age, temperature, gender, skin pigmentation, ventilator status and vasoactive drug use would be predictors of the PF ratios. Methods: Nurses in the ICUs at Vanderbilt Medical Center and the Brazilian National Institute of Cancer prospectively recorded arterial blood gas data, while simultaneously collecting pulse oximetry data, ventilator settings, and patient demographics. A generalized estimating equation (GEE) regression was used to identify the relationship between SF and PF ratios, while adjusting for PEEP, age, temperature, gender, skin pigmentation, ventilator status and vasoactive drug use. Additional sensitivity analysis excluded patients with SpO2⬎97%. Results: A total of 1710 simultaneous measurements of arterial blood gases and pulse oximetry data were obtained. The median (IQR) age of the cohort was 60 (45, 67); 75% were on a ventilator and median FiO2 was 0.4 (0.3, 0.5) and PEEP was 8 (0, 10). The SF ratio highly correlated with the PF ratio (p ⬍0.0001; R2 ⫽ .59). Additionally, PEEP, age, temperature, skin pigmentation, being on the ventilator and the interaction of SF ratio with PEEP, were all significant predictors of the PF ratio (p ⬍0.01). Correlations between SF and PF were strengthened when SpO2⬎97% were excluded (R2 ⫽ .66). Conclusions: The SF ratio is a useful surrogate for calculating PF ratios when arterial blood gas data are unavailable. Age, temperature, skin pigmentation and being on the ventilator were predictors of PF; additionally level of PEEP affected the relationship between SF and PF, though all these may not be clinically significant. Based on the regression equation, an easy to use bedside normogram was created to assist clinicians and researchers to calculate PF ratios for all levels of SF ratios, incorporating PEEP and the significant demographic information.

Introduction: The PD2i (Point Correlation Dimension) is a nonlinear timedependent algorithm for analysis of heart rate variability that has been used for risk evaluation of cardiac death due to arrhythmia or pump failure, requiring as little as 5 min of electrocardiogram recording. Hypothesis: We hypothesized that it would be predictive of 30-day mortality in intensive care unit (ICU) patients. Methods: A four month prospective study of the utility of PD2i as predictor of mortality in the ICU patients was undertaken. The minimum PD2i (min PD2i) score was determined at time of admission. A min PD2i score of ⱕ1.4 was considered high risk. In order to determine mortality, patients were followed during hospitalization in the ICU and up to 30 days after discharge. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), relative risk, and area under the curve (AUC) were then calculated. Results: From August through December 2010 fifty seven patients were admitted to the ICU. Fifty four patients completed the study, 69% were male. Admission diagnoses were sepsis (57%), coronary disease (20%), stroke (11%), and trauma (11%). Thirty one patients were in the high risk group and 23 in the low risk group. The mean age was 68.4 years (⫾ 17.4 years). The mortality at 30 days was (48.4%) for high risk vs., (4.3%) in low risk, p ⬍0.001. The sensitivity for death at 30 days was 93.8%, specificity 57.9%, NPV 95.7%, and PPV 48.4%. The relative risk of death at 30 days for the high risk group was 11.1 (p ⬍0.001) and for the low risk group was 0.6 (p ⫽ 0.003), and the AUC was 0.789. Using a 1.26 cut-off level showed a sensitivity 92.3%, specificity 63.4%, NPV 96.3%, and PPV 44.4%, with a relative risk of death at 30 days of 15.0 (p ⬍0.001) for the high risk group. Conclusions: These data demonstrate that the min PD2i score is a powerful predictor of 30-day mortality in a cohort of ICU patients. This diagnostic test is fast, easy to perform, and can be used routinely.



502

NEIGHBORHOOD POVERTY RATE IS ASSOCIATED WITH BLOODSTREAM INFECTIONS IN THE CRITICALLY ILL

VENTRICULOSTOMY-PLACEMENT BUNDLE AND DECREASED VENTRICULAR INFECTIONS: A SINGLE INSTITUTION’S EXPERIENCE

Mallika Mendu, Brigham and Women’s Hospital, Sam Zager, Harvard Medical School, Fiona Gibbons, Massachusetts General Hospital, Kenneth Christopher, Brigham and Women’s Hospital Introduction: It is postulated that immune-system function may decrease in response to the increased psychosocial stress of poverty. Hypothesis: We hypothesize that Neighborhood Poverty rate, a proxy for socioeconomic status, is associated with the risk of bloodstream infection at critical care initiation. Methods: We performed an observational cohort study of 14,657 patients, age ⱖ18 years, who received critical care between 1997 and 2007 in two hospitals in Boston, Massachusetts. Data sources included the US Census and hospital administrative data. Bloodstream infection was determined by blood cultures obtained 48 hours prior to and 48 hours following critical care initiation. Vital status for the cohort was obtained from the Social Security Administration Master Death File. The exposure of interest was Neighborhood Poverty rate categorized as ⬍5%, 5–10%, 10 –20%, 20 – 40% and ⬎40%. Neighborhood Poverty rate is the percentage of residents below the federal poverty line. The primary end point was bloodstream infection. The secondary endpoint was all cause mortality. Associations between Neighborhood Poverty rate and bloodstream infection were estimated by logistic regression models. Adjusted odds ratios were estimated by multivariable logistic regression models. Results: Neighborhood Poverty rate was a strong predictor of risk of bloodstream infection. Following adjustment for age, gender, race, patient type (medical/surgical), Deyo-Charson Index, TPN, HCT, WBC, creatinine and BUN, patients with 20 – 40% Neighborhood Poverty rate were associated with a 26% increase in bloodstream infection risk (OR 1.26; 95%CI 1.09 –1.47, p ⫽ 0.002) while patients with ⬎40% Neighborhood Poverty rate were associated with a 49% increase in bloodstream infection risk (OR 1.49; 95%CI 1.05–2.11, p ⫽ 0.03). OR are relative to patients with ⬍5% Neighborhood Poverty rate. Following multivariable adjustment, Neighborhood Poverty rate was not associated with all cause 30-day, 90-day, 365-day mortality post-critical care initiation or in-hospital mortality. Conclusions: Increased Neighborhood Poverty rate, a proxy for decreased socioeconomic status, appears to be associated with risk of bloodstream infection among patients who receive critical care.

Shahram Amini, Zahedan University and The University of Florida College of Medicine, Loretta Fauerbach, Shands Hospital at the University of Florida, Lennox Archibald, William Friedman, University of Florida College of Medicine, Abraham Layon, Geisinger Health System Introduction: Infection is a complication of ventriculostomy (Ven) placement, carrying high mortality. Responding to Ven infection rates, a multidisciplinary performance improvement team was formed & a comprehensive protocol for Ven placement was developed; efficacy was evaluated. Hypothesis: Bundle use decreases ventricular infection. Methods: Protocol included hand hygiene before procedure; prophylactic antibiotics; sterile gloves changed between prep/draping/procedure; hair removal by clipping for dressing adherence; skin prep using Iodine Povacrylex [0.7% available Iodine] and Isopropyl Alcohol, 74%; full body & head drape; full surgical attire for operator and other bedside providers; an antimicrobial impregnated catheter. A checklist of critical components was used to teach proper insertion and to monitor practice; an RN was empowered to stop procedure for violations. Completed checklists were reviewed by Critical Care Medicine Chief & Neurosurgery Chair. Procedure specific infection rates were calculated using number of infections and number of Pts who had Ven inserted x 100 (%). Data was reported back to providers and Committee. Bundle compliance was monitored over a 4-year period. Results: 2,928 Ven were done 2007 through 2011; only 588 (19.8%) were checklist monitored (increasing from 7% to 23% over study period). Infection rate before bundle implementation was 9.2%. During study period, the rate decreased quarterly to 2.6% & then 0%. Over 4 years, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), 0.34% (2010); 0% in 1st 6 mo of 2011; overall Ven infection rate of 0.46% since bundle implementation. Conclusions: Bundle implementation including an antimicrobial impregnated catheter dramatically decreased Ven-related infections. Although bundle compliance when observed was near perfect, most procedures were not monitored/did not have a completed compliance sheet. Training & awareness of appropriate practice, initiated with the checklist, plus use of the antibiotic impregnated catheter resulted in sustained reduction in ventriculitis. Formation in 2007 of a Neurosurgery Infection Prevention Team increased focus on practice and compliance; this was as important as the checklist.

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ASSOCIATIONS AMONG VITAMIN D LEVELS, SINGLE NUCLEOTIDE POLYMORPHISM OF VITAMIN D RECEPTOR, AND OPERATIVE SEVERITY OF THE PATIENTS WITH CARDIOVASCULAR AND AORTIC DISEASE ?

USING PROPENSITY SCORE MATCHING TO DEMONSTRATE THE INCREASED COMPLICATION RATES ASSOCIATED WITH INTRAOPERATIVE TRANSFUSION OF PACKED RED BLOOD CELLS

Yusuke Tsutsumi, Jikei University of Medicine, Masamitsu Sanui, Akira Shimojima, Jikei University School of Medicine, Haruhiko Ishioka, Jichi Medical University Saitama Medical Center, Mitsuyoshi Urashima, Jikei University School of Medicine

Nichole Urban, Oakland University William Beaumont School of Medicine, Ellen Kraft, Judith Boura, William Beaumont Hospital, James Robbins, Oakland University William Beaumont School of Medicine

Introduction: Recent studies have suggested that low levels of serum vitamin D are associated with cardiovascular risk in medical patients. Association between FokI, a vitamin D receptor gene polymorphism, and various chronic conditions has been shown. However, these associations have not been well documented in high risk surgical patients. Hypothesis: We hypothesized that serum 25-hydroxyvitamin D (25OHD), 1,25-dihydroxyvitamin D (1,25OHD) and FokI gene polymorphism would be associated with cardiac operative risk stratification scores. Methods: The study was conducted with cross-sectional design at a single academic medical center in Japan. Two-hundred thirty-one adult patients scheduled for major cardiovascular surgery were included consecutively. Cardiac operative risk was evaluated with European System for Cardiac Operative Risk Evaluation (EuroSCORE) scoring system. For the determination of serum 25OHD, 1,25OHD and FokI polymorphism, blood samples were collected in the operating room prior to anesthesia induction. Correlaitons between serum 25OHD and 1,25OHD, and the EuroSCORE were assessed using two linear regression models in multivariate adjustment followed by corrections for multiple comparisons. Genotypes frequencies for FokI polymorphism were verified by confirming to Hardy-Weinberg proportions. Results: Median 25OHD and mean 1,25OHD were 19 (14 – 24) ng/ml and 47.3 ⫾ 21.6 pg/ml, respectively. The EuroSCORE was negatively correlated with 25OHD (p ⫽ 0.003), but not with 1,25OHD, even after adjusted with high sensitive C-reactive protein, ionized calcium, intact parathyroid hormone, body mass index, albumin, hypertension, dyslipidemia, diabetes mellitus, and creatinine. After stratification for FokI polymorphism in vitamin D receptor gene, the EuroSCORE was negatively correlated with 25OHD in the patients with FokI CC (p ⫽ 0.002) but not with FokI CC⫹ CT genotypes. Conclusions: These results suggest that serum 25OHD levels are inversely associated with operative severity of patients with FokI CC genotypes undergoing major cardiovascular surgery.


Introduction: Previous studies have demonstrated that packed red blood cell transfusions are associated with increased postoperative complications. The question remains whether these complications are caused by the transfusion themselves or are merely associated with the severity of the patient’s illness. Hypothesis: The objective of this study was to examine the association between intraoperative transfusions and morbidity in risk-adjusted general surgical patients. Methods: This study was performed using 2005 to 2009 data collected from The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database at our institution. Standard ACS-NSQIP preoperative and post-operative risk variables were collected. Propensity score analysis was used to create matched cohorts in order to conduct a risk-adjusted comparison of general surgery patients receiving intraoperative blood transfusions versus patients receiving no blood intraoperatively. Propensity score analysis is a statistical technique that can be used to estimate, without bias, the causal effect of an exposure in the presence of confounding variables. The two groups were also examined in univariate analysis to ensure that our controls were truly matched for all variables. Results: There were 167 patients identified who had intraoperative transfusion. Using propensity scores, we were able to match 143 of these patients. Patients receiving intraoperative transfusion of packed red blood cells were found to have a higher incidence of pulmonary complications (35% vs. 23%; p ⫽ 0.027), infectious complications (41% vs. 30%; p ⫽ 0.048), and cardiac complications (7% vs. 2.1%; 0.047) compared to those who did not receive transfusion. Conclusions: After matching for severity of illness and pre-operative conditions by propensity score matching, intraoperative blood transfusions were found to be significantly associated with increased pulmonary, infectious and cardiac complications. Based on this analysis, it is probable that these complications are secondary to the transfusion and not the severity of illness.

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IMPACT OF CLOSTRIDIUM DIFFICILE—ASSOCIATED DIARRHEA ON MORTALITY AND MORBIDITY OF PEDIATRIC BURN PATIENTS

CAN THE USE OF APACHE II SCORE IN HYPOTENSIVE PATIENTS IN THE GENERAL WARD PREDICT INTENSIVE CARE UNIT TRANSFER?

Noe Rodriguez, University of Texas Medical Branch Hospitals, Celeste Finnerty, Shriners Hospital for Children, Jong Lee, University of Texas Medical Branch, Brendan Calhoun, The University of Texas Medical Branch, Marc Jeschke, Sunnybrook Health Sciences Center, David Herndon, University of Texas Medical Branch

Imran Khalid, King Faisal Specialist Hospital & Research Center, Jeddah, Ahlam Almasari, Salma Alkhammash, Mohammad Qabajah, Tabindeh Khalid, Ahmad Al-Zyoud, King Faisal Specialist Hospital & Research Center,Jeddah

Introduction: Clostridium difficile (C. difficile), is a spore forming gram-positive anaerobic bacillus linked to nosocomial diarrhea. C.difficile has been associated with antibiotic use and is considered to lead to worst survival among critically ill patients with a diagnosis of diarrhea. Hypothesis: Our working hypothesis was that C. difficile infection impacts morbidity and mortality outcomes of pediatric burn patients. Methods: Two thousand eight hundred and forty records of pediatric burned patients were reviewed. Stool specimens from 302 patients with at least two consecutive days of stool output ⬎10 ml䡠Kg-1 䡠min-1 were immunoassayed for C. difficile Toxin A and B. For the case-control study, cases were matched to controls using logistic regression and propensity scores to control for age, time of admission, and time at risk. Analyses were performed with the use of SAS software (v.9.1). Significance was set at an alpha level of 0.05. Results: Eighteen patients (median age 4 years and 56% TBSA burned) acquired CDAD. There were 284 patients with diarrhea who tested negative for C. difficile. The unadjusted in-hospital-attributable mortality in the CDAD group was 28 percent (OR ⫽ 5.4, CI ⫽ 1.7–16.7, P ⫽ 0.01). Length of hospital stay in the CDAD group was 48 days vs. 34 days in the non-CDAD (P ⫽ 0.07). Length of stay as a function of %TBSA burned was increased in the CDAD group (0.82⫾0.4 vs. 0.60⫾0.4, P ⫽ 0.03). Number of days with diarrhea complicated by acidosis were increased in the CDAD group (13⫾16 vs. 4⫾5, P⬍0.001). Eighteen risk factors were evaluated in this patient population, case patients were more likely than matched controls to have presented with concomitant inhalation injury at time of admission (59% vs. 31%, P ⫽ 0.04). Conclusions: Acquiring CDAD in the burn unit is associated with increased post burn mortality. C.difficile was associated with an increased tendency to present acidosis after controlling for severity of injury and may have played a role in the increase of the length of hospital stay as function of %TBSA burned. The role of C. difficile as a marker of severe illness is unknown.

Introduction: Severity scores are used in patients admitted to the Intensive Care Unit (ICU). However, usefulness of a severity score for triaging at the time of initial evaluation in hypotensive patients in the general ward is not clear. Hypothesis: We hypothesized that calculating APACHE II score at the time of new onset hypotension in the ward would help prognosticate transfer of patients to the ICU. Methods: Rapid response team (RRT) is activated for any hypotensive patient with SBP⬍90 mm of Hg in our tertiary care hospital. We retrospectively looked at all those encounters from Jan 2009 till Oct 2010. Patients were divided into two groups; those who did not require an ICU transfer after RRT evaluation, and the other who were transferred to the ICU within 48 hours. APACHE II scores were calculated from the data available at the time of RRT call. We also looked at the 28 day mortality as a secondary outcome. Data was analyzed using student t-test and Pearson chi-square test, as appropriate. Results: A total of 281 hypotensive patients were identified. 126 patients were treated and stabilized in the ward while 155 were transferred to the ICU. 44/155 of the later were deemed stable initially but later deteriorated and admitted to the ICU within 48 hours. The mean APACHE II score for patients who remained in the ward was 16.5 ⫹ 6.9 and for those transferred to the ICU was 20 ⫹ 5.4 (p⬍0.0001). Using Receiver Operating Characteristic analysis, an APACHE II score of 20 as a cutoff to predict ICU transfer had an area under the curve of 0.67, and sensitivity, specificity and positive predictive value of 61%, 74% and 74% respectively. 28 day mortality in patients who remained in the ward was 4.7% (6/126) and in those transferred to ICU was 31% (48/155), p⬍0.0001. An alarming 44% (21/ 48) of patients (mean APACHE II 21.7) who died in ICU were deemed stable at the initial RRT evaluation, but had to be transferred later. Conclusions: An APACHE II score of 20 or more is associated with an ICU transfer in hypotensive patients in the general ward. As an adjunctive tool it may help identify borderline patients, which in our study had the highest mortality. These results should be validated prospectively in a multicenter study.

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A NEW TOOL TO ASSESS FUNCTIONAL MOBILITY IN CRITICALLY ILL PATIENTS: THE PERME ICU MOBILITY SCORE

LEAN MANAGEMENT AND A3 THINKING TO DECREASE MEDIAN VENTILATION TIMES AND PROLONGED VENTILATION RATES AFTER CORONARY ARTERY BYPASS SURGERY

Christiane Perme, The Methodist Hospital, Theresa Nalty, TRON Rehab, Colleen Lettvin, The Methodist Hospital, Chris Winkelman, Case Western Reserve University, Peter Morris, Wake Forest University School of Medicine, Ricardo Nawa, Universidade de Sao Paulo, Faisal Masud, The Methodist Hospital Introduction: Functional assessment tools currently used in intensive care unit (ICU) are unable to detect functional improvements or measure subtle changes in patients with significantly impaired mobility.The Perme ICU Mobility Score (Score) is a tool designed to capture these important functional changes. Hypothesis: It was hypothesized that a high Perme ICU Mobility Score would be associated with improved function as reflected by discharge home. Methods: The Perme ICU Mobility Score ranges from 0 to 32. It consists of 15 items grouped in 7 subscales: mental status,potential mobility barriers/pain,functional strength,bed mobility,transfers,gait, and 2 minute walk test.This report is based in a subsample of a larger study examining mobility of patients with femoral lines in ICU.The subsample was 56 patients in a cardiovascular ICU (24 women;32 men, age 61⫾ 16 years). All data were collected prospectively, with the Score obtained at enrollment (initial) and when the femoral catheter was removed (final). All subjects received at least two episodes of mobility activity. Results: The average initial Score was 11.21 and final Score was 15.14. The 3.93 increase in Scores was significant (t ⫽ 6.67, CI 2.77–5.09, p⬍.001). Three items in subscales demonstrated associations (pⱕ.03) to discharge location after ICU: a)need for mechanical ventilation; b) transfer to chair; and c)the 2 minute walk test. Deaths/discharges to long term care were associated with low initial Scores ⬍14 (X2 ⫽ 34.45, p ⫽ .005). The final Score was associated with discharge location (Kendall tau-b ⫽ .314, p ⫽ .003). A stepwise linear regression with discharge location (ordered in 5 rankings) as the dependent variable resulted in mechanical ventilation at initial assessment (CI.25–1.59) and the final Score (CI .01-.53) being significant. Conclusions: High final Perme ICU Mobility Scores were associated with discharge home, supporting the hypothesis. Low initial Scores were associated with discharge to dependent care. This tool is a simple scoring system that empirically verifies mechanical ventilation as a mobility barrier, captures subtle functional mobility changes in critically ill patients, and demonstrated potential to predict discharge disposition in ICU.

Ravi Tripathi, Erik Abel, Dane Yuratich, Michelle Farneman, Jason Uhrig, Jason Galloway, Deven Kothari, Thomas Papadimos, Susan Moffatt-Bruce, The Ohio State University Medical Center Introduction: Our purpose was to reduce mechanical ventilation (MV) rates after isolated coronary artery bypass surgery (CAB) as defined by the Society of Thoracic Surgery (STS) database. Hypothesis: Using lean management and A3 thinking, gaps can be identified and countermeasures implemented to avoid prolonged MV after CAB. Methods: DEFINE. With a multidisciplinary task force, the current state was defined. Approval for use of the concurrently compiled STS database was approved via Institutional Quality Data Release. Early extubation was defined as occurring within 6 hours of ICU arrival; prolonged MV was defined as the requirement for MV 24 hours after ICU arrival. Task force goals included achieving median MV times and prolonged MV rates comparable to national benchmarks within 9 months. ANALYSIS. Gap analysis was conducted via interviews of involved disciplines and observational findings. Root cause variables of current performance included lack of communication, unstandardized extubation practice and goals, and excessive use of non-goal directed sedation and analgesia. Countermeasures included standardized work, visual management and management of the entire team. The task force conducted ongoing measurement of success and focused studies for continuous improvement with prolonged MV. Results: Prior to the quality improvement project (QIP) in quarter 1 2010, 68 CAB’s were performed; 58 were performed during the quarter of 2011 after the QIP. No preoprerative or intraoperative differences were identified. The same group of surgeons performed all procedures. Median initial MV times decreased from 12.8 to 7.2 hours, with more patients ventilated less than 6 hours (41.1% vs. 19.2%, p ⫽ 0.05). The incidence of prolonged MV decreased from 27.8 to 8.6% (benchmark 11.2%, p⬍0.01). Concurrently, reintubation decreased from 11.8% to 3.4% (p ⫽ NS); pneumonia, 5.9% to 1.7% (p ⫽ NS). All results were shown on A3 documents to teams at weekly huddles. Conclusions: Lean management and A3 thinking effectively decreased median MV time and the incidence of prolonged MV after CAB to below national benchmarks in less than 1 year. A3 thinking facilitates multidisciplinary process improvement work that fosters measurable sustainability.


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TELEMEDICINE INTERVENTION IMPROVES ICU OUTCOMES

FACTORS ASSOCIATED WITH POOR NEUROPSYCHOLOGICAL OUTCOMES FOLLOWING ANEURYSMAL SUBARACHNOID HEMORRHAGE

Farid Sadaka, Wendy Deibert, Donna Gudmestad, Ashok Palagiri, Steven Trottier, Steven Sommer, Christopher Veremakis, Mohsin Iqbal, Saint John’s Mercy Medical Center/St. Louis University Introduction: The association of Tele-ICU (Intensive Care Unit) intervention with ICU mortality, hospital mortality and length of stays remains controversial and understudied. Hypothesis: We hypothesized that the application of TeleICU intervention to a 17-bed medical-surgical ICU of a community hospital improves ICU mortality, hospital mortality, ICU length of stay and hospital length of Stay (LOS). Methods: Data were collected on patients admitted to the ICU in pre-intervention period (June 2009 till December 2009) and duringintervention period (January 2010 till September 2010). The ICU in the preintervention period was an “Open” ICU where the primary care provider (PCP) admits a patient to the ICU and continues to act as the primary physician, with consult on some patients to an inhouse intensivist who will manage these patients during day time only. The Tele-ICU was staffed by board-certified intensivists 24 hrs a day, 7 days a week. The patients in the Tele-ICU period are divided into two categories, based on the PCP’s assignment. For category I patients (52.5 % ), the Tele-intensivist can initiate interventions for any urgent/emergent conditions, as well as evidence-based therapies and hospital-approved protocols. For category II patients (47.3 %), the Tele-intensivist has full order writing privileges and may fully manage the patient. Results: The patients in the pre-Tele-ICU period (n ⫽ 616) and during the Tele-ICU period (n ⫽ 1256) were matched on baseline characteristics and acute physiologic and chronic health evaluation (APACHE) IV scores. Mean APACHE IV scores were 49.7 and 50.9 respectively. ICU mortality was 8.3 % during the pre-Tele-ICU period compared with 2.7 % during the Tele-ICU intervention period (OR ⫽ 0.31, 95 % CI, 0.20 – 0.48, p ⬍0.0001). Hospital mortality was 8.7% compared with 5.1 % respectively (OR ⫽ 0.56, 95% CI, 0.38 – 0.81, p ⫽ 0.002). ICU LOS in days was 2.61 compared with 2.13 respectively (p⬍0.05). There was no difference in hospital LOS between the two periods. Conclusions: In a single ICU of a community hospital, implementation of Tele-ICU intervention was associated with reduced ICU mortality, hospital mortality, and ICU length of stay.

511 NT-PRO-BNP IS A STRONG PREDICTOR OF OUTCOME IN CRITICALLY ILL PATIENTS ADMITTED TO THE ICU AFTER CARDIAC SURGERY Brigitte Meyer, Paul Wexberg, Gottfried Heinz, Thomas Szekeres, Richard Pacher, Martin Huelsmann, Medical University of Vienna Introduction: NT-pro-BNP has emerged as a potent predictor of outcome in critically ill and cardiologic patients. Whether NT-pro-BNP is also a predictor of outcome in patients admitted to the ICU after cardiac surgery, is still to be elucidated. Hypothesis: We aimed to assess the utility of NT-pro-BNP for risk stratification in critically ill patients admitted to the ICU after cardiac surgery. Methods: This prospective, observational study was done at the University Hospital of Vienna. During the 24 months study period, patients admitted to the ICU after cardiac surgery were included. NT-pro-BNP was measured in all patients on ICU admission. ICU and hospital survival were recorded in all patients. Results: A total of 101 patients were included (66 male [65%]; age 65 ⫾ 15 years, APACHE II-score 18 ⫾ 9). Surgical diagnosis comprised bypass surgery (n ⫽ 37), valve surgery (n ⫽ 27), combined valve/bypass surgery (n ⫽ 11) and various others (n ⫽ 26). There were 94 (93%) ICU survivors and 89 (88%) hospital survivors. ICU survivors had significantly lower NT-pro-BNP values on ICU admission compared to ICU non-survivors (1443 [26 - 35000] pg/ml vs 21183 [5159 - 35000] pg/ml, respectively, p⬍0.001). Likewise, hospital survivors had significantly lower NT-pro-BNP values compared to hospital non-survivors (1411 [26 - 21401] pg/ml vs 17715 [1266 - 35000] pg/ml, respectively, p⬍0.001). In Cox regression analysis, NT-pro-BNP was a strong predictor of ICU survival (Wald 12.999; p⬍0.001). In the Kaplan-Meier blot, survival rates were significantly higher for patients with NT-pro-BNP plasma levels below the mean (4815 pg/ml) compared to patients with NT-pro-BNP levels above the median (p ⫽ 0.002). Conclusions: NT-pro-BNP is a potent prognostic marker in critically ill patients admitted to the ICU after cardiac surgery.


Pei-Ying Chuang, NIH, Allison Hricik, UPMC, Chien-Wen Kuo, University of Pittsburgh, Elizabeth Crago, University Of Pittsburgh School of Nursing, Catherine Bender, University of Pittsburgh, Paula Sherwood, University of Pittsburgh School of Nursing Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) survivors experience neuropsychological (NP) impairment that significantly limits their ability to resume previously held roles. Prior reports of NP impairment with aSAH did not include domains of NP function that could reveal deficits amenable to intervention. Hypothesis: This study identified factors associated with scores below normative values on 12 NP measures at three and 12 months after aSAH. Methods: Inclusion criteria were age 21–75 years, diagnosis of aSAH via cerebral angiogram, and Hunt and Hess (H&H) grade ⬎2 and/or a Fisher score ⬎1. The sample (n ⫽ 246) consisted primarily of female (n ⫽ 169; 69%), Caucasians (n ⫽ 208; 85%), mean age 52 years with damage located in anterior brain (n ⫽ 198; 81%) that was most commonly treated with coil or embolization (n ⫽ 150, 61%); Glasgow Coma Scores of 13–15 (n ⫽ 180; 73%); H&H grade 3 (n ⫽ 87; 35%); and Fisher score of 3 (n ⫽ 113; 46%). Descriptive statistics, paired t-tests, chisqaure, and logistic regression tests were used. Results: Older females with a lower H&H score who had less education experience showed poorer NP outcomes at both time points. Functional ability (p⬍.01), learning/memory (p⬍.05), attention (p ⫽ 0.3), mental flexibility (p⬍.05), and language (p ⫽ .03) had improved at 12 months compared with three months. More subjects had scores two standard deviation (SD) below normative value on functional ability, learning/memory, and executive function at both time-points. After adjusting for age, gender, education status, and H&H, the results were as significantly predicted with scores below normative values. Conclusions: Screening individuals for potential factors associated with poor NP outcomes following aSAH would allow for early targeted intervention.


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ASSESSMENT OF DAILY BATHING PROTOCOLS: A COMPARISON OF CHLORHEXIDINE SOLUTION AND CHLORHEXIDINE IMPREGNATED CLOTHS

OUTCOME OF EXTREME ELDERLY PATIENTS REQUIRING MECHANICAL VENTILATION

Ranekka Dean, NYU Langone Medical Center, Judy Dillworth, New York Langone Medical Center, Michael Phillips, NYU Langone Medical Center

Introduction: There is a perception of futility regarding the use of mechanical ventilation (MV) in the elderly. Moreover, in an era of increasing healthcare expenditures in the US, the associated resource utilization has been questioned. Hypothesis: Extreme elderly (EE), defined as age 85⫹, is an independent predictor of hospital mortality (M) and increased resource utilization after MV but the outcome of EE undergoing MV is influenced by preadmission functional status (FS). Methods: A retrospective review of prospectively collected data was undertaken. Demographics, APACHE IV predicted mortality % (APIV PM) and clinical outcomes were abstracted from the unit’s comprehensive clinical database. Between 10/1/05 and 5/31/11 5,665 patients were admitted to the 16 bed adult ICU of a university affiliated hospital. The study cohort includes 1,940 patients undergoing MV. Patients were stratified into 4 age groups (85⫹ [EE, n ⫽ 260], 70 – 84 [E3, n ⫽ 674], 50 – 69 [E2, n ⫽ 602], and ⬍50 [E1, n ⫽ 404]), and EE was further subdivided into 4 FS groups: FS1 (home, independent of activities of daily living [ADL], n ⫽ 96); FS2 (home, partially dependent, n ⫽ 59); FS3 (nursing home, rehab facility); FS4 (complete dependence with ADL) (FS3/4, n ⫽ 102). Outcomes included M, ICU and MV duration (MVD) and tracheostomy (T) use. Results: The % of patients with FS1 for EE, E3, E2 and E1 was: 36.9, 60.1, 80.1 and 91.3.APIV PM (%) for EE, E3, E2 and E1 was: 50.7, 43.7, 32.3 and 21.3.ICU LOS, MVD and T were not clinically signicantly different among the 4 age groups.M% for EE, E3, E2 and E1 was 48.5, 35.0, 24.8 and 14.1.Observed:Expected (O:E) M for EE, E3, E2 and E1 was 0.96, 0.80, 0.77 and 0.66.Among the 260 EE the APIV PM% of FS1, FS2 and FS3/4 was 44.9, 56.0 and 52.5 and M% was 39.6, 61.3 and 49.0.O:E M for EE with FS1, FS2 and FS3/4 was 0.88, 1.09 and 0.93. Conclusions: MV of EE is not futile 51.5% of our cohort survived to hospital discharge and there were no significant differences in resource utilization comparing this group to younger patients undergoing MV. Rate of survival is strongly influenced by FS. These data may help guide clinicians facing triage decisions of EE with respiratory failure.

Introduction: Chlorhexidine Gluconate (CHG), a broad spectrum antiseptic agent with low toxicity and prolonged residual effects has proven effective to prevent hospital acquired infections such as CLABSI. A study of systematic daily application of 2% CHG solution vs. 2% CHG impregnated cloths was initiated. Hypothesis: Daily patient bathing with 2% chlorhexidine cloths vs. CHG solution will allow for nursing staff preference, ease of use, perceived effectiveness and compliance for each method to be determined. Patients systematically bathed with chlorhexidine will have a lower rate of CLABSI compared to the previous six months in the study units. Methods: An IRB approved 24 week cross over study was conducted. Criteria for eligibility included all patients admitted to the Cardiovascular ICU, Medical ICU, Surgical ICU and Pediatric ICU. During the first 12-week period, two ICUs were randomly assigned to use CHG impregnated cloths while the other two ICUs used CHG solution to bathe patients daily. Bathing protocols were crossed over during the second 12-week period to control for confounders. Anonymous likert scale questionnaires were distributed four times during the study to measure staff preference, ease of use and perceptions of effectiveness. Analysis of variance was used to compare mean scores. CLABSI were measured using Centers for Disease Control and Prevention case definitions. Unit consumption of materials was reviewed to determine compliance and cost. Results: Analysis of 206 respondents revealed nursing preference (p ⬍0.05), ease of use (p ⬍0.05) and perceived effectiveness (p ⬍0.05) for CHG wipes over CHG solution. Mean compliance rate was 89% for CHG wipes (range 40%100%) and 36% for CHG solution (range 16%-42%), (p ⬍0.05). CLABSI rates in the study units decreased from 3.1 per 1000 central venous catheter (CVC) days in the 6 months prior to the study period to 1.5 per 1000 CVC days during the study period. Conclusions: Nursing staff preferred CHG wipes over the CHG solution which was substantiated by greater compliance. Overall rate of CLABSI decreased by 50% during the study period compared to the prior 6 months.

Fouad Otaki, James Krinsley, Stamford Hospital

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ASSOCIATION BETWEEN DELAYS IN CENTRAL VENOUS CATHETER UTILIZATION AND ORGAN DYSFUNCTION IN PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK

EARLY TRACHEOSTOMY CHANGE IS ASSOCIATED WITH EARLIER USE OF SPEAKING VALVE AND EARLIER ORAL INTAKE

Markos Kashiouris, Rahul Kashyap, Insara Jaffer-Sathick, Ognjen Gajic, Rodrigo Cartin-Ceba, Mayo Clinic

Dan Fisher, Edward Bittner, Dhimiter Kondili, Faraz Alam, Dean Hess, Ulrich Schmidt, Massachusetts General Hospital

Introduction: There is paucity in literature about the impact of central venous catheter utilization timing and outcomes in patients with severe sepsis and septic shock. Hypothesis: We hypothesize that delayed central venous catheter placement is an independent predictor of worsening multiorgan failure within the first 2 days of ICU admission (48-hour delta SOFA), a known predictor of hospital mortality. Methods: In a retrospective cohort of 651 patients with severe sepsis and septic shock admitted to the medical ICU in between 2006 to 2009, we identified 341 patients who had received a central venous catheter with 24 hours after sepsis recognition. Time of sepsis onset, time to first Central Venous Pressure (CVP), 1 hour APACHE III score, day 1 and 2 SOFA score, adherence to early goal directed therapy and time from sepsis onset to first antibiotics were collected. Results: Simple linear regression suggested that every additional hour of delay from sepsis recognition to the first central venous pressure measurement was associated with an average of 0.14 additional point increase in the 2-day delta SOFA score on (95% CI 0.10 – 0.18 p ⬍0.002). Using a multiple linear regression model, adjusting for the APACHE III score one hour after ICU admission, the time from sepsis recognition to antibiotics, completion of early goal-directed therapy and the first baseline SOFA score, we confirmed that every additional hour of delay from sepsis recognition to the first central venous pressure measurement was associated with an average additional 0.13 point increase in the delta SOFA score on (95% CI 0.09 – 0.17 p ⬍0.003). Conclusions: In patients with severe sepsis and septic shock, every additional hour of delay in central venous catheter utilization was associated with worsened multiorgan failure in the first forty-eight hours after ICU admission.

Introduction: Tracheostomy tubes are placed in over 10 percent of patients who require greater than 3 days of mechanical ventilation. Presence of a tracheostomy tube often decreases the patient’s ability to communicate and to tolerate oral intake. The first tracheostomy tube change is commonly between day 7 and 14 post insertion. Local guidelines permit tracheostomy change 5 days after insertion. Hypothesis: We hypothesized that changing tracheostomy tubes before day 7 is associated with earlier use of a speaking valve, as well as earlier oral intake, compared to changing tracheostomy tubes after 7 days. Methods: We prospectively enrolled 130 patients admitted after tracheostomy placement to a Respiratory Care Unit between July 2008 and May 2010. Exclusions were: tracheostomy in place more than one year, transfer from an outside institution with a tracheostomy in place, and progressive neuromuscular weakness. Primary endpoint was the time from tracheostomy placement to tolerate speaking valve. Secondary endpoint was the time from tracheostomy placement to tolerate oral intake. Complications of tracheostomy change were recorded. Results: There were 38 patients who underwent a tracheostomy change before day 7 (early group), and 92 after 7 days of tracheostomy placement (late group). There was no difference in patient demographics, severity of disease, and surgical approach to tracheostomy placement between the groups. The early group was more likely to be liberated from the ventilator on day 7 (100% vs. 45% p ⫽ 0.0001). The early group tolerated speaking valve significantly earlier (7 days vs. 12 days, p ⫽ 0.001). The early group tolerated oral intake significantly earlier (10 days vs. 20 days, p ⫽ 0.04). The early group also had a shorter unit length of stay (11 d vs. 17 d, p ⫽ 0.001) and hospital length of stay (p ⫽ 0.048). There was no difference in mortality and there were no complications associated with tracheostomy change. Conclusions: Early tracheostomy change is safe and associated with earlier ability to tolerate speaking valve and oral intake. Earlier ventilator liberation allows more rapid progression to use of speaking valve and oral intake.


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HOSPITAL LENGTH OF STAY AND COSTS IN PATIENTS WITH CANDIDEMIA TREATED WITH ECHINOCANDINS ONLY OR INITIAL FLUCONAZOLE WITH SWITCH TO ECHINOCANDINS

SURVIVORS OF CRITICAL ILLNESS HAVE MORE THAN TWICE THE RISK OF ONE-YEAR MORTALITY AFTER CONTROLLING FOR PRIOR HEALTH STATE

Rolin Wade, Cerner LifeSciences, Paresh Chaudhari, Astellas Pharma US, Rebecca Campbell, Jing Yi, Cerner LifeSciences, Smita Kothari, Astellas Pharma US Inc, Brian Nathanson, OptiStatim, LLP, David Horn, David Horn, LLC Introduction: Hospital length of stay (LOS) and costs associated with choice of initial antifungal therapy (Rx) and switching to other agents are not well understood. Recommendations for initial Rx of candidemia generally include fluconazole or an echinocandin. This study compares LOS and costs in patients (pts) treated with an echinocandin only (echinocandin group) or initial fluconazole switched to echinocandin (step-up group). Hypothesis: We hypothesize that shorter LOS and lower costs will occur in the echinocandin Rx only group. Methods: A retrospective analysis of the Health Facts® electronic medical record (EMR) database identified pts ⬎⫽ 18 years of age with a positive blood culture for Candida. Univariate inference tests, multivariate generalized linear models (GLM), and marginal effect (ME) analyses assessed differences between groups. Results: 493 pts with candidemia were studied (249 echinocandin, 244 step-up groups). In univariate analyses, mean age (61.5 vs 60.9 years), gender (56.6 vs 52.9 % male) and ethnicity (69.9 vs 70.5 % Caucasian) were similar (echinocandin vs step-up groups, respectively). Echinocandin pts were less likely to be surgical pts (44.6 vs 56.1 %, p ⫽ .03) or require critical care (67.9 vs 75.8 %, p ⫽ .05). LOS and LOS after initiation of antifungal Rx (LOS-AF) were significantly greater in the step-up group (Mean 37.8 vs 26.5 and 25.5 vs 13.1 days, both p ⬍.001). Mean total costs (TC) in 2010 dollars were lower in the echinocandin group ($79,508 vs $97,938, p ⫽ .03). After adjustment for baseline characteristics and comorbidities, LOS-AF was significantly greater in the step-up group (ME 5.9 more days; 95% CI, 3.5– 8.4) as was total days with antifungal Rx (TD-AF) (ME 4.9 more days; 95% CI, 3.3– 6.5) but TC were comparable. Conclusions: Using a large multi-center EMR database, LOS-AF and TD-AF were significantly longer in pts with an initial fluconazole Rx followed by an echinocandin. TC in the echinocandin group was significantly less in the univariate but not multivariate analysis suggesting that more severely ill patients were in the step-up group. This study was supported by Astellas Pharma US.

Mary Hartman, Washington University in St. Louis, Sachin Yende, University of Pittsburgh, Hannah Wunsch, Columbia University Medical Center, Derek Angus, University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Walter Linde-Zwirble, Z D Associates Introduction: Hospitalization and ICU admission may modify baseline estimates of 1-year mortality after discharge. Hypothesis: Hospitalization and ICU admission will be associated with a reduction in health-state and higher 1-year mortality. Methods: We used the Medicare Standard Analytic Files, containing all inpatient, outpatient, SNF and provider claims for 5% of all Medicare beneficiaries aged ⱖ66 years in 2003. Recent History of Acute Illness (RHACCI) scores were calculated from all encounters in 2002. The first discharge alive from an acute hospitalization in the first quarter of 2003 was the index event, with ICU LOS⬎0 used to identify ICU care. Mortality 1-year following the discharge quarter was the primary outcome. Baseline 1-year mortality was calculated from the primary RHACCI model. Results: There were 1,267,632 living Medicare beneficiaries in the cohort at the end of the first quarter of 2003. Of those, 1,178,212 had never been hospitalized and 88,420 had at least one hospitalization in the quarter. Hospitalized beneficiaries had a higher baseline RHACCI score than non- (13.3 vs. 8.1, p⬍0.001), but RHACCI was nearly identical for those with and without ICU care (13.27 vs. 13.32, p ⫽ 0.43). Those never hospitalized had 4.82% 1y mortality, consistent with the predicted rate of 4.81%. Those with non-ICU care had an expected mortality of 10.25% from RHACCI, but an observed 17.32% 1y mortality, an increase of 68%. ICU patients similarly had an expected 1y mortality of 10.1% from RHACCI but an observed rate of 20.7%, a 105% increase over baseline. The increased risk of 1y mortality was equivalent to hospitalization having added 6 points to the RHACCI score and ICU adding 3 points more. Adding these equivalent points to the baseline RHACCI model yielded a predicted 1y mortality for non-ICU patients of 17.21% and ICU patients of 21.24%, very close to the observed. Conclusions: A patient’s recent medical history accounted for nearly 60% of a non-ICU patient’s 1-year mortality risk, but less than half of the 1-year risk for those with ICU care. Use of RHACCI scores adjusted for hospital and ICU use allows for a better detailed description of survival expectation after critical illness and better discharge planning.

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IMPROVED SURVIVAL IN WARFARIN-ASSOCIATED INTRACEREBRAL HEMORRHAGE AFTER IMPLEMENTATION OF A PCC-BASED WARFARIN REVERSAL PROTOCOL AND EDUCATIONAL INTERVENTION

LIKELIHOOD OF PRENATAL DETECTION OF CONGENITAL HEART DISEASE MAY BE INDEPENDENT OF SOCIOECONOMIC AND RACIAL/ETHNIC FACTORS

Jennifer Duprey, Jennifer Palminteri, John Dziodzio, Anand Rughani, Jeffrey Florman, Katherine Cabral, David Seder, Maine Medical Center Introduction: Warfarin use in patients with intracerebral hemorrhage (ICH)has been associated with higher rates of hematoma expansion and higher mortality than in patients without coagulopathy. Prothrombin complex concentrates (PCC) rapidly normalize the INR though its effect on hematoma expansion and clinical outcomes is not known. Implementation of a PCC-based warfarin reversal protocol and provider education regarding its use may improve outcomes for patients with (ICH). Hypothesis: Implementing a PCC-based warfarin reversal protocol and performing an educational intervention may decrease time to documented INR reversal, hematoma expansion, and in-hospital mortality in patients with ICH. Methods: After documenting 3 years retrospective experience with warfarin-associated ICH, a PCC-based warfarin reversal protocol was institutionally approved and an educational intervention performed targeting staff and residents and including lectures, eLearn modules, and computerized order sets. We obtained IRB approval to compare demographics, clinical factors, neuroimaging, laboratory values, and in-hospital outcomes of these patients to similar admissions over 18 months after the protocol and intervention. Results: Age, medical comorbidities, and ICH scores [median 2 (0 –3) vs 2 (1–3), P ⫽ 0.41] were similar between 51 patients admitted prior to and 33 after the intervention. Despite low PCC utilization post-intervention (11/33 patients), documented INR normalization occurred faster (⬍6 hours in 12.2 vs. 42.4%, P ⫽ 0.0025, and ⬍12 hours in 16% vs 61%, P⬍0.001). The incidence of hematoma expansion (38% vs 36% , P ⫽ 0.9) did not differ, but in-hospital mortality declined (45.1% vs 18.2%, P ⫽ 0.013). Conclusions: Implementing a PCC-based warfarin reversal protocol and performing an educational intervention was associated with faster INR normalization and lower mortality in patients with primary ICH. Interestingly, the intervention did not clearly affect the incidence of hematoma expansion, suggesting other factors such as more aggressive care might be responsible for the better outcomes.


Adler Salazar, Childrens Hospital Los Angeles, Luca Trento, Kaiser Permanente Roseville Medical Center, Priscilla Yu, Jay Pruetz, Jon Detterich, Childrens Hospital Los Angeles, Mark Sklansky, Ronald Reagan UCLA Medical Center, David Epstein, Children’s Hospital LA Introduction: Fetal ultrasonography (US) has made prenatal diagnosis of congenital heart disease (CHD) possible and may improve clinical outcomes. The purpose of our study was to determine whether socioeconomic, racial/ethnic, or other sociocultural factors (insurance, language, living in a medically underserved area [MUA], and race/ethnicity) impact the likelihood of prenatal diagnosis of CHD. Hypothesis: Socioeconomic, racial/ethnic, and other sociocultural factors, play a role on whether CHD diagnosis occurs prenatally or postnatally. Methods: A retrospective cohort of neonates from a single institution with unrepaired CHD admitted to the ICU (9/2007–9/2009) was used for univariate analysis (Pearson Chi-square) and multivariate logistic regression analysis. Results: Of our cohort of 318 patients, 208 (65.4%) were Latino, 66 (20.8%) were Asian/Pacific Islander/Indian, 27 (8.5%) were Caucasian, and 15 (4.7%) were African-American. CHD was diagnosed prenatally in 139 (44%) and postnatally in 179 (56%) of the patients. Insurance type was evenly distributed with 48.2% having private and 51.5% having government/public insurance. English was the predominant language (75.3%) and 35.4% of the patients lived in a MUA. The ICU mortality for this cohort was 8.5%. Only gender (p ⫽ 0.02) and lesion type (p⬍0.001) showed an association with timing of US diagnosis in the univariate analysis. A multivariate logistic regression model controlling for gender, socioeconomic and sociocultural factors, race/ethnicity, and type of CHD lesion, showed that the type of CHD was the only factor significantly associated with timing of US diagnosis of CHD. Heterotaxy (OR ⫽ 7.8, 95% CI 2.88 –20.89; p⬍0.01), single ventricle with ductal-dependent pulmonary blood flow (OR ⫽ 3.6, 95% CI 1.89 – 6.91, p⬍0.01), and single ventricle with ductal-dependent systemic blood flow (OR ⫽ 5.2, 95% CI 2.85–9.30, p⬍0.01) were significantly more likely to be diagnosed prenatally. Conclusions: In our cohort, race, language, insurance type, and residence in a MUA did not impact the likelihood of prenatal diagnosis of CHD. Heterotaxy and other single-ventricle forms of CHD tend to be diagnosed prenatally more commonly than less complex forms of CHD.

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RED CELL DISTRIBUTION WIDTH AND MORTALITY IN SEPTIC SHOCK PATIENTS

UP TO 6 YEARS LONG-TERM HEALTH-RELATED QUALITY OF LIFE IN SEVERE SEPSIS SURVIVORS

Farid Sadaka, Sumi Prakash, Jacklyn O’Brien, Saint John’s Mercy Medical Center/St. Louis University

Baoli Cheng, Yue Jin, Guohao Xie, the 1st Hospital, College of Medicine, Zhejiang University, Tao Zhu, The Children’s Hospital, College of Medicine, Zhejiang University, Haihong Wang , the 1st Hospital, College of Medicine, Zhejiang University, Xiwang Liu, The Children’s Hospital, College of Medicine, Zhejiang University, XiangMing Fang, the 1st Hospital, College of Medicine, Zhejiang University

Introduction: Red cell distribution (RDW) is an expression of the variation in size of the red blood cells that make up the total population in an individual patient. RDW is reflective of inflammation. It is a predictor of mortality in the general critically ill population. The prevalence of increased RDW and its significance in septic shock patients are unknown. Hypothesis: The objective of this study was to investigate the association between RDW on day 1 of development of septic shock and inhospital mortality. Methods: This retrospective cohort study was completed at a large University-affiliated hospital. All patients with septic shock admitted to a 50-bed ICU between July 2003 and February 2009 were included. Patients were treated according to sepsis management guidelines. A total of 239 septic shock patients were included. Patients transfused anytime the week prior or anytime after the development of septic shock were excluded. The normal range of RDW is 11.5% to 14.5%. We categorized the patients into a priori groups based on RDW as follows: ⬍13.5% (n ⫽ 30), 13.6% to 15.5% (n ⫽ 72), 15.6% to 17.5% (n ⫽ 67), 17.5% to 19.4% (n ⫽ 40), and ⬎19.5% (n ⫽ 30). Results: On Day 1, RDW was a strong independent predictor of inhospital mortality: RDW 13.6% to 15.5% (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.22 –1.72; p ⬍.001); RDW 15.6% to 17.5% (OR, 2.49; 95% CI, 1.83 –3.38; p ⬍.001); RDW 17.5% to 19.4% (OR, 3.22; 95% CI, 1.99 –5.19; p ⬍.001); RDW ⬎19.5% (OR, 3.62; 95% CI, 1.99 – 6.58; p ⬍.001), all relative to patients with RDW ⬍13.5%. Estimating the receiver operating characteristic (ROC) area under the curve shows that RDW has a good discriminative power for in-hospital mortality (area under the curve ⫽ 0.76 [For APACHE II, the ROC area under the curve ⫽ 0.72]). Conclusions: Red cell distribution width is a strong predictor of in-hospital mortality in septic shock patients. Red cell distribution width is commonly measured, inexpensive, and widely available and may reflect overall inflammation, and oxidative stress in the septic shock patient population.

Introduction: Severe sepsis has been a leading cause of death and a major public health burden in critical illness throughout the world. Several studies have focused on the short-term outcomes of severe sepsis; however, health-related quality of life (HRQOL) assessments beyond 2 years in severe sepsis survivors remain scarce. Hypothesis: Although impaired HRQOL of sepsis survivors has been observed in several studies up to 2 years after discharge, it could improve over years. Methods: From Jan, 2003 to Dec, 2009, all adult patients diagnosed as severe sepsis from 4 university hospital ICUs were screened and the survivors were enrolled. Age-, gender- and Charlson Comorbidity Index (CCI)-matched non-septic critical patients discharged from these units were recruited as controls. Between Aug and Dec, 2010, all these patients were called back for in-person interviews to assess their long-term HRQOL using the SF-36 instruments. Results: A total of 42 survivors of severe sepsis and 33 non-septic critical ill patients (controls) completed their interviews. The median response time of the two groups are 43.56 months, range from 11.37 to 74.40 months. Compared with non-septic survivors, survivors of severe sepsis had an increased APACHE II score, length of ICU and hospital stay. The patients surviving from severe sepsis had clinically meaningful decrement during the first 2 years after discharge in physical functioning (PF), role-physical (RP), bodily pain (BP) and roleemotional (RE) domains compared with both non-septic survivors and population norms. Interestingly, these domains were improved after 2 years. But, the RP domain is still significantly lower than population norms (p ⫽ 0.003) beyond 2 years after discharge. Furthermore, a clinically significant reduction in mental component score (MCS) was revealed in a comparison of severe sepsis groups and critical ill controls during 2 years follow-up period (P ⫽ 0.049) and was disappeared after 2 years. Conclusions: The present study showed a decreased long-term HRQOL after severe sepsis during the first 2 years, and the decrements could recover up to 6 years. These results indicated the importance and worthiness to put mass medical resources in surviving sepsis.

522 CLINICAL OUTCOMES OF TYPE III PSEUDOMONAS AERUGINOSA BACTEREMIA Ali El-Solh, University of Buffalo Introduction: Pseudomonas aeruginosa bacteremia is a serious and life-threatening infection associated with high mortality. Among the multitude of virulence determinants possessed by P. aeruginosa, the type III secretion system (TTSS) has been implicated with more acute and invasive infection in respiratory diseases. However, the relationship between TTSS and clinical outcomes in P. aeruginosa bacteremia has not been investigated. Hypothesis: We hypothesize that Pseudomonas aeruginosa Type III bacteremia is associated with increased 30-day mortality compared to non secretory P. aeruginosa bacteremia. Methods: we conducted a retrospective analysis of 85 cases of P. aeruginosa bacteremia at a tertiary care hospital. Bacterial isolates were assayed in vitro for secretion of type III exotoxins (ExoU, ExoT, and ExoS). Strain-relatedness was analyzed using randomly amplified polymorphic DNA PCR genotyping. Antimicrobial susceptibilities were determined by means of the Kirby-Bauer disk-diffusion test. Results: At least one of the TTSS proteins was detected in 37 out of the 85 isolates (44%). Septic shock was identified in 43% of bacteremic patients with TTSS⫹ isolates compared to 23% of patients with TTSS- isolates (p ⫽ 0.12). A high frequency of resistance in the TTSS⫹ isolates was observed to ciprofloxacin (59%), cefipime (35%), and gentamycin (38%). There was a significant difference in the 30-day cumulative probability of death after bacteremia between secretors and nonsecretors (p ⫽ 0.02). None of the TTSS⫹ patients who survived the first 30 days had a P. aeruginosa isolate which exhibited ExoU phenotype. Conclusions: The expression of TTSS exotoxins in bacteremic isolates of P. aeruginosa confers poor clinical outcomes independent of antibiotic susceptibility profile.



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EXTERNAL VALIDATION AND CUSTOMIZATION OF SIMPLIFIED ACUTE PHYSIOLOGY SCORE 3 ADMISSION SCORE IN KOREAN INTENSIVE CARE UNITS

VENTILATOR SETTING DISCORDANCE WITH COMPUTERIZED PHYSICIAN ORDERS IN A PEDIATRIC ICU: A HUMAN FACTORS PERSPECTIVE.

So Yeon Lim, Samsung Medical Center,Sungkyunkwan University School of Medicine, Younsuck Koh, Asan Medical Center, Univ. of Ulsan College of Medicine, Shin Ok Koh, Yonsei University College of Medicine, Severance Hospital , Won-Il Choi, Keimyung University, Dongsan Hospital, Gyu Rak Chon, Chungju hospital, School of medicine, Konkuk university, Je Hyeong Kim, Korea University Ansan Hospital, Jae Yeol Kim, Chung-Ang University College of Medicine, Gee Young Suh, Division of Pulmonary and Critical Care Medicine

Paul Bauer, Medical College of Wisconsin, Khris O’Brien, Children’s Hospital of Wisconsin, Kathleen Murkowski, Martin Wakeham, Matthew Scanlon, Medical College of Wisconsin

Introduction: Although Simplified Acute Physiology Score (SAPS) 3 proposed customized equations for the prediction of hospital mortality in different geographic regions, global SAPS 3 and customized Australasia version have never been externally validated in a large representative database of Korean intensive care units (ICUs). Hypothesis: This study was designed to validate global and Australasia SAPS 3 in Korea. Methods: This is prospective multicenter cohort study, and involved Korean fifteen ICUs from the Validation of SAPS 3 in Korean ICUs (VSKI) study cohort. The patients consecutively admitted to 15 ICUs from July 1st, 2010 to January 31st, 2011 and randomly divided into equal development and validation groups for customization. Results: A total of 4,617 patients were enrolled. The ICU mortality was 13.6% (658/4,617), and the hospital mortality was 19.6% (949/4,617). The global SAPS 3 revealed good discrimination (aROC ⫽ 0.829), but poor calibration with Hosmer-Lemeshow goodness-of-fit (GOF) test (H ⫽ 123.06, p ⬍0.0001, C ⫽ 118.45, p ⬍0.0001). The Australasia SAPS 3 exhibited good discrimination (aROC ⫽ 0.829), and poor calibration (H ⫽ 73.53, p ⬍0.0001, C ⫽ 70.52, p ⬍0.0001). The specifically customized equation for Korea showed good discrimination (aROC ⫽ 0.835) and good calibration (H ⫽ 4.61, p ⫽ 0.7988, C ⫽ 5.67, p ⫽ 0.6843). Conclusions: In Korea, hospital mortality rates predicted using global and Australasia SAPS 3 exhibited poor calibration and good discrimination. The Korean SAPS 3 as a specific customized equation for Korea improved the calibration and could be used to predict hospital mortality accurately in Korean ICUs.

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Introduction: Although lifesaving, mechanical ventilation has the potential to cause harm in patients. Based on incident reporting in our PICU, we know that actual ventilator settings do not always match orders for these settings. There is no study reporting mismatch for ventilator settings and orders in the pediatric ICU. Hypothesis: There will be no more than a 5% discrepancy rate between orders for conventional mechanical ventilation (CMV) and actual ventilator settings. Methods: A prospective, observational design was used in a 72-bed pediatric intensive care unit (PICU). Ventilator settings (Maquet) were compared to orders in the computerized physician order entry (CPOE) system (Eclypsis). The institutional review board approved the study. Patients receiving active surgical care, non-invasive ventilation, high-frequency ventilation, or support with a home ventilator were excluded. Data were collected over a period of 25 weekdays. Frequencies of order/setting mismatch, missing settings or orders were established as a percentage of total observations. Results: A total of 1184 patient observations were obtained. Of these, 276 (23.3%) patients were receiving CMV. 7 were excluded because of active medical care at observation. No patients received CMV without an order. Of eligible observations, excluding FiO2, 112 (42%) had discrepancies. By mode of ventilation, there were 225 (84%) matches, 6 (2%) mismatches, and 38 (14%) missing mode orders for a total of 44 (16%) mode discrepancies. There were 54 (20%) parameter mismatches, 4 (1%) missing settings and 62 (23%) missing parameter orders. Conclusions: Discrepancies between CMV settings and orders were common. More than 2 in 5 of all CMV observations had a discrepancy, and more than 1 in 10 lacked an order for the mode of ventilation. The findings are consistent with discrepancies for other technologies within the ICU such as infusion pump medication delivery[1] where errors and incorrect use present risk of harm to patients. Reference: 1. Russell, R.A., et al, Discrepancies between medication orders and infusion pump programming in a paediatric intensive care unit. Qual Saf Health Care. 2010 Oct;19 Suppl 3:i31–5

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THE IMPACT OF PHARMACIST INTERVENTION IN CLINICAL MANAGEMENT OF CRITICALLY ILL PATIENTS

OUTCOMES OF SEVERE SEPSIS IN MORBIDLY OBESE PATIENTS

Julia Pires, Jose Luiz Amaral, Isaac Castro, Flavio Freitas, Bruno Mazza, Miriam Jackiu, Antonio Baffi, Murillo Assuncao, Flavia Machado, Federal University of Sao Paulo

Gagan Kumar, Amit Taneja, Medical College of Wisconsin, Abhishekh Deshmuk, University of Arkansas, Jayshil Patel, Medical College of Wisconsin, Jennifer Weston, Froedtert Hospital, Rahul Nanchal, Medical College of Wisconsin

Introduction: Drug interactions are a great concern in intensive care units (ICU). However, routine screening for potential drug-drug interactions (PDI) and clinically relevant drug-drug interactions (CDI) is not a broadly used strategy. Hypothesis: To determine the incidence, characteristics and risks factors for PDI/CDI and the impact of a clinical pharmacist intervention on medical prescription in critically ill patients. Methods: This prospective, observational study enrolled all patients admitted in an ICU for more than 48 hours from November/ 2009 to December/2010. A pharmacist audited medical prescriptions on a daily basis to determine the number of prescribing doctors, number of drugs prescribed and the characteristics of all PDI, using Micromedex® software. All PDI were discussed with medical staff to determine the presence of CDI. Medical management was recorded. CDI risks factors was assessed thought a multivariate analysis. ROC curves were used to categorize the number of days using each drug category. Results were considered significant if p⬍0.05. Results: We included 313 patients and analyzed 3,565 prescriptions. In 67.9%, a PDI was identified, with a total of 8,412 (1.0(0.0 – 4.0) PDI/prescription). In 438 PDI (5.2%) symptoms were present and 169 (2.0%) were considered CDI. Medical decision were withdrawn the drug although still considered necessary (35.3%), withdrawn because it was not essential (16.5%) or symptomatic treatment because withdrawn was not possible (30.0%). Sixty-four patients (20.4%) had CDI and they had higher APACHE and SOFA scores and more frequently presented with chronic renal failure, mechanical ventilation and shock. In the multivariate model, a higher number of days using diuretics, corticosteroids, antiacids, antilipemics and antiepileptic remained as risks factors for CDI. Conclusions: PDI are frequent in ICU. Although CDI are less common, daily pharmacist audit resulted in changes in prescription in the majority of cases. CDI was associated with high use of specific drug categories.

Introduction: About 30% of adult population in United States is obese. The data regarding outcomes of these patients in critical care unit has been subjected to debate and a metanalysis has shown that obesity is not associated with excess mortality. Severe sepsis is one of the common medical conditions with high mortality. The outcomes of severe sepsis in obese patients are scarce. Hypothesis: Obesity predisposes to higher mortality in patients with severe sepsis. Methods: Using the Nationwide Inpatient Sample 2000 –2008, patients older than 18 years, discharged with severe sepsis were identified using ICD-9-CM codes as described in literature. The morbidly obese (Body mass index ⬎40) were similarly identified using ICD-9CM code 278.01. Outcome variables included frequency, in-hospital mortality and length of stay. Chi square test and Wilcoxon rank-sum test were used to compare variables for unadjusted analysis. Logistic regression model was developed to find if morbid obesity was independent predictor of mortality. The model was adjusted for demographic and hospital characteristics, co-morbidities and severity of severe sepsis as defined by number of organ failures. Results: There were total of 4,747,262 estimated adult discharges with severe sepsis from 2000 –2008. There were 79,814 (1.7%) morbidly obese patients. In-hospital mortality in patients admitted with severe sepsis was significantly lowered in morbidly obese when compared to those without (20.6% vs. 32.9%, p⬍0.001). Morbid obesity was found to be independent predictor of mortality in patients with severe sepsis (OR 0.68; 95% confidence interval 0.65– 0.71). The length of stay was similar in both groups (mean: 15.4 days in non obese vs. 15.1 days in obese). Conclusions: Patients with morbid obesity have 0.68 times lower odds of mortality in severe sepsis when compared to non obese. Further studies are needed to understand the causation.


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ACUTE KIDNEY INJURY (AKI)IN LIVE DONOR LIVER TRANSPLANT(LDLT)RECIPIENTS

IMPACT OF A DEDICATED CLINICAL PHARMACIST IN THE MEDICAL INTENSIVE CARE UNIT

Sachin Gupta, Deepak Govil, Shaleen Bhatnagar, Shrikanth Srinivasan, Sweta Patel, Prashant Pandey, Jagadeesh KN, Manuj Sodhi, Sanjiv Saigal, Arvinder Soin, Medanta The Medicity

John Marshall, Andrea Handeli, Beth Israel Deaconess Medical Center, Michael Howell, Silverman Institute For Health Care Quality and Safety, John Hrenko, Beth Israel Deaconess Medical Center

Introduction: Acute kidney injury is among the most common complication associated with orthotopic liver transplantation in the early postoperative period and it bears a direct impact on patient outcome. Hypothesis: Retrospective data of 100 LDLT recipients was evaluated. Methods: AKI was defined as per RIFLE and AKIN classification. Pre-operative serum creatinine and creatinine clearance were noted. Hourly urine output and daily serum creatinine were noted up to first week after transplant and then at the time of discharge or at postoperative day twenty eight whichever was earlier. Need for renal replacement therapy and its effect on overall outcome of the patients were documented. Both RIFLE and AKIN criteria were compared in defining AKI and their usefulness in early detection was also analysed. Results: Thirty one patients (31%) developed AKI during the defined period and out of these thirty one only four patients (13%) required RRT. Pre-operative serum creatinine (0.92 vs 0.79 mg/dl) and creatinine clearance (72.67 vs 81 ) did not show any significant difference between the AKI and non-AKI group . AKI was detected early by AKIN classification as compared to RIFLE. Glomerular filteration criteria in AKIN classification was more sensitive in early detection of AKI. Out of thirty one patients in the AKI group five patients (16%) died within 28 days and all the four patients (100%) who required RRT died within 28 days. Whereas 28 day mortality in Non AKI group was three (4%) out of sixty nine patients. Conclusions: AKI is one of the most dreaded complication in post LDLT patients and leads to increased mortality. Need for renal replacement therapy in LDLT patients is associated with very high mortality. Both RIFLE and AKIN classification are equally sensitive in defining AKI.

Introduction: The purpose of this study was to compare the effect of a dedicated Medical Intensive Care Unit (MICU) pharmacist with a multi-unit pharmacist staffing model on ICU length of stay (LOS). Hypothesis: A dedicated MICU pharmacist will reduce MICU length of stay when compared to a multi-unit pharmacist staffing model. Methods: This was a before-after study. The before group consisted of a pharmacist covering the MICU as well as 3 medical/surgical units. The after group consisted of a pharmacist being dedicated to the MICU. Data collected included baseline demographics, APACHE II score, pharmacist interventions, drug cost, and adverse drug events utilizing the IHI trigger tool. A sample size of 300 patients was required to detect a 12 hour difference in MICU LOS with a power of 0.8 and an alpha of 0.05. Patients were included if they were admitted to the Medical Intensive Care Unit during the study period. There were no exclusion criteria. The first 150 consecutive patients were included in the before group (multi-unit staffing model) starting November 1, 2010. The after group (dedicated pharmacist) included 150 consecutive patients and began 3 weeks after enrollment was completed in the control group. Results: A total of 300 patients were included in the analysis. The groups had similar baseline characteristics, including admitting diagnosis, severity of illness, and proportion of patients requiring mechanical ventilation. The mean ICU LOS in the control group was 80.1 ⫾ 98.3 h and 76.3 ⫾ 101.3 h in the intervention group (p ⫽ 0.7). The duration of mechanical ventilation was 96 ⫾ 112 h (n ⫽ 49) in the control group and 76 ⫾ 115 h (n ⫽ 56) in the intervention group (p ⫽ 0.36). Secondary outcomes demonstrated a statistically significant decrease in the amount of sedative agents utilized and a significant increase in pharmacist interventions (87 in the control group, 1187 in the intervention group). Drug costs were also reduced in the dedicated pharmacist group by $15,200 USD. Conclusions: There was no effect of a dedicated MICU pharmacist on ICU length of stay. Several secondary outcomes including quantity of interventions, amount of sedation utilized, and drug costs were positively impacted.

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HIGH BLOOD GLUCOSE VARIABILITY IS ASSOCIATED WITH INCREASED MORTALITY IN CRITICALLY ILL PATIENTS

EPIDEMIOLOGY AND DETERMINANTS OF RED BLOOD CELL TRANSFUSIONS IN PEDIATRIC INTENSIVE CARE

BalajiYegneswaran,UniversityofPittsburghMedicalCenter,RobertParker,Universityof Pittsburgh, Gilles Clermont, University of Pittsburgh Medical Center Introduction: The objective of the study was to determine the association between glucose variability and mortality in critically ill patients. Glucose variability was assessed by standard deviation of patients’ glucose level. Hypothesis: Increased glucose variability is a marker of impaired homeostasis and is associated with increased mortality. Methods: A retrospective chart review of MIMICII dataset of ⬎26000 patients admitted to the ICUs at Boston’s Beth Israel Deaconess Medical Center (period 2001–2007), was conducted. All complete charts of patients ⬎15 yrs without the diagnosis of diabetic ketoacidosis or hyperosmolar state were included. Patients were classified into 5 groups on the basis of glucose standard deviation (GSD) (0 –20, 20 – 40, 40 – 60, 60 – 80 and ⬎80 mg/dl respectively) computed on all glucose values recorded during admission. Chi-square and Kruskal-Wallis were used to analyze the association between GSD, mortality, average glucose (AGlu) and hospital length of stay (LOS). Results: Of 19889 admissions with complete data, 18816 (94.6%) were available for analysis. Forty-three percent were females. Mean LOS was 12.5⫾13.6 days; AGlu was 133.5⫾32 mg/dl and mortality was 11.8%. LOS (mean ⫾ SD days) across groups 1–5 was 10⫾14, 13.9⫾12.8, 15.5⫾15.2, 13.5⫾10.9 and 10.6⫾8.9 (p⬍0.0001), and AGlu (mg/dl) was 118.3, 132.4, 152.3, 170.4 and 185.6 (p⬍0.0001). Mortality was 7.2%, 11.6%, 17.7%, 20.2% and 23.2% (p⬍0.001). In diabetic patients (n ⫽ 4971, 25%), LOS was 8.6⫾8.1, 11.6⫾9.3, 14.1⫾12.6, 13.2⫾10.4 and 10.5⫾9 (p⬍0.0001) days, and AGlu (mg/dl) was 113.5, 140, 158.4, 175.1 and 190.6 (p⬍0.0001). Among non-diabetics LOS was 10.1⫾14.6, 14.6⫾13.8, 16.8⫾17.3, 14⫾11.7, and 10.7⫾8.8 days (p⬍0.0001), while AGlu was 113.5, 140, 158.4, 175.1, and 190.6 (p⬍0.0001). Mortality among diabetics was 8.9%, 7.6%, 12.5%, 13.7% and 15.4% (p⬍0.001), while among non-diabetics, mortality rate was 7%, 13%, 22.6%, 29.6% and 33.7% (p⬍0.001). Conclusions: In a large dataset, increased glucose variability was significantly associated with increased average glucose, longer length of stay and increased mortality in critically ill patients. The effect on LOS and mortality was more pronounced in non-diabetic patients.

Pierre Demaret, Marisa Tucci, Sainte-Justine Hospital, Thierry Ducruet, CHU Sainte-Justine Research Center, Jacques Lacroix, Sainte-Justine Hospital Introduction: Evaluation of current transfusion practices is important and helpfull to develop appropriate transfusion strategies. Hypothesis: Our aims are to determine the incidence of red blood cell transfusions in critically ill children hospitalized in our pediatric intensive care unit (PICU),and to identify the main determinants of transfusions. Methods: Single-center prospective observationnal study of all children admitted to the PICU over a one-year period.Data collected in medical charts and from questionnaires administered to prescribing physicians.The possible determinants of transfusions were sought until the time of transfusion (transfused children (TC)) or until the end of PICU stay or death (non transfused children (NTC)). Results: During the study period,913 admissions were documented.Among the 843 included patients,144 (17%) were transfused at least once.TC were younger than NTC (57.7 months⫾74 versus 74.9⫾71.3).Among TC,a respiratory disease was present in 25.7% versus 37.4% in NTC,shock was present in 16% of TC versus 3.7% of NTC, and admission post cardiac surgery was present in 25.7% of TC versus 10.6% of NTC.The average admission PRISM score and the PELOD score were lower in the NTC (5.21⫾5.27 versus 9.6⫾6.97 and 3.92⫾6.01 versus 9.1⫾8.53,respectively).Admission hemoglobin was higher in the NTC (115.7⫾21.4 versus 92⫾29.6).After univariate analysis,significant determinants of transfusion during the PICU stay were hemoglobin level,any organ dysfunction,and severe sepsis/septic shock.For prescribing physicians,the most significant reason for the first transfusion was a low hemoglobin level (39.6%),followed by a need to improve oxygen delivery (17.3%). Conclusions: The proportion of children transfused in the PICU is significant.Young age,admission for shock or post cardiac surgery,severity of illness and hemoglobin level were significant determinants of transfusion observed at PICU entry.During PICU stay, hemoglobin level,organ dysfunction,and severe sepsis/septic shock were significantly associated with transfusion.Moreover,our study suggests that the hemoglobin level is the main factor leading to transfusion,in addition to the desire to improve oxygen delivery.


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FIREARM INJURIES IN THE UNITED STATES: A PUBLIC HEALTH ISSUE

SEPTIC SHOCK FROM MYCOBACTERIUM TUBERCULOSIS

Veerajalandhar Allareddy, Rainbow Babies and Children’s Hospital, Sankeerth Rampa, Cleveland State University, Veerasathpurush Allareddy, Harvard University

Introduction: Septic shock due to M. tuberculosis (MTB) is an uncommon but well recognized clinical syndrome. Data on this condition is limited due to the paucity of reported cases. Hypothesis: To describe the unique clinical characteristics, epidemiologic risk factors and covariates of survival of patients with MTB septic shock in comparison to other bacterial septic shock. Methods: Retrospective nested cohort study. 52 patients diagnosed with MTB septic shock derived from a tri-national, 8760 patient database of patients with septic shock between 1989 and 2008 Results: MTB accounted for 1.0% of cases of bacterial septic shock cases within the database. Patients with MTB and other bacterial septic shock had an in-hospital mortality of 79.2% and 49.7% respectively (p⬍.0001). Of the cases of MTB shock, all but 5 patients had respiratory tract involvement. 32 of 52 patients were documented as having disseminated infection involving at least 2 major organ systems. Immunosuppressed patients including those with liver failure had the highest overall mortality of 92.6% (Only 2/27 survived); among those with AIDS 1 of 8 patients survived. Alcohol was the single most common co-morbidity observed in the series (16/53), 7 of whom had liver failure; Alcohol abusers overall had a 75% mortality rate. Inappropriate and appropriate initial empiric therapy was delivered in 28 (52.8%) and 25 (47.2%); survival was 7.1% and 36.0% respectively (p ⫽ .0114). The median time to appropriate antimicrobial therapy for MTB septic shock was 31.0 (18.9 –71.9 interquartile range [IQR]) hrs. Only 11 patients received anti-MTB within 24 hours of documentation of hypotension; 7 (63.6%) of these survived. Only 1 of 21 (4.8%) patients who started anti-MTB therapy after 24 hours survived (p ⫽ .0003 vs ⬍24 hrs). Survival differences between these time intervals are not significantly different than seen with bacterial septic shock due to standard pathogens. Conclusions: MTB septic shock behaves similarly to bacterial septic shock . As with bacterial septic shock, early appropriate antimicrobial therapy appears to improve mortality. Earlier recognition of infection is the most obvious effective strategy to improve hospital survival.

Introduction: Firearm related injuries is a major cause of morbidity and mortality in United States. Firearms are important sources of non-fatal and fatal injuries among children and young adults in the United States. Hospital based Emergency Departments (ED) are one of the points of entry into the health care system for victims of firearm injuries. Hypothesis: The objective of this study is to provide outcomes of hospital based emergency department visits attributed to firearm related injuries in the United States. Methods: The Nationwide Emergency Department Sample, a component database of the Healthcare Cost and Utilization Project for the year 2008 was used. All ED visits that had an External Cause of Injury for firearm related injuries were selected. The demographic profile and outcomes including hospital charges and mortality rates were examined. Results: A total of 86,194 ED visits in the United States had a fire arm injury. The average age of the ED visits was 30 years. Children aged 18 and years and less accounted for 18% of such visits. Males constituted a predominant proportion of all ED visits (89.7%). Close to 39% of all ED visits resulted in inpatient admission into the same hospital. A total of 4491 patients died in the emergency departments while 2937 died following hospitalization. 76% of all ED visits were amongst those residing in areas with mean household income levels less than $49000. The average charge for each ED visit was $3857. The mean charge for those visits that resulted in hospitalization was $75011 and the total hospitalization charges for the entire United States was about $2.48 Billion. Conclusions: The current study used the largest all-payer hospital based emergency department dataset to provide national estimates of firearm related injuries in the United States during the year 2008. Young adult males are at the highest risk of firearm injury. The study results highlight the public health impact of such injuries.

533 ECONOMIC IMPACT OF ADVERSE DRUG EVENTS RESULTING IN INTENSIVE CARE ADMISSION IN ONCOLOGY PATIENTS Lama Nazer, Rana Eljaber, Feras Hawari, King Hussein Cancer Center Introduction: The economic impact of serious adverse drug events (ADEs) in patients with cancer is not clear. The purpose of this study was to describe the direct cost associated wtih adverse drug events that necessitate admission to the intensive care unit (ICU) in oncology patients. Hypothesis: Adverse drug events that require admission to the ICU in oncology patients are associated wtih a significant economic impact. Methods: This was a cost analysis on data that was collected during a 5-month prospective observational study of oncology patients admitted to the ICU of a comprehensive academic cancer center. The study included patients who were admitted to the ICU for the management of a drugrelated adverse event. The hospital and ICU billing systems were used to determine the direct cost, defined as the patient charges, associated with each admission. In addition, patient demographics and length of stay were recorded. Results: For the 54 patients identified, the average cost of the ICU stay for the management of an ADE was $11,692 ⫹ 17,529 (SD) (range 383–99,235), corresponding to $1.5 million in annual charges for a 170-bed cancer institution. The average cost for the management of chemotherapy-related adverse events (n ⫽ 34, 61.8%) was $13,476 ⫹ 17,764 (SD) (range 383–99,235). The average cost for non-chemotherapy related adverse events (n ⫽ 20, 37%) was $8,660 ⫹ 17,137 (SD) (range 554 –74,427). Chemotherapy-induced febrile neutropenia, which was the most common ADE (n ⫽ 26, 48.1%), was associated with an average cost of $12,234 ⫹ 9,954(SD) (range 1,091–37,270). Opiates were responsible for the most non-chemotherapy related ADEs and were associated with an average cost of $5,608 ⫹ 4,540 (SD) (range 1,295–12,227). The average length of stay for the patients admitted to the ICU for the management of ADEs was 5.95 days ⫹9.43(SD). Conclusions: Adverse drug events resulting in ICU admission in patients with cancer are associated with a significant economic burden. Future studies should address measures to reduce the incidence of severe adverse events that require ICU admission.


Shravan Kethireddy, Duane Funk, Anand Kumar, University of Manitoba


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REPEATED PROCALCITONIN LEVELS FOR MONITORING OF SEPSIS PATIENTS IN THE CRITICAL CARE SETTING

FROM 1996 TO 2011: FIFTEEN YEAR SURVIVORS OF A PROLONGED SICU STAY: HOW ARE THEY DOING?

Philipp Schuetz, Harvard School of Public Health, Paula Maurer, Baycare Health System, Devendra Amin, Bay Area Chest Physicians

Sandra Swoboda, Pamela Lipsett, Johns Hopkins Medical Institutions

Introduction: Previous studies suggested that repeated procalcitonin measurements may help to guide duration of antibiotic therapy in ICU patients. The prognostic potential of repeated procalcitonin measurements to guide site-of-care decisions in ICU patients with sepsis remains undefined. Hypothesis: We hypothesized that repeated procalcitonin measurements would predict fatal outcomes in a cohort of sepsis patients in a US critical care setting independent of severity of illness scores (APACHE IV). Methods: This is a retrospective, observational cohort study of adult patients with severe sepsis or septic shock and with least 2 procalcitonin measurements within the first 5 days hospitalized in the ICU of Morton Plant Hospital (Clearwater, Florida). Cox regression models were calculated to assess the association of a PCT decrease from days 0 –1 to days 2–5 adjusted for severity using the APACHE IV score. Results: The in hospital mortality rate of the 359 included patients was 31.2% (95%CI 26.4%-36.0%). Mortality was 10.0% in patients with a high procalcitonin decrease of ⬎90% and increased to 27.7% and 48.6% in patients with a decrease of 50 –90% and ⬍50%. This was also true across different APACHE IV categories and in cox regression analysis adjusted for the APACHE IV score. Compared to procalcitonin decrease of ⬎90% (reference group), a decrease of 50 –90% and ⬍50% had adjusted hazard ratios of 2.91 (95%CI 1.25, 6.8) and 5.58 (95%CI 2.38, 13.08) to predict fatal outcome. Sensitivity of a procalcitonin decrease of ⬎90% was 94.6% and specificity of a decrease of ⬍50% was 76.9%. Adding procalcitonin decrease to the APACHE IV score increased the area under curve to predict mortality from 0.69 to 0.74 and improved classification of patients by 37% in reclassification tables (Net reclassification index 0.37, SE 0.07). Conclusions: The decrease of procalcitonin in the first days of ICU provided prognostic information beyond the APACHE IV score in this sepsis cohort. Prospective trials are needed to confirm these results and demonstrate whether improved prognostic assessment translates into better triage and therapeutic decisions.

536 THE EFFECT OF HEART RATE ON SURVIVAL FROM ICU Tara Quasim, Colette Lange, University of Glasgow, Kathryn Henderson, NHS Greater Glasgow and Clyde, Laura Moss, John Kinsella, University of Glasgow Introduction: As tachycardia may contribute to a worse outcome in the critically ill we examined the effect of heart rate on the outcome of critically ill patients. Hypothesis: We hypothesised that a persistent sinus tachycardia in the critically ill is associated with a higher mortality. Methods: Patients admitted to a tertiary referral hospital between January 2009 -January 2010 were studied. Exclusions included: a stay ⬍48 hours, any arrhythmia during their stay, readmissions and patients with incomplete information. Data collected included: age, gender, admission diagnosis, length of ICU stay, APACHE II and predicted hospital mortality. Individuals’ hourly heart rates were categorised as ⬍90 bpm, between 90 –120 bpm or ⬎120 bpm. Patients were further categorised into one of three groups: heart rate always ⬍90 bpm throughout their ICU stay, heart rate always ⬎120 bpm or a third mixed group with heart rates in all 3 categories. The patients were then quantified into time spent in each heart rate category. Data was evaluated using binary logistic regression. Odds ratios were used to confirm the strength of association between the variables. Results: After exclusions, 136 patients were studied. Only 2 patients always had a heart rate ⬍90 bpm whilst 134 were in the mixed group. For every additional 10% of time spent with a heart rate ⬍90 bpm, there was a 22% increase in survival from ICU (p ⫽ 0.026). For every additional 10% of time spent with a heart rate ⬍90 bpm, there was a 20% increase in hospital survival (p ⫽ 0.011). For every additional 10% of time spent with a heart rate ⬎120 bpm, there was a 31% reduction in survival from ICU (p ⫽ 0.001). For every additional 10% of time spent with a heart rate ⬎120 bpm there was a decrease in hospital survival by 25% (p ⫽ 0.007). For every additional 10% of time spent with a heart ⬎90 bpm there was an 18% decrease in ICU survival (p ⫽ 0.025). Conclusions: There is an association between the time spent with a heart rate ⬎120 bpm and mortality and an association between time spent with a heart rate ⬍90 bpm and survival. This was independent of illness severity. This observation may have prognostic and intervention implications.

Introduction: Little is known about long term survival and quality of life (QOL) of patients 15 years after a prolonged surgical ICU stay (⬎7 days). Hypothesis: 15 years after a prolonged SICU stay survivors will have a good QOL and life expectancy (LE) will be no different than the general population. Methods: Prospective survey of previously studied SICU patients with LOS ⬎7 days in FY1996. 15 year survival and QOL was obtained via 128 item Sickness Impact Profile Score (SIP). 1996 LE tables were used to predict survival with a comparator group. Survivor status was determined from vital statistics and interviews. Analysis included t-test, logistic regression (LR) and Kaplan-Meier (KM) curves, significance was p⬍0.05. Results: In FY 1996, 128 patients had a continuous SICU stay ⬎7 days and 58 (45%) survived to 1 year. In FY2011, 21/58 (36%) survived to 15 years. 14 patients participated in follow up interviews. Survivor mean age was 60 (range 33– 83), and the majority male 15/21(71%). The average life years expected of the survivors was an additional mean of 33 years (range 14 –57). KM curves revealed that if a patient survived 8 years after a prolonged ICU stay, long term survival was no different than the general population, p ⫽ 0.88. Survivors to 15 years had a mean index APACHE II score of 21 and a mean 15 day SICU length of stay (range 7– 48); p ⬎0.55. At one year, CASEMIX was significantly different between diagnosis groups (p ⫽ 0.01) and favored 100% survival from trauma. Significant differences in CASEMIX continued at 15 years; however, only 5/9 (55%) trauma patients were alive. Other survivors included: GI 7/21 (33%), Vascular 3/13 (23%), Transplant: 2/9 (22%), Other: 4/6 (66%). APACHE II and CASEMIX predicted alive status at 15 years (p⬍0.04) via LR. Functional outcome at 15 years was excellent with SIP scores of 5.8 (15 year), 9.5 (I year), 18.8 (PRE ICU), p ⫽ 0.02 and not different than the general population SIP ⫽ 3.6. Conclusions: 21 patients with a prolonged ICU stay in FY1996 and an average index APACHE II score of 21 survived to 15 years. Patients with prolonged SICU stay have both a similar LE and QOL as the general population. For these patients, our investment in their care 15 years ago was worthwhile.

537 POSTOPERATIVE ATRIAL FIBRILLATION AMONG NON CARDIO-THORACIC SURGICAL PATIENTS: ASSOCIATED CLINICAL FACTORS AND OUTCOME Cosimo Chelazzi, Dario Giugni, Gianluca Villa, Raffaele De Gaudio, University of Florence Introduction: Postoperative atrial fibrillation (POAF) is common following surgery. POAF is associated to higher length of stay (LOS) and higher morbidity and mortality. Previous studies mostly focused on cardiothoracic patients though other patients may be affected. Our aim was to evaluate incidence, associated factors and outcome of POAF in patients admitted to an Intensive Care Unit after surgery. Hypothesis: Knowing POAF associated factors may contribute to understand its pathophysiology and reduce its incidence among at-risk patients. Methods: The study included all patients admitted to a general ICU after surgery between 1/1/2010 and 31/03/2011. Patients with chronic atrial fibrillation (AF) were excluded. POAF was defined as a new-onset AF within 6 days after surgery. Rate of POAF was calculated. Association between clinical factors and POAF was tested with a Chi-square test and then a univariate and a multivariate analysis were done. Differences in outcome between POAF and non-POAF group were evaluated considering ICU-LOS and ICU-mortality. Results: A total of 295 patients were included. Rate of POAF was 3.1%. Factors associated with POAF were male sex (p ⫽ 0.05), coronary artery disease (CAD, p ⫽ 0.04), cancer (p ⫽ 0.002) and hyperthyroidism (p⬍0.001). At univariate analysis, conditions associated to POAF were CAD (OR 4.82; 95%CI[0.925–25.115]; p ⫽ 0.045), cancer (OR 8.56;95%CI[1.742– 42.064]; p ⫽ 0.008) and hyperthyroidism (OR 35.62; 95%CI[2.041– 621.738]; p ⫽ 0.014). At the multivariate analysis CAD (OR 6.10; 95%CI[0.93–39.80];p ⫽ 0.045), cancer (OR 9.33; 95%CI[1.66 –52.52]; p ⫽ 0.011) and hyperthyroidism (OR 32.13; 95%CI[1.05–985.66]; p ⫽ 0.047) were all indipendently associated with POAF. Patients with POAF had higher ICU LOS (3.44 vs 2.37 days, p ⫽ 0.02) and higher ICU mortality rates (22.2% vs 4.54%,p ⫽ 0.04). Conclusions: Associated clinical factors included CAD, neoplasms and hyperthyroidism. Patients who developed POAF had longer ICU stays and higher mortality. AF or related complications (i.e. stroke) were never the cause of death in the POAF-group. Based on these results, POAF could be seen as an indirect sign of a complicated postoperative course rather than a direct cause of death.


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USE OF A HAZARD REPORTING SYSTEM WITH USER CENTERED DESIGN AND WEEKLY FEEDBACK INCREASES STAFF PARTICIPATION

LONG-TERM MORTALITY AND PREDICTORS AMONG PATIENTS WITH ACUTE RESPIRATORY FAILURE – A POPULATION-BASED STUDY

Andrea Ryan, Washington Hospital Center, Rollin Fairbanks, MedStar Institute for Innovation, George Sample, Brian Lee, Jani North Saale, Nancy Barton, Washington Hospital Center

Michelle Biehl, Balwinder Singh, Rahul Kashyap, Gregory Wilson, Ognjen Gajic, Guangxi Li, Mayo Clinic

Introduction: The adult ICUs at the Washington Hospital Center have been participating in the Comprehensive Unit-Based Safety Program (CUSP) since November 2010. One of the tenets of CUSP is to identify and evaluate defects. Our ICUs have had an occurrence reporting system (ORS) in place for many years, but staff tend to report more actual events than near misses. Estimates show that there are 600 near misses for each actual occurence. We identified and trialed a third party hazard reporting system (Hazard Alerting Loop [tm] or HAL) with touch screen kiosks on each unit, a simple interface for collecting narrative on actual and potential hazards, a robust reporting system and a weekly feedback system to notify the staff quickly of trends noted and leadership response to identified hazards. Hypothesis: Reporting rates improve using a hazard reporting system with use centered design and weekly feedback. Methods: In May 2011, HAL was deployed in five surgical ICUs. Reporting rates and topics were compared between HAL and ORS. The HAL and ORS entries were sorted into an eight point taxonomy that covers Delivery of Care, Support Services and Satisfaction. The number and type of events recorded in each system were compared. The ORS sessions for the three months prior to the trial, the same time frame in 2010, and during the first three months of the trial were compared to the HAL sessions for the first three months of trial. Results: There were 703 HAL entries in 3 months (average 235/month). In the nine months of comparative ORS entries, there were 370 (41/month). HAL recieved 5 times as many Delivery of Care entries, 6 times as many Support entries and 10 times in Satisfaction as compared to ORS. Percentage of entries in the 3 major taxonomy groups were roughly equal, but there were distinct differences in the subgroups; the most notable being that over 50% of the HAL entries in Delivery of Care were related to Team Communication as compared to 5% in ORS. Most Support entries in HAL were about delays in service rather than actual events. Conclusions: The addition of an easy access, touch screen, near miss reporting system with weekly feedback generated a large increase in hazard reporting data from our SICU staff.

Introduction: Acute respiratory failure (ARF) is associated with substantial morbidity and short and long-term mortality. We propose to evaluate the long-term survival and the predictors of mortality in patients requiring mechanical ventilation (MV) during the years of 2005 to 2009 in a defined community. Hypothesis: We hypothesize that age, comorbidities, severity of illness and ARF due to medical etiologies are associated with worse long-term survival. Methods: This is a population-based retrospective cohort study, where we evaluated a sample of adults from Olmsted County admitted to the all the Mayo Clinic Rochester ICUs with ARF requiring invasive MV during the years of 2005 to 2009. We excluded post-operative patients on MV for less than 12 hours. Predictors included patients’ demographics, Charlson index, Apache III and etiology of ARF. The primary outcome was long-term survival. Cox regression model was used to identify predictors of survival. Results: Of 701 patients who met our inclusion criteria, 42.7% were female, 86.7% Caucasians, median age of 64(IQR 45–77) years. The median Charlson comorbidity index was 4(IQR 0 –7) and Apache III score 70(IQR 50 –91). The main reasons for MV were post-operative (37.1%), airway protection/unresponsiveness (26.5%), trauma (20.9%), sepsis (11.1%), shock (10.5%), and pneumonia (5.7%). The median follow up time was 1.5(IQR 0.1–3.8) years. ICU and hospital mortality was 13.6% and 20.9% respectively. The median survival was 4.4(95% CI 4.2–5.3) years. In the Cox proportional hazard model, the Hazard Ratio for each point increase in Charlson index was 1.07(p⬍0.0001, 95%CI, 1.04, 1.11), Apache III 1.01(p⬍0.0001, 95%CI 1.01, 1.02) and age 1.02(p⬍0.0001, 95%CI 1.01, 1.03). None of the medical reasons for MV were associated with mortality, while trauma and post-operative were found to be protective, with HR of 0.41(p ⫽ 0.0001, 95%CI 0.23, 0.66) and 0.5(p⬍0.0001, 95%CI 0.39, 0.65) respectively. Conclusions: In this population-based study, age, Charlson comorbidity index and Apache III score predicted long-term mortality for patients receiving invasive MV, while trauma and post-operative are protective factors.

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541

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) IS NOT ASSOCIATED WITH SEPSIS IN THE BURN PATIENT

THE TIMING OF ADMISSIONS TO NORTHERN IRELAND’S CRITICAL CARE NETWORK AND MORTALITY

Elizabeth Mann-Salinas, US Army Institute of Surgical Research, Mara Baun, University of Texas Health Science Center-Houston, Janet Meininger, University of Texas Health Sciences Center-Houston, Charles Wade, University of Texas Health Science Center-Houston

Helen Murray, Darryl Stewart, Belfast City Hospital, Gerard McCarthy, Critical Care Network of Northern Ireland CCaNNI

Introduction: Use of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) sepsis criteria based on presence of systemic inflammatory response syndrome (SIRS) has not been validated in the chronically hypermetabolic and immunocompromised burn patient. Sepsis is defined as ⱖ2 SIRS criteria (heart rate [HR]⬎120 bpm, temperature [T]⬍36°C or ⬎38°C, respiratory rate [RR]⬎20 bpm, and WBC⬍4,000 or ⬎12,000 c/mm3) in presence of infection. Hypothesis: The purpose of this study was to determine the ability of the ACCP/SCCM criteria to predict sepsis in the burn patient. Methods: A retrospective, case-controlled, within-patient comparison of burn patients admitted to a single ICU was conducted for the period JAN 2005 to SEPT 2010. Blood culture results were paired with clinical condition to define 3 groups: “positive-sepsis (PS)”; “negative-sepsis (NS)”, and “negative-not septic (NNS)”. SIRS variables were collected for the 72 hours prior to obtaining each blood culture. Evaluation for each 24 hour period and total 72 hour period prior to culture was performed using ANOVA, regression and ROC AUC to assess SIRS criteria ability to predict group. Results: Fifty-nine subjects were included in the study, representing 177 culture periods, with mean age 40⫾19 years, 88% male, 81⫾64 ICU days, 49⫾20% total burn size, and 49% hospital mortality. No difference in incidence of SIRS criteria was noted among groups: ‘PS‘: day -3: 100%, day -2: 98.3%, day -1: 100% (mean 99.4%, p ⫽ .37); ‘NS‘: day -3: 98.3%, day -2: 100%, day -1: 98.3% (mean 98.9%, p ⫽ .61); ‘NNS‘: day -3: 94.9%, day -2: 98.3%, day -1: 96.6% (mean 96.6%, p ⫽ .60). T⬍36°C (p ⫽ .01) and T⬎38°C (p ⫽ .01) were the only variables associated with prediction of culture type, and were independently associated predictors for only the ‘PS‘ group (p ⫽ .005 and .003, respectively). AUC for SIRS criteria to predict sepsis versus non-sepsis was 0.514 (95% CI: 0.45, 0.57, p ⫽ .65). Conclusions: SIRS criteria are not appropriate for identifying sepsis in the burn population due to the near-universal occurrence of SIRS both in the presence and absence of clinical suspicion of sepsis. Studies using SIRS criteria to define sepsis in burns should be regarded with suspicion.


Introduction: There are conflicting interpretations of the significance of ICU admissions out of normal working hours on subsequent mortality and therefore on the utility of this data for quality purposes. The Critical Care Network of Northern Ireland (CCaNNI) is charged with a review of quality for the 9 closed units which make up the network and take all adult local ICU admissions. Hypothesis: We hypothesised that there would be an effect on ICU mortality from time factors around admission. Methods: All primary ICU admissions to CCaNNI were analysed for 2009 and 2010. The delay from hospital admission to referral, hospital CPR, the hour of the day, the day of the week, month of the year, and holiday period were the time factors considered along with severity of illness (using the ICNARC scoring system), diagnosis and emergency status. Unpaired tand Mann-Whitney tests with corrections for repeated testing were used, while chi-squared tests were used for comparison of nominal variables. The time factors and severity scores surrounding outcomes were subjected to a stepwise logistic regression analysis for mortality and interactions. Results: There were 7,993 primary admissions, of which 72% were emergencies, these had significantly higher median ICNARC severity scores 19.0 vs 12 [95% CI 19 –20 vs 8 –17; P⬍0.05], were significantly younger (mean 58 vs 65 yrs [95% CI 6.2–7.9; P⬍0.05]) than non-emergent cases and were more likely to die [P⬍0.05]. There were 1142 deaths and 6851 unit survivors. Hospital CPR (269 cases) was not more likely out of hours, nor were the deaths of cases time associated. Instead the ICNARC score and emergency status of an admission had the greatest predictive value with odds ratios of 3.8 [95% CI 3.0 – 4.9] and 1.07 [95% CI 1.068 –1.078] for emergency status and ICNARC score respectively. Conclusions: For CCaNNI, there was no effect on ICU mortality from time factors around admission, however, mortality was dependant on the emergency status of the admission and the severity of illness on arrival.

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543

BODY MASS INDEX (BMI) DOES NOT AFFECT OUTCOME IN PATIENTS WITH SEPTIC SHOCK

SUSTAINED SUCCESS OF A SEPSIS BUNDLE AT A COMMUNITY HOSPITAL

Christie Mannino, Akash Ajmera, Samuel Giordano, Philip Willsie, Sergio Zanotti-Cavazzoni, Steven Peikin, Cooper University Hospital

Nicki Roderman, Gita Patel, Medical Center of Plano, Nidhi Jindal, The Medical Center of Plano

Introduction: The impact of body weight on outcome in septic patients is not known. We examined the effect of BMI and multiple known risk factors on survival, ICU and hospital Length of Stay (LOS) in patients with septic shock. Hypothesis: Obese septic shock patients have higher mortality. Methods: Mortality risk was examined for 293 ICU patients (252 were able to have BMI measured) using the Project Impact database and chart review for a three year period. Factors evaluated included BMI, APACHE II score, age, and various comorbidities including cirrhosis, chronic kidney disease and multiple organ dysfunction (MOD). BMI was classified into four groups: underweight (⬍18 [n ⫽ 13]); normal (18 –24.9 [n ⫽ 80]); overweight (25–29.9 [n ⫽ 72]) and obese (⬎30 [n ⫽ 87]). There were not enough subjects in the underweight group to make an adequate analysis. Each variable was tested for a significant difference between patients discharged from the hospital as either dead or alive. Univariate results were Bonferroni adjusted to account for increased Type I error due to multiple testing. Subsequently, risk factors identified at p ⬍0.03 were included in a multivariable logistic regression model to assess whether any were independent predictors of mortality in patients with septic shock. Results: Among all subjects, 36.8% of patients died. No significant difference in mortality was found between overweight and obese patients compared to individuals with normal BMI (normal 33.0 % deceased; overweight 30.9% deceased p ⫽ 0.835; obese 32% deceased, p ⫽ 0.561). Age (p ⫽ 0.00), MOD (p ⫽ 0.03), cirrhosis (p ⫽ 0.03) and Apache II (p ⫽ 0.00), when considered independently, were significantly associated with an increased risk of mortality. Marginally significant variables included CKD (p ⫽ 0.05]) and lactate on ICU admission (p ⫽ 0.05). Conclusions: Although our study showed MOD, APACHE II, and cirrhosis were all independently associated with significant negative outcomes as previously shown, no association was found between BMI and mortality in patients with septic shock. No significant difference was found in ICU or hospital LOS (not shown) among different BMI categories. Multivariable adjustment for other confounding factors did not change the results.

Introduction: A sepsis bundle implemented in 2007 in a community hosptial yielded a 41.1% decrease in mortaltiy in one year. The purpose of this study was to examine if positive results of a sepsis bundle implementation were sustainable over a 4 year period using regular data reporting. Hypothesis: Maintaining a program for sepsis management using a data-driven approach will result in sustained improvement in overall morbidity and mortality. Methods: All sepsis patients admitted to a critical care unit from 2007 to 2010 were retrospectively examined. Data collected included compliance with the sepsis bundle, APACHE II score, percentage of patients initated on the ventilator or vasopressors, time on the ventilator or vasopressors, ICU and hospital length of stay, and mortality. Results: A total of 472 severe sepsis or septic shock patients were examined. There were 301 patients treated with the bundle versus 171 sepsis patients with partial or no bundle treatment (63.8% compliance). The mean APACHE II score was 32.59 for bundle patients versus 33.4 for non-bundle patients (p ⫽ NS). Bundle patients had fewer patients initiated on the ventilator (56.7%) as compared to non-bundle patients (68.4%, p ⫽ .013), and mean days on the ventilator were 7.64 days for patients on the bundle compared to 11.8 days for non-bundle patients (p ⫽ .02). Bundle patients initiated on vasopressors (82.4%) was similar to non-bundle patients (88.7%, p ⫽ NS), mean days on vasopressors was 3.72 days for bundle patients compared to 7.16 days for non-bundle patients (p ⫽ .024). Length of stay in the ICU for bundle patients was 8.73 days compared to 11.03 days for non-bundle patients (p ⫽ NS). However, mortality was significantly lower over the 4 year period for the bundle patients (24.7%) versus the non-bundle patients (44.8%, p⬍0.001). Conclusions: Although there is room to improve compliance, the study shows that a commitment to a sepsis bundle with frequent data reporting can yield sustained success over a 4 year period.

544 THE INCIDENCE OF CARDIOPULMONARY RESUSCITATION AS AN OUTCOME VARIABLE IN A PEDIATRIC CARDIOVASCULAR CRITICAL CARE PROGRAM Shekhar Raj, Lee Tosi, Alexandre Rotta, Riley Hospital for Children at Indiana University Health Introduction: Considering the relatively low mortality observed in most pediatric cardiovascular intensive care units (CVICU), the incidence of events requiring cardiopulmonary resuscitation (CPR) within a given unit has been suggested as an alternate metric of unit efficiency and patient outcome. Hypothesis: We hypothesized that incidence of CPR in patients cared for by a CVICU service would correlate with hospital mortality after cardiac surgery to repair or palliate congenital heart defects. Methods: On January 1, 2009, care at our institution transitioned from a surgeon-led team with physician extenders and on-demand multispecialty support to an intensivist-directed cooperative dedicated multidisciplinary CVICU team model. We retrospectively reviewed data from patients who required critical care following cardiac surgery in 2007–2008 (previous care model) and in 2009 –2010 (current care model). All patients who required CPR during the postoperative period were identified through CPR records and the CVICU database. Overall hospital mortality, the incidence of CPR per 1000 patient days and outcome of CPR were studied. Categorical data were analyzed with the two-tailed Fishers exact test and statistical significance was taken at a p⬍0.05. Results: Case volume was similar for the 2007–2008 and 2009 –2010 periods (643 and 644 cases, respectively) but hospital mortality was significantly lower during the later period (3.88% versus 1.85%, p ⫽ 0.03, respectively). The incidence of CPR/1000 patient days (3.23 and 3.75) and survival after CPR (75% and 76.4%) were not significantly different between the earlier and later periods, respectively. Conclusions: In our CVICU program, the incidence of CPR per 1000 patient days did not correlate with hospital mortality and did not discriminate between two very distinct care delivery models marked by significantly different mortality rates.



546

PROXIMATE CAUSE OF MORTALITY IN PATIENTS WITH TRAUMATIC BRAIN INJURY

RISK OF BLEEDING AND ROLE OF PLATELET AND FRESH FROZEN PLASMA TRANSFUSIONS IN CRITICALLY ILL PATIENTS UNDERGOING CENTRAL VENOUS CATHETER PLACEMENT

Shuai Shao, Deborah Stein, University of Maryland School of Medicine, Joseph Kufera, R Adams Shock Trauma Center, Bizhan Aarabi, University of Maryland School of Medicine, Thomas Scalea, University of Maryland Medical Center R Adams Cowley Shock Trauma Center, Kevin Sheth, University of Maryland School of Medicine Introduction: Prior studies have identified patient characteristics, such as Glasgow Coma Scale score and age, that are associated with increased mortality in patients with traumatic brain injury (TBI). However, there is limited data available with regard to the proximate mechanism of death in TBI patients. Hypothesis: We tested the hypothesis that withdrawal of life support, brain death, and cardiac arrest are the primary mechanisms of death after TBI and that etiology of death occurred at different time points after admission. Methods: Using a prospective TBI registry at a tertiary academic level I trauma center, we performed a retrospective analysis of all patients with traumatic brain injury, defined by admission diagnosis, in 2009. Baseline clinical characteristics, etiology of death, and in-hospital mortality were prospectively collected and entered into the trauma registry. Recorded etiology of death was confirmed by review of the medical record. Descriptive statistics were performed and differences were analyzed using t-test and Wilcoxon rank sum. Time to death was compared using Kaplan-Meier methods. Results: Amongst 948 patients admitted with TBI, there were 122 (13%) in-hospital deaths. Amongst patients who died, 70 (57%) patients underwent withdrawal of life support, 38 (31%) suffered cardiac arrest, and 14 (11%) received a diagnosis of brain death. Patients with brain death were younger (mean age 38 versus 59 – withdrawal of care, 54 – cardiac arrest, p ⫽ .01). Time to death was most rapid for patients who died secondary to cardiac arrest and longest for patients who underwent withdrawal of care (p ⫽ .02). Conclusions: Proximate mechanisms of death after TBI occur at distinct times, and withdrawal of life support is the most proximate cause of in-hospital mortality. Further study is needed regarding factors associated with early cardiac arrest and withdrawal of life support in patients with traumatic brain injury.This work was supported by a grant from the American Academy of Neurology (KNS)

Jennifer Weston, Froedtert Hospital, Pamela Souders, Medical College of Wisconsin, Sarah Vanderlinden, Froedtert Hospital, Gagan Kumar, Rahul Nanchal, Medical College of Wisconsin Introduction: Most patients requiring admission to the intensive care unit undergo central venous cannulation (CVC) and often have to be placed in patients with coagulopathy, thrombocytopenia or both. Common practice prior to placement is to correct the coagulopathy and/or thrombocytopenia by transfusing platelets and fresh frozen plasma (FFP) though the evidence for it is scarce. Hypothesis: CVC can be placed safely without correction of coagulation or platelet defects. Methods: Retrospective chart analysis was performed in a tertiary care hospital medical ICU. Charts were accessed from January to June 2011, for international normalized ratio (INR) and platelet count before the CVC placement along with platelet and FFP transfusions prior to CVC placed. Coagulopathy was defined as INR ⬎2 and thrombocytopenia was defined as platelet count ⬍50,000/␮l. Physician and nursing notes were reviewed for 2 days after the procedure to determine bleeding related to the CVC. Significant bleeding was defined as hematoma formation or written documentation of excessive bleeding from the CVL site. Chi square test was used to compare the outcomes. Multivariate logistic regression model was used to find the odds ratio of bleeding. The model adjusted for coagulopathy, thrombocytopenia and site of line placement. Results: Of the 250 central line placements, 165 had normal coagulation and platelet profile, 71 had coagulopathy, 28 had thrombocytopenia and 14 had both abnormalities. The bleeding complication rate in the normal patients was 1.3%.The bleeding was observed in 1.8% in patients with coagulopathy alone, 7.1% (p⬍0.05) in thrombocytopenia alone and 28.6% (p⬍0.05) in those with both abnormalities.On multivariate analysis, only platelet count less than 50k (OR 10.1; 95% CI 2.1 – 48.7) was found to be significant predictor of bleeding.In either thrombocytopenic and coagulopathic groups, transfusion of platelets or FFP did not significantly reduce bleeding complications. Conclusions: Thrombocytopenia is greater risk than coagulopathy for causing bleeding in post CVC placement. Transfusion of platelets or FFP did not reduce the bleeding complications.

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548

PREVALENCE OF NEVER EVENTS IN PATIENTS UNDERGOING HEART VALVE REPLACEMENT SURGERIES IN UNITED STATES

DEFINITION AND CLINICAL VALIDATION OF ASPRA SCORE TO ASSESS THE RISK FOR POSTOPERATIVE COMPLICATIONS

Veerajalandhar Allareddy, Rainbow Babies and Children’s Hospital, Sankeerth Rampa, Cleveland State University, Veerasathpurush Allareddy, Harvard University

Cosimo Chelazzi, Gianluca Villa, Ilaria Vignale, Raffaele De Gaudio, University of Florence

Introduction: More than 15 Million people in Unites States suffer from valvular heart disease and valve replacement surgery improves morbidity and mortality outcomes. About 90,000 valve replacement surgeries were performed in 2009 in US. National Quality Forum(NQF) defined Never Events are rare but when they occur they could be devastating and are preventable. Hypothesis: The objective of the current study is to examine the prevalence estimates of the Centers for Medicare and Medicaid Services (CMS) defined never events in patient undergoing valve replacement surgeries in the United States. Seven never events were examined. Methods: The Nationwide Inpatient Sample for the year 2008 was used. All hospitalizations that underwent valve replacement procedures (ICD9-CM procedure code of 35.2X) were selected. Occurrence of never events were identified by using ICD-9-CM codes in the secondary diagnoses fields. All estimates were projected to national levels using the discharge weight variable. Results: A total of 84,997 hospitalizations had a valve replacement procedure performed. The average age of each discharge was 66 years. The prevalence rates for seven CMS defined never events are: postoperative pneumonia (5.2% of all hospitalizations), clostridium difficile enterocolitis (1.3%), methicillin resistant staphylococcus aureus infection (0.4%), surgical site infection (1.4%), intravascular device infection (0.4%), catheter associated urinary tract infection (0.2%), and decubitus ulcers (1.5%). One of these events occurred in 9.3% of all hospitalizations. The overall in-hospital mortality rate was 5.6%. Close to 35% of all hospitalizations occurred on an emergency/urgent basis. About 64% of all hospitalizations occurred in teaching hospitals. Conclusions: Of the seven Never events examined atleast one event occured in about 9% of all hospitalizations in patients undergoing heart valve replacements. The study highlights the national prevalence of such events in cardiac valve surgeries.


Introduction: Postoperative complications (PoCs) may increase morbidity, mortality and costs. Postoperative monitoring of high risk patients in surgical intensive care unit (SICU) could reduce risk of PoCs. Clinical scores may help to detect those patients at high risk of PoCs. Hypothesis: A new score, the ‘Anesthesiological and Surgical Perioperative Risk Assessment‘ (ASPRA), may be a valuable tool to predict PoCs. Methods: To create ASPRA score, risk factors for PoCs were identified on papers published in English from 1/1/2000 to 1/6/2010 on PubMed database using “postoperative complications” and “risk factors” as Key words. A score between 1 and 3 has been given to each identified factors, depending on strength and independency of their association to PoCs. As preliminary validation step, a ROC curve and AUC were calculated on clinical data retrospectively collected from a cohort of ⬎18yrs. patients electively admitted at the local SICU for postoperative monitoring (1/1/11–28/2/11). For each patient ASPRA score was obtained and PoCs identified and classified according to Clavien score. Based on the ROC analysis, a cutoff value was identified that could maximize specificity/sensitivity of ASPRA as to detect PoCs. In order to validate ASPRA score, a set of patients who underwent elective general surgery were prospectively observed (1/4/11–31/5/11). ASPRA score was obtained for each patient before the procedure and PoCs prospectively identified during postoperative course. For all patients, the incidence of PoCs was compared with that expected according to ASPRA score. Results: Data of 176 pts. were processed for preliminary ROC analysis; AUC was 0.77 (p⬍.01). ASPRA scores of 6 showed a specificity and sensitivity of 70% and 78% respectively in predicting PoCs. The prospective analysis was done on 186 pts. Incidence of PoCs was 74%. On a total of 106 pts. with ASPRAⱖ6, 104 (98%) showed one or more PoCs, while on 80 pts. with ASPRA⬍6, 47 (59%) did not (p⬍.01). Conclusions: At the preliminary validation, the new ASPRA score resulted moderately accurate in discriminating between postoperatively complicated and uncomplicated patients. Scores cutoff of 6 showed the best sensitivity/specificity ratio in predicting PoCs.

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550

SALIVARY CORTISOL DIURNAL VARIABILITY IS LOST IN CRITICALLY INJURED PATIENTS

NATIONWIDE TRENDS IN DISPOSITION OF ELDERLY PATIENTS (AGES SIXTY FIVE OR MORE) WITH SEVERE SEPSIS

Michael Corneille, University of Texas Health Science Center at San Antonio, Viktor Bartanusz, Univeristy of Texas Health Science Center at San Antonio, Marianne Guildea, Jacqueline Richa, Salvador Sordo, University of Texas Health Science Center at San Antonio, Daniela Jezova, Slovak Academy of Sciences, Prakash Nair, Joel Michalek, Ronald Stewart, University of Texas Health Science Center at San Antonio, Steven Wolf, UT Southwestern

Gagan Kumar, Medical College of Wisconsin, Jennifer Weston, Froedtert Hospital, Thomas Kaleekal, Jayshil Patel, Amit Taneja, Rahul Nanchal, Medical College of Wisconsin

Introduction: Following injury, there is known dysfunction of the hypothalamic-pituitary-adrenocortical axis. Assesment of changes in cortisol release is confounded by standard laboratory assays which measure total - both bound (inactive) and free (active) - cortisol concentrations in blood plasma or serum. Critically ill patients often present with plasma protein derangements, thus the direct measurement of free cortisol may reflect adrenocortical function more accurately. Concentrations of free cortisol in plasma are in equilibrium with those in saliva. Hypothesis: We hypothesize that it is feasible to measure salivary cortisol in critically ill trauma patients and that diurnal salivary cortisol level will differ from normal controls. Methods: Eligible subjects were ⱖ18 y/o, admitted to a single level I trauma ICU for ⬎72 hrs. Saliva was collected at 0600 and 1600 daily. Cortisol levels were measured by Enzyme-Linked Immunosorbent Assay. Normal controls were assessed with the same protocol. We recorded demographic information, medical history, hospital and ICU length of stay and Injury Severity. Mean AM and PM cortisol values were compared using repeated measures models. Continuous variables for subjects and controls were contrasted using t-tests. Results reported as means ⫾ standard deviation. Results: We enrolled 50 subjects: 65% were male, 92% sustained blunt injuries, mean age was 50 ⫾19.7, median (IQR) ISS was 22 (13) and TRISS was 0.9 (0.4). There were 26 normal controls. Comparing subjects to controls: mean PM cortisol concentrations were significantly higher in subjects vs. controls: 9.4 ⫾ 7 vs. 3.1 ⫾ 3.5; (p⬍0.001). However, no difference in mean AM cortisol values, 7.8 ⫾6.4 vs. 6.7 ⫾ 4.3; (p ⫽ 0.44) was observed. Regarding diurnal variability, subjects failed to present the expected AM vs.PM decrease in cortisol concentrations 0.5 ⫾ 5.1 vs. -3.5 ⫾ 4.3; (p ⫽ 0.002) seen in controls. No difference in mean AM and PM cortisol values across ISS was observed (p ⫽ 0.75). Conclusions: Cortisol levels remain elevated throughout the day, indicating loss of normal diurnal pattern in critically ill trauma patients. There was no relationship between injury severity and mean cortisol level.

Introduction: The elderly constitute an increasing proportion of the national population. The data regarding discharge disposition of these patients with severe sepsis (SS) including discharge to hospice placement is limited. The aims of our study were to describe the disposition in patients aged 65 or more with severe sepsis. Hypothesis: Even though the mortality in SS has improved, decreasing number of patients are being discharged home. Methods: Using the Nationwide Inpatient Sample from 2000 to 2008, patients aged 65 or above, discharged with severe sepsis were identified through appropriate ICD-9, clinical modification codes as used in literature. They were divided into 2 groups – age 65 to 79 and age 80 and above. Disposition variables included discharges to nursing home, long term acute care, home health care and hospice placement. Chi-square test was used to compare variables between the 2 groups. Results: Of 4,747,262 estimated hospital admissions with SS during 2000 to 2008 in the United States, the patients above age 65 accounted for about 61.7%: 34% between ages 65 to 79 and 27.7% age 80 and above. The all cause in hospital mortality in elderly has decreased from 46% in 2000 to 32.8% in 2008 (P ⬍0.01). In age group 65–79, while mortality decreased from 43.7 %(in 2000) to 27.5% (in 2008), the proportion of surviving patients being discharged home decreased (from 28.9% to 22.1%). Similar trend was seen in age group 80 and above where the percentage discharged to home fell from 19.7 to 12.3 (p⬍0.01). The surviving elderly patients are being increasingly discharged to skilled nursing facility (28.1 to 31.7%), long term acute care (1.3 to 6.0%), rehabilitation facility (1.4 to 3.2%) and home health care (8.1 to 11.7%). The number of elderly patients being discharged to hospice care has increased from 0.5% to 7.2% (p⬍0.01). Conclusions: Though mortality in the elderly with SS has improved over the years, fewer proportion of patients are being discharged home while more are being discharged to skilled facilities. There is also an increasing trend of discharges to hospice care.

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RISK OF MORTALITY SCORING SYSTEMS MAY DISCRIMINATE SURGICAL COMPETENCE AND CHANGES IN TEAM PERFORMANCE: A REVIEW OF 1227 OPEN HEART OPERATIONS IN A LOW VOLUME SURGICAL UNIT

MINIMIZING COMMUNICATION BREAKDOWNS: AN EMPIRICAL EVALUATION OF A HANDOFF INTERVENTION TOOL

Stephen Woodford, Macquarie University

Joanna Abraham, Bela Patel, Khalid Almoosa, Mark Warner, Thomas Kannampallil, UTHealth, Vimla Patel, Columbia University

Introduction: Risk of mortality scoring systems are widely used as a crude performance indicator and to inform patients of perioperative risk. Merely ensuring that a unit outperforms a scoring system based on pooled data overlooks the value of deconstructing the data. Hypothesis: This study hypothesised that a widely used risk-of-mortality score (Logistic Euroscore) could discriminate surgical performance within a cardiac surgical service and detect significant changes in performance. Methods: The Logistic Euroscores for patients undergoing elective and urgent surgery in a low-volume surgical unit (84 OHS p.a.) were collected independently of the Cardiac Surgery departmental database. The cumulative predicted mortality and observed mortality were compared for 4 surgeons performing 1227/1352 cases (91% of cases) over 15 years. The ratio of observed mortality to predicted mortality (fractional mortality) for individuals was plotted chronologically,as well as pooled data. Results: All surgeons had a similar casemix and similar age and gender profiles to their patient sets. Risk of mortality scores reflect the pooling of performance data from proceduralists of varying skill. Each surgeon outperformed the scoring system after a statistically useful number of cases had been performed (40 –70 cases), and each surgeon achieved a fractional mortality that was defined within a unique bandwidth of 20%. Three surgeons remained within a clearly defined performance band, but a fourth surgeon breached the performance band, and then traced a rising mortality trajectory which exceeded unity (observed mortality exceeding predicted mortality). Conclusions: Logisitc Euroscore appears to differentiate between surgeons, and provide a useful measure of performance. The trajectory of the fractional mortality raises the possibility that personnel specific sources of morbidity within a team (including anaesthesia and intensive care) can be identified and addressed and mortality reduced by independent tracking of outcome indicators. Institutionally monitored non-mortality performance indicators may identify skill deficits that currently remain hidden.

Introduction: Information handoffs between clinicians comprise of three interdependent phases: pre-handoff, handoff and post-handoff. Design of handoff aids that support information organization during pre-handoff and effective communication in handoff phase can potentially mitigate transition errors. We designed a handoff aid, Hand-IT, based on content standardization (using a body system-oriented format) and summarization (using a patient-care narrative format) for standardizing communication events during handoffs and coordinating information organization during pre-handoff. Hypothesis: We hypothesized that information organization using Hand-IT in pre-handoff phase will lead to lesser omissions in information, lesser incorrect (& conflicting) information, and fewer modifications to clinician plan of care. Methods: We conducted a pre-post prospective intervention study in the MICU of an academic hospital where the Hand-IT was compared to the current tool, a SOAP note. 20 patient cases (10 SOAP, 10 Hand-IT) were completed by 10 different outgoing clinicians (residents & interns) over a 1-month period. Each completed note was analyzed during multi-professional rounds (MPR) attended by the MICU team where they jointly evaluated the accuracy of information contained in the handoff tool completed in previous shifts. Based on their collective content evaluation in the handoff tool, the team characterized information breakdowns into omissions, inaccuracies, and modifications to plan of care. Information on both handoff tools were organized into units, which were scored (as omissions, incorrect or changed) for analysis. Results: We found that less information was missed when using Hand-IT (M ⫽ 2.8) than SOAP (M ⫽ 12.5) [p⬍0.001]. There were less incorrect and conflicting information when using Hand-IT (M ⫽ 0.9) than SOAP (M ⫽ 1.8) [p⬍0.05]. Lesser number of changes to plan of care were made using Hand-IT (M ⫽ 0.8) than with SOAP (M ⫽ 4.0) [p⬍0.001]. Conclusions: Tools supporting content standardization and summarization can reduce information loss and decrease needs for plan modification. Better information organization practices of clinicians can minimize transition breakdowns enhancing patient safety and quality.


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SOCIO-TECHNICAL BARRIERS TO EFFECTIVE USE OF A WEANING PROTOCOL IN A MEDICAL INTENSIVE CARE UNIT

FAILURE TO VALIDATE THE IVH SCORE AS BETTER THAN THE ICH SCORE ALONE TO PREDICT NEUROLOGICAL OUTCOME IN INTRACEREBRAL HEMORRHAGE

Sahiti Myneni, UTHealth, Debra McGinnis, Memorial HermannHospital, Khalid Almoosa, Trevor Cohen, Bela Patel, UTHealth, Vimla Patel, Columbia University

Jennifer Duprey, John Dziodzio, Jennifer Palminteri, Anand Rughani, David Seder, Maine Medical Center

Introduction: Protocol-directed weaning of critically-ill adult patients from mechanical ventilation reduces the risk of preventable complications such as ventilatorassociated pneumonia, barotrauma, and increased need for sedation. However, standardized protocols may yield sub-optimal outcomes because of several socio-technical factors. Hypothesis: Our hypothesis is that the effective use of the weaning protocol will be influenced by factors that are inherent to the protocol, externalized in the environment, and also distributed across cognitive artifacts. Methods: We conducted 105 hours of in-situ observations of the daily use of an evidence-based computerized weaning protocol in a Medical Intensive Care Unit (MICU). During this study period, we observed a total of 65 weaning attempts. In addition, we interviewed eight respiratory therapists and four attending physicians. Data from the 65 weaning attempts were analyzed and classified into three categories: unfavorable outcome (deviation from protocol, patient at risk), near miss (deviation from protocol, patient being safe), and favorable outcome (protocol followed). Results: Results indicated that 45 of the 65 attempts were favorable, 16 fell into the near-miss category, while the remaining four were unfavorable. Near-misses and unfavorable outcomes together constituted almost 31% of total outcomes. Based on observations and interview data, the problems identified with the weaning protocol were due to 1) knowledge gaps pertaining to protocol mechanisms such as sedation score assessment, 2) confusing and conflicting information in the protocol operational content, 3) lack of quality information sharing among clinicians, and 4) lack of confidence towards the protocol. Conclusions: These results show that implementation of a weaning protocol in an ICU constitutes more than a change in procedure. Newly identified factors affecting protocol outcomes are socio-technical in nature, with trust between colleagues and confidence in the protocol playing a major role. In the context of this particular weaning protocol, we have identified high priority intervention areas such as clinician education, impact demonstration, and protocol clarification to improve its effectiveness.

555 ECONOMIC OUTCOMES ASSOCIATED WITH THE USE OF TAPER-SHAPED VERSUS BARREL-SHAPED TRACHEAL TUBES Santosh Agarwal, Mary Erslon, Scott Kelley, Covidien Introduction: Tracheal tubes with taper-shaped cuffs with subglottic secretion drainage (SSD) have been shown to reduce microaspiration by as much as 90% compared to tracheal tubes with barrel-shaped cuffs (510k claim). Reduced microaspiration may decrease the risk of respiratory complications and resource utilization. No studies have assessed the economic impact of tracheal tubes with taper-shaped cuffs and barrel shaped cuffs. Hypothesis: Patients intubated with a taper-shaped cuff with SSD (TAPER) exhibit lower costs and resource use compared to those intubated with barrel-shaped cuffs (BARREL). Methods: In the Premier Perspective® (Premier, Inc.) Database (Jan 2010 –Mar 2011), we identified all inpatient adults alive at discharge, intubated with TAPER (TaperGuard™ Evac) or BARREL (Mallinckrodt™ Hi-Lo). We evaluated length of stay (LOS) and costs for hospitalization, ICU, and pharmacy. We matched the two groups based on hospital characteristics. We used generalized linear modelling to get adjusted estimates accounting for age, gender, race, comorbidity index, APR severity, admission source/type, medical/surgical stay, ventilator associated Diagnosis Related Groups and tracheal tube used. We performed a 1:1 match between the two groups based on propensity scores (PS) accounting for confounders and evaluated the adjusted estimates. Results: Three hospitals coded for TAPER, one hospital accounted for 94.7% of all cases (N ⫽ 252). Two hospitals were excluded due to low sample size (N ⫽ 6,8). BARREL group cases were identified and matched from a similar group of hospitals (N ⫽ 428). Pre PS matching, adjusted mean total hospitalization cost, LOS were $33460, 12.0 days for BARREL and $15648, 8.8 days for TAPER, respectively (p⬍0.001). Post PS matching (N ⫽ 94 each), adjusted mean total hospitalization cost, LOS were $36079, 17.4 days for BARREL and $16707, 11.9 days for TAPER, respectively (p⬍0.001, 0.003). Adjusted mean pharmacy and ICU costs were $4309, $9501 for BARREL and $2685, $5735 for TAPER, respectively (p ⫽ 0.002, 0.003). Conclusions: For both unmatched and matched patients, TAPER exhibited lower LOS and costs compared to BARREL. Additional studies are recommended to assess clinical and economic outcomes.


Introduction: When integrated into the ICH score, the Intraventricular Hemorrhage Score (IVHS) may improve the prognostic power of the ICH score. We attempted to validate the so-called “composite score” using data collected at our center from 207–2009. Hypothesis: The IVHS, when integrated into the ICH score to form a composite score, predicts mortality and neurological outcome in patients with IVH more accurately than the ICH Score alone. Methods: Over a 3 year period, of 287 patients admitted to a teaching hospital with ICH, 110 also had intraventricular hemorrhage (IVH). We calculated parenchymal hematoma volumes using the ABC/2 method, and estimated IVH volume using the IVHS according the methodology described by Hallevi (1). Mortality and estimated discharge modified Rankin scores (mRs) were derived from charted records. We replicated the authors’ logistic regressions including the following variables: Age, GCS, location, hydrocephalus, and total volume (IVH⫹ICH). Models were created using both in-hospital mortality and poor outcome (mRs 4 – 6) as the outcome variable. Spearman correlations were calculated to compare the relative correlations of ICH and IVH score with mRs. Results: Lower GCS (OR ⫽ 6.27, CI2.5–15.8, P⬍0.0001) was validated as an independent predictor of mortality. Both lower GCS (OR ⫽ 5.52, CI 1.18 –25.84, P ⫽ 0.03) and increased age (OR ⫽ 1.07, CI 1.008 –1.125, P ⫽ 0.024) were associated with poor outcome. When severity of illness markers were considered, early limitation of care (DNR⬍24h of admission) was not independently associated with increased mortality. Unlike the original cohort studied, IVHS correlated only weakly with mRs at hospital discharge (r ⫽ 0.17, P ⫽ 0.05). The composite score was strongly associated with outcome (r ⫽ 0.51, P⬍0.00001), but was outperformed by the original ICH score (r ⫽ 0.54, P⬍0.00001). Conclusions: In our population, the IVHS was no more predictive of outcome than the original ICH Score proposed by Hemphill (2). References: 1. Hallevi H, et al. Critical Care Medicine 2009 Vol. 37, No 3; 969 –974.2. Hemphill JC III, et al. Stroke 2001; 32: 891– 897.


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MODIFIED SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (MSIRS) SCORE AND RISK OF MORTALITY IN MEDICAL INTENSIVE CARE UNIT (MICU) PATIENTS

MODIFIED SIRS CRITERIA IN PERI-OPERATIVE PATIENTS ADMITTED TO SURGICAL INTENSIVE CARE UNIT: CLINICAL COURSE AND OUTCOME

Supriya Srinivasa Gowda, Michael Hooper, Lisa Weavind, Hui Nian, Arthur Wheeler, Vanderbilt University Medical Center

Supriya Srinivasa Gowda, Hui Nian, Lisa Weavind, Vanderbilt University Medical Center

Introduction: Incidence of SIRS is high among MICU patients; however the relationship between the number of modified SIRS criteria and mortality is unvalidated. Hypothesis: The higher the MSIRS score greater the risk of mortality. Methods: MICU patients were electronically screened for MSIRS (ⱖ2 SIRS criteria, with one being either abnormal temperature ⬎38 or ⬍36, or WBC ⬍4 or ⬎12) using an automated surveillance program over 4 months. Each criterion carries a score of 1, with maximum overall score of 4. Patient’s clinical course and outcomes reviewed retrospectively, from the time of first MSIRS detection to 28 days, death or hospital discharge whichever happened first. Results: Of 611 patients screened, 442 (72%) patients met MSIRS. Median time from ICU admission to electronic detection of MSIRS was 1.61hrs (6.06⫹/⫺12.13hrs). ICU length of stay was significantly longer in patients who developed MSIRS (median ⫽ 66 hrs) versus those who were MSIRS negative (median ⫽ 41 hrs), p⬍0.0012. Mortality rate among patients who met ⱖ2 MSIRS (18%) and those who were negative for MSIRS (17%) was similar. Among patients who met MSIRS, 226 (51.1%) patients had a MSIRS score of 2, 178 (40.3%) had a score of 3, and 38 (8.6%) met all four criteria. And mortality rates increased directly as patients met two, three and four criteria for MSIRS, 8%, 15% and 21% respectively. Multivariable logistic regression analysis showed that after accounting for infection and time to electronic detection of MSIRS, mortality rate was significantly associated with MSIRS Score (p ⫽ 0.008). The odds of death for patients with MSIRS score of 3 was 1.87 times greater than patients with MSIRS score of 2 (95% CI, 1.11 to 3.14) and 3.14 times greater when MSIRS score was 4 compared to those with MSIRS score of 2 (95% CI, 1.36 to 7.24). Conclusions: There is a significant association between high MSIRS score and risk of mortality. The simplicity of scoring this syndrome makes it an efficient method of risk prediction in MICU patients.

Introduction: Surgery induces a pro-inflammatory state in patients in the perioperative period. Most patients, who are post surgical, will manifest standard SIRS criteria with tachypnea, tachycardia, mild hypothermia and leukocytosis. Our study used Modified SIRS (MSIRS) criteria to identify patients who may be manifesting a more robust post surgical inflammatory response. MSIRS includes ⱖ2 SIRS with one being either abnormal temperature (⬍35 or ⬎38.5) or abnormal WBC (⬍4 or ⬎15). Hypothesis: Post-operative patients who met MSIRS in SICU immediately following their procedure had a prolonged clinical course and worse outcomes compared to patients who did not have MSIRS in SICU during this period. Methods: SICU patients were screened for MSIRS using an automated electronic program for a four month period of time. Data for clinical course and outcome collected from the time of first MSIRS detection to 28 days, death or hospital discharge whichever happened first. Results: Of the 439 patients screened in SICU, 219 (50%) of patients met MSIRS criteria. 243 (55%) patients were admitted to SICU immediately following surgery, and 113 met MSIRS. Median time to MSIRS detection from the time of ICU admission was 7.6 hrs. (17.6⫹/⫺45.4). Patients who met MSIRS had significantly (p⬍0.001) longer ICU stay (3.5 ICU days and 10.4 hospital days), compared to patients who did not have MSIRS (2.2 ICU days and 6.7 hospital days). Number of days on inotropic support (0.91 days) and days on ventilator (2.12 days) was significantly (p⬍0.001) greater among patients who met MSIRS criteria then the other group. APACHE II score was significantly higher among patients who had MSIRS (16.5) compared to patients negative for MSIRS (13). Mortality was 1% among patients with no MSIRS and 8% among patients with MSIRS positive. Conclusions: Modified SIRS criteria in immediate post-operative surgical patients could be of value in predicting patients at high risk for prolonged clinical course and worse outcomes. Diagnosis of MSIRS in post surgical patients may facilitate early intervention to optimize and support organ dysfunction to minimize these outcomes.

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RISK FACTORS AND IMPACT OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS NASAL COLONIZATION IN THE ICU

INNOVATIVE STRATEGIES TO DECREASE CERVICAL COLLAR RELATED PRESSURE ULCERS

Christina Chen, Kevin Kelly, Dallas VA Medical Center, Steven Pass, Texas Tech University Health Sciences Center School of Pharmacy Introduction: The risk factors and outcomes associated with Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization have been studied but have not been well defined. We hypothesized that compared to intensive care unit (ICU) patients with a negative MRSA nasal swab, ICU patients with a positive MRSA nasal swab would have higher rates of healthcare-associated multi-drug resistant (MDR)-related infections, longer lengths of ICU stay, and greater inpatient mortality. Hypothesis: The primary objective was to investigate the impact of MRSA colonization on subsequent healthcare-associated MDR-related infections, ICU length of stay, and inpatient mortality. The secondary objective was to assess the predictors of MRSA nasal colonization. Methods: This was a retrospective cohort study performed in the MICU at the Dallas VAMC. All patients who were 18 years of age or older, who received a MRSA nasal swab within 24 hours of ICU admission, and who were admitted to the ICU during the period from July 1, 2009 through June 30, 2010 were enrolled if they had a positive MRSA nasal swab. Data on baseline characteristics, underlying conditions, infection rate, length of stay, and mortality was collected. Results: A total of 90 patients were identified that met the inclusion criteria. 90 patients with a negative MRSA nasal swab admitted to the ICU during the study period were identified to serve as the comparison arm. Univariate analysis did not show a statistically significant association between MRSA nasal colonization and healthcare-associated MDR-related infections, ICU length of stay, or inpatient mortality. Significant risk factors for MRSA colonization by univariate analysis included diabetes mellitus (DM), congestive heart failure (CHF), acute renal failure (ARF), or recent surgery (all p⬍0.05). Significant risk factors by multivariate analysis were DM and CHF (all p⬍0.05). Conclusions: This study did not show any difference in outcomes between patients who were colonized with MRSA in the nares compared to patients who were not colonized. Certain underlying conditions, such as DM, CHF, ARF, or recent surgery, appear to be significant predictors of MRSA nasal colonization.

Christine Marsiello, Kim Marshall, Jeanmarie Moorehead, Yvette Ahamed, Silvana Justiano, Jonas DeMuro, Adel Hanna, John McNelis, Winthrop University Hospital Introduction: Pressure ulcers are a serious problem for hospitals causing infections, longer stays, higher costs, and mortality. Reported cervical collar related pressure ulcers range from 20 –50%. In late 2009 and early 2010, the SICU of a NYS Regional Trauma Center, noted an increase in the number of cervical collar related pressure ulcers. Hypothesis: A multidisciplanary quality initiative would decrease the incidence of cervical collar related pressure ulcers. Methods: The Nurse Educator in SICU researched the issue of cervical collar related pressure ulcers. Trauma center protocols from all over the world were reviewed and best practices from these centers were used as the foundation for the creation of a new procedure for cervical spine injury patients. Multidisciplinary trauma meetings and surgical quality improvement meetings were the forums for discussions related to care of patients in cervical collars and pressure ulcer incidence. It was determined that a knowledge deficit among the team in the SICU regarding spinal precautions, responsibility for manual neck immobilization, and the fit, removal and care of cervical collars presented a major challenge, as did the lack of a formal multidisciplinary and interdepartmental procedure to refer to. A procedure for care of patients with cervical collars was collaboratively developed and approved. Education on the procedure and care of cervical collars was provided to the SICU team in July 2010. Results: From January-June 2010, 7 of 10 patients with cervical collars in place for greater than 72 hours developed collar related pressure ulcers, a 70% incidence. After implementation of the new procedure and education, only 1 of 16 patients from July-December developed a related pressure ulcer, or 6.25%. Conclusions: Multidisciplinary commitment to development of evidence-based policies and procedures, implementation of interdepartmental protocols, and educational initiatives to support practice at the bedside will provide the health care team with the tools needed to provide care and improve patient outcomes.


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DIABETIC STATUS AND THE THREE DOMAINS OF GLYCEMIC CONTROL IN THE CRITICALLY ILL

RISK FACTORS AND OUTCOMES ASSOCIATED WITH ACUTE KIDNEY INJURY FOLLOWING RUPTURED ABDOMINAL AORTIC ANEURYSM

Abid Iqbal, James Krinsley, Stamford Hospital Introduction: Hyperglycemia, hypoglycemia (HYPO) and increased glycemic variability (GV) are associated with increased mortality (M) in critically ill patients. The impact of diabetic status (DS-DM and NON) on the relationship betwen M and these 3 domains of glycemic control has not been well defined. Hypothesis: DS impacts the relationship of the 3 domains of glycemic control to M in the critically ill. Methods: This is a retrospective review of prospectively collected information from the unit’s clinical database, including blood glucose values (BG), DS, APACHE IV predicted mortality % (APIV PM) and M. Between 10/1/05 and 5/31/11 4520 patients were admitted to a 16 bed adult ICU of a university affiliated hospital. The BG target was 80 –140 before 1/07 and 80 –125 after. Results: DM (n ⫽ 960) were older and had higher APIV PM and M than did NON (n ⫽ 3560). Mortality %Mean BG ⬍80 80 –110 110 –140 140 –180 ⬎180NON 50.0 12.7 13.8 17.7 44.9DM 42.9 19.2 16.1 15.7 24.6 Min BG ⬍40 ⬍70 ⬎69NON 59.3 30.6 10.4DM 46.6 27.3 11.0CV (%) ⬍15 15–30 ⬎30NON 5.4 15.4 30.5DM 8.5 16.1 20.0 Multivariate analysis: risk of mortality NON DM OR (95% CI) p OR (95% CI) pMean BG 80 –110 1.01 (0.76 –1.35) 0.92 1.40 (0.77–2.56) 0.27 Mean BG ⬎180 1.16 (0.45–3.04) 0.76 1.22 (0.54 –2.77) 0.63 Min BG ⬍40 3.62 (1.96 – 6.67) ⬍0.01 2.82 (1.39 –5.73) ⬍0.01 Min BG ⬍70 1.88 (1.44 –2.47) ⬍0.01 2.06 (1.34 –3.16) ⬍0.01CV ⬍15% 0.50 (0.36 – 0.69) ⬍0.01 0.92 (0.39 –2.21) 0.86CV ⬎30% 1.96 (1.45– 2.66) ⬍0.01 1.12 (0.73–1.71) 0.61. Conclusions: Crude but not adjusted mean BG was associated with mortality in DM and NON. HYPO was independently associated with mortality in DM and NON. GV had an independent association with mortality only in NON. These data may help inform the design of glycemic management protocols in the critically ill.

Ilana Kopolovic, University of Alberta, Kimberley Simmonds, Alberta Health Services, Shelly Duggan, Mark Ewanchuk, Daniel Stollery, Sean Bagshaw, University Of Alberta Introduction: Evidence describing the incidence and risk factors associated with acute kidney injury (AKI) following ruptured abdominal aortic aneurysm (rAAA) repair are limited, and the long-term renal outcomes are largely unknown. Hypothesis: We hypothesized that in rAAA patients, post-operative AKI would be common and would portend a more complicated course and worse clinical outcomes. Methods: Retrospective population-based cohort study of all referrals undergoing emergency repair of rAAA in northern Alberta from January 1, 2002 to December 31 2009. AKI was defined by the AKIN criteria. Results: In total, 141 patients survived to receive emergent rAAA repair. Post-operative AKI occurred in 70.2% (n ⫽ 99). Of these, 47 had AKIN stage I, 31 had AKIN stage II, 21 had AKIN stage III. Eighteen received renal replacement therapy (RRT). Patients developing AKI had lower baseline glomerular filtration rate (62.8 mL/ min vs. 70.8 mL/min, p ⫽ 0.035); greater intra-operative transfusion requirements (5.3 units vs. 2.8 units, p⬍0.001); and higher Acute Physiology and Chronic Health Evaluation II score (25.6⫾7.7 vs. 17.5⫾6.5, p⬍0.001). AKI patients were also more likely to have early post-operative elevated cardiac-specific troponin (61.6% vs. 35.7%, p ⫽ 0.008). Post-operative AKI was associated with higher in-hospital mortality (34.3% vs. 7.1%, odds ratio (OR) 6.8; 95% CI, 2.1–22.1, p⬍0.001) and longer lengths of stay in ICU (5 (2–12) vs. 3 (1– 6) days, p ⫽ 0.01) and hospital (13 (8 –23) vs. 9 (7–11) days, p ⫽ 0.004). Of AKI survivors to hospital discharge, 43.8% (n ⫽ 42) had complete recovery of kidney function. At 1-year, 48.2 of survivors had partial or non-recovery of function. Factors associated with non-recovery at hospital discharge included: greater AKI severity, female sex, and higher APACHE II score; whereas; at 1-year, only greater severity of AKI was predictive of non-recovery. Conclusions: Post-rAAA AKI is common, occurs more often in those with reduced renal reserve, higher blood loss, greater illness severity and concomitant myocardial injury. AKI also predicts higher mortality. Those with more severe AKI had a lower likelihood of long-term kidney recovery amongst survivors.

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SECULAR TRENDS IN PERSISTENT SEPTIC SHOCK HOSPITALIZATIONS, US 2004 –2010

ESTIMATION OF COST SAVINGS ASSOCIATED WITH TOLVAPTAN-MEDIATED LENGTH OF STAY (LOS) REDUCTION AMONG SIADH PATIENTS IN THE US, BASED ON SALT-1 AND SALT-2 TRIALS

Marya Zilberberg, EviMed Research Group, LLC, Brian Nathanson, OptiStatim, LLC, Mark Williams, BioCritica, Andrew Shorr, Washington Hospital Center Introduction: Sepsis remains an important cause of morbidity and mortality. Multiple studies over the last decade indicate that while sepsis hospitalizations are on the rise, sepsis-related case-fatality is declining. These trends have not been defined well for very severely ill patients with persistent septic shock (PSS). Hypothesis: We hypothesized that the volume and associated hospital mortality for PSS hospitalizations mirror those in general sepsis. To fill this gap, we quantified trends in volume and outcomes of hospitalizations with PSS in a US database over time. As a secondary analysis, we explored the sensitivity of administrative coding for PSS. Methods: We conducted a time series analysis between years 2004 and 2010 in the Premier Perspectives, a database representing 15% of all US hospitalizations. Patients with shock on admission were identified by the need for a vasopressor on hospital days 1 and 2, as well as the presence of one or more of the seven sepsis codes. We examined patient and admission characteristics and outcomes over time. Significance of the linear trends was tested. Results: From 2004 to 2010, PSS hospitalizations rose from 31,490 (108/hospital) to 54,172 (146/ hospital). While demographic characteristics remained stable, such comorbidities as diabetes mellitus (30.0% to 36.2%, p⬍0.001), hypertension (28.7% to 48.6%, p ⫽ 0.001) and renal failure (19.9% to 33.3%, p ⫽ 0.01) increased in prevalence. Concurrently the proportion of surgical patients declined from 40.0% to 32.3% (p⬍0.001). Mean hospital length of stay (LOS) dropped from 19.1⫾22.2 days to 14.2⫾15.1 days, as did hospital mortality, from 43.9% to 36.7% (p⬍0.001). Both new codes for severe sepsis (995.92; 39.8% to 70.4%, p ⫽ 0.001) and septic shock (785.52; 34.7% to 56.0%, p⬍0.001) experienced pronounced and steady growth in use from 2004 to 2010, yet each had low sensitivity for PSS when the current algorithm was used as reference. Conclusions: PSS population continues to grow accompanied by shifts in the case mix. Both hospital LOS and mortality have fallen over time. Relying on administrative coding for septic shock alone may underestimate the true prevalence of PSS. Study supported by BioCritica, Inc., Indianapolis, IN.


Joseph Dasta, The Ohio State University, Jun Chiong, Loma Linda University, Rudell Christian, Otsuka America Pharmaceutical, Inc., Jay Lin, Novosys Health Introduction: Two randomized clinical trials, SALT-1 and SALT-2, showed that tolvaptan was an efficacious and safe therapy for the treatment of hyponatremic patients, including many treated in intensive care units (ICU). Hypothesis: This study evaluated the potential cost savings associated with tolvaptan usage based on the SALT-1 and SALT-2 trials. Methods: Hospital LOS reduction associated with tolvaptan vs. placebo was evaluated among hyponatremic SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) patients (⬍135 mEq/L) from the combined data in the SALT-1 and SALT-2 trials. The Healthcare Cost and Utilization Project (HCUP) 2009 Nationwide Inpatient Sample (NIS) database was used to estimate hospital cost and LOS for hospitalizations of adult (age ⱖ18 years) SIADH patients. A cost offset model was constructed to evaluate the impact of tolvaptan on hospital cost and LOS, with univariate and multivariate Monte Carlo sensitivity analyses. Results: In the SALT-1 and SALT-2 trials, SIADH patients receiving tolvaptan had a shorter hospital LOS than placebo patients (4.98 vs. 6.19 days, respectively). A total of 21,718 hospitalizations for SIADH were identified from the HCUP NIS database, with a mean LOS of 5.7 days and mean total hospital costs of $8,667. Using an inpatient tolvaptan treatment duration of 4 days with a daily wholesale acquisition cost of $250, the cost offset model estimated a LOS reduction among SIADH hospitalizations of 1.11 days. The mean total cost offset, including hospital cost saving from LOS reduction and incremental tolvaptan drug cost, was estimated to be $694 per admission. The cost neutral break-even duration of tolvaptan therapy is 6.78 days. Univariate and multivariate sensitivity analyses demonstrated consistent cost reduction associated with tolvaptan usage. 10,000 cycles of Monte Carlo simulation showed the 95% confidence interval for cost offset to be $73$1,405. Conclusions: Based on the SALT-1 and SALT-2 trials, tolvaptan usage is associated with a shorter hospital LOS than placebo among SIADH patients. Including the drug cost for four days of inpatient tolvaptan therapy, tolvaptan is associated with an estimated mean hospital cost reduction of $694 per admission in the US.

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PERIOPERATIVE CARE OF PATIENTS UNDERGOING OPEN ABDOMINAL AORTIC ANEURYSM REPAIR IS MORE COMPLEX IN THE ENDOVASCULAR ERA

SURVIVAL IN A PEDIATRIC INTENSIVE CARE UNIT (PICU) WITH PHYSICIAN EXTENDERS AS PROVIDERS

Olof Viktorsdottir, Columbia University, Adam Was, Harvard Medical School, Shirling Tsai, Rae Allain, Massachusetts General Hospital Introduction: The advent of endovascular aortic aneurysm repair (EVAR) has resulted in a higher complexity of patients presenting to the ICU for postoperative care following open aortic repair (OAR). Hypothesis: In the contemporary era of EVAR, patients requiring OAR have a more complicated perioperative course with higher incidence of renal injury and prolonged hospitalization (LOS). Methods: We retrospectively reviewed anesthetic, operative, ICU, and hospital databases of all patients undergoing OAR at a single academic hospital and divided them into two groups. Group 1 consisted of 244 patients operated on between 8/2003 and 4/2006, the early stage of institutional EVAR experience. Group 2 consisted of 244 patients operated on between 10/2006 and 6/2010, when surgical experience with EVAR had achieved a level of expert proficiency. Clinical variables were evaluated, including procedural time, aortic clamp site, visceral ischemic times, ventilator days, and LOS. Perioperative variables, morbidity, and mortality were assessed using chi-square, t-test and Wilcoxon rank sum test. Results: More patients in Group 2 (164, 67%) required suprarenal aortic cross-clamp (SR) compared to Group 1 (128, 52%, p⬍0.005). Group 2 renal ischemic times and total procedure times were longer (p⬍0.05). There was a trend toward higher postoperative creatinine levels in Group 2 (p⬍0.06). A greater number of Group 2 patients had ⬎3 preoperative comorbidities (p⬍0.001). Interestingly, the mean number of ventilator days was higher in Group 1 (1.8 vs 1.1 days, p⬍0.05). Median LOS was higher in Group 2 (8 vs 7 days, p⬍0.05), but there was no difference in 30-day mortality between the two groups. Conclusions: Patients who present for OAR in the era of EVAR are more likely to have complex perioperative courses, evidenced by more comorbidities, higher rate of SR cross-clamp with greater renal ischemic times, and longer hospital stay. To optimize outcomes, these patients may benefit from skilled intensivist management in the postoperative setting.

Kristina Kypuros, The University of Texas-Health Science Center At San Antonio, Richard Taylor, University of Texas HSCSA, Minnette Son, UTHSC at San Antonio Introduction: Physician staffing of critical care units is a scarce resource. We developed an alternative model in 2008 to use physician extenders (nurse practioners & physician assistants) as the primary in-house provider in our PICU with back-up pediatric intensivists after hours. No data has examined the impact of this model. The objective was to evaluate the difference in survival and length of stay (LOS) for our patient population with a mid-level staffing model as compared to pediatric hospitalist model with intensivists as back-up. Hypothesis: The use of physician extenders is a safe and effective alternative to pediatric hospitalist in providing care in the PICU. Methods: This is a retrospective study comparing the quality of care as measured by specific outcomes between two separate cohorts of patients. Patients were birth to age 18 years admitted to the PICU at our study hospital, University Hospital or Christus Santa Rosa Children’s Hospital, which served as a control, between the dates of July 1, 2005–September 1, 2010. The cohorts represent two time periods; one during which the hospitalist model was in place and the other when the physician extender model was in place.Outcomes of survival and LOS were compared by multivariate regression analysis to evaluate cohorts for independent associations, adjusted for severity of illness and diagnostic groups. Pediatric Risk of Mortality Scores (PRISM II) and diagnostic categories typically associated with higher mortality rates were included as independent variables to adjust for severity of illness. Results: 9912 patients were evaluated. There was no significant difference in mortality between the era when pediatric hospitalists were the primary providers after hours (mortality rate 2.1%) compared to the era when the care was provided by physician extenders (1.8%), p ⫽ 0.714. Likewise, the LOS in hours did not differ significantly between the two eras. Multivariate analyses to adjust for severity of illness using PRISM II scores did not show significant differences between the eras. Conclusions: There was no difference in survival or LOS, with adjustment for severity of illness, with physician extenders providing care as compared to pediatric hospitalists.

566 FULFILLMENT OF RENAL ANGINA IDENTIFIES CHILDREN AT-RISK FOR SUBSEQUENT SEVERE AKI Rajit Basu, Cincinnati Childrens’s Hospital Medical Center, Lori Brunner, Cincinnati Children’s Hospital, Derek Wheeler, Cincinnati Children’s Hospital Medical Center, Lakhmir Chawla, George Washington University, Stuart Goldstein, Cincinnati Children’s Hospital Medical Center Introduction: Earlier detection of acute kidney injury (AKI) with novel biomarkers holds promise to expedite treatment and improve outcomes. Unfortunately, AKI lacks physical signs and symptoms to identify patients at-risk for AKI to trigger biomarker assessment. We recently proposed the empiric concept of Renal Angina (ANG), to “rule-in” or “rule-out” children at-risk for AKI in the pediatric intensive care unit (PICU). ANG stratifies known AKI risk factors (e.g., intubation, stem cell transplantation) and pairs them with early clinical AKI signs (graded thresholds of decreases in estimated creatinine clearance (eCrCl) or increases in fluid accumulation). In formulation of renal angina, we stipulated that the risk of developing severe AKI is a composite of risk and threshold such that the higher the risk, the lower the threshold; in some patients, the threshold for fulfilling ANG is less than currently accepted criteria for pediatric AKI (pRIFLE). Hypothesis: We hypothesized that stratifying patients by ANG fulfillment on Day 0 or Day 1 of PICU stay would improve the ability to predict subsequent severe AKI (⬎50% eCrCl decrease; pRIFLE I or F) 72 hours later over not fulfilling ANG (RF). Methods: We performed a retrospective review of 150 children admitted to the PICU with a diagnosis of “shock.” Results: ANG on Day 0and Day 1 yielded better PPV and NPV for subsequent severe AKI after 72 hours than did RF (Day 0: ANG 0.46/0.86 vs RF 0.14/0.54 and Day 1: ANG 0.37/0.88 vs RF 0.12/0.63). ANG was associated with significantly increased length of stay (9 days [4,16.5] vs 4 days [2,8.9] for RF), higher use of renal replacement therapy (19.6% vs.4.7%), and greater mortality (16.7% vs. 2.5%) (all p⬍0.01). In summary, we found 1) Lack of ANG was associated with a very low likelihood of AKI development in the next 72 hours, 2) ANG fulfillment was associated with high illness severity, and 3) ANG fulfillment increased the ability to predict AKI development (PPV). Conclusions: We suggest fulfillment of renal angina criteria identifies patients for whom biomarker testing would have the highest yield, improving the efficiency of biomarkers to predict severe AKI.



568

THE EPIDEMIOLOGY OF SEVERE SEPSIS IN THE PEDIATRIC INTENSIVE CARE UNIT: A REAPPRAISAL USING A LOCAL CLINICAL DATABASE

A RISK BASED EMPIRIC ANTIBIOTIC PROTOCOL REDUCES TIME TO APPROPRIATE ANTIBIOTICS IN CRITICALLY ILL CHILDREN

Cody Tigges, Michael Forbes, Michael Bigham, David Gothard, Akron Children’s Hospital

Todd Karsies, Nationwide Children’s Hospital/The Ohio State University College of Medicine, Cheryl Sargel, Nationwide Children’s Hospital, David Marquardt, Mark Hall, Nadeem Khan, Nationwide Children’s Hospital/The Ohio State University College of Medicine

Introduction: The clinical milestones from systemic inflammatory response syndrome to septic shock have been clarified substantially due to efforts by the ACCP/ SCCM and the CDC. Nonetheless, the epidemiology of severe sepsis in the pediatric intensive care unit (PICU-SS) remains incompletely understood. Reports of PICU-SS have been clouded by mixed population analyses & small sample sizes. Furthermore, parsing PICU-SS acuity may facilitate the development of benchmarks & identification of best practices. The need for a reliable tool that will clarify the epidemiology of PICU-SS is needed. Hypothesis: We hypothesized that a scoring system based on a local clinical database (VPS, LLC http://www.myvps.org) would aid in the clarification of the epidemiology of PICU-SS. Methods: Severe sepsis was defined as SIRS⫹organ dysfunction. Infection/organ dysfunction-weighted fields(1), were used to generate a PICU-SS acuity score. Three acuity groups were identified by the PICU-SS (Groups A-⬎C, low-⬎high). Patient demographics, age(months), initial (PIM2), and 1st day (PELOD, PRISM3) severity of illness scores, & length of stay (LOS) were compared among the groups using nonparametric tests. Significance, p⬍0.05. Data is presented as median & Group A,B,C. Results: From 7/09 –1/11, 1135 (60.5% male) of 2324 admissions included actionable fields. The groups accounted for 50.7%, 45.2% and 4.1%, respectively. There were differences in age (80.2, 31.8, 116.5 p⬍0.0001), PIM2 (1.06, 0.95, 3.05 p⬍0.0001), PELOD (11, 10, 12 p⬍0.0001), and PRISM3 scores (0.49%, 0.51%, 0.63%, p⬍0.0001) and LOS (1.76, 2.35, 12.49 p⬍0.0001). Mortality in Group C was higher (4.5%, 3.5%, 6.5%, p⬍0.01). Conclusions: We have demonstrated the feasibility of using an existing clinical database to further clarify the epidemiology of PICU-SS. The score appears to identify those with greatest acuity. Limitations include the unknown impact of diagnostic miscoding & lack of distinction between Groups A & B. Further data analysis quantifying the differential impact of comorbidities, diagnostic categories & procedures/interventions are underway. An analysis of the international VPS database may prove informative in many ways. References (1) Angus D, et al, 2001

569 STRUCTURED ROUNDING CHECKLIST IMPROVES QUALITY OF CARE IN THE PICU Rani Ganesan, Rush University Chidlren’s Hospital, Priya Rajakumar, Laura Conley, Susan Nelson, Jason Kane, Rush University Medical Center Introduction: The purpose of this study was to implement a daily checklist to improve team member participation on rounds and standardize communication in the PICU. Hypothesis: We hypothesized that a structured checklist would increase nursing participation on rounds and increase the frequency of discussion of nationally and institutionally prioritized PICU clinical process and outcome measures. Methods: Baseline data collection of undisclosed key elements was performed by covert observations during rounds. A comprehensive nurse driven rounding checklist was created. Sample components of the checklist included catheter-associated infection prevention, diagnostic testing, safety statements, and 4 specified daily goals. Tool optimization was achieved after several PDSA cycles. Frequencies of pre and post intervention metrics were assessed. Proportions were compared using 2-tailed Fisher’s Exact test. Sustainability was tested by comparing early to late post-intervention data. Results: During the 15 week post-intervention period, 86% of the 1060 eligible checklists were completed. Nursing presence during rounds increased from baseline (83% vs 100%, p⬍0.001). Discussions related to catheter-associated infection prevention increased post-implementation (14% vs 79%, p⬍0.001). The frequency of discussions of required diagnostic testing and extubation planning also increased (35% vs 100%, p⬍0.05; 64% vs 91%, p⬍0.05). Parental presence during rounds and discussions related to care conferences did not change from baseline. After 15 weeks, neither the frequency of nursing participation nor discussion of infection prevention was statistically different from week 1. Discussion related to diagnostic testing improved from week 1 to week 15 (50% vs 89% p⬍0.001) while discussion surrounding extubation planning deteriorated in the late post-intervention period (91% vs 25%, p⬍0.001). Conclusions: Implementation of a daily rounding checklist in the PICU increased multidisciplinary caregiver presence on rounds. Discussion of critical safety and quality measures including catheter-associated infection prevention and diagnostic testing improved. Daily rounding checklists can improve team communication and standardization of care.


Introduction: Early appropriate empiric antibiotics may improve outcomes in critically ill adults and children with infections, but extended coverage in all patients would likely be unnecessary. Hypothesis: A risk-based empiric antibiotic protocol will decrease time to appropriate antibiotics in critically ill children. Methods: We designed an EMR-based antibiotic protocol using risk stratification to identify critically ill children at high risk for infection with resistant bacteria. Risk factors include immunocompromise, recent/ current hospitalization, recent antibiotics, and chronic lung disease. These patients received vancomycin, an aminoglycoside, and an antipseudomonal ␤-lactam. Those at low risk got vancomycin and cefotaxime (⫹anaerobic coverage as clinically indicated). We analyzed PICU patients with infectionrelated ICD-9 codes for a year before (2004) and after (2007) protocol implementation. For children with⫹cultures, time to 1st appropriate antibiotic was compared pre- vs post-protocol. Antibiotics were deemed appropriate if organism was sensitive to 1 agent ordered; in polymicrobial infections, each organism had to be sensitive to at least 1 ordered antibiotic. Baseline data were compared using t-test, Wilcoxon, or chi-square as appropriate. Time to appropriate antibiotics was analyzed using logrank test. Results: 174 protocol patients with⫹cultures were compared to 136 pre-protocol patients. Patient characteristics were similar pre- vs post-protocol, including % meeting highrisk criteria (68% each; p ⫽ 0.98) and growth of resistant organisms (57% vs 48%; p ⫽ 0.1). Protocol patients had shorter time to appropriate antibiotics than pre-protocol patients (logrank p⬍0.0001) despited ⬎30% of protocol patients being treated with low risk antibiotics. At 6 hours, 59% of protocol vs 47% of pre-protocol patients received appropriate antibiotics (p ⫽ 0.025), increasing to 85% of protocol vs 63% of pre-protocol patients by 24 hours (p⬍0.0001). Conclusions: Institution of a PICU empiric antibiotic protocol was associated with significantly reduced time to appropriate antibiotics while limiting use of extended spectrum antibiotics. The impact of this protocol on outcomes is currently being investigated.

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A MEDICAL STUDENT-LED QUALITY IMPROVEMENT INITIATIVE TO ENSURE CONSISTENT AND OPTIMAL COMMUNICATION IN THE DAILY REVIEW OF CENTRAL LINE NECESSITY

EVALUATION OF MEDICATION ERRORS WITH IMPLEMENTATION OF AN ELECTRONIC HEALTH RECORD IN THE MEDICAL INTENSIVE CARE UNIT

R. Reza Zonozi, Jamie S. Padmore, Georgetown University School of Medicine Introduction: The daily review of line necessity with prompt removal of unnecessary lines is an evidence-based method to lower rates of central line-associated blood stream infections (CLABSI).1 Observations during morning rounds in the surgical intensive care unit at Georgetown University Hospital show that the daily review is characterized by inconsistent, inadequate, and implicit communication between resident and attending physicians. The purpose of this study was to design an intervention to ensure consistent and optimal communication between physicians during daily rounds in the surgical intensive care unit. Methods: In the observation period, the number of central venous access devices (CVAD) on the unit that received optimal communication during morning rounds was counted each day. This was divided by the total number of CVADs currently in place on the unit that morning, giving the percentage of central lines that received optimal communication that day. We defined optimal communication as explicitly reporting the presence of each CVAD, stating that day’s removal status, providing the rationale for why it cannot be removed that day if the status is for it to remain, followed by a discussion with the attending physician about line necessity if the rationale is equivocal. After the observation period, we designed and implemented an intervention, which was adding a check box to the template of the resident progress notes that asks if the line can be removed, followed with a space for the rationale to be written. Results: In the pre-intervention period, out of a total of 41 CVADs, 12 (29%) received optimal communication. In the postintervention period, out of a total of 30 CVADs, 30 (100%) received optimal communication. Conclusions: By adding a designated section in the template of the resident progress notes about line removal status and rationale, communication regarding the line necessity became explicit, adequate, and consistent. References: 1. Pronovost, P., D. Needham, S. Berenholtz, D. Sinopoli, H. Chu, S. Cosgrove, B. Sexton, R. Hyzy, R. Welsh, G. Roth, J. Bander, J. Kepros, and C. Goeschel. 2006. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N.Engl.J.Med. 355:2725–2732.

T. Vivian Liao, Grady Health System, Rebecca Spivey, Grady, Prasad Abraham, Grady Health Systems, Marina Rabinovich, Grady Health System, Debbie Vigliotti, Grady, Jenny Han, Eric Honig, Emory University, Greg Martin, Grady Memorial Hospital Introduction: Implementation of electronic health records (EHR) has been associated with both beneficial and adverse effects. We sought to compare medication errors (ME) before and after EHR implementation in the medical ICU (MICU), with additional evaluation of error severity and specific high-risk medications. Hypothesis: We hypothesized that EHR implementation would increase the frequency and alter the type of captured ME. Methods: Prospective, observational study of all patients admitted to a single MICU service at an urban academic hospital before EHR implementation (August-September 2010) and after EHR implementation (January-February 2011). All medication orders and administration records were reviewed by an ICU clinical pharmacist to capture ME. The frequency and classification of ME were compared between groups by chi square; p-values ⬍0.05 were considered significant. Results: Patient demographics for the pre (n ⫽ 178) and post (n ⫽ 186) EHR implementation periods were: mean age was 53 vs. 54 years (p ⫽ 0.25), mean APACHE II score was 19 vs. 23 (p⬍0.001), median ICU length of stay (LOS) was 3 vs. 4 days (p ⫽ 0.24), and ICU mortality was 8.0% vs. 13.7% (p ⫽ 0.04). For the primary outcome of ME per 1,000 patient days, there were 2248.9 in the pre EHR period vs. 3096.5 in the post period (p⬍0.001). There was a reduction in prescribing and dispensing errors post-EHR (p⬍0.001), however there was a significant increase in administration errors (p⬍0.001). Errors severity was categorized per standard ME guidelines as A (least severe) through I (most severe). Overall there was a reduction in all ME severity categories (p⬍0.001) except for category C errors which increased from 56.1% of pre-EHR errors to 88.4% in the post-EHR period (p⬍0.001). Overall, there was a reduction in ME related to high risk medications (p ⫽ 0.008). Conclusions: EHR implementation led to an overall increase in the number of medication errors detected. However, significant reductions were seen for high risk medications and in the severity of medication errors, and a shift in the types of errors may have been beneficial despite an increase in observed mortality in the post-EHR period.

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IS VITAMIN D DEFICIENCY ASSOCIATED WITH CRITICAL ILLNESS IN CHILDREN?

AN EPIDEMIOLOGICAL ASSESSMENT OF WATER RECREATIONAL INJURIES FROM 2006 –2010

Azadeh Fayazi, Virginia Commonwealth University Health System, Gary Francis, Virginia Commonwealth University, Mark Marinello, Medical College of Virginia Hospital, Sue Sreedhar, Medical College of Virginia, Leroy Thacker, Lorin Bachmann, Virginia Commonwealth University

Alexander Axelrad, AtlantiCare Regional Medical Center, Kristofer Steingall, Richard Stockton College of New Jersey

Introduction: Vitamin D deficiency is common in the pediatric population and is associated with multiple diseases including sepsis, infections, asthma, and diabetes. It is even more prevalent among critically ill adults in whom it is associated with increased mortality. The purpose of this study was to examine potential associations between serum level of 25(OH)-vitamin D (25(OH)-D) and the severity of illness in children. Hypothesis: Vitamin D deficiency is more prevalent among critically ill children than the general pediatric population. Serum 25(OH)-D levels are inversely related to the severity of disease and mortality. Methods: This was a prospective, cross-section study design. Serum 25(OH)-D concentration was measured on admission and discharge from the PICU. Severity of illness was determined using the Pediatric Index of Mortality 2 scoring system. Mortality, race, gender, and socioeconomic status between the vitamin D deficient (D) and vitamin D non-deficient (ND) groups were compared using t-tests and Chi-squared tests as appropriate. To determine the longitudinal change in 25(OH)-D, change scores were calculated for the two groups and a two sample t-test was used for comparison. Results: Vitamin D deficiency or insufficiency were extremely common among the 50 subjects: 10% severe vitamin D deficiency (25(OH)-D ⬍10 ng/dL), 26% vitamin D deficiency (25(OH)-D ⬍15 ng/dL), and 60% vitamin D insufficiency (25(OH)-D 15–30 ng/dL). The average mortality in the ND and D groups was ⫽ 0.75). Of interest, the average vitamin D level for adolescents (ⱖ12 yrs) was significantly lower (15.8 ⫾7.85 ng/dL) than for children 0 –11 yrs of age (23.3 ⫾9.60 ng/dL, p ⫽ 0.02). Conclusions: Vitamin D deficiency is common in critically ill children but the prevalence is similar to that of the general pediatric population. The severity of illness is not associated with serum vitamin D concentration. Longitudinal change in 25(OH)-D levels showed an increase during recovery that was similar between the two groups (ND and D). In the critical care setting, adolescents are more likely to be vitamin D deficient.

Introduction: From 2006 to 2010, 139 water recreational injuries were treated at Atlanticare Regional Traum Center. Both local inhabitants and tourists alike share their enthusiasm towards water recreational activities, which have increased immensely in popularity over the past two decades. Coincidently, the numbers of significant injuries and even mortalities associated with these activities have increased as well. Very little data exists on the epidemiologic causes associated with water recreational traumatic injuries. Hypothesis: To describe the characteristics of patients injured in water recreational related (WR) activities. Methods: Trauma registry records of WR injury patients during the years 2006 –2010 requiring admission to a mid-atlantic coastal trauma center were reviewed. The study population was analyzed in relation to demographics, mechanism of injury, injury severity, injury type, and length of stay. Association between mechanism and other studied variables were explored using contingency tables. Results: 139 WR injured patients were admitted from 2006 –2010, representing 1.7% of all admissions and 3.6% of the admissions during the summer months. Their mean age was 36.3 years and 101 were of male gender. The mean ISS was 9 and the mean LOS was 4.3 days. The three most common mechanisms of injury were Jet-skiing (34), Surfing (31), and Boating (25). The two mechanisms with the highest ISS were Diving (ISS ⫽ 18) and Jet-Skiing (ISS ⫽ 12). The six most common injuries were cervical spine fractures/dislocations (33, 10 with cord injury), thoraco-lumbar fractures/dislocations (31), traumatic brain injuries/concussions (29), torso-visceral injuries (20), facial fractures (16), and cervical strains (15). Torso-visceral injuries were associated with Jet Skiing mechanism [(Odds ratio 4.18 (1.50 –11.63)] and C-spine injuries with Surfing and Diving mechanisms [Odds ratio 11.68 (4.53–30.14)]. Conclusions: Surfing and Jet-skiing are the most common WR mechanisms leading to admission. Diving and Jet-skiing are the mechanisms of highest severity. Jet Ski mechanism warrants comprehensive assessment of Torso Visceral injury. Surfing mechanism injuries mandate assessment of the entire vertebral column.


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COMPARISON OF CLINICAL FEATURES AND OUTCOMES OF HOSPITALIZED PATIENTS WITH NOVEL INFLUENZA A (H1N1) PNEUMONIA AND OTHER PNEUMONIA

ASSOCIATION BETWEEN LENGTH OF INTUBATION AND DEVELOPMENT OF DYSPHAGIA IN CRITICALLY ILL PATIENTS

Seung Mok Ryoo, Won Young Kim, Jang Hee Lee, Asan Medical Center

Atsumi Takeuchi, Tomoko Taniguchi, Yuko Ishii, Miho Izumi, Keiko Furuya, Kohei Kato, Kunihiko Maekawa, Yasufumi Asai, Sapporo Medical University

Introduction: Although the majority of patients infected with 2009 H1N1 influenza virus had self-limiting illness in the absence of treatment, pulmonary complications such as pneumonia are common and can lead to respiratory failure or ARDS. However, the clinical characteristics and outcomes of patients with 2009 H1N1 pneumonia have not been determined. Hypothesis: The aim of this study was to compare clinical features and outcomes of 2009 pandemic H1N1 influenza pneumonia with those by other organism. Methods: A prospective cohort study was undertaken of consecutive patients who were suspected community acquired pneumonia with requiring admission in university affiliated hospital during the second wave of 2009 H1N1 influenza. Based on the results of real-time reverse transcriptase-polymerase chain reaction (RT-PCR), the staff completed a standard assessment form and managed the patients according to the uniform protocol. Clinical feature, laboratory and radiologic data were collected and analyzed between 2009 H1N1 pneumonia and non-H1N1 pneumonia. The outcome measures were the severity of illness, length of intensive care unit stay, and requirement for mechanical ventilation and mortality. Results: Of the 135 enrolled patients, 59 were H1N1 pneumonia. Patients with H1N1 pneumonia were significantly younger than non-H1N1 pneumonia patients (46 vs. 68 yrs, p⬍0.01). They more frequently had lymphopenia on admission (46 vs. 26%, p ⫽ 0.02), bilateral infiltration in chest radiography (58 vs. 30%, p⬍0.01), lower C-reactive protein (CRP) level (5.2 vs. 13.4 mg/dL, p ⫽ 0.02), lower pneumonia severity index (PSI) score (56 vs. 91, p⬍0.01), and hospitalized days (6 vs. 9 days, p ⫽ 0.01) than those who did not. However, there were no significant differences in length of ICU stay, requirement for mechanical ventilation and mortality. Conclusions: Our study shows that clinical feature and outcomes of 2009 H1N1 pneumonia are comparable to the non-H1N1 pneumonia. However, some characteristics including young age, lymphopenia, lower initial CRP and PSI score may help the clinician to differentiate a pneumonia caused by 2009 H1N1 virus from other organisms before results of RT-PCR.

576 PEDIATRIC TRAUMA CARE IN THE U.S: PATTERNS OF EMERGENCY DEPARTMENT VISITS, AND VARIATION IN HOSPITAL OUTCOMES AND RESOURCE USE BY HOSPITAL TRAUMA CENTER STATUS. Fola Odetola, Achamyeleh Gebremariam, University of Michigan Introduction: Trauma is the leading cause of child mortality and morbidity in the U.S. It is unknown if outcomes are worse for injured children who receive care at non-trauma centers (NTCs) versus trauma centers (TCs). Hypothesis: Injured children hospitalized via the emergency department (ED) to NTCs versus TCs, will have higher severity-adjusted hospital mortality and longer duration of hospital stay. Methods: Retrospective study of children 0 –20 years old evaluated for injuries at U.S. EDs and either hospitalized or released, using the Nationwide Emergency Department Sample. Multivariate regression methods assessed the relationship between the hospital trauma center status, and outcomes of inhospital mortality and duration of hospitalization, with adjustment for injury severity and other potential confounders. Results: Of an estimated 33 million visits to the ED by children 0 –20 years nationally in 2007, 6 million were for trauma. Male children comprised 62% of these visits, and 57% of all children were below 6 years of age. Injuries were from motor vehicle accidents, falls, non-motor vehicle-related accidents, fire, and natural disasters; in descending order of frequency. Injuries most often involved the extremities (61%), and the head (32%). 76% of the most severely injured children were evaluated at EDs within TCs. Nationally, there were an estimated 166,159 child hospitalizations for trauma in 2007. Children hospitalized at TCs were more severely injured, were more likely to receive invasive medical devices in their care, and stay longer in the hospital, than those hospitalized at NTCs. Unadjusted mortality was higher at TCs compared with NTCs (2% vs. 0.1%, p⬍.01), a difference no longer statistically significant after multivariate analysis (Odds Ratio: 1.63, 95% Confidence interval: 0.85–3.12). Conclusions: Childhood injuries are frequent, and the most severely injured children were more likely to receive care at TCs. This differential severity burden was reflected in higher crude mortality at TCs versus NTCs which was no longer observed after multivariate adjustment. This finding is important for future research into quality-of-care factors that influence clinical outcomes after pediatric trauma.


Introduction: Dysphagia is common among survivors of critical illness who required mechanical ventilation. Prolonged orotracheal intubation, even for longer than 8 hr, can cause transient injury to the larynx resulting in swallowing disorders. But, the association of length of intubation with development of dysphagia in critically ill patients is not well known. Hypothesis: We could determine the time period of orotracheal intubation that causes dysphagia in critically ill patients. Methods: We performed a case-control study on patients admitted in our ICU over 12 months. Patients were eligible if they were orotracheal intubated, successful in extubating and surviving to hospital discharge. We excluded the patients who were performed tracheotomy. Data were abstracted including demographics, diagnostic category at ICU admission, occurrence of decreased level of consciousness (GCS ⬍15) and delirium tremens requiring any tranquilizers after extubation, and length of intubation. Outcome measure was dysphagia after extubation. Dysphagia was defined as observed any disorders in the swallowing evaluation. Receiver-operator characteristic (ROC) curve analysis was used to evaluate a cut-off value of time period. Logistic regression model was used to evaluate the association of length of intubation with dysphagia. Results: Of 102 eligible patients, 31 (30.4%) developed dysphagia (dysphagia group). Compared to non-dysphagia group, dysphagia group was significantly older (70 [54 – 80] vs. 52[38 –70] yr), had less trauma patients without severe brain injury (6.5% vs. 22.5%), less intoxicated patients (3.2% vs. 21.1%), more patients with decreased level of consciousness (77.4% vs. 49.3%) and received prolonged intubation (5 [2–9] vs. 2 [1– 6] day). ROC curve analysis showed an area under the curve was 0.67 and determined length of intubation⬎1 day as an optimal cut-off value predicting dysphagia. Multivariate logistic regression analysis showed that intubation ⬎1 day was significantly associated with development of dysphagia (adjusted odds ratio; 5.88, 95%CI; 1.04 –33.21). Conclusions: Prolonged intubation was associated with development of dysphagia and intubation of more than 1 day was an independent risk factor.


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EVALUATION OF DIGITAL SIGNATURE OF CHARLSON COMORBIDITIES USING AUTOMATIC ELECTRONIC NOTE SEARCH STRATEGIES IN CRITICALLY ILL PATIENTS

URINARY BIOMARKERS FOR THE EARLY DETECTION OF ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS

Balwinder Singh, Amandeep Singh, Jyothsana Giri, Rupinder Kaur, Gregory Wilson, Vitaly Herasevich, Ognjen Gajic, Guangxi Li, Mayo Clinic Introduction: The goal of this study was to develop and validate a digital signature to identify Charlson comorbidities among critically ill patients. Hypothesis: It is feasible to accurately identify Charlson comorbidities with digital signature. Methods: A population-based patient sample (n ⫽ 1447) admitted to intensive care units (ICU) in year 2006 from Olmsted County, Minnesota. The digital signature was built by a series of programmatic queries based on an institutional electronic database including all sampling patients past medical/surgical history. The validity of the comorbidity information that we derived from the digital signature and ICD-9 codes were compared to the comprehensive medical chart review (gold standard) in all sampling patients. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were compared between digital signature and ICD-9 codes for Charlson comorbidities. Results: At least one Charlson comorbidity was identified in 982 (68%) patients. Digital signature achieved a median sensitivity of 100 %(range, 99%-100%) and a median specificity of 99.7% (range, 99%-100%) as compared to 57 %(range, 48%68%) and 97 %(range, 92%-100%) respectively for ICD-9 codes. In different Charlson comorbidity domains, PPV ranged from 70%-100% for digital signature, lowest being DM with end organ damage while PPV for ICD-9 codes ranged from 29%-90%, lowest being hemiplegia/paraplegia. NPV ranged from 99%-100% for digital signature as compared to 90% -100% for ICD-9 codes. Conclusions: Our results indicated the feasibility and accuracy of digital signature for identifying Charlson comorbidities other than complex manual chart review and unreliable ICD-9 coding search.

Shunji Kasaoka, Takahiro Yamamoto, Yohei Otsuka, Takashi Miyauchi, Kotaro Kaneda, Yoshikatsu Kawamura, Yasutaka Oda, Ryosuke Tsuruta, Yamaguchi University Hospital Introduction: Acute kidney injury (AKI) is a major complication in critically ill patients. The early detection of AKI is an important issue in the intensive care unit (ICU). Hypothesis: Urinary biomarkers will be useful for the early detection of AKI. Methods: Forty consecutive patients (29 males, 62 ⫾ 17 years) admitted to our ICU were studied. Renal function was evaluated using the Acute Kidney Injury Network (AKIN) criteria. Urinary liver-type fatty acid binding protein (L-FABP) and neutrophil gelatinase-associated lipocalin (NGAL) were measured at admission. We examined the relationship between the onset of AKI and urinary biomarkers (L-FABP, NGAL). Results: The causes of admission to the ICU were severe trauma in 12 patients, poisoning in 4 patients, severe infection in 4 patients, post-cardiac arrest in 4 patients, cardiovascular disease in 2 patients, cerebrovascular disease in 2 patients, and others. AKI occurred in 15 (38%) of the 40 patients after admission to the ICU. The acute physiology and chronic health evaluation (APACHE) II score (22 versus 12, p ⫽ 0.0008) and the ICU mortality (27% versus 0%, p ⫽ 0.0149) in the AKI group were significantly higher than those in the non-AKI group. Compared with the non-AKI group, urinary NGAL was significantly higher in the AKI group (28.5 ng/mL versus 1.2 ng/mL, p ⫽ 0.01). However, urinary L-FABP was not significantly different between the groups (37.6 ng/mL versus 5.4 ng/mL, p ⫽ 0.06). The best cut-off value of urinary NGAL for the early detection of AKI was 8.5 ng/mL (sensitivity 0.67, specificity 0.80). Conclusions: In the ICU patients, urinary NGAL may be more useful for the early detection of AKI than urinary L-FABP.

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LENGTH OF STAY IN THE REFERRING HOSPITAL AFFECTS OUTCOMES OF CRITICALLY ILL INTERHOSPITAL TRANSFERS

PREDICTORS OF CLINICAL FAILURE IN HEALTHCARE-ASSOCIATED PNEUMONIA

Tarik Hanane, Mohamed Abou El Fadl, Cleveland Clinic Foundation, Anita Reddy, Cleveland Clinic Foundation, Jorge Guzman, Cleveland Clinic Foundation Introduction: Interhospital transfers comprise a large number of the patient population in tertiary intensive care units. This group of critically ill patients has been shown to have a higher risk of morbidity and mortality. This study goal is to investigate the effects of the length of stay in the referring outside hospital (OSH) on clinical outcomes. Hypothesis: Patients with length of stays (LOS) in outside hospitals greater than 7 days have worse outcomes. Methods: A retrospective chart review of all patients transferred to our medical ICU (MICU) from OSH between January 1st 2010 and December 31st 2010. Only patients transferred from OSH ICU were included and divided into 3 groups according to their LOS in the referring hospital [⬍48 hrs (I), 48 hrs–7 days (II), ⬎7 days (III)]. Outcome data was obtained from the APACHE IV database and compared between the three groups. Results: 609 patients were transferred from an outside hospital to our MICU during the study period. Of these 509 met the criteria of ICU to ICU admission. 129 (25.4 %) had LOS ⬍48 hours (Group I), 167 (32.8 %) had LOS of 48 hours to 7 days (Group II), 185 (36.3%) had LOS ⬎7 days (Group III) and in 28 (5.5%) LOS was unable to be determined. Patients in groups I and II were younger than in group III (59 [47.5– 69] vs. 59 [48 – 68] vs. 64 [51.5–73] years, respectively (p ⫽ 0.03)). No differences were found in gender, mechanical ventilation or APACHE III score between the three groups. Patients in Group III had longer ICU stay (4.97 [1.63–11.7] vs. 2.5 [1.14 – 6.11] vs. 2.96 [1.18 –7.69] days (p 0.004)) and longer hospital stay (13.7 [7.69 –22.3] vs. 9.52 [5.02–15.1] vs. 11.3 [6.57–18.9] days (p ⫽ 0.004)) when compared to Groups I and II respectively. ICU mortality [17 (13.2%) vs. 24 (14.4 %) vs. 38 (20.5%) p ⫽ 0.15] and Hospital mortality [29 (22.5) vs. 37 (22.2) vs. 56 (30.3%) p ⫽ 0.14] were comparable between groups I, II and III respectively. Conclusions: Patients with longer LOS in the referring hospital appear to have longer ICU and hospital stay without differences in ICU or hospital mortality. Further studies are warranted to understand how outside hospital length of stay may influence the outcomes in this patient population.

Mary Warlaumont, Amaninder Dhaliwal, Creighton University, Mark Malesker, Lee Morrow, Creighton University Medical Center Introduction: Factors associated with clinical treatment failures in healthcareassociated pneumonia (HCAP) patients have not been well studied. Hypothesis: We hypothesized that HCAP patients with advanced age, more comorbid illnesses, higher severity of illness and inappropriate empiric therapy would be most likely to fail therapy. Methods: We retrospectively reviewed the medical records for all patients with HCAP admitted to a single academic hospital during 2008. Data abstraction included variables related to demographics, severity of illness, HCAP-defining criteria, therapeutic interventions, and clinical outcomes. Clinical failure was defined as a composite endpoint that included death and/or development of a pneumonia-related complication. Multivariate logistic regression modeling was used to identify variables associated with clinical failure and to assess the relative importance of these variables in predicting poor outcomes. Results: The study cohort (n ⫽ 278) was 51% male with an average age of 62.8⫾17.4 years. The average severity of illness scores were 13.9⫾7.9 for the Acute Physiology and Chronic Health Evaluation II (APACHE II) and 4.5⫾2.5 for the Clinical Pulmonary Infection Score (CPIS). Clinical failure was seen in 95 patients (34.2%) including 40 deaths (14.4%). Pneumonia complications included development of bacteremia (n ⫽ 22, 7.9%) or empyema (n ⫽ 2, 0.7%), abscess formation (n ⫽ 4, 1.4%), Clostridium difficile superinfection (n ⫽ 6, 2.2%) and septic shock (n ⫽ 30, 10.8%). Adjusted predictors of clinical failure included hospital length of stay (p ⫽ 0.02, OR ⫽ 1.10), homelessness (p ⫽ 0.04, OR 5.86), APACHE II score (p ⫽ 0.001, OR ⫽ 1.12) and prior hospitalization within 90 days (p⬍0.001, OR ⫽ 7.4). Noncompliance with antibiotic treatment guidelines was not significantly associated with clinical failure. Conclusions: These data suggest that patient-specific factors and severity of illness independently affect clinical outcomes. Prior hospitalization was the only HCAP-defining criterion that was also associated with treatment failure.


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RETROSPECTIVE REVIEW OF SURGICAL COMPLICATIONS IN PATIENTS AT HIGH RISK FOR OBSTRUCTIVE SLEEP APNEA

EFFECT OF A MULTIDISCIPLINARY TEAM APPROACH TO ERADICATE CENTRAL VENOUS CATHETER (CVC) BLOODSTREAM INFECTIONS (CRBSI)

Jahan Porhomayon, Strong Memorial Hospital Rochester University, Munish Sharma, Vandana Sharma, univ of buffalo, Andy Sifain, univ of rochester, Nader Nader, university at buffalo

Jens Walz, Richard Ellison, Helen Flaherty, John McIlwaine, Deborah Mack, Kathleen Whyte, Stephen Heard, UMass Memorial Medical Center

Introduction: Obstructive Sleep Apnea (OSA) is a prevalent condition in surgical population but a vast majority of cases are undiagnosed. We compared the surgical outcomes in patients at high risk for OSA with matched controls undergoing similar surgery. Hypothesis: Surgical patients with high score OSA are at increased risk of respiratory complications in the immediate postoperative period. Methods: This was a retrospective, case-control study conducted on all surgical patients undergoing general anesthesia at our institution. On the basis of a preoperative OSA scoring, patients were classified as high (HR) or low (LR) group. The HR group was matched with the same number of patients in control group (LR) using propensity scoring and logistic regression. Both groups were compared for premorbid conditions, intra-operative course and postoperative events using cross tabulation and paired t-test. Development of a defined complication in the postoperative period was considered as the primary end point. Logistic regression was used to identify OSA as a risk factor for co-morbid conditions. Results: We reviewed a total of 3593 patients and 306 patients were found to be at high risk for OSA. The HR group was found to have a higher incidence of hypertension and diabetes preoperatively compared to controls. Postoperatively, the HR group had higher incidence of hypoxia (SatO2⬍90%), reintubation and postoperative use of CPAP. The HR group had longer PACU stay and but a similar overall hospital stay. They were also found to have higher overall postoperative complications. Conclusions: Patients at high risk for OSA have a higher incidence of adverse events in the postoperative period compared to their matched controls.Abbreviations: OSA ⫽ Obstructive Sleep Apnea; ASA ⫽ American Society of Anesthesiologists; CPAP ⫽ Continuous Positive Airway Pressure; PACU ⫽ Post Anesthesia Care Unit; HR ⫽ High risk group; LR ⫽ Low Risk group.Level of Evidence: 2c (Outcomes research)

Introduction: CRBSI remains a significant problem in the intensive care unit. Hypothesis: A multimodal approach for the insertion and care of CVC will prevent CRBSI. Methods: A Critical Care Operations Committee was formed to transform care in 8 intensive care units (ICU) in an academic medical center in 9/2004. One goal was to reduce CRBSI. Using evidence based medicine, a clinical practice guideline was developed that incorporated the use of maximum barrier precautions, chlorhexidine skin preparation, avoidance of the femoral insertion site, dedicated catheter cart, a check list, the tracking of high risk CVC, anti-septic or antimicrobial impregnated catheters, a recommendation to use ultrasound guidance when inserting CVC in the internal jugular vein, daily determination of the need for the CVC and treatment of CRBSI as a critical event.CRBSI were adjudicated by the hospital epidemiologist and CVC days were tracked. Rates of CRBSI were followed from 9/2004 through 7/2011. The Spearman correlation coefficient was used for statistical evaluation. A p⬍0.05 was considered significant. Results: CRBSI rates (per 1000 catheter-days) declined dramatically from 2004 to 2011 (p⬍0.05): 2004: 5.86; 2005: 3.46; 2006: 3.74; 2007: 2.89; 2008: 1.34; 2009: 1.12; 2010: 0.84; 2011 (annualized): 0.49. One ICU has not had a CRBSI for over 3 years. Conclusions: A multimodal approach to CVC insertion and care reduces CRBSI by over 90%. Our ultimate goal is the complete eradication of CRBSI in our institution.

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THE POWER OF TEAM: UTILIZING A MULTI-FACETED, INTERDISCIPLINARY APPROACH TO REDUCE CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS

BURDEN OF EMERGENCY VISITS FOR SELF INFLICTED INJURIES

Kelly Torrence, Brenda Vermillion, Jamie St. Clair, The Ohio State University Medical Center, Nancy Zikri, Ohio State University Medical Center, Madhuri Sopirala, The Ohio State Medical Center, Naeem Ali, Matthew Exline, Ohio State University Hospital Introduction: Central Line Associated Blood Stream Infections (CLA-BSI) are generally recognized as a preventable and costly iatrogenic complication of hospitalization. An interdisciplinary team comprised of critical care physicians and nurses, environmental services, and Clinical Epidemiology (CE) collaborated to focus on strategies aimed at reducing CLA-BSIs to a near-zero rate in our Medical Intensive Care Unit (MICU). Hypothesis: A data-driven, multi-faceted approach to reduce CLA-BSI and improve patient outcomes through interdisciplinary engagement, teamwork, and communication. Methods: Surveillance of the CLA-BSI rate per 1000 patient days, within the 25-bed academic medical center MICU, was observed for two years pre- and post- initiation of the interventions. Strategies included weekly surveillance by CE with timely unit feedback and case reviews. Identification of non-compliance with evidence-based guidelines; investigation of a cluster of cases resulting in partnering with environmental services and acquisition of disposable patient equipment to reduce environmental contamination; daily chlorhexidine gluconate bathing for patient decontamination; staff re-education and demonstration of competencies for line maintenance and access; implementation and re-design of insertion and daily goals checklists to improve usability and decision making; and heightened staff accountability reflective of leadership expectations. Results: CLA-BSI rates in the MICU decreased over the four year period. In 2008 the infection rate (IR) per 1000 Line Days in the unit was 2.23 ⫾ 1.08 (mean ⫾ SD). In 2009 rates increased over the NHSN benchmark of 2.9 (3.025 ⫾ 1.49). In 2010, the average IR had decreased (1.95 ⫾ 1.05) compared to a benchmark of 2.3. In 2011, the IR has remained well under benchmark without any CLA-BSIs in the unit for over 150 days. Conclusions: While many isolated initiatives aimed at reducing CLA-BSIs in an ICU setting have proved to be marginally successful, sustained strides were achieved when the data-driven, multi-faceted interventions engaged an interdisciplinary team promoting combined contributions to the culture of safety.


Veerajalandhar Allareddy, Rainbow Babies and Children’s Hospital, Sankeerth Rampa, Cleveland State University, Veerasathpurush Allareddy, Harvard University Introduction: Suicide or deaths resulting from self inflicted injuries are relatively common, serious and is one of the leading causes of preventable hospitalization and death among adolescents and young adults. Hypothesis: The objective of the current study is to provide nationally representative estimates of hospital based emergency department visits (ED) attributed to self inflicted injuries in the United States. Methods: The Nationwide Emergency Department Sample (year 2008), the largest all-payer nationally representative sample of hospital based ED visits was used. All ED visits with an External Cause of Injury for any of self inflicted injuries were selected. Outcomes examined include hospital ED charges and hospitalization charges. Results: 459,672 visits to hospital based emergency departments were attributed to self inflicted injuries. Females comprised of 57.3% of these visits. Children aged less than 18 years and less accounted for 18.3% of ED visits. 1,946 patients died in ED’s and 2,790 died in hospitals following in-patient admission. 181,708 ED visits necessitated admission into same hospital. About 25% of all ED visits occurred among the uninsured. Close to 59% of ED visits occurred among those residing in areas with annual household income levels less than $49,000. The mean charge for each ED visit was $2,358. The mean charge for those cases that necessitated inpatient admission into the same hospital was $20,935 and the average length of stay was close to 4 days. The total ED charges in the entire United States was $823.6 million. The total hospitalization charges in the entire United States was $3.78 Billion. The total hospitalization days was 704,676 days. The most frequently reported self inflicted injury was use of tranquilizers and psychotropic agents (29.4% of ED visits) and injury by cutting and piercing instruments (22.8%). Conclusions: Females comprise a greater proportion of ED visits attributed to self inflicted injuries. Most common self inflicted injury was with use of tranquilizers and psychotropic agents. Self inflicted injuries are preventable and this study examines the Hospital discharge patterns of such visits.

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THE ROLE OF AN ASTHMA PATHWAY IN THE PEDIATRIC INTENSIVE CARE UNIT(PICU): A PRELIMINARY REPORT

COMPARISON OF SERUM PREALBUMIN CONCENTRATION WITH PRESSURE ULCERS IN AN ADULT URBAN ICU POPULATION

Maria Enrione, Michael Forbes, Children’s Hospital Medical Center of Akron, Kim Spoonhower, Akron Children’s Hospital Introduction: Patients with severe status asthmaticus(SSA) are often admitted to the PICU. Heterogeneity in asthma care has been identified as a national problem in need of innovative solutions. Our institution has implemented an asthma pathway(AP) to optimize care for PICU patients with SSA. Inpatient studies have demonstrated improvements in hospital length of stay(LOS) and compliance. Currently, there is no data published using a standardized PICU-AP. Hypothesis: The use of a PICU-AP will reduce PICU/hospital LOS and improve implementation rates of prevention measures (asthma specialist consultation, education and action plan development). Methods: Patients with the primary diagnosis of SSA(ICD9 491.1) were identified using the VPS, LLC clinical database (http://www.myvps.org). Charts were reviewed from 9/07–9/09 (preAP) and 9/10 –7/11 (postAP). Patients were excluded if they had cystic fibrosis, cyanotic heart disease or severe developmental disablities, were less than 13 m of age, orwere ventilator-dependent preadmission. Significance was defined as p⬍0.05. Data are presented as preAP v postAP, median(range) where appropriate. Results: We reviewed 41 cases (19 preAP, 22 postAP). The AP was used initially in 86.4% of cases and removed due to ’high acuity’ in 21.1%. There were no differences between groups in the use of leukotriene inhibitors (50 v 47.4%) but the postAP group had less chronic inhaled corticosteroid use (40.9 v 21.1%). There was no difference in initial severity of illness, (PIM2) 0.18(0.16 – 0.24) v 0.18(0.16 – 0.98) or hospital LOS. There was a reduction in magnesium (26.3% v 10%) and terbutaline (10.5% v 0.0%) use. High flow nasal cannula oxygen therapy was higher (10.5% v 20%) in the postAP group. There was a nonsignificant trend in PICU LOS reduction, 1.02 (0.28 –5.06) v 0.70 (0.25–3.06) days, p ⫽ 0.21 and no reduction in hospital LOS. Conclusions: This preliminary report shows that the use of a PICU-AP is feasible. While the PICU LOS reduction is nonsignificant, the preliminary trend is favorable. Additional data collection and analysis is underway. Severity-adjusted LOS analysis and multivariate analysis may inform the specific patient populations that will benefit the most from the use of a PICU-AP.

Herbert Patrick, Neil Khare, Valerie Opdyke, Geralyn Sincavage, Angela Garvey, Barbara Salapata, ARIA Health-Frankford Campus Introduction: Serum prealbumin (PAB), a hepatic protein, is a commonly used, sensitive and cost-effective method of assessing malnutrition in patients who are critically ill. (1) Malnutrition is known to be associated with adverse outcomes including impaired wound healing, muscle wasting, longer lengths of hospital stay and increased mortality. (2) As quality measures being imposed on hospitals include reporting patients with acquired pressure ulcers (PU), we questioned whether PAB concentration could help predict occurrences of PU. Hypothesis: Reduced PAB, reflecting malnutrition, will correlate to an increased occurrence of PU in patients admitted to our urban adult intensive care unit (ICU). Methods: This was a retrospective Performance Improvement project. PAB was measured by a standard in-house laboratory assay within 3 days of ICU admission with PAB 18 mg/dl as a threshold concentration. Pressure ulcers (PU) were recorded as Stage I-IV during standard Nursing Assessments. PU within 1 day of admission were classified as community acquired (CA-PU). Results: Patients (n ⫽ 125) were studied in a 3 month period. The average PAB was 17 mg/dl. There were a total of 6 patients with 18 CA-PU: 1 Stage I, 10 Stage II, 7 Stage III and 0 Stage IV. For those patients with PAB below threshold (n ⫽ 69, 55%), there were 17 CA-PU: 1 Stage I, 9 Stage II, 7 Stage III and 0 Stage IV. For those patients with PAB above threshold (n ⫽ 56, 45%), there was a single Stage II CA-PU. Conclusions: Patients with PAB below threshold were associated with increased CA-PU in our ICU. Our hypothesis was supported.Future Research: Additional studies may define ICU and non-ICU patients susceptible to Stage III and IV hospital acquired PU, which now have associated financial penalties. Selected References: (1) The use of prealbumin and c-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center. JPEN. 2011 Jul 28; Epub ahead of print (2) Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011 Feb; 8 (2): 514 –527.Research funding: None.

588 LARGE NATIONAL DATABASE HIGHLIGHTS SIGNIFICANT RISK FACTORS FOR RESPIRATORY COMPLICATIONS AND MORTALITY AFTER ABDOMINAL SURGERY Santosh Agarwal, Mary Erslon, Jen Seda, Scott Kelley, Covidien Introduction: Respiratory insufficiency, arrest and failure (RIAF) are common after surgery and have become a hospital focus under Medicare’s Inpatient Quality Reporting Program. Risk factors for RIAF have been examined in a number of studies; however, there is no current estimate of their impact after abdominal surgery. Hypothesis: Patient history of obesity and sleep apnea (SA) are independent risk factors for RIAF in abdominal surgery patients receiving parenteral opioids and are associated with increased morbidity and mortality. Methods: We included inpatient adults receiving parenteral opioids from Premier Perspective® (Premier, Inc.) Database 2010. We selected surgical Diagnosis Related Groups related to digestive, hepatobiliary and pancreatic systems. RIAF were identified using ICD-9 diagnosis codes. 1:5 match was performed between those with RIAF (cases) and those without (controls) based on propensity scores accounting for age, sex, race, Charlson Comorbidity Index and provider institution. We used logistic regression to estimate the adjusted odds for development of RIAF during the hospital stay. Obesity, SA, naloxone administration and non-elective surgery were identified as a priori risk factors of RIAF. Results: Of the 150,284 discharges that met the inclusion criteria, 2.8% had RIAF. Post-matching, 23,964 discharges were included in the study (3994 cases, 19970 controls), with mean age and CCI of 68.7 and 2.9, respectively. RIAF cases were associated with increased mortality (23.2% vs 2.9%, p⬍0.001), length of stay (17.2d vs 8.3d, p⬍0.001) and total cost ($48,487 vs $19,611, p⬍0.001). Obesity alone (OR: 1.18, 95%CI: 1.08 –1.30), SA alone (1.17, 1.02–1.35), obesity & SA (1.71, 1.48 –1.97), naloxone administration (2.57, 2.27–2.90) and non-elective surgery (1.82, 1.71– 1.94) were significant risk factors for RIAF. Conclusions: Obesity, sleep apnea, naloxone administration and non-elective surgery are independently associated with increased RIAF rate in abdominal surgery patients receiving parenteral opioids, resulting in increased mortality, hospital stay and costs. Better strategies for prevention of, monitoring for, and management of RIAF in this population could lead to improved outcomes and savings.



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RETROSPECTIVE REVIEW OF CLOSTRIDIUM DIFFICILE INFECTIONS IN THE MEDICAL INTENSIVE CARE UNIT

THE CLINICAL UTILITY OF NASAL SWABS AS A PREDICTOR OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS PNEUMONIA

Daisy Chang, Veterans Affairs of North Texas Care System, Sara Brouse, Texas Tech University Health Sciences Center School of Pharmacy, Kevin Kelly, VA North Texas Health Care System, Steven Pass, Texas Tech University Health Sciences Center School of Pharmacy Introduction: Clostridium Difficile (C. difficile) is the most common cause of infectious diarrhea in the healthcare setting and the incidence and mortality rates are increasing in the United States. Reasons for this growing problem include advanced age, use of anti-ulcer medications, and continued use of non-C. difficile antibiotics after diagnosis of C. difficile infections (CDI). Hypothesis: To analyze the clinical impact of length of therapy and single versus combination therapy, and to assess the implications in patient outcomes. Methods: Computerized patient records were retrospectively reviewed and thirty-seven patients were included in the final analysis. Patients at least 18 years of age and stool Toxin A/B positive for C. difficile within 24 hours of admission to medical intensive care unit (MICU) service from January 2007 to December 2009 at the Veterans Affairs North Health Care System were included. Exclusion criteria included patients without stool culture(s) positive for C. difficile within 24 hours of admission to MICU service or patients who did not receive treatment for CDI. Primary endpoints were resolution rates and recurrence rates. Secondary endpoints included treatment duration (monotherapy versus combination therapy) and antibiotic usage history prior to CDI diagnosis. Results: The mean resolution rates between monotherapy and combination therapy were 71% and 77%, respectively. The mean rates of recurrence between monotherapy group and combination therapy were 8% versus 23%, respectively. The mean treatment duration of the initial CDI episode between the combination and monotherapy groups was similar (15 ⫾ 14.7 days for monotherapy and 14 ⫾ 8 days for combination therapy). Conclusions: This study found improvements in CDI resolution rates, but higher recurrence rates, associated with combination CDI therapy, although the treatment duration was similar between the two groups. There was an association between longer CDI therapy and higher recurrence rates.

Jennifer Pollock, St. Mary’s of Michigan, Audis Bethea, Aaron Bown, Charleston Area Medical Center Introduction: Pneumonia is a leading cause of death from nosocomial infections and a factor in 60% of all healthcare infection related mortality. Methicillin resistant Staphylococcus aureus (MRSA) accounts for up to 30% of nosocomial pneumonias. Colonization with S. aureus occurs in 15–25% of the general population and has been shown to significantly increase the risk of infection. Current guidelines for the management of nosocomial pneumonia recommend empiric coverage for MRSA. Antibiotics used to treat MRSA pneumonia often entail increased cost, monitoring and potential adverse effects. The purpose of this study was to determine the incidence of pneumonia in our intensive care units and examine the distribution of MRSA pneumonias among patients with MRSA positive and MRSA negative nasal swabs. Hypothesis: The presence of MRSA nasal colonization can be used as a predictor of MRSA pneumonia and promote early streamlining of antibacterial therapy. Methods: This was a retrospective chart review of all adult inpatient admissions to a trauma and a general surgical ICU, from March 1 to November 30, 2008. All ICU admissions were screened for MRSA by rapid assay nasal swab at the time of admission and once weekly thereafter. Comparisons were then made between MRSA positive and negative nasal swabs and the clinical diagnosis of pneumonia and microbiologic culture data. Results: Seventy-six of 954 (7.9%) patients screened by nasal swab developed pneumonia. No differences were seen in the incidence of pneumonia between the groups who tested positive or negative for MRSA colonization (p ⫽ 0.73). Eleven (9%) patients had positive nasal swabs, 4 of which developed MRSA pneumonia. Four (6%) of the remaining 65 patients (p ⫽ 0.01) with negative nasal swabs developed MRSA pneumonia (negative predictive value of nasal swab ⫽ 94%). Conclusions: Negative nasal swabs are predictive of MRSA negative respiratory cultures in critically ill patients who develop pneumonia and may be useful in guiding clinicians’ empiric antibiotic selection.

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IMPACT OF RENAL INSUFFICIENCY ON THE RISK OF HYPOGLYCEMIA IN THE CRITICALLY ILL

INITIAL AND ACQUIRED THROMBOCYTOPENIA IN CRITICALLY ILL MEDICAL PATIENTS: RISK FACTORS AND OUTCOMES

Silvi Simon, James Krinsley, Stamford Hospital Introduction: Although end stage renal disease (ESRD) is recognized as a risk factor for hypoglycemia (H) in the critically ill, the risk has not been well quantified in the literature and there are no data on the risk of H in patients with renal insufficiency (RI) but not ESRD. Hypothesis: Acute and chronic RI are risk factors for H in the critically ill. Methods: This is a retrospective review using the unit’s prospectively collected comprehensive database, including demographics, diabetic (DM) status, APACHE IV predicted mortality % (APIV PM), and lab values. Between 10/1/05 and 5/31/11 5233 patients were admitted to the 16 bed mixed ICU of a university affiliated hospital. 3 categories of RI included ESRD (n ⫽ 212); initial RI (IRI), (Creatinine [CR] ⬎2.4, no ESRD, n ⫽ 420); and BUMP, (initial CR ⬍2.5 with increase during ICU ⬎0.9, n ⫽ 162). H was stratified: ⬍70 (H70) and ⬍40 (H40) mg/dL. Results: Comparison of patients ESRD IRI BUMP No RIDM (%) 55.2 33.6 29.0 18.5APIV PM (%) 31.6 44.4 40.5 15.5 MV (%) 37.3 52.1 68.5 32.6 Mortality (%) 24.5 39.5 39.5 10.9 H70 (%) 43.9 42.1 51.9 18.9H40 (%) 9.4 7.6 10.5 1.8 Univariate Multivariate OR (95% CI) p OR (95% CI) p H40ESRD 3.92 (2.40 – 6.41) ⬍0.0001 2.44 (1.43– 4.16) ⬍0.0001IRI 2.73 (2.22–3.35) ⬍0.0001 1.33 (0.85–2.10) 0.2104BUMP 4.52 (2.69 –7.59) ⬍0.0001 1.73 (0.96 –3.13) 0.0690 H70ESRD 2.79 (2.11– 3.69) ⬍0.0001 2.17 (1.59 –2.95) ⬍0.0001IRI 2.73 (2.22–3.35) ⬍0.0001 1.48 (1.17–1.87) 0.0012BUMP 3.80 (2.79 –5.19) ⬍0.0001 1.56 (1.08 –2.24) 0.0175. Conclusions: Admitting and ICU-acquired renal insufficiency, as well as ESRD, are each independently associated with increased risk of hypoglycemia in critically ill patients.


Pragya Singh, James Krinsley, Stamford Hospital Introduction: Thrombocytopenia (T) is associated with increased mortality (M) in critically ill patients. There are limited data relating severity of T and M, different implications of initial (IT) or acquired (AT) T, or risk factors for T. The objective of this study is to assess risk factors and outcomes of IT and AT in a large cohort of medical ICU patients. Hypothesis: IT and AT, as well as the severity of T, are independently associated with M in critically ill. Methods: This is a retrospective evaluation of prospectively collected information inluding demographics, APACHE IV predicted mortality % (APIV PM), lab values and outcomes abstracted from the ICU’s comprehensive database. Between 10/1/05 and 5/31/11 2,840 patients were admitted to the medical service of the 16 bed adult ICU of a university affiliated hospital. T was stratified by nadir platelet (P) count: T1 100 –149; T2 50 –99; T3 ⬍50. Multivariate analysis for mortality risk included APIV PM, ICU LOS and P. Observed:expected (O:E) M ratio ⫽ M/APIV PM. Results: Initial P ⬎149 100 –149 50 –99 ⬍50N 2204 406 166 64APIV PM 24.3 31.0 39.2 46.6 M 18.6 26.4 37.3 46.9O:E 0.77 0.85 0.95 1.01 Acquired T Never T 100 –149 50 –99 ⬍50N 1862 252 65 25APIV PM 21.4 34.9 53.6 60.7 M 15.7 26.6 47.7 76.0O:E 0.73 0.76 0.89 1.25 OR (95% CI) for M p No IT 0.72 (0.55– 0.94) 0.02IT1 1.16 (0.84 –1.60) 0.38IT2 1.50 (0.96 – 2.34) 0.08IT3 1.77 (0.87–3.60) 0.12 No AT 0.74 (0.58 – 0.95) 0.02 AT1 0.84 (0.57–1.24) 0.37AT2 1.05 (0.56 –2.00) 0.87AT3 5.12 (1.61–16.23) 0.01. Conclusions: IT and AT correlate with severity of illness and are associated with increased risk of mortality. Normal platelet count on admission and absence of acquired T are independently associated with decreased risk of mortality in critically ill patients.

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CHANGES IN TRANSFUSION PRACTICE IN THE PEDIATRIC INTENSIVE CARE UNIT—A 12-YEAR ANALYSIS

SARCOPENIA IN CRITICAL ILLNESS: SERIAL CHANGE IN PSOAS MORPHOMICS IN SURGICAL INTENSIVE CARE UNIT PATIENTS

Michael Dallman, Xinggang Liu, Anthony Harris, John Hess, Bennett Edelman, Giora Netzer, University of Maryland Medical Center Introduction: Red blood cell (RBC) transfusion is common in the Pediatric Intensive Care Unit (PICU). Temporal trends in transfusion practice are unknown. Hypothesis: We hypothesized that changes have occurred in pediatric transfusion practice over time and that greater illness severity increases the likelihood of transfusion. Methods: This was a retrospective, observational study of patients admitted to the University of Maryland Medical Center PICU between January 1, 1998 and December 31, 2009. First and single admissions of critically ill children between the ages of 3 days and 14 years were evaluated. Patients with hemorrhage, hemolytic anemia, hemoglobinopathies, and congenital heart disease were excluded to reflect the population of prior randomized clinical trials evaluating transfusion strategy. The proportion of patients transfused and pretransfusion hemoglobin (Hgb) levels for the first RBCs given were assessed by calendar year and in aggregate. Clinical variables associated with transfusion were evaluated in univariate and multivariable models. Results: Among 5327 patients meeting inclusion criteria, 335 were transfused. Between 1998 and 2004, this proportion declined from 10.5% to 2.5%, then rose to 6.6% in 2009 (p⬍0.001). No statistically significant change in mean pre-transfusion Hgb was found over time. The following characteristics were associated with increased likelihood of transfusion in both univariate and multivariable models (OR provided for multivariable model): neonatal age (OR: 4.1, 95% CI: 2.8 to 6.1, p⬍0.001), respiratory failure (OR: 1.9, 95% CI: 1.3 to 2.6, p⬍0.001), acidosis (OR: 2.3, 95% CI: 1.6 to 3.2, p⬍0.001), shock (OR: 4.2, 95% CI: 2.9 to 6.2, p⬍0.001) and multiorgan dysfunction (OR: 6.9, 95% CI: 4.8 to 9.8, p⬍0.001). Conclusions: While significant changes in the proportion of patients transfused have occurred between 1998 and 2009, the overall incidence of transfusion did not decrease over time. Variables indicating greater acuity were associated with increased likelihood of transfusion.

Jon Dorfman, University of Michigan Hospitals, Rachel Lee, University of Michigan, Sven Holcombe, Stewart Wang, University of Michigan Hospitals, Lena Napolitano, University of Michigan School of Medicine, Pauline Park, University of Michigan Hospitals Introduction: Previous studies have demonstrated core muscle sarcopenia to be independently correlated with adverse outcomes in vascular surgery, general surgery, transplant and melanoma patient populations and mortality in critically ill patients. It is not known whether sarcopenia is present as a baseline finding or if it evolves during the course of critical illness. Hypothesis: Core muscle sarcopenia develops during acute critical illness and serves as a marker of frailty and adverse outcome. Methods: Radiology records of adult patients admitted to the Surgical ICU were electronically searched to identify those who underwent serial CT imaging during hospitalization for critical illness. Patients with a baseline CT scan within one week before or after ICU admission and at least 1 subsequent scan for comparison were selected for further analysis. Computer-assisted quantitative image analysis was performed and linked with clinical data. Results: 158 CT scans were analyzed in 27 ICU patients (mean number of CTs per patient 5.85 ⫾ 2.6). The patient cohort was 56% female with a median age of 47 years and comprised of postoperative (65%) and severe pancreatitis (21%) patients. A majority of patients were transferred from an outside hospital or other inpatient units to the SICU, with a median 4 days of hospitalization prior to SICU admission. Hospital mortality was 26%. Baseline mean ⫾SD psoas area was 1257 mm3 ⫾416 mm3 in male survivors and 899 mm3 ⫾141 mm3 in male nonsurvivors; 796 mm3 ⫾230 mm3 in female survivors and 632 mm3 ⫾94 mm3 in female non-survivors. 75% of patients lost muscle mass following ICU admission; 63% had at least 1 measurement 20% smaller than baseline and 40% lost at least 40% of mean psoas cross sectional area. 5 of the 7 deaths occurred in this last group. Conclusions: Sarcopenia develops during the course of critical illness and the degree of muscle loss may be associated with higher mortality. Further study of the changes in psoas muscle size and attenuation is required to assess the ability of this technique to identify the highest risk patients.

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WHERE ARE MECHANICALLY-VENTILATED INFANTS AND CHILDREN CARED IN JAPAN? ICUS VS. PEDIATRIC WARDS

A NOVEL SYSTEM FOR DETECTING MYOCARDIAL DAMAGE IN THE CRITICALLY ILL PATIENT

Satoshi Nakagawa, Nat’l Center for Child Health & Development, Yoshinosuke Yamada, Nat’l Center for Child Health and Development, Kiyohide Fushimi, Tokyo Medical and Dental University

Malcolm Sim, Laura Moss, Robert Docking, University of Glasgow, Kathryn Henderson, Jennifer McCallum, NHS Greater Glasgow and Clyde, Derek Sleeman, University of Aberdeen, John Kinsella, University of Glasgow

Introduction: There is shortage of pediatric intensive care units (PICUs) in Japan. PICUs are estimated to serve for only 30% of infants and children who need critical care in the country. Therefore, mechanical ventilation in infants and children is carried out not only in PICU, but in adult ICU and general wards in Japan, however, its distribution is unknown. Hypothesis: Substantial number of infants and children are mechanically ventilated in the pediatric wards in Japan. Methods: Data on pediatric patients (younger than 15 years of age) who required mechanical ventilation were extracted from the Diagnosis-Procedure Combination (DPC) Grouping System Database. Analysis was performed on the data of total 18 months from 2008 to 2010 (from July to December, each year). Eight hundred and fifty-eight, 818 and 953 acute care hospitals participated to DPC Grouping System in the study periods in the years of 2008, 2009 and 2010, respectively. Results: 23,016 infants and children, who were mechanically ventilated, were identified. Among them, 12,523 patients were neonates who were managed in neonatal intensive care units or nurseries. 611 patients were managed in emergency center (Group E), 5,094 patients were in ICUs (Group I), and 4,788 patients were in general wards (Group W). Group I contains pediatric and adult ICUs. The mortality rate in the Groups E, I and W were 13.4%, 7.0% and 6.9%, respectively. Conclusions: Significant number of pediatric patients are mechanically ventilated in the general wards. Although disease backgrounds were different among the three groups, the mortality rate of Group W was as high as Group I. Providing more critical care beds to infants and children must be considered to improve quality of medical care in Japan.

Introduction: Myocardial damage is common in critically ill patients, indeed we previously demonstrated a troponin rise in over 50% of a critically ill cohort. This is an independent risk factor for intensive care (ICU) length of stay and both short and long term mortality. These patients often have a variety of characteristic physiological derangements resulting in an imbalance of myocardial oxygen supply and demand. Hypothesis: By analysing routinely collected physiological data it is possible to detect events which are associated with myocardial damage as evidenced by a troponin rise. Methods: Data sets were collected from critically ill patients in ICU who had myocardial damage confirmed by a troponin rise. These datasets contained every relevant routinely recorded physiological parameter and intervention data throughout the entire critical illness. Data included hourly oxygen saturation, mean arterial pressure, heart rate and inotrope use as well as regularly recorded troponin-I measurements. A sequence of raised troponins was defined as sequential troponin I values above 0.04 micrograms/litre. Severity of cardiovascular derangement in each category was scored from A-E. One hourly episode with category E or several from category C or D were considered to be clinically significant. If sustained these parameters were considered likely to identify a cardiovascular event associated with a troponin rise. The detection tool was refined on 17 sets of data to determine the most appropriate severity and duration of the abnormalities and then the effectiveness of the predictor was tested on a further 34 data sets. Results: The initial data set contained 12 sequences of troponin elevations. The final confirmatory data sets contained 33 sequences of elevations and 20 sequences of no troponin elevation. The true positive rate in the confirmatory data set for the detection tool was 76 % (25/33). The false negative rate was 24%. Conclusions: Using this tool we have detected the majority of events leading to myocardial damage. With refinement the tool may be able to predict impending damage based on acute physiology and trigger clinical evaluation, investigations and interventions to prevent or minimise cardiac damage.


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TIMING OF ARDS RESOLUTION UNVEILED–A PILOT OF T.A.R.U. STUDY

THE MORTALITY IMPACT OF MILD-TO-MODERATE HYPOGLYCEMIA & NUMBER OF HYPOGLYCEMIC EVENTS WITH USE OF COMPUTER-GUIDED TIGHT GLYCEMIC CONTROL

Rahul Kashyap, Myriam Vela, Guangxi Li, Daryl Kor, Michelle Biehl, Rodrigo Cartin-Ceba, Rolf Hubmayr, Ognjen Gajic, College of Medicine, Mayo Clinic Introduction: Despite of a myriad of studies on pathophysiology and treatment modality for ARDS, there is paucity of literature for a definition of ARDS resolution time. We aim to propose a definition for the ARDS resolution time, and determining it’s correlation with hospital mortality. Hypothesis: ARDS Resolution time could be determined as with improvement in ARDS definition variables, which may correlate with ICU mortality. Methods: In this retrospective observational pilot study Olmsted county patients, who admitted to Mayo Clinic, Rochester Hospitals in year 2009 with diagnosis of ARDS, were included. AECC guidelines were used for determination of ARDS onset time. Medical charts were manually reviewed for first time improvement of Pao2-Fio2 ratio (P:F)⬎200, since ARDS onset, which should have lasted for at least 48 hours or at discharge (Proposed as ARDS resolution time). Above proposed definition was applied after excluding patients, who died within 48 hours from ARDS onset time. Other pertinent variables such as PEEP, tidal volume, mean airway pressure, oxygen index (OI) etc. for both time points were collected. Results: Pilot study consisted of a total of 27 patients with a diagnosis of ARDS. Four patients were excluded, who died with in 48 hours of ARDS onset. Median age was 62 years and 78% (18 out of 23) of them were males. The median duration of ARDS resolution was 35 hours. The proposed ARDS resolution was achieved by 15 patients. In matched paired analysis (N ⫽ 15), the mean values at ARDS onset time and at proposed ARDS resolution time were respectively P: F ⫽ 147 vs. 304 (p⬍0.05), Pao2 ⫽ 85 vs. 121 (p⬍0.05), Fio2 ⫽ 0.6 vs. 0.4(p⬍0.05), S:F ⫽ 168 vs. 246(p⬍0.05), PEEP ⫽ 8 vs. 12(⬍0.05) and OI ⫽ 11 vs. 6 (p ⫽ 0.08). No significant association was found in between change in PEEP (⌬PEEP) and change in Pao2 (⌬Pao2) for both time points (p ⫽ 0.7). Unadjusted mortality was lower in patient who met ARDS resolution definition vs. who didn’t {7% vs. 75% (p⬍0.01)}. Conclusions: Proposed ARDS resolution definition can easily be applied. The need for such application and it’s association with hospital mortality in a derivation and independent validation cohort is imminent.

599 PREVALENCE OF ELECTROCARDIOGRAPHIC T-WAVE INVERSION AFTER ADJUVANT RADIOTHERAPY FOR BREAST CANCER Lafayete Ramos, Edilberto Castilho, Eliane Elly, Brazilian Institute for Cancer Control, Barbara Cristina, Pontif␮␮a Universidad, Marcelo Calil, Jo␮Carlos G␮␮ Brazilian Institute for Cancer Control Introduction: An electrocardiogram (ECG) is typically the first exam ordered in patients complaining of chest pain. Among the ECG alterations raising suspicion of acute coronary syndrome (ACS) is the inversion of T-wave polarity. Recipients of radiotherapy after breast surgery frequently complain of thoracic pain, but the relationship between ECG changes and radiotherapy in this particular setting has been not studied. Hypothesis: The present study was conducted to demonstrate the prevalence of eletrocardiographic T-wave inversion after adjuvant radiotherapy for breast cancer. Methods: Seventy-two consecutive patients (age 55.7 ⫾ 12.7 years) who had undergone left breast surgery for malignancy, followed by adjuvant radiotherapy, were recruited for study. Four separate ECG test procedures were sequentially performed: the first, prior to initiating radiotherapy; the second, 20 days after de start of therapy; the third, at the end of the treatment sessions; and the fourth, 30 days after the trird ECG. All patients has normal baseline ECGs, without historical evidence of heart disease. Age, race, surgical procedures, number of sessions, dose, and isodose curve were analyzed. Results: Of the 72 subjects studied, 23 (31.9%; 95% CI ⫽ 21.7– 44.1) presented with T-wave inversion of anterior or septal left ventricular wall (group A). The ramainder of patients (group B) ECGs remained normal. No significant differences were observed between groups relative to age (p ⫽ 0.527), race (p ⫽ 0.456), type of surgery (p ⫽ 0.912), number of sessions (p ⫽ 0.355), radiation dose (p ⫽ 0.288), and isodose curve (p ⫽ 0.161). Conclusions: The prevalence of inverted T-wave polarity is high in this setting and should be factored into the differential diagnosis of ACS.


Lavi Oud, Craig Spellman, Zainab Akhtar, Texas Tech University HSC Introduction: Hospital mortality (M) was recently reported to increase with mild-to-moderate hypoglycemia (H), with inconsistent association between M and the number of hypoglycemic events (NH) in critically ill patients; the applicability of these findings to computer-guided insulin dosing (CG), targeting tight glycemic control (TGC) is unknown. Hypothesis: H & NH are predictors of death in CG TGC in critically ill patients. Methods: We studied a retrospective cohort of patients in a Med/Surg ICU of a university-affiliated hospital, requiring IV insulin infusion (I) for TGC, targeting blood glucose (BG) 90 –130 mg/dl, using CG (GlucoStabilizer™) between 3/1/08 – 6/30/09. Exclusions were age ⬍18 yrs, ⬍10 BG values, ICU LOS ⬍24 hrs, diabetic ketoacidosis/hyperglycemic hyperosmolar state, & hospital readmission. Time-weighted BG (BGtw) was derived. H was defined as BG 41–70 mg/dl. We examined M with NH, H, & across 10 mg/dl strata of minimal H. Mann-Whitney & Chi-square tests, and multivariate regression were used, as appropriate. Results: Four hundred thirty eight patients (64%) met study criteria. Patients had mean (SD) age 58.7 (15.4) yrs; 56% were male; 40.9% Hispanic; 55.5% had diabetes (DM); median (IQR) ICU LOS 4.8 days (2.8 –9.5); mean (SD) BGtw 108.7 (35.6) mg/dl; M 19.9%. One or more H events (HE) occurred in 46.8% of patients (⬎2 HE in 40.7% of H patients), with 2.8 events/100 hrs of I, being similar in DM & non-DM. M was higher in H than in non-H, similar across H strata, but H was not a predictor of death (OR 0.99 [95% CI 0.97–1.02]). M was 10.3%, 21.2%, & 29.6%, with 1, 2– 4, & ⱖ5 HE, respectively (p ⫽ 0.004). NH was an independent predictor of death on multivariate analysis (OR 1.11 per event [95% CI 1.03–1.20]). No M difference was noted between DM and non-DM for H & NH. Conclusions: Nearly 1 in 2 patients had H. Recurrence of HE was common, increasing risk of M in a dose-dependent manner with CG TGC in the present cohort, and may have accounted for the higher M with H. The generalizability of these findings should be examined with other GC, TGC targets, and settings.


601

PROVIDERS ARE NOT AWARE OF THEIR INCORRECT USE OF LUNG PROTECTIVE VENTILATION (LPV) IN PATIENTS WITH ACUTE LUNG INJURY (ALI).

NOISE POLLUTION IN THE PEDIATRIC INTENSIVE CARE UNIT AND ITS EFFECT ON SEDATION MANAGEMENT

SeungHye Han, National Institute of Health Introduction: LPV has been shown to improve the outcomes of patients with ALI. Previous studies, however, showed only up to 50 % of intubated ALI patients received LPV on the day after ALI onset. The barriers to implement LPV in intubated patients with ALI are unknown in community hospitals. Hypothesis: The aim of this study is to identify the barriers to initiating or continuing LPV in ALI patients. Methods: A cross-sectional, self-administered survey was conducted among attending and resident physicians, nurses and respiratory therapists who had worked in a 16-bed medical ICU at a 528-bed, private community hospital. A survey was designed to evaluate the barriers related to knowledge, attitude, and behaviors regarding the use of LPV in intubated ALI patients based on a published framework of barriers to physician adherence to practice guidelines. The individual items were derived from literature reviews and revised through pilot testing. Analysis of variance (ANOVA) was used for comparison. Results: 104 surveys were completed with a response rate of 61%. Most of the respondents perceived that their knowledge regarding ALI and LPV as adequate (97% and 55%, respectively). However, the scores of their knowledge test were lower than their perception: only 35% and 12% answered correctly on the knowledge test of ALI and LPV, respectively. The knowledge test score of LPV was significantly higher among physicians and respiratory therapists than nurses (p ⫽ 0.0003). Most of the participants had positive attitude to LPV: 73% believed the effectiveness of LPV and 83% responded they would use LPV again to take care of intubated ALI patients. Conclusions: Knowledge deficit was reported as an important barrier. A big gap between the perception and the reality of respondents’ knowledge level was identified, which may hinder the use of LPV further. Comprehensive strategies to address these barriers would be necessary to improve the use of LPV in intubated patients with ALI.

Bree Kramer, Women & Children’s Hosp of Buffalo, Christopher Heard, Children’s Hospital of Buffalo Introduction: The detrimental effect of noise on neonates has been documented. It is proposed that older patients have similar physiologic responses. 80 dB is thought to be the noise level that doesn’t produce damage. A recent study demonstrated patients in a PICU experience noise that exceeds the recommendation. Hypothesis: Noise levels at the bedside remain above 80 dB and patients are receiving boluses of sedation during these periods. Methods: Noise levels at a PICU bed were measured with the use of the NoisePro® noise logging device, over a 48 hour period. The device was placed 1 meter from the patient’s head. Noise levels were recorded every minute. Peak noise levels above 100 dB were also noted. Data was collected from the patient’s chart regarding the use of sedation boluses/increases in sedation infusions; the time and dose of this sedation were noted. These sedation requirements and noise levels were then compared to ascertain correlation between noise exposure and extra sedation. Noise levels were averaged for the 5 mins prior, 5 mins during, and 5 mins after a bolus. Results: To date, 20 patients have been enrolled in the study, 8 male/12 female, mean age of 4.5 yrs. The average bedside max, min, and mean dB was 82.2, 53.3, and 62.4, respectively. The average percent of time spent above 80 dB was 0.1% of the 48 hour period. A total of 107 boluses of sedation/increases in infusion rates were recorded. The range showed 1 patient required no extra sedation and 1 patient required 22 boluses of sedation over a 48 hour period. The extra medications were Fentanyl (63% of sedation), Midazolam (18%), Lorazepam (13%), Morphine (4%), Isoflurane (2%), and Methadone (1%). There was no statistical significance in the rooms when noise levels were compared before, during or after a bolus. There were statistically significant differences in the percent of maximum, minimum, and average noise levels amongst the 5 minutes before, during, and after boluses. Conclusions: Mean noise levels in rooms were mostly within recommendations. There was variability in noise levels at different bedsides and during the assessment period; however, this was not associated with increased sedation.

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SICU PATIENTS: DIAGNOSIS AT 30 DAY HOSPITAL READMISSION

VARIABILITY OF ICU TRIAGE PRACTICES IN A CANCER HOSPITAL

Avinash Narayana, Ilan Rubinfeld, Henry Ford Hospital, Lisa Takis, Henry Ford Health System, Marites Cumba, Peter Perakis, Dionne Blyden, Horst Mathilda, Henry Ford Hospital

Nisha Rathi, Sajid Haque, Lei Feng, Kristen Price, Joseph Nates, The University of Texas MD Anderson Cancer Center

Introduction: Unplanned hospital readmissions are placing a financial burden on our health care system and patients. This has lead hospitals and payors to utilize 30 day hospital readmissions as a quality indicator and a harm prevention target. Previous literature has identified pulmonary issues as the most common cause for hospital readmission in mostly medical ICU patients. Hypothesis: We hypothesized that our readmission rate would be similar to MICU data but less related to pulmonary system issues. Methods: We conducted a retrospective observational review of patients that were admitted to the SICU. Those readmitted within 30 days of their initial visit to Henry Ford from January 2007 to December 2011 were analyzed using corporate data. The readmit diagnoses were categorized using ICD-9 codes and further subcategorized based on organ system dysfunction. Results: 9896 SICU patients were discharged from the hospital. 1735 were readmitted within 30 days. Percentage of readmissions as characterized by organ system dysfunction were as follows: GI(22.9%), Infection(22.1%), cardiovascular(16.2%), pulmonary(9.4%), GU/Renal(6.5%), Neurological(6.0%), Musculoskeletal(5.1%), lab abnormality(2.9%), Miscellaneous (2.8%), Sepsis(2.5%), OB/GYN(0.4%), Nutrition(0.3%). Miscellaneous (MISC) category included ICD-9 codes that could not be generalized under any individual organ system (example: malaise and fatigue, tissue graft malfunction, Encephalopathy, unspecified). Conclusions: Our study supports the hypothesis that readmissions to the SICU 30 days after discharge are common. However, we found that GI complaints were the most frequent diagnosis. This could relate to underlying biases not analyzed here, including that MICU patients tend to have pulmonary disorders both acutely and chronically. Our study is retrospective and these factors should be examined prospectively in order to improve the discharge process and quality of care.

Introduction: Triaging intensive care unit (ICU) patients is a necessary process when resources and bed availability are limited. The Society of Critical Care Medicine (SCCM) developed a Prioritization Model (PM) in 1999(1) using criteria such as prognosis and illness severity for categorization. Hypothesis: We hypothesized that for oncologic patients, determining the level of benefit for ICU admission is often complicated due to the variability in cancer progression and treatment responses. Agreement amongst physicians in the prioritization of cancer patients for ICU admission was therefore evaluated. Methods: Full time critical care faculty from a single ICU in a dedicated cancer hospital participated in an anonymous survey. They reviewed 13 case scenarios that included information similar to that obtained during a triage phone call. Physicians independently prioritized each patient on a 5 point scale to indicate urgency of admission using the SCCM PM as a guide. The level of agreement in prioritization between faculty was then measured. Results: Seven critical care faculty completed the survey. There was a high degree of variability in prioritization of patients amongst the study participants. The overall Fleiss’ Kappa coefficient was estimated to be 0.12 (95% CI: 0.05– 0.18), implying only a slight agreement amongst faculty. For individual priority levels, agreement was strongest on priority level 4b (Kappa coefficient ⫽ 0.268), and weakest on priority 4a (Kappa coefficient ⫽ 0.048). The Fleiss’ Kappa was tested to be significantly different from zero (p ⫽ 0.0001). Conclusions: Prioritization of patients is ideally an objective and uniform process that optimizes consistency in resource utilization and patient care. Amongst faculty, there was significant disagreement in the prioritization of cancer patients when using patient scenarios. The SCCM PM was designed to help provide a framework for decision making. Oncologic patients in varying stages of disease, however, may pose a specific challenge for ICU triage necessitating more specific guidelines for this patient population. Reference: 1.Egol et al. Guidelines for Intensive Care Unit Admission, Discharge and Triage. Crit Care Med 1999; 27(3): 633– 638.


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DEATHS FORETOLD: THE IMPACT OF HYPOALBUMINEMIA ON SHORT-TERM MORTALITY DUE TO RESPIRATORY FAILURE IN THE ICU

A COMPARISON OF THE RIFLE AND AKIN CLASSIFICATIONS OF ACUTE KIDNEY INJURY IN PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK

Kenneth Jensen, Jens Borglum, Copenhagen University Hospital Bispebjerg

Jang Hee Lee, Won Young Kim, Seung Mok Ryoo, Asan Medical Center

Introduction: It is widely recognized that protein deficiency has prognostic value for long-term mortality of medical in-patients. Hypothesis: We hypothesized that hypoalbuminemia may be a surrogate marker for respiratory muscle weakness and immune deficiency, negatively affecting short-term survival after ICU admittance for mono-organ respiratory failure. Methods: A retrospective cohort study of 287 consecutive patients requiring mechanical ventilation was undertaken. Mono-organ respiratory failures included pneumonia, exacerbation of chronic obstructive lung disease, and exhaustion by other causes such as asthma, cerebrovascular insult, or non-cardiac, non-pulmonary surgery. Respiratory failure associated with cardiac insufficiency, multiple organ failure or trauma were excluded. The lowest measured serum albumin level was recorded for each patient. Patients were followed for at least one year, and reliable mortality statistics were recorded from available databases. Results: 81% were ASA physical class III-IV, with median age 69 years (range, 23–99 years). 30% had normal albumin levels (36 – 45 g/l), 38% had moderate deficiencies (25–35 g/l), and 32% had severe deficiencies (10 –24 g/l). Within each of these groups, 15-day, 1-month, and 1-year all-cause mortality was (in brackets): normal levels (24%, 30%, 36%), moderate deficiencies (24%, 26%, 39%), and severe deficiencies (56%, 58%, 85%). Conclusions: Not only is severe hypoalbuminemia associated with increased all-cause mortality, but it also carries a significantly increased risk of death in the short-term after mechanical ventilation for mono-organ respiratory failure. This increased risk may be related to terminal respiratory muscle weakness or immune incompetency and should be readily anticipated, begging the question of whether this subgroup of patients actually benefit from ICU admission at all.

Introduction: Acute kidney injury (AKI) is a common and serious complication in patients with severe sepsis and septic shock. AKI can be classified using the RIFLE (Risk, Injury, Failure, Loss, and End-stage) and/or the Acute Kidney Injury Network (AKIN) criteria. Hypothesis: The aim of this study was to determine which of the two systems better predicted 28 day mortality in patients with severe sepsis and septic shock. Methods: We retrospectively examined the medical records of all patients with severe sepsis and septic shock who were admitted to our medical ICU between January 2005 and December 2006, and compared the ability of the RIFLE and AKIN criteria to predict mortality. Results: Of the 326 patients admitted during the study period, 291 were included. AKI 48 h and 72 h after ICU admission was observed in 62.9% and 55.5% of patients, respectively, according to RIFLE criteria, and in 65.6% and 59.2%, respectively, according to AKIN criteria. The overall 28 day mortality rate was 48.5%, and mortality was significantly associated with the severity of AKI, by both RIFLE and AKIN criteria. Both criteria had a similar ability to predict 28 day mortality 48h (0.65– 69, p⬍0.01) and 72h (0.66 –70, p⬍0.01) after ICU admission. Conclusions: The incidence of AKI in patients with sepsis and septic shock was slightly higher using AKIN than RIFLE criteria. However, employing the AKIN criteria did not enhance the ability of AKI to predict 28 day mortality in such patients.

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OUTCOMES OF MECHANICAL VENTILATION IN PATIENTS WITH VARICEAL BLEED

DISCHARGE SETTING FOR ELDERLY TRAUMA PATIENTS: DEMOGRAPHIC RISK FACTORS

Gagan Kumar, Shahryar Ahmad, Muhammad Ali, Nilay Kumar, Amit Taneja, Medical College of Wisconsin, Jennifer Weston, Froedtert Hospital, Rahul Nanchal, Medical College of Wisconsin

Tiffany Littleton, Terry Rives, Carrie Hecht, Rajesh Gandhi, John Peter Smith Hospital

Introduction: Invasive Mechanical ventilation (IMV) is widely used in patients with hypoxemic and hypercapnic respiratory failure as a supportive technique. Depending on the clinical severity of patients, mechanical ventilation must be used for protecting upper airways and life-threatening hypoxemia in patients with variceal bleed. Hypothesis: Patients with variceal bleeding undergoing mechanical ventilation have worse outcomes. Methods: Using the Nationwide Inpatient Sample 2005 to 2008, patients older than 18 years, discharged with a primary diagnosis of variceal bleed were identified using ICD-9 codes-456.0 and 456.20. The status of invasive mechanical ventilation (96.7x) was similarly identified. Primary outcome studied was all cause in-hospital mortality and length of stay (LOS). Chi square test and Wilcoxon rank test were used to compare the variables. Logistic regression model was developed to find if mechanical ventilation was independently associated with mortality. The model adjusted for demographic and hospital characteristics, Charlson’s–Deyo co-morbidity index and severity of admission using number of organ failure. Results: There were total of 189,241 adult discharges with variceal bleeding from 2005 to 2008. Of these, 13.2% were mechanically ventilated. Of these 37.4% underwent mechanical ventilation for ⬎96 hours.In-hospital mortality in patients admitted with variceal bleed who underwent IMV was significantly higher (47.9% vs. 5.2%; p⬍0.001) when compared to those who were not. In patients who underwent IMV for ⬎96 hours, mortality was not significantly higher than those who had shorter period of IMV (46.7% vs. 48.6%). Mechanical ventilation was found to be independently associated with mortality in patients with variceal bleeding (OR 9.0; 95% Confidence Interval 8.2–9.9). The LOS was longer (11.1 days vs. 5.7 days, p⬍0.01) in those who were mechanically ventilated. Conclusions: About 1 in 8 acute variceal bleed admissions undergo mechanical ventilation. Need for mechanical ventilation is an independently associated with higher mortality in these patients.


Introduction: Trauma care for elderly patients has generated more attention in recent years due in part to an increasing elderly population. While most research focuses on activation levels, resource allocation, and aggressiveness of care for elderly trauma patients, the literature is scant regarding patients’ age and discharge setting. Previous research found no differences in the proportion of patients’ discharge setting across age groups. The current study examined patients’ discharge setting by age, race, and gender. Hypothesis: We hypothesized that differences in the proportion of patients discharged home or to a care facility may vary by race and/or gender. Methods: We analyzed data from 2,409 blunt injury patients ⱖ50 years old from a county hospital’s Level I trauma registry who presented from 2006 –2010. Discharge setting was classified as discharged home (with, without assistance) or discharged to a facility (residential, rehabilitation, nursing home). Results: Chi-square analyses showed significant differences between discharge setting and age (50 – 64, 65–74, 75– 84, and 85⫹years) for race and gender. As age category increased, significantly fewer patients were discharged home for Caucasians (p⬍0.001) and Hispanic males (p⬍0.001), but not for African Americans. This proportion increased for the 85⫹age category for Hispanic females (p⬍0.001). Additionally, when separated by condition on discharge (no disability, moderate disability, severe disability), there were no significant differences between racial groups and discharge setting for patients without disabilities, but for patients with moderate disability a significant difference between races exists for the 85⫹age group (p⬍0.05). Of these patients, over 80% of African Americans and Hispanic patients and 40% of Caucasian patients were discharged home. Conclusions: In our population, disparities in the proportion of elderly patients discharged home varied by race and gender. Patient race and gender may be important demographic factors to consider for elderly trauma patients’ care after discharge.

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OUTCOMES OF CRITICALLY ILL ICU PATIENTS ARE INFLUENCED BY THE SOURCE OF ADMISSION

THE IMPACT OF NEW-ONSET ATRIAL FIBRILLATION ON CLINICAL OUTCOMES IN THE MEDICAL INTENSIVE CARE UNIT

Mohamed Abou El Fadl, Tarik Hanane, Anita Reddy, Jorge Guzman, Cleveland Clinic Foundation Introduction: It has been postulated that the source of admission play a role in patients clinical outcomes but definitive data is lacking. The aim of this study is to compare the outcomes of ICU patients based on their source of admission. Hypothesis: Outcomes of ICU patients is affected by the source of admission. Methods: Retrospective chart review of all patients admitted to the medical ICU (MICU) between January 2010 and December 2010. All included patients were divided in 3 groups according to the source of admission [Emergency Department (I), Other Hospital Transfer (II) and General Floor (III)]. Admissions from the operating room, another ICU of the same hospital and long term acute care hospitals were excluded. Outcome data was extracted from the APACHE IV database. Results: Of the 2066 patient who met the inclusion criteria 722 (35%) were admitted from the ED, 530 (25.6 %) from another hospital and 814 (39.4%) from the ward. Overall, the median age was 62 years (IQR 51-72), with male predominance (52.6%) and with 60% of patients requiring mechanical ventilation on ICU admission. APACHE III score was higher in group III compared to II and I (75 [56 –98] vs. 70 [51– 89] vs. 65 [47– 87] P⬍0.0001). Patients in Group II had longer ICU LOS compared to groups I and III (3.21 [1.28 – 8.6] vs. 1.97 [1.07–3.98] vs. 3.04 [1.61–7.29] p⬍0.0001). However, group III had longer hospital stay (19.7[9.92–35.1] vs. 6.45 [3.68 –12.1] vs. 11.4 [6.57–19.5] days, p⬍0.0001), higher ICU mortality (198 (24.3%) vs. 93 (12.9%) vs. 89 (16.8%) p⬍0.0001) and higher hospital mortality (326 (40%) vs. 130 (18%) vs. 133 (25.1%) p⬍0.0001) than group I and II respectively. After adjustment for severity of illness in multivariate analysis, group II had higher odds of ICU mortality (I vs. III, OR 0.51, 95% CI [0.37, 0.7]; II vs. III OR 0.72, 95% CI [O.52, O.99] p⬍0.001) and hospital mortality (I vs. III, OR 0.34 95% CI [0, 26, 0.44]; II vs. III, OR 0.54, 95% CI [0.41, 0.71] p⬍0.001). Conclusions: Patients who were admitted to the ICU from a general floor had worse outcomes than those who came from the ED and other hospital transfers even after adjustment for the severity of illness. This hypothesis generating data warrants further investigation.

Candice Preslaski, Ishaq Lat, Katherine Mieure, Leah Bentley, James Lund, University of Chicago Hospitals, Jesse Hall, Pritzker School of Medicine, University of Chicago Hospitals, John Kress, University of Chicago Hospitals Introduction: New-onset atrial fibrillation (AF) during the post-operative period of cardiothoracic surgery has been shown to be associated with an increase in morbidity and mortality. The effect of new-onset AF in non-cardiothoracic critically ill patients is unclear. Hypothesis: Development of AF while in the medical ICU significantly and independently increases the risk of in-hospital mortality. Methods: Retrospective data collection was performed on all patients admitted to a 16-bed medical ICU at a tertiary academic medical centerbetween June 2008 and June 2010 without a history of cardiac arrhythmias or recent cardiothoracic surgery. Baseline characteristics were evaluated using chi-square or Fischer’s exact test for nominal data and Mann-Whitney U test for continuous data. Multivariate, stepwise logistic regression was performed to determine if new-onset AF was an independent risk factor for in-hospital mortality and for all other categorical outcomes data. Results: Of the 757 patients included for analysis, 53 (7.0%) developed AF. Patients that developed AF had a significantly higher incidence of in-hospital (45.3% vs. 18.5%, p⬍0.001) and 60-day mortality (50.9% vs. 25.7%, p⬍0.001). New-onset AF was associated with an increased risk of inhospital mortality (OR ⫽ 3.65, 95% CI 2.06 – 6.48) and remained significant when evaluated in the multivariate regression model (OR ⫽ 2.01, 95% CI 1.01– 3.98). Patients that developed AF were older with a median age of 69 years (IQR 61–77) versus 56 years (IQR 45– 69) p⬍0.001, had a higher median APACHE II score of 27 (IQR 23–31) versus 20 (IQR 14 –27) p⬍0.001, and were more likely to have a history of coronary artery disease (28.3% vs. 15.5%, p ⫽ 0.021), a diagnosis of septic shock (47.2% vs. 24.3%, p ⫽ 0.001), a requirement for renal replacement therapy (35.2% vs. 10.7%, p⬍0.005) and requirement for mechanical ventilation (70.4% vs. 39.1%, p⬍0.001). New-onset AF was also associated with increased median ICU (5.4 vs. 2.9 days, p⬍0.001) and hospital (16 vs. 8 days, p⬍0.001) lengths of stay. Conclusions: New-onset AF is an independent predictor of in-hospital mortality. It is uncertain if new-onset AF is an indicator of severity of illness rather than a direct cause of death.



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PREDICTORS OF SHORT TERM SURVIVAL IN PATIENTS WITH ACUTE EXACERBATION OF COPD REQUIRING MECHANICAL VENTILATION

FUNCTIONAL OUTCOMES AFTER SEVERE SEPSIS IN THE PEDIATRIC INTENSIVE CARE UNIT: A PRELIMINARY REPORT

Noureddine Nciri, Sameh Farrouk, Hesham Saad, Welcare Hospital, EHL Group

Cody Tigges, Michael Forbes, Michael Bigham, David Gothard, Akron Children’s Hospital

Introduction: Recent studies had shown tricuspid annular displaement (TAD) an echocardiographic parameter, FEV1 and hyponatremia as prognosis parameters in patients with heart failure, COPD and pulmonary hypertension. Few data available concerning short term survival in COPD patients with acute exacerbation (AECOPD). Hypothesis: The purpose of our study is to evaluate short term survival parameters in this category of patients. Methods: Patients admitted to ICU for AECOPD requiring invasive and non invasive Ventilation (NIV) during the study protocol were included. Demographic data, clinical and laboratory parameters were recorded on admission. A Doppler echocardiography was done on admission (LVEF, diastolic function of LV, RV diameter, systolic pulmonary artery pressure and TAD recorded on M mode). A comparison of data was done between survivors and non survivors. Results: One hundred twenty four patients were included in study, mean age 58 y. Twenty one patients (17%) died in the ICU. Comparison between survivors and non survivors did not show any difference on demographic and clinical finding. Death was more likely in patients who needed invasive ventilation, had higher severity score (SAPS2), higher PaCO2, higher NT pro-BNP, had lower serum protein and lower TAD. Logistic regression after multivariate analysis shows only low serum protein as an independent risk factor of short term survival (63.3 ⫾ 4.7 vs 51.2 ⫾ 3.8, p ⫽ 0.000). When we restrict the analysis to patients managed by NIV, non survivors had higher PaCO2, lower serum protein, lower serum sodium, higher serum urea, higher NT pro-BNP and had lower TAD. Logistic regression after multivariate analysis shows only TAD as an independent risk factor of short term survival (19.3 ⫾ 3.0 mm vs 14.5 ⫾ 2.7 mm ; p ⫽ 0.0001). A cut-off value of TAD ⱖ17 mm can predict survivors with a sensitivity of 88% and a specificity of 92%. The area under the curve of the receiver operating characteristic curve was 0.94. Conclusions: The present study shows that serum protein and TAD had an important prognostic implications for patients with AECOPD. Thus, added to routine investigations, TAD should be incorporated as routine echocardiographic assessment for patients with AECOPD.

Introduction: With improvements in definition & new frontiers in molecular diagnostics, mortality due to severe sepsis (SS) in the pediatric intensive care unit (PICU-SS) has been decreasing over the past 2 decades. Concomittant with this is a growing recognition of the morbidities associated with surviving PICU-SS. In order to optimize functional outcomes after PICU-SS reliable, acuity-adjusted metrics after PICU-SS are needed to identify best practices. Hypothesis: We hypothesize that VPS, the local clinical database (http://www.myvps.org) can be used to quantify functional outcomes after PICU-SS. Methods: We developed a VPS-based, PICU-SS acuity score that produces 3 acuity levels (A-C, low-high). Functional outcomes (1) were measured in all groups using the Pediatric Overall Performance Criterion (POPC) and the Pediatric Cerebral Performance Criterion (PCPC) . These 2 criteria have been used to determine the longitudinal impact of critical illness in children. Demographics, admission(a), discharge(d) and delta (d-a) POPC and PCPC were compared. Significance was defined as p⬍0.05. Data are presented as Groups A,B, and C. Results: We identified 1135 cases (60% male). There were no differences among the groups in aPOPC or aPCPC. Group C was functionally worse at discharge in both criteria; dPOPC(2.201, 2.090, 3.152), dPCPC (2.14, 2.04, 3.04, p⬍0.0001. Additionally, Group C had the largest reduction in function in both criteria [deltaPOPC (0.306, 0.174, 0.783), deltaPCPC (0.288, 0.166, 0.781), p⬍0.01, and the highest mortality rate (6.5%). Conclusions: We have demonstrated the feasibility of using a local clinical database to quantify acuity-based functional outcomes after PICU-SS. Those with the highest PICU-SS acuity suffered the greatest functional reduction in both criteria. Further investigation to improve the predictive value of the scoring tool and define the differential impact of clinical interventions on POPC/PCPC are warranted. REFERENCES References (1) Fiser DH, et al 2000; PCPC 1 Normal, 2 mild, 3 moderate, 4 severe disability, 5 coma, 6 brain deathPOPC 1 Good overall performance, 2 mild, 3 moderate, 4 severe overall disability, 5 coma, 6 brain death

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RED BLOOD CELL TRANSFUSION THRESHOLDS AMONG CHILDREN WITH VARIOUS CLINICAL CONDITIONS ADMITTED TO A PEDIATRIC INTENSIVE CARE UNIT

THE ASSOCIATION OF THE THREE DOMAINS OF GLYCEMIC CONTROL TO MORTALITY IN PATIENTS ADMITTED TO THE ICU WITH HEAD TRAUMA

Madhuradhar Chegondi, Andre Raszynski, Balagangadhar Totapally, Miami Children’s Hospital

Warren Strutt, Kevin Dwyer, James Krinsley, Stamford Hospital

Introduction: The optimum hemoglobin transfusion threshold in pediatric intensive care unit patients is unknown. Hypothesis: We analyzed our pediatric intensive care unit patients who received red blood cell transfusions, to determine our hemoglobin transfusion threshold practice in four clinical conditions. Methods: We retrieved target patient population data from our blood bank database. Patients were subdivided into four subgroups: hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, and sickle cell disease), surgical (post-surgical, trauma and acute bleeding), unstable (FiO2 ⬎0.6 and/or inotropic support), and stable patients. Critically ill children between 1 month and 21 years of age were enrolled. We excluded patients who underwent ECMO. Results: A total of 253 transfusion episodes in 129 patients were analyzed. The distribution of transfusions included hematologic 39.13% (n ⫽ 99), surgical 26.48% (n ⫽ 67), unstable 14.22% (n ⫽ 36), stable 20.15% (n ⫽ 51). The mean(SD) pre-transfusion hemoglobin(g/dL) in all patients and children in hematologic, surgical, unstable and stable groups were 7.38 (3.79), 7.02 (1.30), 7.89 (1.11), 7.80 (1.08), and 7.11 (0.88) respectively. The mean (SD) pretransfusion hematocrit values in all patients and children in hematologic, surgical, unstable, and stable groups were 21.51 (3.79), 20.05 (3.98), 23.29 (3.39), 22.88 (3.29), and 21.04 (2.94) respectively. The transfusion threshold for surgical and unstable groups was higher compared to hematologic and stable groups (p⬍0.001; ANOVA with multiple comparison test). Mortality was 7% (n ⫽ 9) in transfused patients compared to 1.4% in other children admitted to PICU (p⬍0.001; OR 5.6 (2.6 –12.4); Fisher’s Exact Test). Conclusions: Hemoglobin threshold for transfusion varied according to clinical conditions. Overall hemoglobin and hematocrit thresholds of 7.3 (1.2) g/dL and 21.51 (3.79) are comparable to published data in stable (N Engl J Med 2007;356:1609 –19) and postsurgical critically ill children (Ann Surg 2010;251: 421– 427).


Introduction: The 3 domains of glycemic control-hyperglycemia (HY), hypoglycemia (HO) and glycemic variability (GV)-have been associated with mortality (M) in critically ill patients. While HY has been studied in patients with head trauma (HT) the impact of HO and GV is unclear. Hypothesis: HY, HO and GV are all associated with increased risk of M in patients admitted to the ICU with HT. Methods: This is a retrospective investigation of prospectively collected data abstracted from the unit’s clinical database. Between 10/1/05 and 5/31/11 316 patients with HT were admitted to the 16 bed ICU of this university affiliated hospital; 272 were non-operative (NON) and 44 required surgery (OP). Analysis included demographics, APACHE IV predicted mortality % (APIV PM), Injury Severity Score (ISS), mortality (M), ICU LOS, Mean blood glucose (BG, mg/dL), Min BG ⬍40 and ⬍70 and coefficient of variation % (CV). Results: OP were younger (p ⫽ 0.0140), ventilated more often, had higher ICU LOS and had higher APIV PM, ISS and M (all p⬍0.0001). OP NON P valueMean BG 128 (120 –141) 116 (105–128) 0.0001 Min BG ⬍70 % 27.3 14.0 0.0433 Min BG ⬍40 % 9.1 0.3 0.0003CV % 20.6 (17.3–31.3) 14.7 (9.3–21.5) ⬍0.0001 M % Mean BG80 –110 4.8110 –140 12.5140 –180 24.4⬎180 50.0 Min BG⬍70 20.0⬍40 40.0None 10.5 CV⬍15% 2.815–30% 16.3⬎30% 32.4 Multivariate analysis (APIV PM in model): risk of M OR (95% CI) Mean BG ⬍140 0.25 (0.09 – 0.69) Mean BG ⬎140 3.95 (1.44 –10.80) p ⫽ 0.0074CV ⬍15% 0.26 (0.08 – 0.85) p ⫽ 0.0258 Min BG ⬍70, ⬍40 and CV ⬎30% NSSimilar results were found with ISS substituted for APIV PM. Conclusions: Hyperglycemia was independently associated with increased risk of M in this cohort of critically ill HT patients. Low glycemic variability was independently associated with reduced risk of M. Hypoglycemia correlated with severity of illness but was not independently associated with increased risk of M.

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IMPACT OF OBESITY ON MORBIDITY AND MORTALITY IN THE PEDIATRIC INTENSIVE CARE UNIT

PREDISPOSING FACTORS FOR PROLONGED VIRAL SHEDDING OF PANDEMIC (H1N1) 2009 INFLUENZA VIRUS IN 5 DAYS OSELTAMIVIR TREATED PATIENTS

Grace Oei, Natalie Yee, Ashley Henderson, Daniel Noriega, Douglas Deming, Shamel Abd-Allah, Loma Linda University Children’s Hospital Introduction: The incidence and prevalence of pediatric obesity have increased in the United States. Few studies have investigated the effect of obesity on critically ill children. Hypothesis: Obesity increases morbidity and mortality in critically ill children. Methods: We retrospectively studied consecutive admissions to the pediatric intensive care unit (PICU) in a tertiary care facility over a twelvemonth period (January 2009 to December 2009). Obesity was defined as admission weight for length greater than the ninety-fifth percentile for children under two years or admission BMI greater than the ninety-fifth percentile for age and sex for children over two years. The patients were divided into obese and non-obese groups. We analyzed age, gender, race, admission PRISM2 score, length of mechanical ventilation, PICU length of stay, inotrope need, requirement for hemodialysis, and mortality between the two groups using Pearson Chi-square and Mann Whitney U. Results: In the twelve-month period there were 1423 admissions to the PICU. 21% of the total population and 22% of the population requiring mechanical ventilation were obese. Age, gender distribution, and admission PRISM2 scores were not different between the groups. The obese patient group was mechanically ventilated for significantly longer time than the nonobese group (p ⫽ 0.001). There were no differences in mortality, ICU length of stay or need for inotropes or hemodialysis between the two groups. Conclusions: Obese patients required longer mechanical ventilation times than non-obese patients. However, the length of PICU stay was not different between groups. Other severity of illness markers were also similar. Further studies are needed to identify how obesity and specific management may affect outcomes in critically ill children.

Seung Mok Ryoo, Won Young Kim, Jang Hee Lee, Asan Medical Center Introduction: For the pandemic (H1N1) 2009 influenza, world health organization (WHO) has recommended 5 days of antiviral agent treatment. However some patients have more active and prolonged viral detection for 5–7 days after illness. Therefore sometimes the patients need additional antiviral treatment and have to be isolated from others to prevent infection. Hypothesis: The purpose of this study was to determine the predisposing factors of persistent viral shedding of pandemic (H1N1) 2009 influenza, after 5 days antiviral treatment. Methods: This was a prospective, observational cohort study of 173 patients with reverse transcriptase polymerase chain reaction (RT-PCR) confirmed pandemic (H1N1) 2009 influenza who visited a tertiary care hospital from 25 August through 31 December 2009. All patients were treated to our institutional protocol and received routine follow-up RT-PCR at 5 days from which the oseltamivir treatment had started. We compared the predisposing factors of follow-up RT-PCR positive patients with negative patients. Results: Of all 173 patients, 88 patients (50.9%) had persistent viral shedding after 5 days of oseltamivir treatment. Viral shedding was significantly prolonged when they had major comorbidities (OR 3.84, [95% C.I. 1.82– 8.08]), and they had respiratory symptoms on the 5th day from antiviral treatment (OR 4.13, [95% C.I. 2.10 – 8.11]). During early visit (within 2 days) from when symptoms develop, the viral shedding was more prolonged (OR 0.45, [95% C.I. 0.23– 0.89]. Conclusions: The patients who have major comorbidities, have remained respiratory symptoms after antiviral treatment, and visit within 2 days can be associated with prolonged shedding period.

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CHARACTERISTICS AND OUTCOMES OF PEDIATRIC RAPID RESPONSE TEAMS BEFORE AND AFTER AUTOMATION BY A PEDIATRIC EARLY WARNING SCORE (PEWS) SYSTEM

A NOVEL APPROACH TO MEASURING FUNCTIONAL RECOVERY IN OLDER SURVIVORS OF CRITICAL ILLNESS: A FEASIBILITY STUDY

Lee Polikoff, Rahul Panesar, Stony Brook Children’s Hospital, Barbara Mills, David Harris, William Greene, Stony Brook University Hospital Introduction: The Pediatric Early Warning Score (PEWS) System was created to help identify unstable patients prior to a life-threatening event. Rapid Response Teams (RRTs) were developed to assist in the evaluation and management of these patients. Since December 2008, we have automated the activation of RRTs by a PEWS of 5 or greater (red score). Hypothesis: We aim to identify differences in characteristics of RRT calls before and after automation by the PEWS System. Methods: We compared RRT data compiled from 2008 to 2010, with 44 RRTs recorded before automation and 69 RRTs after automation by the PEWS System. Chi-Square analysis was performed; P-value ⬍0.05 considered statistically significant. Results: Tachycardia was identified more often as a trigger to an automated RRT, with an increase of 26.1% (p ⫽ 0.004). There was a 22.9% (p ⫽ 0.009) reduction in RRTs triggered by recognition of acute change in mental status or agitation post-automation. Post-automation, an increase of 15.1% of RRTs required no respiratory interventions and the use of supplemental oxygen via nasal cannula or face mask decreased by 24.5% (p ⫽ 0.011) as well as bag-mask ventilation by 11.6% (p ⫽ 0.035). Patients were stabilized less often by initial interventions by 19.7% (p ⫽ 0.038) post-automation, but there was no significant increase in transfer to the pediatric intensive care unit (PICU) or in Code Blue calls. Conclusions: Those RRT calls automatically triggered by the PEWS system more readily identified objective than subjective physiologic changes, such as tachycardia as opposed to changes in mental status. The use of supplemental non-invasive respiratory support decreased after automation. Automation may have influenced clinical practice as clinicians knew a priori that an RRT would be triggered by a red score based on respiratory rate and therefore triaged patients to the PICU. However, automation may also have selected for borderline patients to be triaged to the floor based on their PEWS. These patients subsequently decompensated more acutely, since they were less readily stabilized after initial interventions. Automation did not affect the calls for code blue, or deaths, but did show a trend toward increased transfers to the PICU.

Michele Balas, University of Nebraska Medical Center, College of Nursing, Stephen Bonasera, William Burke, Jane Potter, Joseph Sisson, University of Nebraska Medical Center Introduction: We are developing an innovative approach to measuring functional ability in older adults who survive a serious or life-threatening illness. This technique, “mobile monitoring,” uses available sensor and mobile phone technology to detect in-home position, in-community location, and to measure functional ability over time. Before we can apply this technology into research and clinical practice, we needed to ascertain whether older survivors of critical illness find such methods of monitoring acceptable. Hypothesis: The purpose of this prospective, observational study was to assess the feasibility of following older survivors of critical illnesses’ long-term functional ability using the mobile monitoring technique. Methods: Participants included 43 adults, age 65 and older, admitted to an intensive care unit at a large Midwestern academic medical center. We performed comprehensive, structured assessments of the older adults’ preadmission and discharge physical and functional ability. Prior to hospital discharge, participants complete a semi-structured interview designed to explore their perceptions of mobile monitoring. Results: Six subjects (14%) died during their hospitalization. Nearly 60% (n ⫽ 22) of the survivors completed the discharge interviews. Eleven reported they would agree to participate in a study that involved mobile monitoring. The most common reason they gave was the perception that it would “help learn more about older people.” Older adults reported “intrusiveness,” “fear of losing phone,” “too much effort,” and “difficulties with vision and hearing” as reasons they would not participate in a study that used mobile monitoring. While most of the subjects reported feeling comfortable using the cell phone, they expressed some uneasiness regarding the instillation of the sensor technology in their homes. Conclusions: Future studies using the mobile monitoring technique with older survivors of a serious illness are feasible. Numerous contextual variables affect older adults’ willingness to participate in such trials. The use of mobile monitoring in older adults will require substantial educational efforts.


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EFFECT OF ADDING AN ACUTE CARE NURSE PRACTITIONER (ACNP) TO A STAFF NURSE LED RAPID RESPONSE TEAM (RRT) IN A UNIVERSITY MEDICAL CENTER

INFORMATION SEEKING BEHAVIORS OF PROVIDERS IN CT ICU SETTINGS

Susan M. Hellervik, Cherry B. Chassan, Janna S. Landsperger, Arthur P. Wheeler, Vanderbilt University Medical Center Introduction: RRTs are increasingly dispatched to rescue patients deteriorating outside the ICU, however their effectiveness is controversial and there is little data regarding the effect of team composition on effectiveness or outcomes. Hypothesis: We hypothesized that adding an ACNP leader to a medical RRT would increase efficiency, improve communication, and increase survival during RRT calls. Methods: We compared interventions and outcomes from RRT calls led by staff nurses (Jan-June 2010) with RRT calls led by ACNPs from (Jan-June 2011) using a RedCap QI database. Data mean ⫾ std unless noted. Results: In 2010, 168 RRT calls (96% initiated by RNs and 0% by MDs) occurred compared to 254 in 2011 (93% initiated by RNs and 4% by MDs). Age of RRT subjects was 58⫾17 yr during both time periods. In 2010 and 2011 the most common triggers were respiratory 37% vs 31% and circulatory concerns 30% vs 34%; respectively. Communication with the primary team was documented by ACNPs on 87% of calls (79% with residents, 9% with fellows, 12% with attendings) compared to just 30% of calls in 2010. Interventions ordered by ACNPs, inaccessible to staff RNs were medications (45% of calls), labs (30% of calls), ECG (21% of calls), and x-rays (19% of calls). In 2010 31% of RRT calls ended with ICU transfer compared to 29% in 2011. In 2010 22% of subjects of an RRT had ⬎1 RRT call during their hospital stay compared to 16% of patients with ⬎1 call in 2011. Cardiac arrest was rare, occurring in 0 .6% and 0.8% of RRTS in 2010 and 2011 respectively. Survival to hospital discharge in 2010 was 83% compared to 88% in 2011. With ACNPs call duration was 30⫾ 16 min compared to 33⫾ 25 min with staff nurses. ACNP led calls generated a critical care billable note in 30% of cases whereas previously no billing occurred. Conclusions: We conclude having ACNPs lead the medical RRT in a university hospital results in more diagnostic testing, therapeutic interventions, communication, and perhaps fewer repeat calls, shorter calls and a numerically higher survival to hospital discharge. Supported by (1 UL1 RR024975 from NCRR/NIH).

621 ALTEPLASE USE FOR MALFUNCTIONING CENTRAL VENOUS CATHETERS INCREASES THE RISK OF CATHER ASSOCIATED BLOOD STREAM INFECTION Courtney Rowan, Riley Hospital For Children, Kathryn Miller, University of Arkansas for Medical Sciences, Andrew Beardsley, Terri Hedlund, Sheikh Ahmed, Richard Speicher, Riley Hospital for Children, Mara Nitu, Riley’s Hospital for Children Introduction: Central venous catheters are known to be associated with numerous complications including thrombotic occlusion and bacteremia. A catheter thrombosis and the presence of a catheter-associated blood stream infection (CABSI) often occur simultaneously, but it is unclear if or to what degree the two complications relate. Several animal and adult studies indicate a relationship between fibrin sheaths and thrombi in the development of CABSIs. To date, there has been no human investigation in the pediatric population to determine a clear link between the presence of a thrombus and bacteremia. Hypothesis: The use of alteplase (tPA) for malfunctioning central venous catheters (CVC) may indicate the formation of intraluminal thrombus or fibrin sheath. A line that requires tPA is at higher risk of a CABSI. Methods: A retrospective chart review from July 2008 to December 2010 was conducted looking at all patients with central lines admitted to the pediatric intensive care unit at Riley Hospital for Children. The electronic medical record of patients with CABSIs was examined for the use of tPA in the 5 days preceding the positive blood cultures. The total number of tPA orders was obtained from pharmacy records. Number of central venous catheters and CABSI were obtained from quality and infection control records. Results: Preliminary data during the study period identified 3289 central venous catheters. Twelve percent of these lines required at least 1 dose of tPA. There were 40 CABSI during this same time period of which 28% received tPA during the 5 days preceding the positive blood culture. The odds ratio for getting a CABSI when tPA is needed is 2.87 (CI 1.42–5.60, p ⫽ 0.002). The average age of the CVC at time of infection was not statistically different, 16.1 days in the tPA lines compared to 25.6 days for the lines that did not receive tPA (p ⫽ 0.6). Conclusions: There is a positive correlation between the use of tPA for a malfunctioning line and developing a CASBI. This is likely associated with the development of an intraluminal fibrin sheath or thrombus. This study adds evidence linking thrombus formation to CABSI.


Laura Jones, Emory University, Thomas Kannampallil, UTHealth, Timothy Buchman, Emory University Hospital, Amy Franklin, University of Texas Introduction: Critical care environments represent an information-intensive collaborative setting where clinicians must locate the right information to perform their duties in a timely manner. Using data collected from two CT ICUs, we report on the differences in information seeking behavior of resident and affiliate (midlevel) providers prior to clinical rounds. Hypothesis: We hypothesized that there would be no difference in manner of resource utilization between resident and affiliate (NP and PA) providers during pre-round information seeking. Methods: Providers were observed creating progress notes prior to rounding. Clinicians’ use of ICU resources such as paper-based notes, lab reports, and verbal discussions were captured using an iPad application including the total time on each resource. Data were collected for 9 providers (4 residents, 5 NPs, 2 PAs) during 19 shifts and include the documentation of 100 patient progress notes. Results: Two distinct patterns of information seeking were observed. Affiliate providers gathered information using a source-based approach (i.e., gleaning information from one source for all patients then moving to the next source). In contrast, residents (and 1 PA) gathered information using a patient perspective (i.e., complete all information seeking for a one patient and then repeating for additional patients). There was no difference in the number of patients documented (mean ⫽ 5.7/shift) or the average time spent gathering information per patient (mean ⫽ 590/540 sec, p ⫽ .69) between the patient and source based groups. Oral information from the overnight provider and nurse was highly utilized by both groups (mean ⫽ 192 sec, p ⫽ .45), but there was no generally favored resource (e.g., labs). Differences between groups include: exclusion of a resource by some residents (EMR) and a trend for increased interruptions during affiliate source based search (p ⫽ .082). Conclusions: Although affiliate and resident providers in our study were completing similar tasks in identical environments, different information seeking behaviors were observed. These differences indicate areas of potential divergence by type of provider in how patient mental models are developed and updated.


623

A FOUNDATION FOR PATIENT SAFETY: PHASE I IMPLEMENTATION OF INTERDISCIPLINARY BEDSIDE ROUNDS IN THE PEDIATRIC INTENSIVE CARE UNIT

RESOURCE UTILIZATION IN SEVERE PANDEMIC INFLUENZA INFECTION: THE COST OF ALI SECONDARY TO H1N1 COMPARED WITH OTHER ETIOLOGIES

Jodi Licata, Raj Aneja, Children’s Hospital of Pittsburgh of UPMC, Tracy Pasek, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Christyne Kyper, Emily Miller, Todd Spencer, Marcie Tharp, Michael Scott, Melinda Fiedor-Hamiliton, Children’s Hospital of Pittsburgh of UPMC

Jonathan Wiesen, Cleveland Clinic Foundation, John Komara, Cleveland Clinic, Herbert Wiedemann, The Cleveland Clinic Foundation, Jorge Guzman, Cleveland Clinic

Introduction: Interdisciplinary teamwork is crucial to the care of critically ill children. Core competencies put forth by the IOM support the delivery of patient-centered care for interdisciplinary teams 1. AACN aligns standards for healthy work environments with these competencies thereby committing to standards that include 1) skilled communication; 2) true collaboration and 3) effective decision making 2. The current rounding process is exclusive to physicians presenting patients. A new process 1) facilitates consistent and structured time for participation by nurses; 2) promotes nurses’ skilled communication and true collaboration and 3) ensures shared decision making among patients, families, and the critical care team. Hypothesis: Interdisciplinary rounds improve patient safety, foster a healthy work environment, and support patient and family-centered care. Methods: The setting is a 36-bed PICU at Children’s Hospital of Pittsburgh. An advanced practice nurse led a core team of professional staff nurses, nurse practitioners, physicians in the design of a new rounding process. A reference tool was developed to lend structure to and guide the presentation of patients. Rounds were observed by the core team members pre- and post- implementation of the new design. Data were collected specific to the nurse 1) actively participating; 2) describing significant overnight events and 3) identifying physician order disparities. Results: Post-implementation of a new rounds design demonstrated a 19% increase in nurse participation. There was a 57% increase in the description of significant overnight events by nurses and the number of nurses who identified physician order disparities increased by 26%. Conclusions: The interdisciplinary rounds design is an appropriate venue for increased communication among providers. As a result of this new process, nurses are empowered to impact collaboration and decision-making. This study was limited by a small sample. Phase 2 may include the analysis of significant overnight event reporting for patient and family-centered care themes. References: 1. www.aacn.org. Retrieved August 30, 2011; 2. http:// www.iom.edu/Reports/2003/Health-Professions-Education-A-Bridge-toQuality.aspx. Retrieved August 30, 2011

Introduction: Pandemic 2009 H1N1 influenza has been characterized by respiratory complications including acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) and associated with high mortality. Hypothesis: We hypothesize that ALI/ARDS secondary to pandemic influenza is associated with increased resource utilization and higher hospital charges as compared to ALI/ARDS from other etiologies. Methods: A retrospective chart review including all patients admitted to the MICU with ALI/ARDS and confirmed influenza A infection (Group I), and ALI/ ARDS from any other etiology (Group II) from September 2009 to March 2010. Results: Forty five patients were included in the study, 23 in Group I (Influenza) and 22 in Group II (other etiologies). Group II had higher APACHE III scores (89 ⫾ 32 vs. 68 ⫾ 23, P ⫽ 0.01). More patients in Group I required rescue therapies on Day 1 of mechanical ventilation (4 vs. 0, P ⫽ 0.108), however overall rescue therapies were similar (7 and 5 patients, respectively). Mechanical ventilation duration and ICU LOS were comparable (22 ⫾ 17 vs. 19 ⫾ 15, and 21 ⫾ 17 vs. 24 ⫾ 16 days for Groups I and II, P ⫽ NS). Hospital mortality was higher in Group II (77 vs. 39%, P ⫽ 0.016). Significant charge differences between the two groups included more blood products utilized and higher pharmacy costs per patient in the ICU in Group II (21 ⫾ 25 vs. 5 ⫾ 6, and 54 ⫾ 74 vs. 29 ⫾ 25, p⬍0.05, cost reported in thousands of US dollars). Group II had larger absolute ICU charges per patient for the following categories: room and board (81 ⫾ 62 vs. 71 ⫾ 53), radiology (17 ⫾ 15 vs. 10 ⫾ 9), laboratory services (74 ⫾ 55 vs. 63 ⫾ 50), miscellaneous (50 ⫾ 36 vs. 35 ⫾ 26), and overall charge (350 ⫾ 270 vs. 260 ⫾ 200). Respiratory charges were similar (31 ⫾ 22 and 36 ⫾ 28, respectively). Conclusions: ALI/ARDS secondary to pandemic influenza infection tended to have lower hospital charges than ALI/ARDS from other etiologies, which is likely a reflection of the higher prevalence of underlying comorbid medical conditions in Group II, such as malignancy, immunosuppression and cirrhosis, which require expensive medications, predispose to anemia, and tend to have a prolonged clinical course with poor outcomes.

624 TEMPORAL MEASUREMENT OF DOPPLER ULTRASOUNDDERIVED CARDIAC PERFORMANCE INDICIES IN INFANTS AND CHILDREN PRESENTING WITH SEPSIS AND SEPTIC SHOCK Matthew Musick, Baylor College of Medicine/Texas Children’s Hospital, Eric Williams, Baylor College of Medicine/Texas Childrens Hospital Introduction: Despite advances in pharmacotherapy, sepsis and septic shock continue to have significant morbidity and mortality in infants and children. The ongoing success or failure of resuscitation is based on interpretation of routine vital signs as well as physical exam findings. There is inherent variability in the interpretation of these findings. More quantitative indices, such as cardiac output measurements via PA catheter or central venous cooximetry are invasive procedures and are routinely not available, nor justifiable, in the routine pediatric resuscitation. Hypothesis: A prospective descriptive study could delineate the physiologic features of severe sepsis and septic shock in infants and children using noninvasive measurements of cardiac performance indices. Methods: This study was approved by the Baylor College of Medicine Institutional Review Board. After informed consent, patients diagnosised with sepsis or septic shock had measurement of cardiac performance indices using a doppler ultrasound device (USCOM). Parameters are automatically calculated from the flow-time signal. Data analyzed included the following: HR, MAP, CI, SVRI, stroke volume index (SVI), Stroke Work, Potential energy to kinetic energy ratio (PE/KE), and the Smith-Madigan Inotropy Index (SMII). Normality was confirmed by the Anderson-Darling method with 0.05 significance. Results are presented as mean percent change from baseline with 95% CI. For clinical equipoise, the treating clinician was blinded to the data. Results: To date 11 patients have been enrolled without any observed mortality. HR decreased by 4.9% (-15.2, 5.3); MAP increased by 15%* (2.5, 27.4); CI increased by 1.3% (-8.3, 10.9); SVRI increased by 24% (-0.2, 48); SVI increased by 7.5% (-2.8, 17.8); SW increased by 22.4%* (9.6, 35.2); PE/KE ratio increased by 40.5% (-15, 96.1); SMII increased by 15% (-7.1, 37.1). Conclusions: The clinical course of all patients improved over time. We observed increases in MAP, SVRI, SW, PE/KE ratio, and SMII over time. This noninvasive technology can provide useful real-time data on cardiac performance. With further data collection we hope to deliniate those cardiac indicies that will help target pediatric resuscitation.


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626

POST EXTUBATION UPPER AIRWAY OBSTRUCTION: RISK FACTORS IN CHILDREN

EFFECT OF BODY SIZE DESCRIPTORS ON INITIAL TREATMENT RESPONSE AND 30 DAY MORTALITY IN PATIENTS WITH GRAM-NEGATIVE INFECTIONS

Joao Fernando Almeida, Milena Nascimento, Marcela Alith, Naiana Val␮o, Cristiane do Prado, Adalberto Stape, Eduardo Troster, Hospital Israelita Albert Einstein Introduction: The prevalence of Upper Airway Obstruction(UAO)after extubation in children ranges between 1,6 and 45%. The presence of post-extubation UAO in children may prolong length of stay in the Pediatric Intensive Care Unit(PICU),particularly if re-intubation is necessary. Hypothesis: The present study was conducted to identify the predictors of UAO after extubation in children admitted in a PICU of a Private Hospital, submitted to mechanical ventilation. Methods: Prospective analysis of all the intubated patients with age less than 18 years submitted to mechanical ventilatory support from January 2008 to April 2011. UAO was defined as the presence of stridor in 24 hours after extubation.The relevant factors for UAO collected were:age,weight,size and type of airway tube(no cuff, de-inflated cuff or inflated cuff)and duration of mechanical ventilation.To evaluate the association between different explicative variables and outcome, a multivariate logistic regression was realized(Chi-Square Tests and Levene’s Test for Equality of Variances)and the results were expressed as Odds Ratio(OR).Statistical significance was defined as p valueⱕ0,05. Results: A hundred and thirty six patients with age between 3 days and 17 years were enrolled in the study. The mean duration of mechanical ventilation was 73,5hours. Fifty six patients(41,2%) presented with UAO after extubation. The multivariate analysis identified one risk factor for UAO after extubation:duration of mechanical ventilatory support ⱖ24 hours(OR: 1,48;95%C.I. 1,14 –16,91;p ⫽ 0,03).The risk increases if the duration of mechanical ventilation is ⱖ72 hours(OR: 2,15; 95%C.I.2,27–32,35;p ⫽ 0,001). Conclusions: We concluded that the main risk factor for UAO after extubation in our population was duration of mechanical ventilation greater than 24 hours. The risk increases if the durantion of mechanical ventilation is greater than 72 hours. It’s important to emphasize that the presence of cuffed endotracheal tube was not related with increased risk for UAO in children, reinforcing the American Heart Association 2010 guidelines for PALS that suggest the use of cuffed endotracheal tube in children with severe respiratory distress.

Meghan Jeffres, Sean Barclay, Mark Decerbo, Roseman University of Health Sciences, Peter Golenia, Boston Medical Center Introduction: Extremes in body mass index (BMI) have been associated with poor outcomes in infected patients, however alternative body size descriptors (total body weight (TBW), body surface area (BSA), lean body weight (LBW)) have not been investigated to identify their predictive value. Hypothesis: It is hypothesized body size descriptors will be increased in patients with Gram-negative infections experiencing initial treatment failure and 30 day mortality. Methods: A retrospective analysis was employed to identify patients with sterile site Gram-negative infections receiving ⱖ120 hours of appropriate therapy at an academic county hospital between January 2005 and January 2010. Patients were excluded for a delay in therapy ⬎24 hours from time of culture collection or a creatinine clearance ⬍60 ml/min during antibiotic therapy. Initial treatment response (complete, partial or failure) was evaluated on day 5 of antibiotic therapy. Results: A total of 234 patients were included in the analysis. 38 (16.2%) experienced initial treatment failure. Differences in baseline characteristics and process of care variables between patients with complete or partial response vs treatment failure were APACHE II scores (11.4 vs 14.9, p⬍0.001), intensive care unit stay (60.7% vs. 86.8%, p ⫽ 0.001), and mechanical ventilation (34.2% vs 76.3%, p⬍0.001). Significant differences in body size descriptors between patients with complete response and those failing to respond were total body weight (77.1 vs 88.4 kg, p ⫽ 0.025), BMI (26.5 vs 29.9 kg/m2, p ⫽ 0.038), BSA (1.9 vs 2.0 m2, p ⫽ 0.043), and LBW2005 (53.9 vs 59.5 kg, p ⫽ 0.029). TBW was statistically higher in non-survivors (79.3 vs 96.2 kg, p ⫽ 0.014). Logistic regression identified TBW, APACHE II score and mechanical ventilation as predictors for both initial treatment failure and 30 day mortality. Conclusions: Increased TBW was associated with initial treatment failure and 30 day mortality in patients with Gram-negative infections. This discrepancy in treatment outcomes warrants further investigation into potential causes including pharmacokinetic and pharmacodynamic changes and or presence of a sick patient bias from higher total body weight.

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628

TASKS ANALYSIS OF RESIDENTS AND FELLOWS PARTICIPATING IN ICU MORNING ROUNDS

ANALYSIS OF EMERGENT IN-HOSPITAL TRANSFERS TO THE INTENSIVE CARE UNIT

Yue Dong, Ramez Smairat, Jyothsna Giri, Mayo Clinic, John Litell, Mayo Clinic (CCM), Ashish Gupta, Minnesota State University Moorhead, Vitaly Herasevich, Felicity Enders, Mayo Clinic, Ognjen Gajic, Mayo Graduate School of Medicine(Rochester), Brian Pickering, Mayo Clinic (CCM)

Deborah Lee-Ekblad, Paul Lange, Borgess Medical Center, William Selde, Kalamazoo Center for Medical Studies, Sue Hanna, William Nichols, Borgess Medical Center

Introduction: Multi-disciplinary intensive care unit (ICU) rounds are an important part of patient care and education activities in academic medical centers. Residents and fellows participate in rounds with other providers through: collection, presentation and exchange of patient information; discussion and formulation of treatment goals and; interaction with family and patients. The time sensitive nature of critical illness and the complexity of the ICU environment make rounds in this environment more prone to medical error. Hypothesis: Multi-tasking during morning rounds is common for residents and fellows of the ICU multidisciplinary team. Methods: This was a time-motion study conducted in both medical and a surgical ICU. Using a validated instrument, trained observers conducted structured field observation of residents, fellow during morning rounds. Pre-defined task (data gathering, presentation, discussion, patient contact, passive involvement in rounds and tasks which resulted from interruptions) time were quantified using an online timer for each provider role. Results: A total of 117.6 hours of tasks performed by 32 residents and 32 fellows were recorded during 32 morning rounds. The median (IQR) patient encounter time (minutes) in ICUs is 9 (5.6 –14.4). For residents and fellows, the median (IQR) tasks time (minutes) spent on each patient are: data gathering 1.8 (0.7–3.3) and 3.7 (2.0 –7.8); presentation 3.0 (1.9 – 4.7) and 1.9 (0.8 – 6.9); discussion 3.3(1.2– 6.8) and 4.1(1.7– 8.8); patient contact 3.5(0.8 – 8.1) and 5.0 (0.8 –12.3); passive involvement 3.7 (1.5– 6.0) and 3.9(2.2–7.2); interruptions 1.0 (0.5–2.3) and 2.2 (0.5–5.6). Conclusions: Provider’s time in ICU rounds at a single center varied between different tasks and providers. Residents and fellows spent a significant amount of time multi-tasking during the rounds, a practice that maybe associated with medical errors and threatened to patient safety. With the recently ACGME resident duty hour restriction, system approaches (new EMR interface and workflow re-redesign) need to be explored to reduce the complexity of the round tasks and improve the round efficiency for patient care and education.


Introduction: Emergent transfers to the Intensive Care Unit (ICU) often result from preventable errors in care. The purpose of this study is to classify the causes of such transfers, tabulate the frequency of preventable errors and determine if the ICU transfer could have been prevented. Hypothesis: While spontaneous worsening of a patient’s condition may require emergent transfer to the ICU, triage errors, errors in assessment or treatment after admission contribute to a significant portion of emergent ICU transfers. We hypothesize 1)emergent transfers to the ICU are associated with higher mortality; 2)many emergent ICU transfers result from triage errors from the emergency department or errors in assessment or treatment after the patient has been admitted to an area of lower intensity care; and 3)many patients meet clinical triggers for physiologic deterioration within 12 hours preceding transfer. Methods: A retrospective cohort study of 245 emergent transfers to the ICU at Borgess Health was conducted. Adult patients who were emergently transferred to the ICU after a rapid response (RR) was called from July 1, 2010 to June 30, 2011 were included. Patients were excluded if they were transferred to the ICU without a RR call or were admitted following a cardiac arrest. Reason for transfer were classified according to a taxonomy by the research team. Results: 245 patients had emergent transfers to the ICU. The diagnoses on transfer were respiratory distress/failure, sepsis, and heart failure. The average Acute Physiological Score on Day 1 in the ICU was 48.7. The average APACHE IV score was 50.5. 44% were admitted to the general floor less than 24 prior to a RR call. The patients with emergent transfers had a mortality rate of 26.9% compared to the mortality rate of all ICU patients of 9.6%. 16% of the emergent transfers were readmissions. The average length of stay for readmissions was 20.2 days. Conclusions: Patients being transferred emergently to the ICU have a 3 fold higher mortality rate and a high severity of illnesss. A significant percentage of patients requiring emergent transfers to the ICU were admitted less than 24 hours. Understanding the reasons for transfer and preventable errors is essential.

629

630

WHAT IS THE RISK OF RADIATION EXPOSURE IN THE PICU

EVALUATING THE ROLE FOR THE OPTICAL DENSITY IN THE DIAGNOSIS OF HEPARIN INDUCED THROMBOCYTOPENIA FOLLOWING CARDIAC SURGERY

Christopher Heard, Syed Amin, Women & Children’s Hospital of Buffalo, Vaseem Iqbal, WCHOB, Tara Ciesla, Women & Children’s Hospital of Buffalo Introduction: Radiation exposure from medical imaging may be responsible for 1–3% of cancers worldwide. This has resulted in recommendations by the American College of Radiology that hospitals should monitor radiation exposure. Children in the PICU often receive daily X-rays as well as the significantly higher dose radiation of a CT scan. Any form of radiation exposure can increase the risk of malignancy. The younger the child, the greater the risk. Hypothesis: The aim of this study was to evaluate the radiation exposure of children admitted to the PICU and estimate the increased risk of malignancy that may be attributable to this radiation exposure as compared to the child’s non ICU X-ray radiation exposure. Methods: After IRB approval, a cohort of PICU patients admitted during 2006 were studied. To allow PRE and POST ICU XR exposure estimation, from the PACS (Picture Archiving and Communication System– digitally stored X-ray images, operational since 2004) only children under 2 years of age were included. All X-rays from each child in the PACS until June 2010 were reviewed. The cumulative radiation risk was calculated for each period. This was age and gender compensated. All risks were based upon standardized radiation doses used for different radiological investigations. Results: During this time period, the radiation exposure for 307 children admitted to the PICU were calculated (38% were female). The average age (SD) of the patients was 0.6 years (⫾ 0.5) with a total of 514 radiographic investigations performed. The median radiation exposure (2.0 mSv) and increased risk (0.4%) of malignancy was higher for the PICU time than PRE (0.2 mSv, 0.004%) and POST (0.5 mSv, 001%) PICU. Half of the plain X-Rays and a third CT scans occurred during their PICU stay. Despite the limited time spent in the PICU (0.5% reviewed child’s life). The ratio of exposure and risk of malignancy was about 100 times for a PICU day compared to a non PICU day. Conclusions: Unsurprisingly there were a large number of radiographic investigations performed in the PICU. Even though the estimated increased risk of malignancy was small in most cases, the time spent in the PICU contributed significantly to this.

Chee Chan, Paul Corso, Xiumei Sun, Peter Hill, Andrew Shorr, Washington Hospital Center Introduction: Cardiac surgery patients are often critically ill and face an increased risk for Heparin-Induced Thrombocytopenia (HIT). Thrombocytopenia is common following cardiac surgery and often these patients develop clinically irrelevant HIT antibodies. In addition, the low sensitivity and specificity of the enzyme immune assay (EIA) contributes to the challenge of diagnosis HIT following cardiac surgery. Hypothesis: Changing the threshold optical density (OD) that defines a positive EIA from 0.4 to 1.0 would improve the test’s accuracy. Methods: We retrospectively identified all adult cardiac surgery patients who had a positive EIA (2004 –2010) and a confirmatory serotonin release assays (SRA). The ability of various OD thresholds to predict a positive SRA represented the primary endpoint. We assessed the accuracy of the OD by computing the area under the receiver operating characteristic (AUROC) curve and then compared the sensitivities and specificities of differing HIT EIA OD cut-points. We determined, via logistic regression, clinical variables independently associated with a positive SRA in the setting of an OD of ⬎0.4. From this we developed a risk score for predicting a positive SRA. Results: The cohort included 99 subjects (mean age: 67.3 years; 51.5% male); 35% had positive SRAs. An OD ⬎0.4 had moderate utility as a screening test for a positive SRA (AUROC: 0.68; 95% CI: 0.55– 0.80). Increasing the OD threshold did not improve the EIA’s screening ability (sensitivities: 65– 68%; specificities: 55– 65% with OD cut-point varying from 0.8 to 1.0). Variables independently associated with a positive SRA included female gender, no diabetes, and utilization of bypass. The clinical risk score was as follows: female-1, no diabetes-1, bypass-3. The prevalence of a positive SRA increased with increasing score (0% for score ⫽ 0 vs 62% for score ⫽ 5; p ⫽ 0.005). The AUROC for the risk score equaled 0.75 (95% CI: 0.63– 0.83). Conclusions: The OD measurement is a poor screening tool for a positive SRA following cardiac surgery. Altering the definition of a positive HIT EIA appears ineffective for improving HIT screening. A simple, clinical decision rule may help to excluding HIT if the OD is already know to be ⬎0.4.

631

632

THE SECULAR TREND OF THE INTENSIVE CARE UNIT PATIENTS WITH ACUTE PANCREATITIS IN TAIWAN, 2000 – 2009: A NATIONAL POPULATION-BASED STUDY

DOES PROCLACITONIN VALUE PREDICT BACTERIAL COINFECTION IN PICU PATIENTS WITH ACUTE BRONCHIOLITIS ?

Hsiu-Nien Shen, Chin-Li Lu, Chi Mei Medical Center, Chung-Yi Li, National Cheng Kung University

James Laham, University of Kentucky

Introduction: We aimed to describe the secular trends in characteristics, resource uses and outcomes of the intensive care unit (ICU) patients with acute pancreatitis (AP). Hypothesis: We hypothesized that outcomes of ICU patients with AP are improving in Taiwan. Methods: In this population-based cohort study, we retrospectively analyzed 12,033 ICU patients with first-attack AP from the Taiwan National Health Insurance Research Database between 2000 –2009. Severity criteria were defined according to a modified Atlanta classification scheme, including organ failure, gastrointestinal bleeding and local complications. Results: During the 10-year study period, the median age of the patients rose from 60 to 66 years; the proportion of men fell from 64.4% to 60.4%. About twothirds of the patients had comorbidities, but the figure decreased gradually, as was seen in most comorbid conditions except end-stage renal disease, for which the prevalence rose from 5.3% to 8.4%. The percentage of patients undergoing cholecystectomy, on average 11.8%, remained stable over the years. Although the incidence of gastrointestinal bleeding fell slightly and that of local complications changed little, the disease severity of the patients increased because of a rising incidence of organ failure, from 48.5% to 61.8%. Despite that, hospital mortality fell from 28.8% to 21.1%. The trend of life-supporting measures varied: it showed an increase in the use of total parenteral nutrition (from 18.0% to 20.0%) and hemodialysis (from 11.9% to 16.5%) and a decrease in the use of vasopressors (from 48.2% to 38.0%) and mechanical ventilation (from 53.6% to 51.8%). Although median lengths of stay remained similar, about 3 days in the ICU and 15 days in hospital, median hospital charges per patient rose by 41.6%, from $2,905 to $4,115 USD. Conclusions: This study shows a trend in improved survival in ICU patients with AP in recent years of Taiwan, which was however accompanied by a rising cost for treatment. Future studies are needed to identify factors associated with patient survival and medical costs.

Introduction: Bacterial co-infection occurs in up to 12.6 % of pediatric patients admitted with acute bronchiolitis.In the absence of evidenced based guidelines, physicians must weigh the risk of empiric antibiotic therapy and threat of bacterial resistance versus timely antibiotic therapy.A biomarker to predict bacterial co-infection at the time of admission would assist physicians in solving this common dilemma. Hypothesis: The use of a serum procalcitonin level, a biomarker that discriminates bacterial from viral infections, may assist physicians in determining presence of bacterial co-infection and need for empiric antibiotic therapy. Methods: A retrospective chart review was conducted in 19 patients with a primary diagnosis of acute bronchiolitis based on ICD-9 codes who also had documentation of procalcitonin, WBC, CXR, and bacterial culture results obtained at the time of admission. Results: Bacterial co-infection was present in 42% (8/19 patients). Diagnosis was made in 5 patients by either positive tracheal or urine cultures; and CXR findings in 3 other patients.There were no positive blood or CSF cultures. Procalcitonin (p ⫽ 0.002) and WBC (p ⫽ 0.025) were significantly associated with bacterial co-infection. A cutoff value for procalcitonin of 2.0 ng/ml. had a sensitivity ⫽ 0.75 and specificity ⫽ 0.90; the cutoff for WBC of ⬍9,300 had a sensitivity of 0.75 and specificity of 0.82. Of note, two of eight patients (25%) were found to have confirmed bacterial co-infection (heavy growth of single organism on tracheal aspirate) despite admission procalcitonin values of ⬍2.0 ng/ml. Conclusions: Bacterial co-infection in PICU patients admitted with acute bronchiolitis is common. Serum procalcitonin values may assist the physician in predicting bacterial co-infection and need for antibiotic therapy. If initial procalcitonin values are ⬍2.0 ng/ml., then, serial values are recommended.A larger, prospective study is planned to investigate further the results of this trial.



634

ADMITTING AND ACQUIRED THROMBOCYTOPENIA IN CRITICALLY ILL SURGICAL PATIENTS: RISK FACTORS AND OUTCOMES

MORBID OBESITY IN THE PEDIATRIC INTENSIVE CARE UNIT: MISSED OPPORTUNITIES

John Hwang, Kevin Dwyer, James Krinsley, Stamford Hospital Introduction: Thrombocytopenia (T) is associated with increased mortality (M) in surgical ICU patients but the relationship between severity of T and M has not been well described. Moreover, it is not known whether initial T (IT) and T acquired during ICU stay (AT) have different implications. Hypothesis: T is associated with increased M in SICU patients, and the relationship is doserelated. Methods: This is a retrospective analysis of prospectively collected data abstracted from the unit’s clinical database. Between 10/1/05 and 5/31/11 2327 surgical patients were admitted to the 16 bed mixed ICU of a university affiliated hospital. Demographics, lab data, APACHE IV predicted mortality % (APIV PM) and M were analyzed. T was stratified by nadir platelet count (P) count: T1 100 –149; T2 50 –99; T3 ⬍50. Multivariate analysis for mortality included APIV PM, ICU LOS and P. Observed:expected (O:E) M ratio ⫽ M/APIV PM. Results: Initial P ⬎149 100 –149 50 –99 ⬍50N 1890 326 98 13APIV PM 8.1 12.7 21.2 32.6 M 5.1 7.4 18.4 30.8O:E 0.63 0.58 0.87 0.94 Acquired TN 1601 212 63 14APIV PM 6.6 14.5 28.9 38.2 m 3.1 10.4 25.4 64.3O:E 0.47 0.71 0.88 1.68 Multivariate analysis demonstrated that IT was not independently associated with M. Multivariate analysis: AT and M OR (95% CI) pNo AT 0.43 (0.28 – 0.66) 0.0001AT1 1.76 (0.99 –3.13) 0.0552AT2 3.02 (1.27–7.21) 0.0126AT3 108.1 (11.0 –1062.2) 0.0001. Conclusions: In a large cohort of SICU patients initial T correlated with severity of illness but was not independently associated with increased risk of M. Absence of T throughout ICU stay was independently associated with decreased risk of M. Acquired T was independently associated with increased risk of M in a dose-related manner.

Joshua Jones, University of Mount Union, Michael Forbes, David Gothard, Ann-Marie Brown, Deborah Carpenter, Michael Bigham, Akron Children’s Hospital Introduction: Morbid obesity (MO) affects 15–20% of all children from 2–20 yrs old. While MO & its critical care implications have been discussed in the adult literature, very little appears in the pediatric literature. The need for accurate recognition and the targeted adjustments in care will optimize effective care for these patients. Hypothesis: We hypothesized that MO (as defined by (a) the CDC and (b) the World Health Organization (WHO)) is an unrecognized problem in the PICU population. Methods: PICU admissions from 12/07–12/10 were identified using the VPS clinical database (http://www.myvps.org), our local electronic nursing record & paper charts. Patient demographics & documentation by any licensed provider of “morbid obesity” were recorded & compared to the reference group (RG). Outcomes, initial (PIM2) & 1st day (PELOD)severity of illness were compared. Significance was defined as p⬍0.05. Data are presented as MO v RG. Results: Of 4904 cases, 2154 had complete data sets & 406 (18.8%) met CDC criteria for MO (RG, n ⫽ 1748 ). MO was documented in 3.97% of MO cases. The WHO criteria would have only identified 19.7% of the 406 MO patients. There was neither a difference between males/females (18.4% v 19.4%) nor among ethnic groups. School-aged (6 –12yo) patients had the highest rate of MO (25%) among all age groups while among diagnostic categories, the Oncology (23% MO) and Neurologic (22% MO) groups were the highest. PIM2 (1.62% v 1.37%) was comparable between both groups. PELOD, however, was lower in the MO group ( 5.68 v 7.00, p⬍0.001). Conclusions: We hypothesized that MO is an unrecognized problem among the PICU population and found less than 5% of all cases are clinically recognized. CDC criteria are more sensitive than the WHO. We speculate that in the PICU, MO identification is a low clinical priority. However, our review of the entire hospital stay suggests that both pediatric subspecialists and specialists failed to properly identify MO. With the evolution of the EMR, passive identification, automated alerts and management strategies should be incorporated into the electronic system.

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RESOURCE UTILIZATION IN PATIENTS WITH CANDIDEMIA TREATED WITH ECHINOCANDINS ONLY VS. SWITCH TO FLUCONAZOLE

ADVERSE EVENTS LEADING TO ICU TRANSFER FROM INPATIENT UNITS: INVESTIGATING TRENDS AND PREVENTABILITY

Paresh Chaudhari, Astellas Pharma US, Rolin Wade, Rebecca Campbell, Jing Yi, Cerner LifeSciences, Smita Kothari, Astellas Pharma US Inc, Brian Nathanson, OptiStatim, LLP, David Horn, David Horn, LLC

Alison Miles, Michael Spaeder, David Stockwell, Children’s National Medical Center

Introduction: Recommendations regarding initial treatment of candidemia include fluconazole or an echinocandin. Patterns of initial antifungal (AF) therapy (Rx) and switching to other agents are not well understood. This study evaluates inpatient length of stay (LOS) and costs in patients (pts) treated with an echinocandin only (echinocandin group) or initial echinocandin Rx switched to fluconazole (switch group). Hypothesis: We hypothesize that shorter LOS and lower costs will be associated with pts in the echinocandin-only group. Methods: A retrospective analysis of the Health Facts® electronic medical record database identified pts ⬎⫽ 18 years of age with a blood culture for Candida. Univariate inference tests, multivariate generalized linear models (GLM), and marginal effect (ME) analyses assessed differences between groups. Results: 405 candidemic pts were studied (249 echinocandin and 156 switch groups) from 48 hospitals. Mean age (61.5 vs 61.4 years), gender (56.6 vs 51.3 % male) and ethnicity (69.9 vs 70.5 % Caucasian) were similar (echinocandin vs switch groups, respectively). Echinocandin pts had more reported organ system dysfunctions (mean 1.69 vs 1.29, p⬍.001), specifically more respiratory (p⬍.001) and hematologic (p ⫽ .007) dysfunction. Unadjusted length of stay (LOS) and LOS after initiation of antifungal Rx (LOS-AF) were significantly longer in the switch group (mean 34.7 vs 26.5 and 21.1 vs 13.1 days, both p⬍.001). After adjustment for baseline characteristics and comorbidities, the switch group still had longer LOS-AF (ME ⫽ 6.4 day increase; 95% CI, 4.0 – 8.8) and more total days of antifungal Rx (TD-AF) (ME ⫽ 5.2 day increase; 95% CI, 3.9 – 6.5). The unadjusted mean total costs (TC) in 2010 dollars were greater in the switch group ($90,398) vs the echinocandin group ($79,508) (p ⫽ .114). The GLM model showed a marginal increase in TC of $9,215 (95% CI, $(-)8-$18,440) in the switch group. Conclusions: In a large multicenter database, pts switching to fluconazole from echinocandin Rx were associated with longer LOS-AF and TD-AF and tended to have higher TC compared to pts receiving echinocandin only. This study was supported by Astellas Pharma US.


Introduction: A portion of unplanned transfers to an ICU from inpatient units results from adverse events (AEs). We examined trends in AE-related ICU transfer to identify at-risk populations. Hypothesis: AEs (and their preventability) may be more common in some populations depending on diagnosis, time of day, and weekday vs. weekend. Methods: A retrospective observational study of ICU transfers from inpatient units during a 1-year period in a tertiary care children’s hospital. Transfers were identified via electronic health record and investigated to establish if an AE had occurred. Predefined AEs included ICU transfers in ⬍12 hours of admission to acute care, re-admissions to an ICU in ⬍24 hours of ICU discharge, and cardiopulmonary arrests on an acute care unit. We determined the preventability of the AEs and categorized them by type, diagnosis, time of day, and weekday vs. weekend to examine trends. Results: 533 ICU transfers occurred with 114 (21.4%) AEs; 27 (23.7%) were preventable. The majority were transfers in ⬍12 hours of admission (60.5%; 15.9% of these were preventable), cardiopulmonary arrests (16.7%; 15.8% preventable) and ICU re-admissions in ⬍24 hours (15.8%; 61.1% preventable). Reasons for transfer included respiratory distress (48.2%), sepsis (13.2%), and need for increased monitoring (9.6%). Among the 55 AEs related to respiratory distress, associated diagnoses were pneumonia (29.1%), status asthmaticus (21.8%), bronchiolitis (16.4%) and upper airway disease (12.7%). Night events accounted for 57% (65) of AE-related transfers with 25% deemed preventable. All 3 preventable cardiopulmonary arrests and all 5 preventable sepsis-related AEs occurred at night as did 73.3% of total sepsis-related AEs. The incidence of preventable AEs on weekends (29.4%) was higher than the overall incidence of preventable events. Conclusions: Understanding reasons for ICU transfers is crucial in order to recognize areas for improvement in care. Status asthmaticus, pneumonia, and bronchiolitis were the most common diagnoses involved in AE-related ICU transfer and may suggest areas for future research to improve assessment of likely clinical course. Nights and weekends were not significantly associated with an increase in AEs.

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COMMUNICATION DURING PEDIATRIC RAPID RESPONSE EVENTS: A SURVEY OF HEALTHCARE PROVIDERS

LAST PATIENTS FINISH LAST: END OF ROUND TIME COMPRESSION DURING CT ICU CLINICAL ROUNDS

Michael McCrory, Wake Forest University, Hanan Aboumatar, Elizabeth Hunt, Johns Hopkins

Thomas Kannampallil, UTHealth, Laura Jones, Emory University, Timothy Buchman, Emory University Hospital, Amy Franklin, University of Texas

Introduction: Rapid response teams have increasingly been used to improve access to personnel and expertise for decompensating patients. Hypothesis: We hypothesized that communication barriers may exist at Pediatric rapid response events, and that a structured method of communication may be of interest to providers involved. Methods: A survey was distributed in May 2011 to all Pediatric residents, Pediatric nurses, Pediatric intensive care (PICU) fellows, and Pediatric responder nurses (intensive care or shift coordinator) at a tertiary care children’s center. Multiple choice questions about communication at rapid response events and about a previously introduced hand-off mnemonic “ABCSBAR” were included, as well as a request for comments and suggestions for improvement. Results: The survey was returned by 76 residents, 56 floor nurses, 9 PICU fellows and 9 responder nurses. Communication was rated as “good,” “very good,” or “excellent” by 85/126 (67%) floor providers (residents and nurses) and 9/18 (50%) responders (PICU fellows and responder nurses), p ⫽ 0.15. The most frequently cited challenges included fractured room entry, inability to determine who was in charge or who could provide the most information about the patient, and general “chaos.” Excessive background or other nonurgent information was reported to delay communication of critical information “often” or “always” by 22/118 (19%) floor providers and 9/17 (53%) responders, p ⫽ 0.004. A structured method of hand-off was indicated to be potentially helpful by 38/53(72%) floor nurses and 8/8 (100%) responder nurses. Among those familiar with the mnemonic “ABC-SBAR,” 19/20 (95%) residents and 7/7 (100%) PICU fellows agreed that it should be used in rapid response hand-offs. Conclusions: Communication barriers are common among resuscitation teams in the context of a rapid response event, and perceptions of communication quality may vary between floor providers and responders. Improved delineation of roles and a structured hand-off that prioritizes critical information may optimize communication in a rapid response system.

Introduction: Time utilization and order of presentation during rounds in critical care are driven by a number of factors including patient acuity, length of stay, and physician preferences. While lesser time spent on discussion about a single patient can be attributed to any of these factors, a systematic change in the average time spent on a patient over the course of a round indicates a trend with significant clinical and organizational implications. Hypothesis: We hypothesized that the relative time utilization per patient does not change significantly across a clinical round. Methods: Clinical teams in a CT-ICU were observed during the morning rounds for twenty (20) non-consecutive days over a period of 1-month [Average patients/day ⫽ 6.4 (s.d ⫽ 1.98), max no. of patients ⫽ 9; Average time per round ⫽ 118 (s.d. ⫽ 37) min]. The team consisted of one attending physician, two affiliate providers, two nurses, and one medical student. The data were collected on all weekdays (Monday through Friday). During rounds, the time spent on discussion, review of labs and other activities were recorded using an iPad-based application. The observer entered time and activity details in a preformatted activity template. Once the data were organized according to the order of patients discussed, corresponding time utilizations were computed. Results: We found that time spent per patient decreased at the rate of approximately 54 seconds (linear fit, slope ⫽ -53.78, R2 ⫽ 0.83) per consecutive patient attended. When all the nine patients were considered, there was an average decrease approximately 8 minutes between the average time spent between the first (patient 1) and last patient (patient 9, when the CT ICU was full). There was also a significant difference between times spent on discussing the first four patients as compared to the last four (p⬍0.05). Conclusions: The relative time utilization per patient decreases linearly over the course of a clinical round with significant decrease for the patients seen last during the rounds. While preliminary, our results have significant implications for the design of appropriate protocols and mechanisms for improving rounding practices.

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EARLY ACUTE KIDNEY INJURY BASED ON SERUM CREATINE OR SERUM CYSTATIN C IN INTENSIVE CARE UNIT AFTER MAJOR TRAUMA

APPLICATION OF THE CLINICAL GLOBAL IMPRESSION SCALE (CGI) TO THE ASSESSMENT OF HYPONATREMIA SYMPTOMS

Farid Zand, Shiraz University of Medical Sciences, Golnar Sabetian Fard Jahromi, Faghihi Hospital, Ghasem Abbasi, Alireza Salehi, Shiraz University of Medical Sciences, Abbas Khosravi, Iranian Hospital of Dubai

Leah Kleinman, Elizabeth Merikle, United BioSource Corporation, Biff Palmer, University of Texas Southwestern Medical Center, Ann Dandurand, Lydia Dyett, Holly Krasa, Frank Czerwiec, Otsuka Pharmaceutical Development & Commercialization, Inc

Introduction: To compare the prognostic value of RIFLE criteria in diagnosis of acute kidney injury (AKI) when either serum creatinine or serum cystatin C is used for calculation of glumerolar filtration rate (GFR). Also abnormally high level of serum cystatin C was used to predict poor outcome. Hypothesis: Serum cystatin C based GFR calculation could be used to predict outcome of trauma patients admitted in ICU. Methods: Prospectively collected data from 300 post trauma victims admitted to a referral university affiliated hospital for more than 24hr during a 9-month period. Significant outcomes such as mortality, length of ICU and hospital stay and days under ventilator were also considered. Results: Incidence of AKIcr (RIFLE criteria defined according to serum creatinine) was 14.7% ; mortality rate 47.7% (odds ratio: 5.5) and significant correlation with peak of serum creatinine during ICU stay was found. Incidence of AKIcys (GFR calculated with serum cystatin C) was 7%, mortality rate 28.5% (odds ratio: 1.78). 23% of patients had serum cystatin C level 3 0.78 mg/L with mortality rate 39% (odds ratio: 5.8). There was significant positive correlation between serum cystatine C level in the first day and peak serum creatinine in ICU coarse. Conclusions: AKIcr and high level of serum cystatin C but not AKIcys were associated with higher mortality and higher serum creatinine levels during ICU admission.

Introduction: Symptoms of hyponatremia vary across patients in presentation, severity and attribution. Standardized assessment of hyponatremia symptoms would improve the identification and management of clinically significant hyponatremia in a hospital setting. Currently, no standardized assessment exists. Hypothesis: An approach to consistently identify and measure hyponatremia symptoms can be achieved. Methods: A Delphi Panel consensus method was employed with two rounds of semi-structured questionnaires targeting consensus (defined a priori as ⬎70% panelist agreement) regarding hyponatremia symptom measurement. Round 1 requested identification of clinically evident and relevant hyponatremia symptoms. Round 2 required evaluation of a set of commonly identified symptoms and assessment of severity using the CGI scale. Results: Eighteen US physicians experienced in hyponatremia management in a hospital setting participated. In Round 1, panelists reported an average of 5.8 symptoms. The most commonly identified symptoms were: confusion (76%), balance/gait issues (65%), nausea/vomiting (65%), headache (53%), lethargy (47%), fatigue (47%), seizure/coma (41%), and muscle cramps (24%). In Round 2, consensus (94%) was achieved for the main symptoms of hyponatremia (mental impairment, falls/balance/gait problems, nausea/vomiting, headache, lethargy/alertness, seizure/coma and muscle cramping), commonly employed methods for symptom assessment, and severity cut points of absent, mild, moderate and severe for individual symptoms similar to a CGI. Generally, consensus of overall hyponatremia severity for CGI ratings based on a defined symptoms set was achieved. Conclusions: The CGI is a reliable method to assess a constellation of hyponatremia symptoms of any severity, even when only a subset of symptoms are evident, providing the basis to further evaluate the use of a hyponatremia CGI instrument.


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PILOT STUDY OF THE PREVALENCE OF ADULTERANTS IN URINE SAMPLES FROM PATIENTS WITH POSITIVE URINE DRUG SCREEN FOR BENZOYLECGONINE

A PREVENTABLE HARM INDEX IS AN EFFECTIVE TOOL TO MEASURE PATIENT SAFETY EVENTS IN A PEDIATRIC CARDIOTHORACIC INTENSIVE CARE UNIT

Jennifer Hong, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Saralyn Williams, Sheila Dawling, Vanderbilt University Medical Center

Anthony Lee, Christopher McKee, Amy Biddle, Sheilah Harrison, Timothy Hoffman, Gina Marcum, Douglas Teske, Richard Brilli, Nationwide Children’s Hospital

Introduction: Cocaine is commonly abused, but exposure to other xenobiotics is a hazard associated with the use of illicit drugs. These contaminants are added to cocaine as a part of the “cutting” process. In 2009, an alert from the Department of Health and Human Services communicated that cocaine sold in the United States was being adulterated with levamisole. Levamisole use in humans has been associated with agranulocytosis and vasculitis. This study evaluates the prevalence of adulterants in urine drug screens (UDS) positive for benzoylecgonine (BEG, a cocaine metabolite). Methods: Urine samples positive for BEG on a UDS at Vanderbilt University Medical Center between January 1, 2009 and March 31st, 2010 were identified. These samples were re-examined via gas chromatography/ mass spectrometry (GCMS) for cocaine metabolites and contaminants (including levamisole). Drugs were salted out from basified urine into ethylacetate by vortex mixing with an internal standard solution. Full scan mass spectrometer data was collected and the compounds of interest were quantitated by selected ion monitoring comparison. Identification of compounds was made by full scan library matching software. Patient charts were reviewed for negative clinical outcomes that correlate with cocaine, its metabolites, or the adulterants. Descriptive statistics were used to relate the prevalence of detection of adulterants in the sample population. Results: The initial pilot study included 46 urine samples which were confirmed positive for BEG. Of the samples, 52% also tested positive for levamisole. Four patients had evidence of vasculitis, 3 of which were positive for levamisole. Four patients had evidence of tachydysarrythmia, 3 of which were positive for levamisole. Fifty-three percent of patients had a complete blood count performed, and 1 showed had evidence of neutropenia with an ANC count of 680cells/microlitre. Conclusions: Based on the pilot study, 52% of the BEG positive urine samples contained levamisole. The reason for the contamination is unclear, but the exposure to levamisole and other adulterants in the urine of patients who have recently used cocaine could be clinically relevant and of public health significance.

643 NORMALIZATION OF LACTATE WITHIN 8 HOURS OR >20% CLEARANCE IN INITIAL 2 HOURS CORRELATES WITH OUTCOMES FROM TRAUMATIC HEMORRHAGIC SHOCK Karim Brohi, Royal London Hospital, Howard Levy, Sangart, Ken Boffard, Charlotte Maxeke Johannesburg Hospital, Bruno Riou, Hopital Pitie Salpetriere, Peter Kiepert, Dirk Zielske, Yun Hardiman, Sangart Introduction: We sought to study the correlation of changes in lactate with outcome from trauma. Hypothesis: Duration of oxygen debt after trauma is associated with outcome. Methods: 51 patients with lactate ⱖ5 mmol/L from hemorrhagic shock were enrolled within 2H of hospitalization and 4H of trauma in an oxygen therapeutic agent study. Patients received standard care including RBC. Lactate at baseline (BL), 0H (end infusion), 1, 2, 3, 4, 8H and clinical outcome to D28 were recorded. Results: All patients were analyzed regardless of randomization. Median values and duration in ICU, on ventilator and in hospital for survivors are listed. Characteristics were similar at BL: Age 35, ISS 25, total fluids 6 L, RBC 5 units by 12H, 47% blunt trauma. There were 11 deaths, 4 within 8H.Median (range) lactate at BL 6.9 (5.0 –19.0) mmol/L, Base excess (BE) -8.7 (-2.6 to -24.5), had no correlation to any outcome when comparing ⬎ vs. ⱕmedian for either lactate or BE.Outcome when lactate normalized (ⱕ2.2 mmol/L) in 20 patients within 8H vs. 31 where it did not: mortality 5% vs. 32% (p ⫽ 0.034), composite of time (days) to complete organ failure resolution by D14 (unresolved ⫽ 15 death ⫽ 16) CTCOFR: 1.5 vs. 15 (p ⫽ 0.009), ventilator-free days 27 vs. 12 (p ⫽ 0.007), days on ventilator 1 vs. 3 (p ⫽ 0.131), ICU-free days 24.5 vs. 8 (p ⫽ 0.012), ICU days 2 vs. 9 (NS), hospital-free days 11.5 vs. 0 (p ⫽ 0.023), hospital days 16 vs. 28 (p ⫽ 0.143), days to discharge 17.5 vs. 28 (p ⫽ 0.027), proportion discharged before D28 and alive at D28 55% vs. 32% (p ⫽ 0.148).Outcome when lactate decreased ⱖ20% from 0 to 2H for 20 patients were compared with 26 where it did not: mortality 10% vs. 19% (NS), CTCOFR: 0.5 vs. 7 (p ⫽ 0.016), ventilator-free days 28 vs. 21 (p ⫽ 0.015), days on ventilator 0 vs. 6 (p ⫽ 0.016), ICU-free days 27 vs. 16.5 (p ⫽ 0.071), ICU days 1 vs. 8 (p ⫽ 0.071), hospital-free days 13 vs. 0 (p ⫽ 0.079), hospital days 13 vs. 28 (p ⫽ 0.115), days to discharge 16 vs. 28 (p ⫽ 0.093), proportion discharged before D28 and alive at D28 55% vs. 38% (NS). Conclusions: There is strong correlation of better outcomes when lactate normalized within 8H or when lactate decreased ⱖ20% in 2H.TRA204 was funded by Sangart Inc., San Diego, CA.


Introduction: As part of a hospital-wide journey to improve safety and reduce patient harm, a Preventable Harm Index (PHI) was developed (1). Preventable Harm (PH) events occur in the cardiothoracic intensive care unit (CTICU) which may adversely affect morbidity and mortality. Eliminating PH therefore will likely improve patient outcomes. The purpose of this study is to describe the use of a CTICU PHI. Hypothesis: A CTICU PHI is an effective patient-centered metric to evaluate the success of interventions implemented to decrease CTICU PH when used as part of a hospital patient safety program. Methods: A prospective, observational study of CTICU PH events was performed. The CTICU PHI is a summation of serious PH events: Hospital-Acquired Infections (HAI), Adverse Drug Events (ADE) (severity E-I), Pressure Ulcers, Serious Falls, and Serious Safety Events. Teams consisting of physician and nurse champions and quality improvement experts implemented changes intended to eliminate PH events for each PHI metric. PHI was reported monthly to hospital staff and leadership as a gauge of the effectiveness of interventions. Results: 455 CTICU patients (2898 patient days) were admitted from Jan to Dec 2010 with 53 (11.6%) experiencing PH (1 event every 54.7 patient days). The most common events were Pressure Ulcers (33/53, 62.3%), ADE (14/53, 26.4%), and HAI (6/53, 11.3%). Central line-associated bloodstream infections accounted for all 6 HAI. With quality improvement interventions, the number of events was 18 during 2Q 2010 and decreased to 8 events by 4Q 2010. That decrease correlated with a decrease in the hospital-wide PHI. Conclusions: Serious PH is common in a pediatric CTICU. A CTICU PHI is a simple metric, easily understood by staff, which focuses upon numbers of events of patient harm and not rates of harm. As such the PHI can effectively energize and motivate staff to eliminate serious PH and improve patient safety. Reports. Reference: (1) Brilli RJ, McClead R, Davis T, et al. The Preventable Harm Index: an Effective Motivator to Facilitate the Drive to Zero. J Pediatr 2010;157(4):681– 683.


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TRANSPORT TIME-OUT: IMPROVING SAFETY IN CRITICALLY ILL PATIENT TRANSPORT

ACUTE LUNG INJURY IN THE EMERGENCY DEPARTMENT

Lindsay Fairfax, Courtney Kaylor, Toan Huynh, Carolinas Medical Center Introduction: Intrafacility transport of critically ill patients is associated with adverse events. Key components to promote safety include assurance of transport necessity and provision of adequate personnel, resources and equipment. This requires a formalized process with consistent structure and interdisciplinary communication. Hypothesis: We hypothesized that implementation of a safety verification process (SVP) will reduce the incidence of adverse events associated with intrafacility transport of critically ill patients. Methods: A multi-professional team developed and implemented a SVP in our 29-bed ICU over an 11-week period. The SVP consisted of nursing and respiratory staff assessing transport necessity, patient condition, required personnel and equipment. Transports were categorized as green, yellow or red based on increasing order of concern. A minimum of two staff members and emergency medications were required for each transport. Ventilated patients had in-line CO2 detection and portable suction. Documents and data included category of transports, compliance and number of transports aborted. Results: Sixty-eight SVP forms were completed prior to transport with 39 green, 18 yellow and 11 red. Transport concerns were present in 29% of cases; all were communicated to physician resulting in 3 procedures changed to bedside and 1 aborted. Adequate staffing was present in 91%, with more staff than required accompanying 19% of transports. A physician or advanced practitioner accompanied 72% of red transports. No adverse events were reported. Conclusions: Our multi-professional initiative for intrafacility transport led to more effective staff communication, improved triage and sufficient resources to ensure transport safety. Multi-professional collaboration was paramount in achieving a culture of safety in our ICU.

Munish Goyal, Georgetown University Hospital/Washington Hospital Center, Daniel Houseman, Nicholas Johnson, Jason Christie, Mark Mikkelsen, David Gaieski, Hospital of the University of Pennsylvania Introduction: Acute Lung Injury (ALI) affects an estimated 190,000 persons per year in US Intensive Care Units, but little is known about its prevalence in the Emergency Department (ED). We aim to describe its prevalence in mechanically ventilated patients in the ED. Hypothesis: We hypothesize that the prevalence of ALI in the ED will be low. Methods: We conducted a retrospective cohort study of admitted non-trauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. We identified the use of mechanical ventilation in the ED in two phases. First, we screened all ED patients for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from 1/1/03–12/31/06. Second, we reviewed each patient record to verify the use of mechanical ventilation. We defined ALI in accordance with the American-European Consensus Conference criteria as 1) hypoxemia defined as partial pressure of arterial oxygen to fractional inspired oxygen concentration ⬍300 mmHg on all vented arterial blood gases in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, 3) and the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Results: 489 patients received mechanical ventilation in the ED and were subsequently admitted. Of these, 209 (43%) patients did not have an arterial blood gas measured in the ED. 89 (18%) met hypoxemia criteria for ALI. Of these, 26 had evidence of left atrial hypertension and 36 did not have chest radiograph findings consistent with ALI. The remaining 27/489 (6%) met criteria for ALI. Interobserver agreement was good for determination of ALI (kappa ⫽ 0.71). Conclusions: The prevalence of ALI was 6% in patients receiving mechanical ventilation in the ED. Arterial blood gas measures were not obtained in 43% of mechanically ventilated patients; it is unclear how this missing data affects the prevalence of ALI. Further study is required to determine which types of patients present to the ED with ALI and the extent to which lung protective ventilation is used in the ED.

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THE COSTS OF UNHEALTHY LIVING: THE IMPACT OF TOBACCO AND ALCOHOL INTAKE ON MORTALITY DUE TO RESPIRATORY FAILURE IN THE ICU

HUMAN RHINOVIRUS LOWER RESPIRATORY TRACT INFECTION: MORBIDITY AND MORTALITY IN THE ICU SETTING


Russell Miller, Intermountain Medical Center, University of Utah, Adam De Havenon, University of Utah

Introduction: Excessive tobacco and alcohol use are commonly regarded as risk factors for a variety of acute and chronic conditions. Hypothesis: We wanted to discover to what extent these lifestyle factors associated with unhealthy living affect short-term and long-term mortality after ICU admittance for mono-organ respiratory failure. Methods: A retrospective cohort study of 287 consecutive patients requiring mechanical ventilation was undertaken. Mono-organ respiratory failures included pneumonia, exacerbation of chronic obstructive lung disease, and exhaustion by other causes such as asthma, cerebrovascular insult, or non-cardiac, non-pulmonary surgery. Respiratory failure associated with cardiac insufficiency, multiple organ failure or trauma were excluded. Current and previous daily and/or excessive tobacco and alcohol intake was recorded for each patient. Patients were followed for at least one year, and reliable mortality statistics were recorded from available databases. Results: 69% were tobacco users, and 44% had daily intakes of alcohol. Within each subgroup of tobacco or alcohol intake, 15-day, 1-month, and 1-year all-cause mortality was (in brackets): ⫹tobacco/⫹alcohol (35%, 40%, 50%); ⫹tobacco/-alcohol (31%, 37%, 53%); -tobacco/⫹alcohol (36%, 36%, 64%); -tobacco/-alcohol (teetotallers; 29%, 41%, 47%). No subgroup was statistically different from the teetotaller group at any point of observation. Conclusions: Although a large proportion of patients admitted to the ICU for mechanical ventilation suffer from chronic obstructive lung disease or weaknesses associated with long-term excessive use of tobacco or alcohol, this aspect of unhealthy living does not in itself seem to influence short-term mortality by respiratory failure or long-term all-cause mortality compared to teetotallers admitted for mechanical ventilation. As a consequence, we suggest that tobacco or alcohol abuse should not be part of end-of-life or ICU refusal decisions in this particular group of patients.

Introduction: Historically, human rhinovirus (HRV) has been considered a benign virus that causes self-limited upper respiratory tract infections. The development of diagnostic tools for detection of viral pathogens has made it possible to reliably detect HRV and a growing body of research, primarily in the pediatric population, has identified HRV as a possible etiology of lower respiratory tract infection (LRTI). Hypothesis: We sought to determine the prevalence of HRV in the ICU and to evaluate the frequency of HRV LRTI in this cohort. Methods: We examined medical records of 549 patients admitted to 13 ICUs in our hospital system from January 2007 to May 2010 with at least one positive test for a respiratory virus within 7 days of ICU admission. We defined our study population as those patients with a positive HRV test result from the lower respiratory tract (i.e., tracheal aspirate in a ventilated patient or bronchoscopic sample). Results: Of 549 patients, 122 (22%) tested positive for HRV. 82 (15%) were positive from the upper respiratory tract and 40 (7%) were from the lower respiratory tract. The latter group was deemed to have HRV LRTI. Of the 40 patients with HRV LRTI, 21 (53%) were male, the average (⫾SD) age was 52.4 (18.1), and 27 patients (68%) were mechanically ventilated for a median (interquartile range, IQR) of 3.9 (0.0 –5.5) days. The median lengths of hospital and ICU stay were 12.2 (6.8 –17.4) and 8.0 (3.1–9.1) days, respectively. 90-day mortality was 23% and the median APACHE II score was 28.4 (20.0 –36.0). 27 patients (68%) met criteria for ARDS with a median (IQR) PaO2/FiO2 of 77.7 (69.9 –104.4) mm Hg. 14 patients were immunosuppressed, 3 had a second positive viral respiratory test, 23 had concomitant bacterial respiratory infection, and 3 had non-respiratory bacterial infection. Conclusions: HRV is associated with severe LRTIs in critically ill adults and with significant morbidity and mortality. While these findings have been described in pediatric populations, HRV remains a comparatively understudied pathogen in adults. Additional study of viral pathogens in adult ICU patients with LRTIs is warranted to further examine this association.


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INCIDENCE OF PERIPARTUM CARDIOMYOPATHY IN CANADA

DESCRIPTIVE CHARACTERISTICS OF SEVERITY OF ILLNESS OF ICU PATIENTS DISCHARGED TO AND SUBSEQUENTLY READMITTED FROM LONG TERM ACUTE CARE

Kazuyoshi Aoyama, University of Toronto Introduction: A previous population-based study in the United States has estimated the incidence of peripartum cardiomyopathy (PC) at 1 case/3,189 live births and mortality rates of 1.36% to 2.05%. Hypothesis: The purpose of current study was to produce the first Canadian population-based study of the incidence and mortality for PC. Methods: Discharge Abstract Database from the Canadian Institute for Health Information was used. The database includes patient demographic information, patient’s disease and intervention, which is described in the International Classification of Diseases–10 (ICD-10) and the Canadian Classification of Health Interventions (CCI) codes, in-hospital course, and outcome. Discharge information was available for 330,621 ante-partum or post-partum patient discharges in Canada in 2009/10, excluding Quebec. ICD-10 defines PC as “O90.3” and codes for cardiac arrhythmia, cardiac arrest and heart failure are “I47, 48, 49,” “I46” and “I50” respectively. In addition to analyze patient demographic information, these ICD-10 codes are captured in current study. Results: There were 62 cases of PC during the study period. During this period, there were 292,982 live births in Canada (excluding Quebec). This gives the incidence of PC as 1 case/4,725 live births. The patients age was 31.2⫾6.6 years (minimum 19, maximum 42). Post-partum PC comprised 72.6% of all cases. Thirty one patients (50%) required admission to Intensive or Coronary Care Unit. There were 7 patients with cardiac arrhythmia, including 4 patients with cardiac arrest, and 23 patients were coded for heart failure. There were no codes for pulmonary embolism or deep vein thrombosis among these patients. There was only one in-hospital death, giving an in-hospital mortality rate of 1.6%. Conclusions: The incidence of PC is 1 case/4,725 live births with a mortality of 1.6% in Canada. These findings are similar to previous reports from the United States.

Fern Malila, Cerner Corporation, Bruce Fleegler, Cindy Grimes, Sarasota Memorial Hospital, Stacy Dickess, St. Mary’s Medical Center, Andrew Kramer, Cerner Corporation Introduction: ICU care advances have resulted in larger numbers of patients surviving their initial illness but requiring additional care and interventions in Long-Term Acute Care settings (LTAC). The literature contains no information about the severity of illness of these patients upon initial ICU admission, initial ICU discharge, or readmission to the ICU. This study provides a descriptive analysis of a severity of illness metric for these patients. Hypothesis: The present study describes severity of illness of patients discharged to and then readmitted from LTAC to determine if their severity is higher than the general ICU population. Methods: Data was collected on consecutive admissions to two ICUs in two hospitals for a minimum 2.5 years. This included APACHE Day 1 and day of discharge Acute Physiology Score (APS) for both the initial ICU admission and the readmission. APACHE IV predicted in-hospital mortality and predicted ICU length of stay were calculated. Results: 353 patients from these two ICUs were discharged to LTAC during the study period; of those 39 (11%) were readmitted from LTAC back to the same ICU. Mean APS at initial admission was 56.2, upon discharge to LTAC was 47.6, and upon readmission was 64.9, while the APACHE IV mean database APS on Day 1 is 39. Mean predicted ICU LOS during the first admission was 6.32 days and was 6.48 days for the readmission. Mean Day 1 in-hospital mortality probability was 25.1% on Day 1 of the first ICU admission, and 16.8% on Day 1 of the readmission. Conclusions: This small but significant population had high severity of illness scores and in-hospital mortality risk on both Day 1 and discharge for both admissions. This validates perceptions that this is a high risk population and one deserving of additional study in order to evaluate common care practices, determine appropriate quality initiatives, and improve patient outcomes.

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RELATION BETWEEN CARDIAC TROPONIN I IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION AND USE OF NON INVASIVE MECHANICAL VENTILATION

WORKFLOW OF A MEDICAL INTENSIVE CARE UNIT (MICU) RESIDENT INDEPENDENT ACUTE CARE NURSE PRACTITIONER (ACNP) SERVICE

Gabriel Patarroyo, Carlos Giraldo, Thomas Newman, Hossam Amin, New York Medical College, Metropolitan Hospital Center Introduction: Chronic obstructive pulmonary disease (COPD) is frequently associated with cardiovascular disease including pulmonary hypertension and right ventricular failure. However, these patients often are at risk for acute coronary syndrome, given the multiple associated comorbidities. Hypothesis: Patients with COPD exacerbation will benefit from non invasive mechanical ventilation (NIMV), not just by improvement in ventilation and oxygenation but also by decrease in risk of myocardial ischemia related with a decrease in cardiac oxygen consumption. Methods: We retrospectively reviewed data (demographics, laboratories including highest troponin I within 24 hours of admission) of 142 patients admitted from January to December 2010 at our institution with diagnosis of COPD exacerbation. We divided these patients in two groups: those treated with NIMV and those who did not receive NIMV. Results: In our cohort, 49 patients requiered NIMV vs 93 patients with no NIMV requirement. There was no statistical difference in age (67 ⫹- 12 vs 66 ⫹- 10 years, p ⫽ 0.41), male (41% vs 57%, p ⫽ 0.07), presence of diabetes mellitus, (59% vs 55%, p ⫽ 0.61), arterial hypertension (69% vs 72%, p ⫽ 0.74) or hyperlipidemia (47% vs 38%, p ⫽ 0.28). Although not statistically significant, patient on NIMV were more often diagnosed with community acquired pneumonia (33% vs 19%, p ⫽ 0.08) and less often diagnosed with acute bronchitis (67% vs 87%, p ⫽ 0.08). As a group, the NIMV patients were more likely to have moderate to severe pulmonary hypertension (83.8% vs 29.1%, p⬍0.0001), and evidence of right ventricular failure (86% vs 14%, p⬍0.0001). Of note, patients on NIMV had a lower troponin I over the first 24 hours (0.08 ⫹-14 ng/ml vs 0.13⫹-0.4 ng/ml, p ⫽ 0.0003). Conclusions: Patients with COPD exacerbation, cardiovascular risk factors and chronic heart failure are more likely to have myocardial ischemia possible due to an increase of cardiac oxygen consumption secondary to the respiratory and metabolic stress. The use of NIMV possibly decreases the respiratory work reducing the cardiac oxygen consumption and the risk for demand ischemia.


Kristina J. Williams, Vanderbilt Medical Center, Emily R. Evans, Arthur P. Wheeler, Vanderbilt University Medical Center Introduction: ACNPs are increasingly being used in ICUs to off-set the shortage of critical care physicians. Understanding the volume and timing of workflow is crucial for adequate staffing. Hypothesis: We hypothesized that work would be sufficiently variable to permit reduced staffing during some parts of the day. Methods: We analyzed data for a resident-independent ACNP service in a Redcap QI database from a 34 bed teaching hospital MICU collected between October 2010 and July 2011. Two ACNPs were present during days and one at night. We calculated the number and timing of admissions, rapid response team (RRT) calls, transfers, discharges and deaths by day of the week and in 4 hour periods beginning at midnight. All data are proportions or mean ⫾ std. Results: The ACNP service admitted 782 (28%) of 2194 total admissions (2.6 ⫾ 1.2 per day). Most admissions (64%) occurred between 1200 and 2359, with modest hour-to-hour variation during this period. The fewest admissions occurred on Thursdays (12%) and most on Fridays (16%). Sources included the ED (53%), other hospitals (24%), in-house transfers (17%) and RRT calls (5%). Tuesdays had the highest percentage of discharges (18%) and Mondays the fewest (11%). Roughly equal proportions of patients were transferred to floor beds (47%) or discharged to locations outside the hospital (45%). Among ICU survivors 36% were discharged directly to home. Transfers and discharges were most often completed between 1200 and 1559 (38%). ICU deaths were uncommon (4.5%) with the greatest proportion (24%) occurring between 0800 and 1159. The frequency of RRT calls was relatively stable throughout the day, although the highest number (19%) occurred between 0800 and 1159. Conclusions: Less work due to fewer morning admissions is offset by a higher frequency of transfers, deaths, and RRT calls suggesting a consistent level of staffing throughout the day is needed. Supported by (1 UL1 RR024975 from NCRR/NIH).

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THE PROGNOSTIC IMPACT AND INSULIN-RELATED DETERMINANTS OF GLUCOSE VARIABILITY WITH USE OF COMPUTER-GUIDED TIGHT GLYCEMIC CONTROL

EPIDEMIOLOGY OF ACINETOBACTER SPECIES INFECTION IN A GASTROENTEROLOGY AND LIVER TRANSPLANT ICU

Lavi Oud, Craig Spellman, Zainab Akhtar, Texas Tech University HSC

Ruchika Bagga, Sachin Gupta, Deepak Govil, Shaleen Bhatnagar, Shrikanth Srinivasan, Sweta Patel, Jagadeesh KN, Manuj Sodhi, Usha Baveja, Yatin Mehta, Medanta The Medicity

Introduction: Glycemic variability (GV) was associated with increased mortality in critically ill patients, while limited data support similar findings with computer-guided insulin dosing (CG), when targeting tight glycemic control (TGC), with limited data on GV determinants; although CG algorithms determine and vary sequential insulin dosing across dynamic levels of insulin resistance, the interaction of GV & insulin excursions (IV) with CG TGC is unknown. Hypothesis: GV is a predictor of death & is independent of IV. Methods: We studied a retrospective patient cohort in a Med/Surg ICU in a university-affiliated hospital, requiring insulin infusion (I), targeting blood glucose (BG) 90 –130 mg/dl, using CG (GlucoStabilizer™) between 3/1/08 – 6/30/09. Exclusions were age ⬍18 yrs, ⬍10 BG values, ICU LOS ⬍24 hrs, diabetic ketoacidosis/ hyperglycemic hyperosmolar state, & hospital readmission. GV & IV were defined as standard deviation of the means of BG (BGave) and hourly insulin dose (Iave), respectively. We examined hospital mortality (M) with GV, M across GV quartiles, and GV determinants. Chi-square test and stepwise multivariate regression modeling were used, as appropriate. Results: Four hundred thirty eight patients (64%) met study criteria. Patients had mean (SD) age 58.7 (15.4) yrs; 56% were male; 40.9% Hispanic; 55.5% had diabetes; median (IQR) ICU LOS was 4.8 (2.8 –9.5) days; mean (SD) BGave was 124.8 (27.1) mg/dl; M was 19.9%. Mean (SD) GV was 40.6 (27) mg/dl. M was similar across GV quartiles (p ⫽ 0.29), and GV was not a predictor of M (OR 0.99, 95% CI 0.98 –1.01; p ⫽ 0.75). IV, but not Iave was key predictor of GV (OR 36.9 per unit/hr, 95% CI 16.7– 81.6; p⬍0.0001), unaffected by BG at start of I (BGst). IV, age (OR 1.14) and BGst (OR 1.16), explained together 81% of GV variance. Conclusions: GV was not associated with M, while insulin dose variability was a major predictor of GV in the present cohort of CG TGC. Further refinement of CG algorithms may help minimize GV across varying insulin resistance. The generalizability of the these findings should be examined with other CG, TGC targets, and settings.

Introduction: Infections influence the outcome of the critically ill patients and are more common in immunosuppressed individuals. Multi drug resistant Acinetobacter species are emerging as one of the most dreaded bacteria and leads to increase in mortality. Hypothesis: Microbiological data of 759 patients admitted from June 2010 to May 2011 in a Gastroenterology and Liver transplant ICU was analysed. Methods: Results of all the culture samples were retrieved. Blood, urine, Endotracheal/Tracheal secretion and body fluid cultures which are positive for Acinetobacter species were analysed. Antibiotic sensitivity pattern were also documented. Results: Fifty eight samples from forty two patients were positive for Acinetobacter species. Thirty two samples (55.2%) were positive from respiratory secretions with radiological confirmation of consolidation, fifteen samples (25.8%) were positive from body fluids (Ascitic, Pleural fluid, Pus) and eleven blood culture samples (18.9%) were detected positive for Acinetobacter species. Out of forty two, twelve patients had positive cultures from two sites, two patients from three sites and rest twenty eight patients had culture positivity from single site. Out of fifty eight Acinetobacter isolates, fifty four (93.1%) were identified as of A. baumanaii, two (3.4%) as of A. hemolyticus and one (1.7%) each as of A. lwolfii and A. junii. All these Acinetobacter isolates were showing high resistant to carbepenems, cephalosporins, aminoglycosides and fluoroquinolones. All the isolates (100%) were sensitive to Colistimethate sodium with MIC ⬍0.5. Tigecycline was sensitive in Fifty three isolates (91.0%) and MIC range was ⬍0.5– 4. Out of fifty eight only eight isolates (13.7%) were sensitive to carbapenams, six (10%) to cifoperazone sulbactum combination and aminoglycosides, and three (5%) to fluroquinolones. Twenty one (48.8%) out of forty three culture positive patients died within twenty eight days of detection of positive cultures. Incidence of Acinetobacter species infection is 5.6% in our ICU. Conclusions: Acinetobacter baumannii is a highly resistant pathogen and carries a high mortality. In our ICU Colistimethate sodium shows excellent sensitivity followed by Tigecycline.

654 ASSOCIATION BETWEEN AIRWAY COLONIZATION BY CANDIDA AND SUBSEQUENT PSEUDOMONAS VENTILATOR-ASSOCIATED PNEUMONIA IN CRITICALLY ILL PATIENTS Veronica Pena Suarez, ITESM-Campus Monterrey, Hospital San Jose, Maria del Rosario Munoz Ramirez, I T E S M Monterrey Campus, Hospital San Jose, Felipe De Jesus Perez Rada, Victor Manuel Sanchez Nava, ITESM-Campus Monterrey, Hospital San Jose Introduction: Ventilatory- associated pneumonia (VAP) is the leading cause of mortality due to nosocomial infections. Candida isolate of respiratory tract in critically ill patients receiving mechanical ventilation without risk factors for immunosuppression is common; altough this have been correlated poorly with invasive candidiasis. Several studies have found evidence of interactions between Candida and Pseudomonas, suggesting the possibility that Candida colonization increases the risk of Pesudomonas infection. Hypothesis: Determine if there was association between airway colonization by Candida and subsequent Pseudomonas VAP. Methods: A retrospective study conducted during a 2 year period in a medical-surgical ICU in a private hospital of Monterrey, Mexico. Data were collected from the medical records of patients hospitalized in the ICU with ventilatory support for longer than 48 hours in the last two years who developed VAP by Pseudomonas aeruginosa and found if there was association between tract colonization by Candida. Results: We retrospectively abstracted information from medical records of 68 patients of which 32 were excluded. Of the 36 cases included in 17 (47%) were documented airway colonization by Candida; mean age 53 yrs, 87.5% male, 12.5% female. Compared with those not colonized, Candida colonized patients were older (60 vs 47 yrs), the APACHE II and SOFA score were higher (16 vs 6 and 9 vs 4) and required a greater number of ventilatory days (13⫾12 vs 6⫾4 days; p ⫽ 0.024). Pseudomonas infection were more common in Candida colonized patients (81% vs 20%; p⬎ 0.001). The lenght of mechanical ventilation was greater in the Pseudomonas infection patients 15 ⫾11.7 vs 5⫾2.2 days; p ⫽ 0.01. Conclusions: In this retrospective cohort the only factor associated with the development of VAP caused by Pseudomonas aeruginosa was the longer duration of mechanical ventilation.



656

ZAP VAP: DEVELOPMENT OF A FUNCTIONAL CASE DEFINITION FOR PEDIATRIC VENTILATOR ASSOCIATED PNEUMONIA (PVAP) AND IMPLEMENTATION OF PREVENTION AND SURVEILLANCE STRATEGIES

IMPACT AFTER ONE YEAR OF ESTABLISHING PEDIATRIC ICU IN NEPAL

Joy Howell, New York Presbyterian Hospital-Weill Cornell Medical College, Jean-Marie Cannon, New York Presbyterian Hospital-Cornell, Lisa Covington, Diane Carp, New York Presbyterian Hospital- Columbia, Jacqueline Scolavino, New York Presbyterian Hospital-Cornell, Lisa Saiman, Katherine Biagas, New York Presbyterian Hospital- Columbia University College of Physicians and Surgeons Introduction: VAP is associated with increased mortality, LOS, and costs. In pediatrics, the diagnosis of VAP is challenging because case definitions in adults incorporate quantitative BAL cultures, which are infrequently used in children. We report a pilot project to develop a pVAP case definition, monitor adherence to interventions, and pVAP rates. Hypothesis: We determined the burden of pVAP at 2 PICUs, with 54 total beds, and ⬃3000 annual admissions. Methods: We convened an interdisciplinary team, adapted CDC case definitions, and developed an algorithm using data obtained from our electronic medical record (EMR). Infection preventionists performed pVAP surveillance by initially reviewing positive respiratory tract cultures obtained from ventilated children. Hyper/hypothermia and abnormal WBC count prompted further evaluation. Remaining ‘inclusion criteria’ included: sustained increase in ventilator settings or secretions and consistent radiographic findings. A PICU attending adjudicated suspect cases. Simultaneously, we monitored adherence to bundle elements (elevation of head of bed (HOB) to 30°, oral care every 4 hours, ulcer prophylaxis, mechanical prophylaxis for DVT, daily assessment of weaning/extubation readiness). We educated the ICU care teams about VAP pathophysiology, our case definition and bundle implementation. Results: From 6/10 –7/11, we diagnosed 5 cases of pVAP, with a cumulative rate of 0.62/1000 ventilator-days, (CDC’s National Healthcare Safety Network’s 50th percentile ⫽ 0.7). Compliance was lowest with HOB elevation (range 25–50%). Otherwise, observed compliance (90 –100%) was consistently higher than EMR documentation of compliance (14 – 81%). To improve EMR compliance we clarified understanding ‘extubation readiness’ and appropriate capture of bundle elements. Conclusions: This interdisciplinary program resulted in good understanding and implementation of the VAP prevention bundle as evidenced by high levels of observed compliance. We could not assess risk factors given our few cases. In efforts to provide more real-time feedback to staff we hope to further automate compliance monitoring and selected surveillance elements.

Sangita Basnet, Southern Illinois University School of Medicine, Shrijana Shrestha, Amrit Ghimire, Dipsal Timila, Jeena Gurung, Utkarsha Karki, Neelam Adhikari, Patan Academy of Health Sciences, Jennifer Andoh, Janak Koirala, Southern Illinois University School of Medicine Introduction: In collaboration with local staff and international medical volunteers, a pediatric ICU was established at Patan Hospital in Kathmandu, Nepal, in June 2009. Hypothesis: To determine impact of PICU after 1 year. Methods: Retrospective review of charts was done of patients admitted to the PICU from July 2009-July 2010. Results: In 12 months, 126 children were admitted including 53% under 5 years old, 65% females, 24% from tertiary hospitals, 36% from rural areas outside Kathmandu. Only 16% were transported by ambulance. Median distance traveled for admission was 30 [interquartile range (IQR) 10 –193] km. Highest number of admissions were in spring (40%) followed by summer (25%).Over half were admitted for shock (51%), mostly septic shock (34%) followed by neurologic etiologies (16%): meningitis, meningo-encephalitis, and cysticercosis. Newborn/perinatal admissions were 14%, mainly neonatal sepsis, severe birth asphyxia, and preterm birth. Mortality rate was 23%, of which 54% were under 5 years and 36% were female. The proportion of deaths in patients originating from within Kathmandu and rural areas were equal (22% and 20% respectively). Patients transferred from other hospitals had more deaths (46%) than those originating at Patan Hospital (25%). Most common cause of death was septic shock (50% of all deaths, 33% of those admitted with septic shock). Other causes included meningoencephalitis, cardiogenic shock, hepatic failure, and prematurity. Highest number of deaths occurred in spring (32%).Thirty percent of patients required mechanical ventilation, mean duration 4.5 (median 2, IQR 1–4.8) days. Main reason was for septic shock (42%). Fifty-eight percent of patients on ventilator died. Mean length of stay in the hospital was 6.2 (median 4, IQR 2.5–9) days. Conclusions: Patan hospital PICU has become a major referral center in Nepal: for rural communities and tertiary care hospitals alike. Although many lives were saved, mortality rate (23%) was high due to increased severity of illness resulting from late presentation, long distances, and lack of efficient transportation. More training and refresher courses may be necessary, especially regarding management of septic shock and mechanical ventilation.

657 IDENTIFYING IMPROVEMENT OPPORTUNITIES THROUGH QUALITY AND SAFETY MONITORING OF CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) PRACTICE Jennie Steen, UCSF Medical Center, Hildy Schell-Chaple, University of Califonia San Francisco Medical Center Introduction: To identify and measure quality indicators for CRRT practice to optimize safety and quality performance of this high risk therapy. CRRT has become a standard therapy in ICUs, yet there are scarce published recommendations for evaluating the safety and quality of CRRT practice. Hypothesis: Monitoring quality indicators for CRRT practice can identify performance improvement opportunities that impact achievement of therapy goals, patient safety, and resource utilization. Methods: Quality and safety indicators were selected based on therapy dose and fluid balance goals as well as identified risks and complications from the literature. We prospectively measured indicators from a convenience sample of 60 treatment days from 27 patients in two adult ICUs at an academic medical center. Results: Modes of therapy used were CVVHD (85%), CVVH (5%) & combined (10%). Percutaneous CVC access was used 75% of days with internal jugular 55%, subclavian 30%, and femoral 15% as sites selected. Fluid balance target achieved was within ⫾500 mLs/day 47% of therapy days and within ⫾750 mLs/day 70% of therapy days. Median therapy fluid (dialysate or replacement fluid) rates were 2000 mLs/hr (28 mL/kg/hr) and the therapy fluid dose was achieved 90% of therapy days. Accuracy of transcription of ultrafiltrate volumes from CRRT device to medical record was imprecise 60% of days, yet there was 90% transcription accuracy within ⫾200 mLs. Adherence to protocol orders for 1) laboratory monitoring revealed 8% omission error and 11% additional test rates, primarily BUN and creatinine tests costing $714; and 2) electrolyte replacement revealed 6% omission error and 2% additional dose error rates. CRRT anticoagulation used: citrate (8%), heparin (10%), and none (82%). Anticoagulation parameter monitoring accuracy was 66% for heparin and 93% for citrate. Conclusions: Opportunities for improving protocol adherence to ensure safety along with optimization of accurate medical record data with upcoming device integration into an electronic medical record were identified. Routine CRRT quality monitoring is essential to evaluate impact of interventions to improve identified practice, safety, and resource utilization issues and trends.


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THE IMPLEMENTATION AND EVALUATION OF AN EARLY MOBILIZATION PROGRAM FOR CRITICALLY ILL ADULT ONCOLOGY PATIENTS

RECENT HISTORY OF ACUTE AND CHRONIC ILLNESS (RHACCI) IS ASSOCIATED WITH HOSPITALIZATION BUT NOT WITH ICU USE.

Mary Lou Warren, Selvaraj Pravinkumar, Shari Frankel, Stacey Ryan, Vi Nguyen, Rebecca Garcia, Mini Thomas, Laura Withers, Quan Nguyen, University of Texas MD Anderson Cancer Center

Walter Linde-Zwirble, Z D Associates, Sachin Yende, University of Pittsburgh, Hannah Wunsch, Columbia University Medical Center, Derek Angus, University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Mary Hartman, Washington University in St. Louis

Introduction: The purpose of this project was to successfully implement a multidisciplinary early mobilization program (EMP) in a large oncological ICU and assess the average number of mobilization activities per patient day, before and after the implementation. Hypothesis: The implementation of a multidisciplinary EMP will result in an increase in the average number of mobilization activities per patient day. Methods: A quality improvement methodology employing the Plan, Do, Study, Act (PDSA) cycle was utilized to pilot the EMP. The program was implemented in 16 of the 54 ICU beds in a large oncological ICU. Baseline information was obtained prior to the implementation of EMP, and during the pilot period. The type and rate of mobilization activities were collected at two, four, and eight weeks after implementation of the EMP. Results: Following eight weeks of the EMP, the average number of total mobilization activities per patient day increased by 47%. Mobilization activities carried out by bed-side nursing staff increased by 31%. Mobilization activities carried out by physical therapists and occupational therapists increased by 86% and 78%, respectively. Conclusions: The implementation of a multidisciplinary EMP in critically ill oncology patients led to an increase in the number of mobilization activities per patient day. The use of an interdisciplinary team approach and the PDSA cycle ensured success and sustainability of the program.

Introduction: The impact of a patient’s recent medical history on the probability of acute hospitalization is unknown. Hypothesis: Recent medical history is strongly associated with acute hospitalization but not ICU care. Methods: We used the Medicare Standard Analytic Files, containing all inpatient, outpatient, SNF and provider claims for 5% of all Medicare beneficiaries aged ⱖ66 years in 2003. Recent History of Acute and Chronic Illness (RHACCI) scores were calculated from all encounters in 2002, with acute hospitalization in the first quarter of 2003 being the outcome of interest. We classified cases with ICU LOS ⱖ1 day as ICU cases. The probability of hospitalization and ICU use were calculated using a binary response model with a generalized logit link with model fit assessed using likelihood r-squared, area under the ROC curve and deviance dispersion. Results: There were 1,287,952 Medicare beneficiaries alive at the beginning of 2003 with an age ⱖ66 years. There were 100,697 beneficiaries with at least one hospitalization in the Q1 2003 (7.8%) with ICU admission in 17,020 (16.9%). The RHACCI score ranged from 0 –58 with an overall mean of 8.5 and was higher in the hospitalized compared to the non-hospitalized (14.1 vs. 8.0, p⬍0.0001), but not very different between ICU and non-ICU cases (14.5 vs. 14.0, p⬍0.0001). The hospitalization model fit well with an r-squared ⫽ 35.1%, ROC ⫽ 0.716 and deviance dispersion ⫽ 1.2. The predicted hospitalization risk was approximately equal to the RHACCI score, ranging from 2.2% (RHACCI 0) to 53.4% (RHACCI 58). The ICU model had little discrimination (ROC ⫽ 0.517) with an r-squared of only 12.1% and a probability of ICU use ranging only from 15.7%-20.9%. Conclusions: A patient’s recent medical history, summarized in the RHACCI score, has a large impact on the need for acute hospitalization, ranging from 2–54% in one quarter. However, ICU use during hospitalization is only very weakly associated with prior medical history with an ROC near 0.5, indicating near random association. Recent history greatly informs the likelihood of acute illness but not the level of acute physiologic derangement that would require ICU management.

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THE EFFECT OF DISCHARGE DISPOSITION AND INITIAL COMORBIDITIES ON RISK OF 30 DAY HOSPITAL READMISSION IN PATIENTS WHO HAVE BEEN CARED FOR IN A SURGICAL INTENSIVE CARE UNIT (SICU)

EARLY IDENTIFICATION AND INTERVENTION OF PATIENTS AT RISK: A RAPID RESPONSE TEAM INITIATIVE

Peter Perakis, Ilan Rubinfeld, Lisa Takis, Avinash Narayana, Henry Ford Health System, Marites Cumba, Henry Ford Hospital, Dionne Blyden, Mathilda Horst, Henry Ford Health System Introduction: It is increasingly important to identify surgical critical care patients at high risk of returning to the hospital. Previous work has focused on readmission to the ICU from the floor, with little attention to hospital readmission in ICU populations. Hypothesis: The admitting Charlson Comorbidity Index (CCI) and discharge disposition may serve as risk factors for hospital readmission for surgical critical care patients. Methods: This is a retrospective observational study based on corporate data and included only patients cared for in the SICU at some point during admission between 2007 and 2010. Readmission was defined as hospital readmission within 30 days of discharge. Analysis was performed in SPSS 19 (IBM, NY) and Minitab 16 (Minitab, PA). Results: A total of 9106 patients were admitted to the SICU of which 1702 (18.7%) were readmitted to the hospital within 30 days of hospital discharge. Readmitted patients had a higher CCI (3.54), were more likely to be African American (AA) or over age 65 when compared to patients not readmitted (CCI ⫽ 2.95) (p⬍0.001). Those patients discharged home who were readmitted had a mean CCI of 2.88, which was a 27% (p⬍0.001) increase from those not readmitted, with a mean CCI of 2.27. Patients discharged to home health-care (HHC) that were readmitted had a mean CCI of 3.36, a 7% (p⬍0.03, OR ⫽ 1.7) increase from those not readmitted with a mean CCI of 3.13. Patients discharged to a skilled nursing facility (SNF) and readmitted had a mean CCI of 4.63, a 6.7% (p⬍0.03, OR ⫽ 1.9) increase from those not readmitted, with a mean CCI of 4.34. Conclusions: CCI, AA race and age greater than 65 were risk factors for readmission. Similarly, patients discharged to a SNF or to HHC were more likely to be readmitted. Targeting resources to those patients at high-risk of being readmitted to the hospital may improve post-discharge outcomes.

Gina McGinn, St Luke’s Hosptial, Cynthia Gerdik, Shands Jacksonville, Miren Schinco-Schaffer, Univ. of Florida, Andrew Kerwin, Univerity of Florida, Jacksonville Introduction: Rapid response teams (RRT) act as an extension of the ICU reaching out to floor patients providing them with basic resuscitative care and evaluating their need to move to a higher level of care. Recently, we have identified a group of high risk patients, those who require agents for reversal of narcotics and benzodiazepines for primary or iatrogenic overdose. Hypothesis: Our hypothesis is that patients requiring these agents require a higher degree of vigilance to avoid increased morbidity. Methods: The RRT records for two hospitals (#1 310 bed community hospital with an average of 66 monthly RRT calls. #2 695 bed academic hospital with an average of 276 monthly RRT calls.) were reviewed from January through July 2011. Results: RRT interventions for these patients averaged from 2 to 5 % of total calls for both hospitals. Several of these patients required multiple interventions and transfer to a higher level of care. In response, both hospitals began a regular review of these cases. Postoperative patients and those with sleep apnea were identified as groups at risk. Hospital #2 instituted a protocol where medication administration technology alerted the RRT via beeper when a patient was administered these medications. They were then able to proactively evaluate the patients. This has resulted in more timely identification of potentially deteriorating patients saving them from further decline. Conclusions: Regardless of size or type of hospital, the need for narcotic and benzodiazepine reversal agents represents a significant population of patients at risk for deterioration who need closer observation. Nursing protocols should be instituted for early identification of these patients and aggressive treatment.


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USING LOCAL MICROBIOLOGIC DATA TO DEVELOP INSTITUTION-SPECIFIC GUIDELINES FOR EMPIRIC ANTIBIOTIC TREATMENT FOR VENTILATOR-ASSOCIATED PNEUMONIA IN INTENSIVE CARE

CASES OF EMERGENCY ADMISSION TO THE ICU: POSSIBILITY OF USING MET/RRT

Raphaelle Lauly, F. Huynh, Elyse Voyer, Andre Bonnici, Marie-Soleil Delisle, Charles Frenette, Ashvini Gursahaney, Marc Perreault, Daniel Thirion, McGill University Health Center

Introduction: In recent years, a medical emergency team/rapid response team(MET/RRT) has been adopted, and its use is increasing in Japan. However, MET/RRT is controversial. In this study, we investigated the status of emergency admissions to the intensive care unit (ICU). Hypothesis: We hypothesized that the vital signs of patients who were transferred to the ICU for an emergency had already become worse hours before. Methods: In total, 111 adult patients (73 males and 38 females) who were admitted to the ICU for an emergency between January 1, 2008 and December 31, 2010 were studied retrospectively. Results: Median patient age was 70.0 years, and the average ICU stay was 7.7 days.The APACHE II score was 24.0 points (median), and mortality was 53.2%. The primary reasons for ICU admission were respiratory failure, followed by shock and cardiopulmonary arrest. In total, 85% of the patients required mechanical ventilation and 36.9% required dialysis. An average of 29 hours was required for a patient to be transferred to the ICU after one change in patient behavior or complaints. The physician did not recommend admission to the ICU, despite abnormal vital signs were found in 43.4% of records 12 hours before ICU admission. In such cases, mortality was significantly higher at 69.7%. In total. 93.0% of the patients required mechanical ventilation and 48.8% required dialysis. In addition, a documented observation of respiratory rate was observed in only 20% of patients in our hospital. Conclusions: The condition of a total of 40% of the emergency cases admitted to the ICU had become worse 12 hours before admission. Mortality in such cases was high. Thus, aggressive early intervention might be required by MET/RRT, in which the core members are intensivists.

Introduction: Ventilator-associated pneumonia (VAP) is the most common infection in the ICU setting. Adequate initial antibiotic therapy is associated with decreased mortality. Also, microbial flora varies significantly between hospitals, as well as within the same hospital. Knowledge of local bacterial flora is essential for selecting optimal empiric antibiotic therapy. Hypothesis: The objectives were to describe the bacterial flora and to verify the adequacy of empiric antibiotic therapy based on microbiology susceptibility in critically ill patients with VAP. There were also to compare patient’s clinical outcomes based on adequacy of empiric treatment, to describe flora of patients with bacteremic VAP and to propose an empiric antibiotic protocol for VAP in our institution. Methods: We reviewed retrospectively the charts of patients for whom a clinical VAP was suspected in an adult medical-surgical ICU. Pneumonia was considered as a VAP if it occured at least 48 hours after initiation of mechanical ventilation and at most 48 hours after its discontinuation. Patients who met the CDC/NHSN criteria and had an associated positive culture finding for a bacterial pathogen were included. Inadequate empiric treatment was defined by the isolation of at least one pathogen with in vitro resistance or intermediate suceptibility to the prescribed antibiotic. Results: Of all the 75 patients with a VAP, 42.9% had an early VAP and 57.1% had a late VAP. The most frequently identified pathogens were Klebsiella spp. (23.6%) and S. aureus (16.4%). Eighteen patients (24%) received inadequate empiric antibiotic treatment. Inadequate therapy was associated with a trend towards longer ventilation duration (31.9 vs 23.7 days), longer ICU stay (38.4 vs 28.8 days) and longer hospital stay (99.1 vs 66.9 days). The highest rate of resistance was to Ticarcillin-clavulanic acid at 22.7%. Fifteen patients (18.3%) had a bacteremic VAP of which 5 cases (33.3%) were associated with S. marcescens. Conclusions: Determination of local bacterial susceptibilities called for more appropriate empiric antibiotic guidelines in treatment of VAP in the ICU. Ongoing identification of local microbial flora is essential to provide adequate empiric treatment for VAP.


Nao Umei, Kazuaki Atagi, Hideo Okuno, Yusuke Seino, Yasunori Otsuka, Atsushi Ujiro, Hideki Shimaoka, Osaka City General Hospital


665

IN THE ICU, 30 DAYS AND COUNTING: A CASE SERIES OF 18 CANCER PATIENTS

PREVALENCE OF SEPSIS AND ITS EVOLUTIONARY STAGES IN CHILDREN ADMITTED TO A PICU IN A DEVELOPING COUNTRY ACCORDING TO THE NEW DEFINITIONS PROPOSED BY THE IPSCC-2005

Daniel Miller, Charity Tumangday, Memorial Sloan-Kettering Cancer Center, Kaye Hale, Memorial Sloan Kettering Cancer Center, Stephen Pastores, Neil Halpern, Memorial Sloan-Kettering Cancer Center Introduction: Prolonged ICU length of stay (LOS) is associated with high medical costs and hospital resource utilization. Much of the published literature on prolonged ICU LOS has focused on non-oncologic patients. Hypothesis: The purpose of our study was to describe the clinical characteristics and outcomes of cancer patients who had prolonged ICU LOS. Methods: Using hospital and ICU databases, we retrospectively identified cancer patients who had prolonged ICU LOS (⬎30 days) in an adult medical-surgical oncologic ICU between January 1, 2010 and June 30, 2011. Data collected were: age; gender; type of malignancy (solid or hematologic); admitting service (medical or surgical); ICU admission diagnosis; Mortality Probability Model (MPM) II and Sequential Organ Failure Assessment (SOFA) scores on ICU admission; need for mechanical ventilation (MV), vasopressors (VP), renal replacement therapy (RRT) and tracheostomy; DNR status; end-of-life care parameters; ICU and hospital LOS and mortality rates; and 90-day post-ICU admission outcomes. Results: There were 1,541 ICU admissions during the 18-month study period. 18 patients (1.2%) had ICU LOS ⬎30 days. Mean age was 61 years, 61% were males; 67% had solid tumors and 33% had hematologic malignancies. 56% were medical and 44% were surgical patients. 72% were admitted for respiratory failure, 10% for septic shock, 6% for VTE, 6% for a neurologic event and 6% for severe hypovolemia. Mean MPM II and SOFA scores were 38% and 9, respectively. 90% required MV, 72% used VP, 22% required RRT, and 72% had a tracheostomy. 6% had DNR orders on ICU admission; 44% were made DNR. 28% were transitioned to comfort care only and 11% had withdrawal of care. Mean ICU and hospital LOS were 40 days and 79 days, respectively. ICU, hospital and 90-day mortality rates were 33%, 44% and 56%, respectively. Conclusions: While this study identified only a small number of cancer patients with prolonged ICU LOS, more than half of them survived to hospital discharge. Further studies are required to identify predictors of prolonged ICU LOS and hospital mortality among ICU cancer patients.

666 ULTRASOUND USE IN THE PICU: HOW LONG SHOULD A CHILD WAIT?

Daniela Carla Souza, University Hospital of The University of SaoPaulo, Shieh Hsin, University Hospital-University Sao Paulo, Eliane Roseli Barreira, University Hospital of The University of SaoPaulo, Juliana Ferranti, Juliana Macieira, University Hospital-University Sao Paulo, Albert Bousso, University HospitalUniversity of Sao Paulo Introduction: Sepsis and its evolutionary stages represent one of the most important diseases of childhood due to the high morbi-mortality. Despite the importance of sepsis, epidemiological data are scarce, mainly in developing countries. In 2005 the members of the International Pediatric Sepsis Consensus Conference (IPSCC-2005) published new sepsis definitions for children. No data on the epidemiology of sepsis in children according to the new IPSCC-2005 definitions have been published so far. The present study aims to describe the prevalence and mortality of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock on admission of children to a pediatric intensive care unit (PICU) of a university hospital in a developing country according to the IPSCC-2005 definitions. Hypothesis: The prevalence of sepsis and its mortality is higher in children living in developing countries. Methods: Retrospective cross sectional study. Hospital charts of all patients admitted to the PICU from January to December 2009 were reviewed. Clinical and laboratory data of the first 24 hours of PICU admission were reviewed, and patients were classified to the presence of SIRS, sepsis, severe sepsis and septic shock according to the IPSCC-2005 definitions of sepsis and organ dysfunction in pediatrics. Results: Three hundred and seven patients were included, 52.1% male, with median age of 16 ⫾ 46.5 months (range 1–166). Mortality was 2.6%. Prevalence of SIRS, sepsis, severe sepsis and septic shock were, respectively, 82.4%, 61.6%, 24.8% and 17.6%. Mortality resulting from sepsis, severe sepsis and septic shock were 0.9%, 0 and 11.1% respectively. Conclusions: This is the first study to assess the prevalence of sepsis according to the IPSCC-2005. In the present study, we observed a high prevalence of sepsis and its evolutionary stages, and a low mortality rate, which is similar to those reported in developed countries. The low mortality observed may be related to the strict adherence to the guidelines of hemodynamic support of pediatric patients in septic shock.

Maria Komer, Miami University, Michael Forbes, Azam Eghbal, Michael Rubin, Michael Gothard, Michael Bigham, Akron Children’s Hospital Introduction: Ultrasound plays an important diagnostic role in critically ill pediatric patients and is commonly used to evaluate pleural/peritoneal fluid, vascular patency, and organ architecture. The role of bedside ultrasound by pediatric intensivists is evolving as an alternative to traditional PICU ultrasound ordering process. Hypothesis: We aimed to (a) describe our local experience with a traditional ultrasound model and (b) measure ultrasound turnaround times for critically ill children. Methods: This study was set in the pediatric intensive care unit of a free-standing tertiary children’s hospital with 1500 annual PICU admissions. Candidate patients were identified using VPS™ and data were extracted via chart review and the local radiology database. The radiology-based ultrasound model includes in-house ultrasonographers who are available during weekday business hours and otherwise available via on-call system. Attending radiologists are available for on-site or remote ultrasound interpretation at all times. Results: There were 247 eligible ultrasounds analyzed in 154 patients. Renal (30%), abdominal (20%), head (13%), and chest (13%) ultrasounds were most common. The median (range) order-to-report turnaround time was 444 (66 –3293) min. The longest time interval in the ultrasound process was from order entry to ultrasound initiation, with median (range) of 247 (0 –3126) min. Interventions occurred based on ultrasound results in 11% of studies, but that intervention began an average of 1419 (97– 4153) min after the initial ultrasound order. Radiologistintensivist verbal order clarification occurred 30% of the time and involved the clinical question and the role of color-flow Doppler. Conclusions: Our description of a traditional ultrasound model revealed significant opportunities for workflow improvement. Specifically, order-to-report turnaround time delay including those where results led to clinical intervention. Further studies are needed to validate our local data. If validated, studies designed to improve operational efficiencies will be able to target workflow limitations. Additionally, selected critical ultrasound usage by the trained pediatric intensivist may further improve operational agility.


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THE PROGNOSTIC VALUE OF DAILY MEDICATION INTAKE FOR CHRONIC ILLNESS ON MORTALITY AFTER RESPIRATORY FAILURE IN THE ICU

POST-OPERATIVE INTRA-ABDOMINAL SEPSIS PRESENTING WITH A CLINICAL PICTURE MASQUERADING AS PULMONARY EMBOLISM


Leon Boudourakis, Mount Sinai Medical Center, Adel Bassily-Marcus, Mount Sinai School of Medicine- Mt. Sinai Hospital, Andrew Kuo, Mount Sinai School of Medicine, Srikar Rao, Mount Sinai Schoolk of Medicine, Ari Moskowitz, Mount Sinai School of Medicine, Constantin Parizianu, Mount Sinai Hospital, John Oropello, Mount Sinai School of Medicine, Anthony Manasia, Mount Sinai Medical Center, Roopa Kohli-Seth, Mount Sinai Hospital, Ernest Benjamin, Mount Sinai School of Medicine

Introduction: Chronic disease often results in an increased use of pharmaceutical drugs to compensate for organ dysfunction. However, this relationship is not linear, and while some patients are heavily medicated, others choose to live without even vital medications. Hypothesis: We wanted to learn if the extent of basic medication use actually influences survival after ICU admittance for respiratory failure in a largely unselected cohort of patients. Methods: A retrospective cohort study of 287 consecutive patients requiring mechanical ventilation was undertaken. Mono-organ respiratory failures included pneumonia, exacerbation of chronic obstructive lung disease, and exhaustion by other causes such as asthma, cerebrovascular insult, or non-cardiac, non-pulmonary surgery. Respiratory failure associated with cardiac insufficiency, multiple organ failure or trauma were excluded. The total number of different drugs taken daily before ICU admission were recorded for each patient. Patients were followed for at least one year, and reliable mortality statistics were recorded from available databases. Results: 81% were ASA physical class III-IV, with median age 69 years (range, 23–99 years). Median daily medication intake was 8 drugs (range, 0 –24). Within each medication group, 15-day, 1-month, and 1-year all-cause mortality was (in brackets): 0 –3 drugs (34%, 34%, 68%), 4 –7 drugs (22%, 24%, 49%), 8 –11 drugs (17%, 19%, 37%), 12–15 drugs (11%, 17%, 54%), 16 –24 drugs (26%, 27%, 56%). Conclusions: Short-term as well as long-term mortality after respiratory failure seems to be affected by the pre-admission intake of medications in a U-shaped fashion. The reasons are probably complex; the high risk of death associated with low intake of drugs may be caused by undertreated or undiscovered illnesses, while the increased risk associated with massive drug intake may reflect an increased burden of chronic organ failure. Future studies should examine these relationships in depth and determine their potential value in a sickness impact profile and prognostic models.

Introduction: Following abdominal surgery, a cardio-pulmonary decompensation brings pulmonary embolism (PE) high in the differential diagnosis. However, we have observed some of these patients with suspected PE to have intraabdominal sepsis. Hypothesis: We hypothesize that a significant proportion of post-operative cardio-pulmonary decompensation suggestive of pulmonary embolism, actually reflects the findings of evolving intra-abdominal sepsis. Methods: All adult general surgery patients that underwent an intra-abdominal procedure at a tertiary care center from 1/1/2009 to 6/30/2010 were retrospectively identified. Patients that underwent a chest computerized tomography angiography (CTA) within 30 days of surgery were further analyzed. Clinical signs, chest CTA results, and subsequent workup including eventual exploratory laparotomy, CT abdomen and percutaneous drainage were reviewed. Results: There were 4650 patients that underwent general intra-abdominal surgery. Within 30 days of the initial operation, 171 (3.6%) patients underwent chest CTA. The most common clinical triggers which prompted evaluation by chest CTA were acute respiratory failure (41.9%) and tachycardia/arrhythmia, hypotension (43.0%). PE was confirmed in 42 patients (24.5%), negative in 129 patients (75.4%). Thirty three (19.3%) patients who initially had chest CTA (171) were ultimately diagnosed with intraabdominal sepsis. Four patients (2.3%) had concomitant PE and intraabdominal sepsis. Conclusions: Among post-operative patients that demonstrate a clinical presentation suggestive of PE, there was a similar incidence of intraabdominal sepsis as PE. Post operative abdominal sepsis can mimic PE in its initial presentation and should be considered early in the evaluation of postoperative respiratory and cardiac decompensation. Delay in recognition of abdominal sepsis may result in increased morbidity and mortality.

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PEDIATRIC EARLY WARNING SYSTEM (PEWS) SCORE: ACCURACY AND INTER-RATER RELIABILITY

SURVIVAL OUTCOMES OF PATIENTS REQUIRING VASOPRESSORS IN THE INTENSIVE CARE UNIT

Sarah Rubin, Lori Marshall, Kay Gilmore, Margaret Frankel, Kathy Derlighter, Kathleen Ostrom, Ronen Zipkin, Randall Wetzel, Robert Bart, Robinder Khemani, Children’s Hospital Los Angeles

Shameem Kunhammed, Arieh Greenbaum, Mohan John, Daniel Farkas, BronxLebanon Hospital Center

Introduction: The Pediatric Early Warning System (PEWS) score was developed to screen children on the pediatric ward for signs of critical illness. Early detection leading to intervention may prevent clinically significant deterioration and improve morbidity and mortality. Potential for early warning scores to affect outcome is based on accurate and reliable score assignment. However, evaluation of accuracy and inter-rater reliability is lacking in the PEWS literature. Hypothesis: Preceded by a comprehensive nurse education program, PEWS score assignment is accurate and reliable. Methods: A committee of PEWS experts, assembled for this study, implemented an education program for all nurses who assigned PEWS scores on the pediatric ward. Nurses then completed a series of hypothetical vignettes in which they independently assigned PEWS scores to the same five fictional pediatric patients. Nurse-assigned scores were compared with an answer key created a priori by PEWS expert consensus opinion. Difference between nurse-assigned and expert-assigned scores was evaluated using the Wilcoxon signed-rank test. Accuracy of nurse-assigned scores was determined by agreement with expert answers (within 1 point of the PEWS scale). CHLA uses a PEWSbased management algorithm in which ICU consult is recommended if PEWS score is ⱖ4. To evaluate clinically relevant score assignment, PEWS scores were categorized into 0 –3 and ⱖ4. Inter-rater reliability of continuous and categorical PEWS scores was assessed by Fleiss’ kappa. Results: 352/487 (72%) nurses completed the vignettes. Nurse-assigned and expert-assigned PEWS scores were similar (P ⫽ 0.2) with 92% agreement overall. PEWS, assessed as a continous variable, had moderate inter-rater reliability (Fleiss’ kappa ⫽ 0.41). PEWS, assessed as a categorical variable, had substantial inter-rater reliability (Fleiss’ kappa ⫽ 0.78). Conclusions: Following a focused nurse education program, PEWS score assignment was accurate and inter-rater reliability of clinically relevant PEWS scores was substantial.


Introduction: Patients in the Intensive Care Unit (ICU) often require aggressive treatment modalities. In patients suffering from the more severe forms of shock, cardiopulmonary resuscitation (CPR) and the use of vasopressors might be necessary to maintain life. The outcomes following CPR have been well studied, and survival rates established. Survival outcomes following the use of vasopressors are not as well established. Hypothesis: The rate of survival following the use of vasopressors in the ICU could be established, and this could be useful to clinicians. Methods: All patients admitted to the ICU from January to June 2011 were included. A retrospective review of their medical records was performed. Patients were classified into those that were treated with vasopressors (VP⫹) and those that were not (VP-), and survival rates were calculated. Patients were considered survivors if they remained alive to be discharged from the hospital. Survival rates were compared between the two groups and statistically analyzed. Results: 1023 patients were admitted to the ICU during the study period: 164 (16.0%) in the VP⫹ group, and 859 (84.0%) in the VP- group. The survival rate in the VP⫹ group was 30.5% (50/164) as compared with a survival rate of 91.4% (785/859) in the VP- group. This difference was highly significant (Chi-square, p⬍0.001). Conclusions: Patients started on vasopressors in the ICU have much worse outcomes than those not given vasopressors. The rate of survival is very poor, with less than one third of patients surviving to discharge. This information can be useful to clinicians as they counsel patients and their families, and are asked to make further treatment decisions in patients on vasopressors.

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WHERE DO CHILDREN RECEIVE INTENSIVE CARE?

VTE RISK FACTORS IN MEDICAL-SURGICAL ICU PATIENTS

Renee Matos, Children’s Hospital of Pittsburgh, Mary Hartman, Washington University in St. Louis, Jeremy Kahn, University of Pittsburgh, Kathryn Felmet, Children’s Hospital of Pittsburgh, Walter Linde-Zwirble, Z D Associates, Derek Angus, University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Robert Watson, University of Pittsburgh School of Medicine Children’s Hospital of Pittsburgh

Ryan Zarychanski, Francois Lauzier, Alexis Turgeon, John Marshall, Joseph Nates, Michael Cox, Yaseen Arabi, Ismael Qushmaq, Nicole Zytaruk, McMaster University

Introduction: Given the specialized nature of pediatric critical care and research showing better outcomes at high volume centers, we sought to determine the extent to which ICU care is provided at centers with different levels of experience in pediatric critical care. Hypothesis: ICU care for children is rare at hospitals with few pediatric ICU admissions (⬍1 per week). Methods: We studied all 695,314 non-federal hospitalizations of 1–19 yo in 2005 in 11 states with 37% of US children (AZ, FL, IA, MA, MD, NC, NJ, NY, TX, VA, WA). We identified children receiving ICU care using charge codes and state-generated variables. Low-Volume Centers (LVC) had ⱕ50 annual ICU admissions of 1–19 yo, Medium-Volume Centers (MVC) admitted 51–200, and High-Volume Centers (HVC), ⬎200. Children’s hospitals were in the Nat’l Assoc. of Children’s Hospitals & Related Institutions. Results: We identified 91,602 admissions to ICUs in 1,018 hospitals (835 LVC, 70 MVC, 135 HVC). Children’s hospitals admitted 56,383 (61.6% of ICU admissions), almost all of which were HVC. Rates of ICU care at children’s hospitals decreased with age (from 71.2% of 1– 4 yo to 44.7% of 15–19 yo).LVC admitted 10.4% (n ⫽ 9,528) of children receiving ICU care; half of these admissions were to hospitals with ⱕ10 ICU admissions/yr (n ⫽ 4,732). Children admitted to LVCs were older than those at HVCs (median 18 vs. 10 yo, p⬍.001); only 9.2% of children admitted to LVC were ⬍10 yo. Children admitted to LVC had less chronic disease (13.1% vs. 35.7%, p⬍.001), and more had diagnoses of injury/poisoning (31.1% vs. 14.8% at HVC, p⬍.001). MV was used in 9.5% of LVC admissions (vs. 13.1% of HVC admissions, p⬍.001). Children admitted to LVC ICUs had a mean (median) length of stay of 4 (2) days and a mortality of 1.1% (vs. 2.3% at HVC, p⬍.001). Conclusions: Most critically ill children receive care in children’s hospitals, but many are admitted to centers with extremely limited experience providing critical care to children. A better understanding of the extent to which these patients could benefit from care at hospitals with pediatric expertise, and the barriers to their receiving such care, has the potential to improve outcomes of thousands of critically ill children in the US.

Introduction: Knowledge of venous thromboembolism (VTE) risk factors may encourage timely thromboprophylaxis, hasten diagnosis and early treatment that could help to reduce VTE-associated morbidity and mortality. However, prior studies in the intensive care unit (ICU) yielded numerous, often non-reproducible VTE risk factors. Hypothesis: The objective of this study was to determine the independent risk factors for VTE in medical-surgical critically ill patients enrolled in a heparin prophylaxis trial. Methods: In 3,764 ICU patients in 6 countries, Research Coordinators collected VTE risk factor data. We defined VTE as any leg or arm DVT or pulmonary embolism (PE) identified by protocolized twice weekly leg ultrasound, by clinical suspicion and objectively confirmation, or found incidentally on imaging to seek another diagnosis. We conducted multivariate Cox regression analyses to determine the independent DVT predictors (both baseline characteristics and time-dependent characteristics), allowing for censoring due to death or discharge. Results: The rate of VTE was 9.1% in this cohort, 89.7% of whom were receiving mechanical ventilation. Personal or family history of VTE was associated with a significantly higher risk of VTE (hazard ratio (HR) 1.64, 1.03–2.59, p ⫽ 0.05) and body mass index (BMI) (HR 1.18 1.04 –1.35, for each 10 unit increase, p ⫽ 0.01). The overall BMI was 28.3 (⫹8.1) in the dalteparin group and 28.2 (⫹7.3) in the UFH group; 3.2% of patients had a personal VTE history and 1.5% had a family VTE history. Conclusions: Robust knowledge about independent VTE risk factors helps to identify patients needing increased attention to DVT prevention, diagnosis and treatment. We identified only 2 independent risk factors for VTE, patient or family VTE history and obesity, neither of which is modifiable in the ICU setting. Funding: CIHR, Heart and Stroke Foundation of Canada.


Posters: Ethics and End of Life 673

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CLINICIANS’ UNDERSTANDING OF THE DETERMINATION OF DEATH

EFFICACY OF PALLIATIVE CARE AND PALLIATIVE CARERELATED INTERVENTIONS IN THE ADULT INTENSIVE CARE UNIT–A SYSTEMATIC REVIEW

Paul Shore, St. Christopher’s Hospital For Children, Jameson Dyal, University of Pennsylvania, Kavita Morparia, St. Christopher’s Hospital for Children, Sharon Leonardo, St Christopher’s Hospital for Children, Scott Halpern, University of Pennsylvania School of Medicine Introduction: The definition of death as “irreversible cessation of circulatory and respiratory functions, or all functions of the entire brain” is conceptually simple but lacks critical specificity. This ambiguity has led to controversy in certain areas, such as organ donation after circulatory death (DCD), where some contend that death must be defined precisely and unambiguously. Whether published guidelines (including SCCM’s) reflect clinicians’ views on when death ensues is unknown. Hypothesis: Pediatric clinicians’ conceptualizations of death may conflict with current guidelines for DCD. Methods: As a preliminary gauge of the “state of the art” in the determination of death, we surveyed clinicians (n ⫽ 108) in a pediatric tertiary care facility who provide end-of-life care for terminally ill children. Using a 2 ⫻ 2 factorial design, we presented 4 vignettes of terminally ill children undergoing withdrawal of support, varying the time after withdrawal (1 or 10 min) and the child’s cardiac rhythm (asystole or sinus rhythm without pulse) at the time respondents were asked whether death had ensued. We elicited factors relevant to respondents’ decisions, and queried a random subset whether they would allow organ donation for the child described. Results: Response rate was 91%. Of 98 respondents (62% physicians, 38% nurses), 82% felt the asystolic child was dead at 1 min and 96% at 10 min; in contrast, 25% felt the child in sinus rhythm without pulse was dead at 1 min and 39% at 10 min. Most respondents (⬎91%) cited physiologic concepts of death (eg, cardiac electrical activity) as rationales; fewer (⬍38%) cited value-based constructs (eg, “personhood”). Most (⬎75%) were willing to donate the organs of those they considered dead even if their determination conflicted with DCD guidelines; those who were unwilling often cited organ perfusion rather than ethical reasons. Conclusions: Pediatric clinicians consider both cardiac electrical activity and time when determining death. They generally support DCD, but practices may not reflect current recommendations due to differences in views regarding when children are dead. Further experimental studies are needed to identify other factors contributing to conceptualizations of death.

Rebecca Aslakson, The Johns Hopkins University School of Medicine, Daniela Vollenweider, John Hopkins University, Dragos Galusca, Johns Hopkins Hospital, Peter Pronovost, The John Hopkins University School of Medicine Introduction: Over the last decade, a Robert Wood Johnson Foundation-funded group identified seven domains of quality end-of-life ICU care, the Improving Palliative Care in the ICU group described types of ICU-based palliative care interventions, and multiple interventions to improve ICU-based palliative and end-of-life care have been tested. Yet, which ICU-based palliative care interventions or types of interventions are actually effective? We conducted a systematic review of the literature. Hypothesis: Certain palliative care interventions and types of interventions (consultative, integrative, mixed) are more effective. Methods: We systematically searched MEDLINE, EMBASE, CINAHL, the Cochrane Library, and the Web of Science, performed a search of articles published by opinion leaders in the field, and reviewed hand-search articles. We included only trials of adult patients that evaluated any ICU intervention and involved a Robert Wood Johnson group-identified domain. We excluded case series/editorials/review articles. We focused on patient and caregiver satisfaction, mortality, and ICU and hospital length of stay. Results: Our search strategy yielded 2,708 references, of which we included 27 studies detailing 23 unique interventions. Interventions were highly heterogeneous, outcome measures varied widely, and many studies were underpowered and/or subject to multiple biases. Only four studies were randomized controlled trials. The majority of interventions significantly shorted ICU and hospital length of stay but did not affect ICU mortality. No studies showed a decrease in patient or provider satisfaction with multiple studies increasing satisfaction. Consultative interventions were more likely than integrative interventions to improve a variety of outcomes. Conclusions: Heterogeneity of interventions and poor study design make comparison of different ICU-based palliative care interventions difficult. However, existing evidence suggests these interventions are likely to decrease hospital and ICU length-of-stay while either improving or not changing satisfaction and not affecting mortality. Certain types of interventions may be more likely than others to impact outcomes.

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GUIDELINE FOR WITHHOLDING AND WITHDRAWING THERAPY AT THE ICU: CAN IT IMPROVE INTERDISCIPLINARY COLLABORATION AND PATIENT CARE?

REAL-TIME PERSPECTIVES OF SURROGATE DECISION MAKERS REGARDING CRITICAL ILLNESS RESEARCHFINDINGS OF FOCUS GROUP PARTICIPANTS

Hanne Jensen, Vejle Hospital, Jette Ammentorp, Faculty of Health Science, ` ding, Vejle Hospital Helle O

Ellen Iverson, Chlidrens Hospital Los Angeles, Aaron Celious, Childrens Hospital Los Angeles, Carie Kennedy, Washington University School of Medicine, Erica Shehane, Childrens Hospital Los Angeles, Alex Eastman, University of Texas Southwestern Medical Center, Victoria Warren, University of Texas Southwestern School of Medicine, Dragana Bolcic-Jankovic, Brian Clarridge, U Mass, Boston, Bradley Freeman, Washington Univ. School of Medicine

Introduction: Considerations to withhold or withdraw therapy are common in intensive care units (ICUs). In order to clarify, describe and attain consensus on standards for the decision process the aim of this study was to develop, implement and evaluate a guideline for withholding and withdrawing therapy at the ICU. Hypothesis: A guideline will increase satisfaction with multi-disciplinary collaboration, decrease experiences of irrelevant changes in withholding therapy orders and unnecessary postponement of withdrawal decisions. Additionally, for patients with therapy withdrawn, length of stay in the ICU will decrease. Methods: A guideline for withholding and withdrawing therapy was developed based on literature, interviews, questionnaire survey, multidisciplinary audits, inspiration from guidelines from American and other Danish ICUs, and hearing among health care professionals.The guideline was implemented in two regional Danish ICUs in May 2011 and will be evaluated in November/December 2011 by: ● A questionnaire survey regarding different aspects of end-of-life practices, including applicability of the guideline. Results will be compared with results from a similar survey conducted in the ICUs in 2010. ● Hospital record review of all patients admitted to the ICUs from 1 June 2011 to 30 November 2011. Results will be compared with a hospital record review conducted in 2009. Results: At baseline 24% of nurses, 42% of intensivists, and 63% of primary physicians found collaboration regarding end-of-life decisions very or extremely satisfactory. Additionally 42% of nurses, 26% of intensivists, and 2% of primary physicians found that withdrawing decisions were often, very often, or always unnecessarily postponed (1). Patients with therapy withdrawn stayed a mean of 7.0 days (median 3.1) in the ICU. Follow-up results will be analysed in January 2012. Conclusions: During both development and implementation the guideline was well received; it is expected that the hypotheses will be fulfilled. Reference: (1) Jensen HI, Ammentorp J, Erlandsen M, Ørding H. Withholding or withdrawing therapy in intensive care units: an analysis of collaboration among healthcare professionals. Intensive Care Med 2011 (in press)


Introduction: Clinical investigations involving cognitively impaired individuals are perceived as higher risk and requiring additional safeguards relative to studies enrolling cognitively intact participants. Previous investigations have examined the manner in which IRB’s apply such protections and have explored the views of individuals regarding substituted judgment for chronic disease research. We undertook the current investigation to examine these issues in the setting of critical illness. Methods: This prospective study involved SDMs for critically ill patients cared for in medical and surgical ICUs at two urban medical centers. SDMs participated in focus groups designed to explore central themes related to ICU care, clinical research, and the intersection of these domains. Transcripts were analyzed to identify common patterns and themes (Atlas.ti, Berlin). Results: The 74 SDMs participating were predominately female and described long-term relationships with patients (on average, over 3 decades). SDMs described their experience as ‘overwhelming’ and ‘stressful’, were often fatigued, and relied on family members, social contacts, and religion as sources of support. Many described a passive approach to decision making (acquiescing to care provider recommendations). Altruism was reported as common motivation for potential study participation. While research was generally perceived as optional, some SDMs viewed invitation for research participation as tacit acknowledgement of therapeutic failure. SDMs expressed a preference for observational studies (perceived as low risk) over interventional designs (perceived as higher risk), and were interested in receiving aggregate study results. Trust in the ICU team and the research enterprise seemed tightly linked. Individuals describing a negative ICU experience placed less trust in the research enterprise than individuals viewing their ICU experience favorably. Conclusions: Despite emotional burdens, SDMs expressed interest in clinical investigation. In study recruitment efforts, investigators must be sensitive to the emotional state of SDMs and potential motivations for participation so as to avoid exploitation of unrealistic expectations or misconceptions.

677

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COPENHAGEN CRITICAL CARE CRITERIA (CCCC): A SYSTEMATIC EVALUATION CHART FOR ADMISSION TO THE ICU

AN EXPLORATION OF THE EXPERIENCE OF PEDIATRIC INTENSIVISTS WITH CONSULTATION OF A MULTIDISCIPLINARY PALLIATIVE MEDICINE TEAM

Jens Borglum, Kenneth Jensen, Copenhagen University Hospital Bispebjerg

Jean Dozier, Jeffrey Gold, Robert Bart, Children’s Hospital Los Angeles

Introduction: The medical emergency team (MET) systems call for professionals to interfere whenever a patient’s condition deteriorates rapidly. It has been the held belief that early intervention (and MET systems) could save lives. However, MET systems may also be viewed as a safety net for an imperfect health care system with understaffed wards and undereducated staff, especially during evening and night-time shifts. MET professionals are often forced to make difficult decisions based upon a very short case history, and decisions are often made under extreme duress. Hypothesis: A recent study (Chrysochoou et al, Critical Care 2006) did not show the expected reduction by MET in the incidence of cardiac arrest, unplanned ICU admissions, or unexpected deaths; a similar investigation at our own hospital led us to propose a revised systematic evaluation chart for admission to the ICU, to aid the MET professionals reach the best possible decisions in a stressed environment. Methods: We have named this evaluation chart The Copenhagen Critical Care Criteria (CCCC). It builds on three basic ethical dilemmas: 1) The principle of justice (the decision must be fair and equitable); 2) the principle of beneficience (the decision must be in the best interest of the patient); and 3) the principle of respect (the patient’s requests are honored to the best of our ability). Results: The CCCC forces the clinician to decide on the presence of each of the following items: 1) futility of treatment; 2) nursing home resident; 3) severely impaired mobility; 4) cachexia; 5) irreversibility of disorder; 6) dementia or severe psychiatric illness; 7) multiple chronic organ failures; 8) patient refusal of life support, or uncooperation. The presence of any one of these criteria will deny ICU admission. Conclusions: We propose that the CCCC is a simple and intuitive chart that may help clinicians decide on ICU admission for a wide group of patients seen by the MET system. Its elements focus on adding value to ICU treatment, and we concede that its contents may be controversial for some.

Introduction: Studies indicate PICU physicians are moderately comfortable addressing end-of-life (EOL), therefore, consultation for EOL by Palliative Medicine (PM) continues to grow. In an effort to understand the experience of involving a multidisciplinary PM team in the care of critically ill children and gain insight into those referred by the PICU, an exploratory study was developed. Hypothesis: The intent is to understand which patients are referred to PM and the experiences of the PICU intensivists most frequently consulting PM. Methods: Charts of patients referred to PM (January 2009 –April 2010) were reviewed for demographics, clinical characteristics and to identify the PICU intensivist consulting PM. 6 semi-structured interviews were conducted (intensivists making ⱖ3 referrals), recorded and transcribed. Interviews were designed to explore physicians’ perceptions of PM. Phenomenological methods were used for analysis. Results: PM function and role are in flux and broadening. These PICU intensivists had no or little exposure to PM prior to and outside of the consults. Education is an important function of PM. Intensivists feel comfortable addressing some issues covered by PM, but feel that all issues encompassing EOL are more comprehensively addressed by the multidisciplinary nature of PM. Although multiple barriers to consulting PM exist, some personal, most barriers can be overcome. Current triggers for obtaining a PM consult are subjective. Overall satisfaction with PM is high; intensivists interviewed are likely to use PM in the future. Conclusions: Although pediatric intensivists generally feel comfortable providing EOL care, additional services and support provided by PM enhance the quality of care for patients, families, and staff. From the intensivists’ perspective, the most significant contributions consist of time, social support, consistent messaging and follow-up. Objective triggers and team standardization may lead to more frequent and efficient utilization of PM. Consistent ICU education regarding PM and services provided by an institution’s team is an important function that can lead to greater patient benefit through increasingly efficient and appropriate involvement of PM teams.


Posters: Patient and Family Support 679

680

MEASURING DECISION-MAKING AND INFORMATION SEEKING PREFERENCES OF PARENTS OF CRITICALLY ILL CHILDREN

PARENTAL SOURCES OF SUPPORT WHEN MAKING DIFFICULT DECISIONS IN THE PEDIATRIC INTENSIVE CARE UNIT AND ASSOCIATION WITH DECISION MAKING PREFERENCES

David Epstein, Children’s Hospital Los Angeles, Jennifer Unger, Keck School of Medicine of USC, Beatriz Ornelas, Jennifer Chang, Barry Markovitz, David Moromisato, Children’s Hospital Los Angeles, Peter Dodek, St. Paul’s Hospital and UBC, Daren Heyland, Kingston General Hospital, Jeffrey Gold, Children’s Hospital of Los Angeles

Vanessa Madrigal, Karen Carroll, Kari Hexem, Children’s Hospital of Philadelphia, Wynne Morrison, The Children’s Hospital of Philadelphia, Chris Feudtner, Children’s Hospital of Philadelphia

Introduction: We assume that parents desire great autonomy in the medical care of their children. The purpose of this study was to validate the Autonomy Preference Index survey (API) by Ende et al (1989) in parents with critically ill children. Hypothesis: We hypothesized that the API would be a valid measure for parents with children admitted to the ICU, with Caucasian parents desiring more autonomy, compared to Latino parents. Methods: We performed a study, using a modified version of the API (1/2011– 8/2011). Parents of children, ⬍18 years old, admitted to the cardiothoracic ICU, and on hospital day 3 or 4 were eligible. Only English-speaking Caucasian and Latino parents present for at least 2 of those hospital days were approached. ANOVA was used for analysis. Results: Sixty-six parents completed the survey (62% Latino). The modified API had a Cronbach’s alpha coefficient (␣) of 0.71. Comprised of 2 dimensions, the API 15 item, decision-making section (DM) ␣ was 0.62, while the API 8 item, information seeking section (IS) ␣ was 0.87. With removal of 6 general items and using only 3 clinical vignettes (9 questions), the DM ␣ was 0.77 for Caucasian and 0.86 for Latino parents. The IS ␣ was 0.85 for Caucasian and 0.81 for Latino parents. Scoring sections from 0 –100 (100 ⫽ greatest DM autonomy/IS preference), there was no difference in the mean ⫾ SD DM score (clinical vignettes only) between Caucasian and Latino parents (32⫾12.7 vs. 32⫾15.2, respectively; p ⫽ 0.94). However, the mean ⫾ SD IS score was higher for Latino parents than Caucasian parents (85.8⫾6.7 vs. 79.6⫾17.1, respectively; p ⫽ 0.04). With only clinical vignettes in the DM section, the overall API score was not different between Caucasian and Latino parents (p ⫽ 0.23). The final ␣ of the modified API, using only DM clinical vignettes, was 0.84. Conclusions: The modified API (using only DM clinical vignettes) is a valid tool for assessing autonomy in DM and IS in Caucasian and Latino parents with children in the ICU. While parents preferred less autonomy in decision-making, they still desired to be well informed. There was no overall difference in the API scores between Caucasian and Latino parents; however, Latino parents had a higher IS preference.

Introduction: When making difficult medical decisions for their ill children, parents rely on a variety of sources for support and guidance. We assessed if the sources that parents’ rank most highly are associated with parents’ preferred mode of medical decision making across a spectrum, from autonomous to shared to delegating to the medical team. Hypothesis: Parents’ “most likely used” sources of support and guidance is associated with their preferred mode of medical decision making. Methods: IRB approved, prospective cohort study of parents whose children were ⬍18 yrs old (or cognitively incapable of making their own decisions) and were hospitalized in the PICU for ⬎72 hours. We developed a five-point Likert scale instrument asking parents how likely they are to rely on specific sources of guidance and support when making a decision regarding the care for their child (5, very likely; 3, neutral; 1, very unlikely). Results: 87 parents of 75 index patients enrolled in the study. Overall, parents’ greatest sources of support included physicians (mean 4.7), nurses (4.2), friends (4.1), and their “instincts” (4.1). Less important sources of support were support groups (2.9), spiritual leaders (2.7), and church community (2.6). Parents’ own research (3.5) and prayer (3.5) ranked in the middle of the available support options, below “other” healthcare providers (3.7) and above spouses or marital partners (2.1), although when only married parents were included, spouses rated higher (3.0).Parents desiring full autonomy were more likely to rely on their spouse (p ⫽ 0.02) and on their own research (p⬍0.01). Parents who relied primarily on MDs ranked “their instinct” lower (p ⫽ 0.05), and were also more likely to rank their spiritual leader (p ⫽ 0.10), church community (p ⫽ 0.09), higher power (p ⫽ 0.09), and prayer (p ⫽ 0.07) lower than other parents. Parents who preferred shared decision making were more likely to rank “what my child wants” highly (p ⫽ 0.05). Conclusions: Our innovative assessment of parental sources of support and guidance when making difficult medical decisions reveals a strong association between most likely used sources and preferred modes of decision making.

681 COMPARISON OF FAMILY SATISFACTION BETWEEN CAUCASIAN AND LATINO PARENTS OF CRITICALLY ILL CHILDREN David Epstein, Children’s Hospital Los Angeles, Jennifer Unger, Keck School of Medicine of USC, Beatriz Ornelas, Jennifer Chang, Barry Markovitz, David Moromisato, Children’s Hospital Los Angeles, Peter Dodek, St. Paul’s Hospital and UBC, Daren Heyland, Kingston General Hospital, Jeffrey Gold, Children’s Hospital of Los Angeles Introduction: It is not known whether race/ethnicity affects satisfaction with critical care. The Family Satisfaction in the Intensive Care Unit survey (FS-ICU 24) assesses satisfaction of family members with care and decision-making (DM) related to their critically ill relatives. The purpose of this study was to compare the satisfaction of Caucasian and Latino parents with children in the ICU, using the FS-ICU 24. Hypothesis: We hypothesized that there would be differences in satisfaction with care and DM between Caucasian and Latino parents of critically ill children. Methods: A modified version of the FS-ICU 24 was studied (1/2011– 8/2011), in a children’s hospital. Parents of children, ⬍18 years old, admitted to the cardiothoracic ICU, and on hospital day 3 or 4 were eligible. Only English-speaking Caucasian and Latino parents present for at least 2 of those hospital days were approached. Differences between groups were assessed using ANOVA, Chi-square, and Student’s t tests as appropriate. Results: Sixty-nine parents completed the survey (64% Latino); 75% of these parents were mothers. The number of prior ICU admissions and percentage of mothers completing the survey did not differ between the two ethnic groups. Latino parents were found to be younger (mean age ⫾ SD: 29.0⫾8.7 vs. 35.0⫾9.1; p ⫽ 0.01), more likely to have state-sponsored health insurance (58% vs. 24%; p⬍0.01), less likely to be born in the US (70% vs. 92%; p ⫽ 0.04), and less likely to have graduated from high school (79% vs. 96%; p⬍0.01) than their Caucasian counterparts. Overall, there were no significant differences in satisfaction scores between Caucasian and Latino parents (p ⫽ 0.12). Parent demographics did not appear to significantly affect the results. However, Latino parents rated concern and caring by ICU staff (p⬍0.01), atmosphere of the ICU (p ⫽ 0.03), and consistency of information (p⬍0.01) higher than Caucasian parents. Conclusions: There was no difference in overall satisfaction with care and DM for English-speaking Caucasian and Latino parents of critically ill children. Because of the small sample size, no difference in overall satisfaction may represent a type II error and further study with a larger sample may be warranted.


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PSYCHOMETRIC EVALUATION OF THE FAMILY SATISFACTION IN THE INTENSIVE CARE UNIT SURVEY (FS-ICU 24) IN PARENTS OF CRITICALLY ILL CHILDREN

VARIATIONS OF PARENTAL PERCEPTIONS REGARDING QUALITY OF CARE IN RELATION TO SEVERITY OF SICKNESS IN PEDIATRIC PATIENTS

David Epstein, Children’s Hospital Los Angeles, Jennifer Unger, Keck School of Medicine of USC, Beatriz Ornelas, Jennifer Chang, Barry Markovitz, David Moromisato, Children’s Hospital Los Angeles, Peter Dodek, St. Paul’s Hospital and UBC, Daren Heyland, Kingston General Hospital, Jeffrey Gold, Children’s Hospital of Los Angeles

Mohammed Naeem, Amir Umair, King Abdulaziz Medical City

Introduction: The FS-ICU 24 has only been validated in family members of adult patients in the ICU. The purpose of this study was to evaluate the psychometric properties of the FS-ICU 24 by comparing it to a pediatric ICU satisfaction survey by McPherson et al (2000). The FS-ICU 24 contained novel questions regarding decision-making (DM) that were not contained within McPherson’s survey. Hypothesis: We hypothesized that a modified version of the FS-ICU 24 was a useful tool to assess satisfaction of parents with critically ill children. Methods: We performed a study using a modified version of the FS-ICU 24 (1/2011– 8/2011), in a children’s hospital. Parents of children, ⬍18 years old, admitted to the cardiothoracic ICU, and on hospital day 3 or 4 were eligible. Only English-speaking Caucasian parents present for at least 2 of those hospital days were approached at this stage of the study. All participants completed both the FS-ICU 24 and McPherson’s survey, with the order of the two surveys counterbalanced. The correlation between the 2 surveys and Cronbach’s alphas (␣) for each survey were calculated. Results: Twenty-five parents completed the surveys (mean age⫾SD ⫽ 35.0⫾9.1 years) and most were mothers (68%). The modified FS-ICU 24 had an ␣ of 0.93 and McPherson’s survey had an ␣ of 0.92. Overall, parents’ scores on the FS-ICU 24 and McPherson surveys were significantly intercorrelated (r ⫽ 0.66; p⬍0.001). The FS-ICU 24 care section and McPherson (r ⫽ 0.647; p⬍.001), FS-ICU 24 care and FS-ICU 24 DM sections (r ⫽ 0.83; p⬍0.001), and FS-ICU 24 DM section and McPherson (r ⫽ 0.587; p⬍0.005) were all highly intercorrelated. Sixty-eight percent of the variance in FS-ICU 24 care section was shared with FS-ICU 24 DM section. Conclusions: The modified FS-ICU 24 was a psychometrically useful measure of satisfaction with care and DM for parents of children in the ICU. Although the FS-ICU 24 and McPherson’s survey were significantly correlated, there were aspects of DM on the FS-ICU 24 that were not captured by McPherson’s survey. Overall, the FS-ICU 24 had a high internal consistency and reliability, was easy to complete, and provided important information on parental DM that was not captured by McPherson’s survey.

Introduction: Parents-centered care (PCC) helps improve quality of care in pediatrics. The perceptions of parents play a key role in PCC. Factors like child’s medical condition, psycho-social and religion influence perceptions and PCC. Understanding these factors shall help improve PCC. Hypothesis: This study aimed at understanding the impact of the patients severity of disease on perceptions of their parents. Methods: In this questionnaire-based survey, a hospital approved questionnaire was completed face to face by parents of admitted (for 5–15d) pediatric (1 mo-14yrs) patients, using convenience sampling, period of 45 days. Admissions in pediatric wards (PW-group 1) or sick children in pediatric intensive care unit (PICU-group2). PICU admissions were under the hospital admission criteria related to severity of sickness based on PRISM II score. Study was approved by Institutional Review Board, Research and Ethics Committees. Questionnaire Items (n ⫽ 37) are divided into 5 categories. Data was analyzed using SPSS utilizing Pearson Chi Square test, fisher’s exact test, Significance noted at p⬍0.05. Results: Parents approached 144. 99 (69%) participated (grouponePW64-group2PICU35). Significant difference in 22/37 items between two groups. Each category: In Patient related: Significant difference present regarding condition, diagnosis, the course of illness, treatment and alternative medicine all p⬍0.0001 . In Support Related: Significant difference present regarding meetings, psychological support, social workers role, all p⬍0.0001. In Staff-related: Significant difference present regarding nursing care (p⬍0.0001), doctors availability (p⬍0.0001), consultations (p ⫽ 0.013) and pharmacists (p ⫽ 0.017). In Ancillary Medical Care and Hospital Policies categories: Significant difference present regarding hospital equipment (p⬍0.0001), hospital capacity (p ⫽ 0.006), personnel resources (p ⫽ 0.006), medical errors (p⬍0.0001), and collaboration needs (p ⫽ 0.004). Conclusions: Parents of children with different severity of disease express significantly different perceptions about care. This impact advises a revision of the current parent satisfaction assessment tools. A larger scale multi-center and multi-ethnic study is suggested.


Posters: Therapeutics-Drugs and Pharmacokinetics-1 684

685

FIVE-YEAR EXPERIENCE WITH HYDROCORTISONE USE FOR SEPTIC SHOCK

PHARMACOLOGICAL VENOUS THROMBOEMBOLIC EVENT PROPHYLAXIS IN HOSPITALIZED CHRONIC LIVER DISEASE PATIENTS

Stephanie Edwin, Saint John Hospital and Medical Center, Cindy Brach, Cathy Strachan, Cesar Alaniz, Robert Hyzy, University of Michigan Introduction: According to the surviving sepsis campaign guidelines, hydrocortisone is a therapeutic option for patients who respond poorly to fluid resuscitation and vasopressor therapy. It has been suggested that use of hydrocortisone (HC) may be of benefit in patients more severely ill at baseline. Hypothesis: Use of hydrocortisone for the management of septic shock will not be associated with decreased mortality, irrespective of baseline APACHE III (AP3) score. Methods: This was a retrospective, case controlled study. Patients were included in the study if admitted to the medical intensive care unit with a diagnosis of septic shock between January, 2004 and December, 2008. Mortality rate was determined for patients who received HC therapy compared to those that did not receive the drug. Mortality was determined for the entire cohort and for quartiles based on baseline AP3 scores. Results: There were 857 patients included for evaluation. The median AP3 score was 92.0 (interquartile range: 71.25–116). Overall mortality for the HC cohort was 36.8% (142/386) compared to 36.9% (174/471) in the non-HC cohort (p ⫽ 0.963). The mortality rate of HC versus non-HC cohorts by AP3 quartiles were as follows: 6.9% vs. 7.1% (AP3⬍71.25, p ⫽ 0.96), 25% VS. 25.9% (AP3 71.25–92, p ⫽ 0.88), 38.2% vs. 40.7% (AP3 92–116, p ⫽ 0.72), and 74% vs. 78.8% (AP3⬎116, p ⫽ 0.41). Conclusions: Use of HC for the management of septic shock was not associated with a decrease in mortality when compared to patients who did not receive HC and were at similar risk of death.

Sean Barclay, Meghan Jeffres, KimChi Nguyen, Tamdan Nguyen, Roseman University of Health Sciences Introduction: Historically chronic liver disease (CLD) has been associated with coagulopathy due to the role of the liver in the production of clotting factors, however the equally important production of anticoagulants is also impaired which may restore the hemostatic balance and place them at risk for venous thromboembolic events (VTE). Hypothesis: The use of pharmacological VTE prophylaxis in patients with CLD will result in a decreased rate of VTE. Methods: Medical records of all adult patients admitted for greater than 24 hours to a university-affiliated hospital from April 2008 through April 2011 with an ICD-9 code for CLD were reviewed. Patients were excluded due to active thrombosis upon admission or receipt of chronic anticoagulation therapy. Medical records were reviewed for the primary outcome of VTE and divided into two groups based on receipt of pharmacological VTE prophylaxis. Results: Over the study period there were 1581 hospitalizations included. Of these 392 (24.7%) received pharmacological VTE prophylaxis. The incidence of VTE was lower in the treatment group (0.5% vs 1.8%, p ⫽ 0.050). Documented bleeding rates were lower in the treatment group (10.3% vs 2.0%, p⬍0.001). Key differences between treatment groups included greater incidence of Child-Pugh class C (28.6% vs 17.9%, p⬍0.001) and higher history of bleed (23.3% vs 5.9%, p⬍0.001) in the non-treatment group. Multivariate logistic regression identified previous VTE and malignancy as predictors of VTE, odds ratio 8.211 (95% CI 2.482–27.171) and 24.875 (95% CI 6.921– 89.404) respectively. Use of pharmacological VTE prophylaxis was identified as a protective against VTE, odds ratio 0.217 (95% CI 0.049 – 0.962). INR was not associated with development of VTE. Conclusions: Pharmacological VTE prophylaxis is associated with a decrease incidence of VTE in patients with CLD without an increased risk of bleed and should be considered upon admission to the hospital. Patients with CLD and an active malignancy or history of VTE appear to be at the highest risk of VTE development and warrant pharmacological prophylaxis, however prospective studies must validate these findings.

686

687

DO NEUROMUSCULAR BLOCKERS IN ACUTE RESPIRATORY DISTRESS SYNDROME REDUCE MORTALITY: A SYSTEMATIC REVIEW AND META- ANALYSIS

DELAYED ANTIFUNGAL THERAPY LEADS TO POOR OUTCOMES IN CANDIDEMIA

Pablo Moreno Franco, Anil Paturi, Anil Patel, Rodrigo Cartin-Ceba, Mayo Foundation For Medical Education and Research Introduction: The use of Neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial, although frequent. The use of NMBA remains poorly studied in this indication. We performed a systematic review and meta-analysis of published randomized trials, examining the impact of neuromuscular blockers in Intensive Care Unit (ICU) mortality of patients with ARDS. Hypothesis: NMBA use in patients with ARDS reduces ICU mortality. Methods: Datasources utilized included Ovid MEDLINE, Ovid EMBASE, Cochrane Library, Web of Science, and SCOPUS, from database inception to January 2011, without language limitations. Study selection was performed by two reviewers independently and in duplicate. Eligible randomized trials where those using neuromuscular blockers for the treatment of ARDS in humans. Data extraction was also done by two reviewers independently and in duplicate using a standardized form to collect data from published trials. Cochrane RevMan Version 5 software was used to perform the metaanalysis. Statistical analysis was done using the Mantel-Haenszel statistical method and the random effect model. The effect size was measured by odds ratio (OR) with 95% confidence interval. Results: Three randomized trials reporting ICU mortality in ARDS patients treated with neuromuscular blockers were identified. Total number of patients included in the analysis was 431. Of those 223 (51.7%) received neuromuscular blockers. There is a statistically significant decrease in mortality in the neuromuscular blockade group (Neuromuscular blockade group 31.4% vs Control group 44.7%), Odds ratio (OR) 0.56, 95% confidence interval (CI) 0.38 – 0.84. No significant heterogeneity between studies was identified. Conclusions: In patients with ARDS, administration of neuromuscular blockers decreased ICU mortality.


Jane Faris, Linda Browning, Philip Williams, Ryan Mynatt, Lisa Hall Zimmerman, Detroit Receiving Hospital Introduction: Isolation of non-albicans Candida spp. in invasive Candida infections is increasing and can be associated with mortality rates as high as 47%. Recent literature suggests that a delay in appropriate antifungal (AF) therapy is associated with worse patient outcomes. Hypothesis: The primary objective of the study was to characterize the relationship between the timing of empiric AF therapy and patient outcomes. Secondary outcomes included identifying the various Candida spp and risk factors for blood stream infections. Methods: This retrospective study included patients with candidemia that were hospitalized from 5/06 –11/10.Exclusion criteria were: age ⬍18 years and neutropenia. The patients were divided into survivors(S) and nonsurvivors(NS). Time to appropriate antifungal therapy (TAAT) was defined as the time of culture collection to the administration of appropriate therapy. P-values ⱕ0.05 were considered significant. Results: 101 patients were evaluated, the mean age was 56.5⫹16, 60% were male, and 73% were African American. Candida spp. identified were C. albicans (36%), C. glabrata (24%), and C. parapsilosis (22%), with fluconazole being the initial therapy in 60% of patients. The overall mortality rate was 28% in this study. Risk factors for increased mortality included: age ⱖ55 years(p ⫽ 0.02), ESRD(p ⫽ 0.001), any central venous catheter(p ⫽ 0.02), and inappropriate AF therapy(p ⫽ 0.009). In comparison 29/65(45%) non-C. albicans group vs. 5/36(14%) C. albicans group were initiated on inappropriate AF therapy(p ⫽ 0.002). The occurrence of severe sepsis was higher in the NS vs. S group [26/ 28(93%) vs. 45/73(62%), p ⫽ 0.002] and the onset of candidemia while in the ICU was higher [26/28(93%) vs. 47/73(64%),p ⫽ 0.005]. Importantly, delayed TAAT ⱖ48 hours impacted mortality, [24/28(85%) NS vs.31/73(42%) S,p ⫽ 0.04]. Conclusions: Delays in TAAT ⱖ48 hours resulted in an increase in mortality rate(p⬍0.05). Increasing isolation of non-albicans Candida spp. in candidemia makes the selection and administration of an appropriate initialantifungal imperative to improve patient outcomes.

688

689

EFFECTS OF PRACTITIONER EXPERIENCE LEVEL ON FREQUENCY OF COMPUTER ENTRY MEDICATION DOSING ERRORS IN A PEDIATRIC INTENSIVE CARE UNIT

BENEFICIAL EFFECT OF IMMEDIATE ’C2-BLOCKER THERAPY IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Lilanthi Balasuriya, Paul Bakerman, Vanessa Holton, Pamela Garcia-Filion, Vinay Vaidya, Joan Westdorp, Phoenix Children’s Hospital

Michael Hirschl, Landesklinikum Waldviertel Zwettl, Christian Wollmann, Harald Mayr, Landesklinikum St.Poelten

Introduction: Practitioner experience should lead to increased familiarity with medication dosing. However, the busy critical care unit environment potentially leads to significant medication errors regardless of experience level. Hypothesis: Increased practitioner experience level decreases the frequency of serious medication prescribing errors. Methods: A custom Dose Range Checking (DRC) system was designed within the framework of computerized physician order entry with soft dose limits (SDL) and hard dose limits (HDL). Medication orders for patients admitted to the Pediatric Critical Care Unit (PCCU) were retrospectively reviewed. Frequency and response to these alerts were measured. Results: A custom dosage range checking program was instituted on 2/15/11 which included dose ranges for over 600 medications. Error rates were determined for residents, nurse practitioners and attending physicians. In the four months after DRC customization 17.9% (24,710/138,039) of medication orders were entered in the PCCUs. Of the total orders, 28.1% (n ⫽ 6,752) were written by residents, 48.2% (n ⫽ 11,604) by nurse practitioner, and 23.7 % (n ⫽ 5,695) by attending physicians. Practitioner level could not be determined in 2.7% (n ⫽ 659).There was a statistically significant difference in the total alert rate based on the experience level (p⬍0.001).Total alert rate was higher for residents [4.1% (274/6,752)] than nurse practitioners [2.6% (304/11,604)], or attending physicians [3.2% (181/5,695)]. For SDL, alerts were more common among residents [3.2% (215/ 6,752)] than for nurse practitioner [2.0% (234/11,604)] or attending physicians [2.0% (114/5,695)] (p⬍0.001). There was a difference in the HDL alert rate (p⬍0.001); HDL alert rate was higher for attending physicians [1.2% (71/ 5,695)] than for residents [0.9% (59/6,752)] and nurse practitioners [0.6% (70/ 11,604)]. Conclusions: Custom DRC effectively detected potentially serious drug dosing errors regardless of experience level. Increased practitioner experience was associated with a statistically significant reduction in total alert rates and SDL alerts. Attending physicians were more likely to order doses exceeding HDL.

Introduction: The American Heart Association recommends the initiation of beta-blockade to all patients with an ST-segment elevation myocardial infarction (STEMI) without contraindications to beta-blocking agents (BB). The few existing data provide conflicting evidence about the use of BBs. Hypothesis: The immediate use of BBs (at the time of first ECG) improves the outcome of patients with STEMI. Methods: Patients presented within 6 hours of the onset of an acute coronary syndrome and the primary diagnosis of a STEMI between January 1st, 2007 and December 31st, 2010 were included to the analysis. The data were drawn from the database of the Lower Austrian Myocardial Infarction Network, which consisted of 5 emergency medical services (EMS), 5 primary care hospitals and a PCI centre located in the western part of Lower Austria. The treatment protocol included thrombolysis or primary PCI as a reperfusion strategy and the optional use of metoprolol (2.5 to 5 mg) at the time of the first ECG. Results: Overall, 665 patients with STEMI were analyzed with regard to 30-day mortality and possible in-hospital complications associated with the use of BBs (congestive heart failure and cardiogenic shock). BBs were given in 343 (52%) patients. The 30-day mortality was significantly lower in those receiving BBs compared to those without BBs (1.75% versus 9.66%, p⬍0.0001). Analysing mortality according to reperfusion treatment the difference was significant in the primary PCI group (1.43% vs. 9.09%; p ⫽ 0.0008) and showed a non significant trend in the thrombolysis group (2.44% versus 6.82%). The rate of cardiogenic shock and congestive heart failure was similar in both groups (with BB vs. without BB: cardiogenic shock: 1.43% vs. 2.67%, congestive heart failure: 1.9% vs. 2.67%). Conclusions: We recommend the immediate application of BBs in patients with STEMI at the time of the first ECG. as this strategy improves the outcome of STEMI patients without an increase of possible BB associated complications.

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TREATMENT OUTCOMES IN SEVERE SEPTIC CANCER PATIENTS TREATED WITH DROTRECOGIN ALFA

IMPACT OF ANTIPLATELET RESISTANCE TESTING ON VASCULAR ANTIPLATELET REGIMENS

Krista Wahby, Harper University Hospital, Francois Gregoire, Ayman Soubani, Wayne State University School of Medicine

Alexis Crawford, William Cahoon, Stacy Voils, Virginia Commonwealth University

Introduction: The efficacy and safety of drotrecogin alfa, activated (DAA) in patients with cancer is underreported. Hypothesis: We hypothesized that DAA in severely septic patients with active cancer would produce similar safety and efficacy outcomes when compared to a matched cohort of non-cancer patients. Methods: This study analyzed all patients treated with DAA for SS at the Detroit Medical Center. Patients were divided into 2 groups, those with a cancer diagnosis (CAN) and those without. The CAN group was matched to a control group (CTR) in a 1:1 fashion based on year of administration, age, body mass index, APACHE score and comorbidities. Efficacy was measured by survival to ICU and hospital discharge. Safety was assessed by incidence of severe bleeding events, defined as, 1) intracranial bleeding (ICH); 2) any life-threatening bleeding event; 3) transfusion of ⬎2 Units of packed red blood cells on 2 consecutive days; or 4) any bleeding classified by the physician as serious. Fisher’s Exact, Student’s t-test and Chi Square were used. Results: 270 pts received DAA since 2002 and 15% (41) had an active cancer diagnosis. Types of cancer include: hematopoietic stem cell transplant 20%, hematologic malignancies 15% and solid tumors 65%. Baseline demographics were similar between groups. APACHE II scores were 30.2 ⫾ 5 and 28.5 ⫾ 7 (p ⫽ 0.28) for the CAN and CTR groups, respectively. Surgery within 2 weeks of DAA was similar (39% vs 37%, p ⫽ 0.18). There was no difference in ICU or hospital length of stay (12 ⫾ 15 and 20 ⫾ 19, p ⫽ 0.07 & 21⫾24 vs 24 ⫾ 20, p ⫽ 0.54) respectively. CAN patients had higher ICU and hospital mortality (56% vs 44%, p ⫽ 0.09 and 61% vs 46%, p ⫽ 0.07) however, this was not statistically significant. Severe bleeding events were similar (15% and 15%, p ⫽ 0.22). ICH occured in 2 CAN patients and no CTR patients. The CAN group required signifianctly more more platelet transfusions (22% vs 5%, p ⫽ 0.02). Conclusions: There was no statistically significant difference in mortality or bleeding events between cancer patients and a matched control group of critically ill patients with SS. Our results suggest that DAA has similar efficacy and safety in cancer patients when compared to non-cancer patients.

Introduction: In March 2010, a black box warning regarding the potential for inadequate antiplatelet response was added to clopidogrel labeling. Recent studies recommend utilization of the point-of-care Platelet Function P2Y12 Response Assay, a test that has been performed at our institution since November 2009, to identify clopidogrel resistant patients. Hypothesis: To assess prescriber response to P2Y12 platelet response testing and describe any therapeutic interventions. In addition, we examined the association between patient characteristics and inadequate antiplatelet response. Methods: A retrospective chart review was conducted of all hospitalized patients with clopidogrel utilization and P2Y12 Response Assay between November 2009 and October 2010. Patient demographics, clopidogrel dose and length of therapy, P2Y12 Response Assay results, and characterization of interventions made were collected from the medical record. Results: Of the 78 patients with a P2Y12 Response Assay, 77% were neurosurgery intensive care unit (ICU) patients and 23% were coronary ICU patients. Based on the P2Y12 Response Assay, 38% of patients were considered clopidogrel resistant. For patients with clopidogrel resistance, 63% had an intervention whereas only 21% of patients with an adequate clopidogrel response had a therapeutic intervention [OR 6.6 (2.4 –18.2), 0.001]. With regards to interventions, reloading with clopidogrel (n ⫽ 18, 23%) and retesting (n ⫽ 16, 21%) were the most common therapeutic interventions. We found no evidence of association between smoking [OR 1.9 (0.7–5.2), p ⫽ 0.21], diabetes [OR 1.2 (0.39 –3.5), p ⫽ 0.79], obesity [OR 0.64 (0.24 –1.71), p ⫽ 0.37], or age [OR 1.5 (0.60 –3.78), p ⫽ 0.39] and inadequate antiplatelet response. Patients who received a clopidogrel loading dose were actually less likely to have an adequate antiplatelet response [OR 0.24 (0.07– 0.79), p ⫽ 0.01]. Conclusions: Patients with clopidogrel resistance received an intervention significantly more often than patients with adequate clopidogrel response. No individual patient characteristic was found to be associated with inadequate platelet response and administration of a clopidogrel loading dose did not improve antiplatelet response.


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REDUCED ARGATROBAN BLEEDING RATES ASSOCIATED WITH AN INTENSIVE CARE UNIT SPECIFIC DOSING ALGORITHM IN THE CRITICALLY ILL

PERI-OPERATIVE SODIUM BICARBONATE INFUSION (POSBI) IN THE POST-CARDIAC SURGERY PATIENT: RESULTS OF SINGLE-INSTITUTION RETROSPECTIVE STUDY

Bruce Doepker, Anthony Gerlach, Crystal Girardot, Kari Mount, Claire Murphy, Lindsay Pell, Gary Phillips, The Ohio State University Medical Center

Ajit Shrestha, Peter Panagopoulos, Wayne State University/Detroit Medical Center, Deepak Gupta, Harper University Hospital, Dept. of Anesthesiology, Philip Khoury, Dimitrios Apostolou, Detroit Medical Center, Yaseer Al-Baghdadi, Wayne State University/Detroit Medical Center, Lawrence Safadi, Pranav Patel, Detroit Medical Center, Marc Orlewicz, Wayne State University/Detroit Medical Center

Introduction: Argatroban is a direct thrombin inhibitor used to treat confirmed or suspected heparin-induced thrombocytopenia. Bleeding rates have been reported between 12.5–29% in the critically ill. To prevent bleeding complications, an intensive care unit (ICU) specific dosing algorithm was created based on internal data. Hypothesis: Implementation of an ICU dosing algorithm will reduce the incidence of argatroban associated bleeding in the critically ill. Methods: A retrospective cohort study was performed to evaluate the incidence of bleeding associated with argatroban in patients admitted to the medical, surgical, and cardiothoracic ICUs. The pre-algorithm group received argatroban from June 2007-July 2008, and was compared to the post-algorithm group who received argatroban from August 2010-July 2011. Major bleeding was defined as a hemoglobin reduction of ⱖ2 g/dL plus a transfusion of ⱖ2 units of blood in a 24hr period, or a retroperitoneal, intracranial, or other life-threatening bleed. Minor bleeding was any bleed reported that did not meet major bleed criteria. Thromboembolic events were defined as any venous or arterial thrombosis that occurred during argatroban therapy. Categorical data was analysed using ?2 or Fisher’s exact. Continuous data were compared using Student’s t-test, or MannWhitney U for non-parametric data. Results: A total of 118 patients were included: 73 in the pre-algorithm and 45 in the post-algorithm group. APACHE II scores 24 hours prior to argatroban were similar between the pre- (23.6 ⫾ 7.9) and post-algorithm groups (21.8 ⫾ 8, p ⫽ 0.2). Initial dose was significantly reduced for the post-algorithm group (0.2 ⫾ 0.1 mcg/kg/min vs. 0.5 ⫾ 0.3 mcg/kg/min, p⬍0.001). There was a significant difference in the incidence of total bleeds between the pre- and post-algorithm groups (21.9% vs. 6.7%, p ⫽ 0.029). Seven (9.6%) pre-algorithm patients experienced a major bleed compared to only 1 (2.2%) post-algorithm patient (p ⫽ 0.15). There were no differences in thrombotic events between the pre- and post-algorithm groups (6.8% vs. 6.7%, p ⫽ 0.99). Conclusions: Bleeding was significantly reduced using an ICU specific dosing algorithm without causing increased rates of thromboembolic events.


Introduction: The acute renal dysfunction after cardiac surgery is multifactorial and although some studies have shown sodium bicarbonate as renal-protective, its use in cardiac surgery still remains controversial. Hypothesis: Peri-operative sodium bicarbonate infusion (POSBI) will decrease acute renal dysfunction in cardiac surgery patients and improve post-operative outcomes. Methods: After institutional review board approval, a retrospective analysis of all post-cardiac surgery patients over a three year period (2007–2010) was performed to compare biochemical renal parameters and clinical parameters in the patients who received or did not receive POSBI at our institution. Two groups were analyzed; 1) African-American (AA) patients (n ⫽ 89 POSBI; n ⫽ 97 no treatment) and 2) Non African-American (NAA) patients (n ⫽ 17 POSBI; n ⫽ 26 no treatment). Measured outcomes in the first five-post-operative days were changes in serum creatinine and incidence of acute renal dysfuntion as per the Acute Kidney Injury Network (AKIN) criteria. Additional analyzed clinical criteria included durations of ventilation, intensive care unit stay and post-operative hosptial stay, and 3-month mortality rates. Results: POSBI showed no difference within AA patients in regards to renal dysfunction [AKIN Stage 1: 31% vs 30% (p ⫽ 0.87); AKIN Stage 2: 4% vs 2% (p ⫽ 0.43); or AKIN Stage 3: 9% vs 10% (p ⫽ 0.81)]. POSBI also showed no difference within NAA patients in regards to renal dysfunction [AKIN Stage 1: 18% vs 35% (P ⫽ 0.3); AKIN Stage 2: 6% vs 4% (p ⫽ 0.99); and AKIN Stage 3: 0% vs 0% (p ⫽ 0.99)]. No difference was observed in the maximal change in the serum creatinine in the first five post-operative days following POSBI within AA patients (p ⫽ 0.91) and within NAA patients (p ⫽ 0.56). For other post-operative clinical outcomes measured, the only statistically significant finding was a decreased duration of ventilation in the AA patients who received POSBI [2.0 days vs 4.8 days (p ⫽ 0.0025)]. Conclusions: POSBI did not result in measurable renal protection in post-cardiac surgery patients. A clinical benefit with POSBI was reduced duration of mechanical ventilation in AA patients.


695

EVALUATION OF VANCOMYCIN AND CEFEPIME PHARMACOKINETICS IN CRITICALLY ILL NEUROSURGICAL PATIENTS

THE INCIDENCE OF PERIPHERALLY INSERTED CENTRAL CATHETER OCCLUSION REQUIRING TISSUE PLASMINOGEN ACTIVATOR

Lynn Anliker, University of MIssouri Kansas City, Tyree Kiser, University of Colorado At Denver and Health Sciences Center, Douglas Fish, University of Colorado, Deb Sherman, University of Colorado Hospital, Robert MacLaren, University of Colorado School of Medicine, Robert Neumann, University of Colorado Hospital Introduction: Critically ill patients with neurologic insults shunt blood to vital organs due to increased sympathetic output and peripheral vasoconstriction. Increased renal blood flow may augment filtration of renally eliminated medications, like vancomycin and cefepime, resulting in subtherapeutic concentrations. Hypothesis: We hypothesized that higher vancomycin and cefepime dosages are required in critically ill neurosurgical patients to achieve goal pharmacodynamic targets when treating nosocomial infections. Methods: This prospective study randomized patients, 18 to 89 years of age, admitted to the Neurosurgery ICU service with creatinine clearance (CrCL) ⬎50 ml/min, to receive vancomycin 15 mg/kg and cefepime 2 g intravenously at either q8 hour or q12 hour frequencies. Serial blood samples for pharmacokinetic analyses were collected on Day 2–3 of therapy and then again between Day 7–10. Vancomycin and cefepime goal pharmacokinetic targets were AUC/MIC ⱖ400 and T⬎MIC ⱖ50% for MRSA and Pseudomonas, respectively. Results: An interim analysis of 9 patients was performed; 5 in the q12h group and 4 in the q8h group. Patients in the two groups were similar in age, gender, race, CrCL, and hospital days prior to antibiotic therapy. The target vancomycin AUC/MIC ratio was achieved in 100% of patients in both groups at a MRSA MICⱕ0.5 (p ⫽ 0.99), 60% of patients in q12h group vs. 100% of patients in q8h group at MICⱕ1 (p ⫽ 0.44), and in 0% of patients in the q12h group vs. 75% of patients in the q8h group at MICⱕ2 (p ⫽ 0.0476). No patients in the q12h group achieved an initial trough ⬎15 mcg/mL vs. 100% of the patients in the q8h group, p ⫽ 0.0075. Time above MIC⬎50% for cefepime was achieved 50% of the time in the q12h group and 83% of the time in the q8h group at a pathogen MICⱕ8, p ⫽ 0.30. Conclusions: This interim analysis demonstrates that more frequent dosing of vancomycin and cefepime is required to achieve optimal pharmacodynamic targets for MRSA and Pseudomonas, particularly as the MIC of the organism approaches the CLSI breakpoints.

Kevin Silinskie, Mindee Hite, Rochester General Hospital Introduction: Catheter occlusion is a common complication of peripherally inserted central catheters (PICC). To date, minimal national benchmarks exist related to occlusion rates. We sought to identify the overall rate of occlusion after Rochester General Hospital (RGH) switched from various PICC manufacturers to a standardized line, the PowerPICC SOLO. At the same time, RGH switched from a heparin-based flush to a saline-only flush policy to minimize the risk of heparin-induced thrombocytopenia. Hypothesis: Implementation of a new PICC line with a saline-only flush policy will not alter the rate of catheter occlusions or utilization of tissue plasminogen activator (tPA). Methods: A database query followed by a retrospective chart review was conducted to identify adult ICU patients who received a PICC line during their hospital admission between September 2009 to November 2009 (pre-group) or September 2010 to November 2010 (post-group). Occlusion rates were determined by counting the number of PICC line occlusions requiring tPA normalizing the rates based upon the number of occlusions per 1000 central line days (CLD). The overall number of times that tPA was administered was collected. Statistical analysis was performed using either a Chi-square or student t-test. Results: Of the 84 patients in the pre-group, 23 patients (27.4%) received at least one dose of tPA as compared to 30 of 108 patients in the post-group (27.8%, p ⫽ 1.0). In the 105 PICC lines placed in the pre-group, 36 doses of tPA were administered (0.34 tPA doses per central line) to clear an occlusion compared to 46 doses of tPA in 118 PICC lines in the post-group (0.39 tPA doses per central line, p ⫽ 0.49). The prevalence of occlusion requiring tPA was 19.7 per 1000 CLD in the pre-group compared to 23.8 per 1000 CLD in the post-group (p ⫽ 0.43). The mean time to tPA administration was 13.3 ⫾ 12.2 days in the pre-group as compared to 18.2 ⫾ 15 days in the post-group (p ⫽ 0.12). Conclusions: We found that the RGH total occlusion rate of approximately 27% to be higher than the national average of 8 –25%. While the difference is not statistically significant, the difference is clinically significant and suggests a need for improvement.

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NICARDIPINE VERSUS LABETALOL FOR THE MANAGEMENT OF ACUTE HYPERTENSION IN CRITICALLY ILL PATIENTS

BENCH TO BEDSIDE: THE IMPACT OF PROLONGED INFUSION OF BETA-LACTAMS FOR THE TREATMENT OF GRAMNEGATIVE INFECTIONS IN ICU PATIENTS

Jill Logan, Johns Hopkins Bayview Medical Center, Stella Papadopoulos, Boston Medical Center, Allan Walkey, Boston University, Kevin Horbowicz, Boston Medical Center

Heather Arnold, Barnes-Jewish Hospital, James Hollands, Barnes-Jewish Hospital, Lee Skrupky, Jennifer Smith, Barnes-Jewish Hospital, Nicholas Hampton, BJC Healthcare, Alex Hoban, Barnes-Jewish Hospital, Justin Hoffmann, St. Louis College of Pharmacy, Scott Micek, Barnes-Jewish Hosptial, Marin Kollef, Washington Univ. School of Medicine

Introduction: The management of acute hypertension in the ICU often requires aggressive treatment with intravenous (IV) antihypertensive agents such as nicardipine and labetalol. To our knowledge, there are no data comparing nicardipine and labetalol, administered as a continuous IV infusion. The purpose of this study was to compare the blood pressure (BP) control and safety of these two agents in a heterogeneous ICU population. Hypothesis: We hypothesized that nicardipine would provide better BP control than labetalol, administered as a continuous IV infusion. Methods: Consecutive adult patients that were admitted to the ICU and received either nicardipine or labetalol, administered as a continuous IV infusion, for at least two hours were included in this retrospective trial. Patients were excluded if a continuous IV infusion of an antihypertensive agent other than nicardipine or labetalol was administered within six hours of or simultaneously with the study drug. Data were collected for the duration of the infusion or for 48 hours, whichever came first. The primary endpoint was the percent time spent within the patient-specific pre-determined BP range. Other outcomes to compare safety and ease-of-use were also evaluated. Results: Sixty-two patient were evaluated (nicardipine n ⫽ 31; labetalol n ⫽ 31). There were more neurocritical care patients in the nicardipine group than in the labetalol group. Patients in the nicardipine group had a higher APACHE II score and lower GCS score. Median percent time spent within the patient-specific pre-determined BP range was 70.8 (interquartile range [IQR] 50.0 to 85.2) and 60.0 (IQR 18.9 to 81.3) in the nicardipine and labetalol groups, respectively. This difference was not statistically significant (p ⫽ 0.099). There was no difference in any of the secondary endpoints including time to hemodynamic range, number of dose titrations, number of additional IV antihypertensives, bradycardia, and hypotension. Conclusions: There was no difference in BP control between nicardipine and labetalol, administered as a continuous IV infusion, in this heterogeneous ICU population. However, a trend towards significance favoring nicardipine was observed.

Introduction: Prolonged infusion (PI) of ␤-lactam antibiotics, devised using Monte Carlo simulation, are theorized to optimize PK/PD parameters and improve patient outcomes. Hypothesis: The objective of this study was to compare the effectiveness of a 3-hour PI of cefepime (C), meropenem (M), or piperacillin/tazobactam (P/T) with a 30-minute intermittent infusion (II) of the same antibiotics for the treatment of proven or suspected gram-negative infections. Methods: Multi-ICU (89 beds), before-after study conducted at Barnes-Jewish Hospital. Patients that received C (2 g q8), M (1 g q8), or P/T (4.5 g q6) for 3 or more days and had an estimated creatinine clearance ⬎30 ml/min were included in the study. The primary endpoint was clinical success defined as resolution of fever or elevated WBC count to normal values without a switch to an alternative antibiotic, or the addition of another antibiotic after at least 3 days of the initial regimen, or mortality attributable to the index infection. Secondary outcomes were 30-day mortality and hospital length of stay from the time of infection to discharge. Results: 561 patients were included, 273 received II, 288 PI. 50% of patients received C, 30% M, 20% P/T. 27 (10%) patients in the II group and 36 (13%) in the PI group received concomitant aminoglycoside or ciprofloxacin during the first 3 days of treatment. 81 patients in the II group and 85 patients in the PI group had positive blood or respiratory cultures with a gram-negative organism. 395 patients had negative cultures. Pseudomonas aeruginosa was the most common pathogen (n ⫽ 57). Baseline characteristics between the II and PI groups were similar including Charlson score (4.2 v. 3.8), APACHE II score (20.1 v. 19.8), vasopressor therapy (49% v. 46%), and mechanical ventilation (65% v. 70%). Clinical success occurred in 48% of the II group compared with 42% in the PI group (p ⫽ 0.181). 30-day mortality was 23% in the II group and 26% in the PI group (p ⫽ 0.410). The hospital length of stay was similar between the II and PI groups (18 v. 19 days, p ⫽ 0.581). Conclusions: PK/PD-based dosing using a 3-hour PI of C, M, or P/T offers no advantage over II with regard to clinical success, 30-day mortality, or hospital length of stay.


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699

THROMBOTIC RISK OF RECOMBINANT ACTIVATED FACTOR 7 FOR REFRACTORY BLEEDING AFTER ACUTE AORTIC DISSECTION SURGERY

VASOPRESSIN AND HYPONATREMIA IN PEDIATRIC CARDIAC SURGERY PATIENTS

Koji Sato, Takumi Taniguchi, Kanazawa University Hospital Introduction: Recombinant activated factor seven (rF7a) is increasingly used as a hemostatic agent in patients experiencing refractory postoperateive hemorrhage. Although the use of rF7a seems promising, there are some concerns about thrombotic complications. Hypothesis: We hypothesized that the use of rF7a increase thrombotic events in patients with refractory bleeding undergoing acute aortic dissection surgery. Methods: Retrospective chart review of 56 patients undergoing emergent cardiac surgery for acute aortic dissection was performed at Kanazawa University Hospital between January 2007 and July 2011. The patients who developed life-threating bleeding during or after surgery despite conventional medical therapy and transfusion of blood products, received rF7a as an additional therapy. We compared the incidence of thrombotic events of rF7a group and control. We also analyzed risk factors for development of thrombotic events in univariate and multivariate analyses. Results: Seventeen patients received rF7a (mean dose: 84 mcg/kg). All patients received rF7a in the operating room. The incidence of thrombotic events was significantly higher in rF7a group (47% VS 10%, P⬍0.01). In rF7a group, ⌬ hemoglobin (Hb) (baseline Hb-nadir Hb) and maximum lactate level were significantly higher in patients who developed thrombotic events (⌬Hb: 6.4 VS 4.1 g/dl, p ⫽ 0.03, maximum lactate: 13.2 VS 8.4 mmol/L, p ⫽ 0.03). No difference was seen in age, gender, EURO score, cardiopulmonary bypass time, perioperative coagulation marker, platelet count, baseline Hb level and cardiovascular risk factors. Multivariate logistic regression analysis identified the following factors as predictors of thrombotic complications: the use of rF7a (odds ratio[OR] 8.03, 95% confidence interval [CI] 1.16 – 55.8, p ⫽ 0.02), and maximum lactate level (OR 1.67,CI 1.16 –2.4, p⬍0.01). Conclusions: The use of rF7a was associated with increasing incidence of thrombotic events after acute aortic dissection surgery. It is important to maintain intraoperative lactate and Hb level to prevent thrombotic complications in use of rF7a.

Jeffrey Cies, St. Christopher’s Hospital For Children, Arun Chopra, Saint Christopher’s Hospital For Children Introduction: Vasopressin (AVP) is released in response to increasing serum osmolality and hypotension. In neonates and children undergoing cardiac surgery, there is conflicting data regarding whether an AVP deficiency exists. AVP has activity at the V2 receptor resulting in renal water retention; this can result in a state of relative hyponatremia in addition to excessive fluid balance. Our primary objective was to evaluate the incidence of hyponatremia in post op cardiac surgery patients receiving AVP. Hypothesis: AVP does not cause hyponatremia in pediatric cardiac surgery patients. Methods: This is a retrospective cohort study of cardiac surgery patients admitted from 1/1/10 to 8/31/11. Individuals that received AVP for ⱖ12 hrs with ⱖ2 serum sodium values were included in Group V. Individuals that did not receive AVP or received AVP for a period ⬍12 hrs were included in Group C. Hyponatremia was defined as a decrease in serum Na concentrations to ⬍132 mEq/dL or a decrease in serum Na concentrations ⱖ10 mEq/dL from baseline.A student’s t-test, chi-square or Fisher’s exact test were used for continuous and non-continuous variables, respectively. An ␣ ⫽ 0.05 was used to determine significance. Results: Through 2/2011,88 patients underwent cardiac surgery and 64 had complete data. Fifteen patients were included in the V group and 49 in the C group. 15 of 15 (100%) patients in the V group and 7 of 49 (14.3%) patients in the C group developed hyponatremia, p⬍0.01. The mean length of stay (LOS) in the V group was 95 days compared with 19 days in the C group, p⬍0.001. Seven of 15 (46.7%) patients in the V group died compared with 0 of 49 patients in the C group, p⬍0.001. Conclusions: This retrospective series examines the use of AVP in post op cardiac patients. The incidence of hyponatremia with AVP use was 100% when compared to controls. Furthermore, the LOS and mortality increased in patients receiving AVP. Retrospectively, it is difficult to determine the true impact of AVP on mortality. However hyponatremia, hypo-osmolarity and positive fluid balance are thought to be detrimental. Hyponatremia increases the risk of cerebral edema and seizures and has been shown to be associated with poor outcome.

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THE EFFECT OF GSK962040, A SELECTIVE MOTILIN AGONIST, ON GASTRIC EMPTYING IN CRITICALLY ILL PATIENTS WITH ENTERAL FEED INTOLERANCE (MOT112571)

SEVERE HYPERGLYCEMIA AFTER CONVERSION FROM INSULIN INFUSION TO BASAL-BOLUS FOR GLYCEMIC CONTROL: CAN IT BE AVOIDED?

Marianne Chapman, Royal Adelaide Hospital, Robert Fraser, Repatriation General Hospital, Nam Nguyen, Adam Deane, Stephanie O’Connor, Royal Adelaide Hospital, Duncan Richards, Kimberley Hacquoil, Lakshmi Vasist, Matthew Barton, George Dukes, Glaxo Smith Kline

Brian McKinzie, Long To, Stuart Leon, Evert Eriksson, Medical University of South Carolina Medical Center

Introduction: GSK962040 (040) significantly enhanced gastric emptying (GE) by 30 – 45% in healthy subjects when given as single oral (50 –150 mg) or repeat doses (50 –125 mg) for 14 days and by 35– 60% in diabetics with gastroparesis when given as single oral doses (25–125 mg). Hypothesis: Single oral doses of 040 will enhance GE in ICU patients who have enteral feed (EF) intolerance (gastric residual volume (GRV)⬎200 ml). Methods: Mechanically ventilated patients (M ⫽ 16, F ⫽ 7) with EF intolerance were randomized (2:1) to receive either 040 50 mg (n ⫽ 15) or placebo (n ⫽ 8) via feeding tube. GE was assessed by 13C-octanoic acid breath test and 3-O-methylglucose (3OMG) absorption at baseline and 24h later, 90 min after study drug. Primary comparison was treatment vs baseline. Safety and pharmacokinetics were also assessed. Data presented as geometric mean and range. Results: 040 was well tolerated; 3 serious adverse events ocurred and were judged unrelated to study drug. Though highly variable, 040 was well absorbed with greater overall exposures [Area Under Curve (AUC) 10.2 (0.8 –29.1) mcg.h/mL] than in previous studies of healthy [6.1 (3.9 –9.9) mcg.h/mL] and diabetic [6.2 (3.7–14.3) mcg.h/mL] subjects; 2 subjects had minimal 040 absorption. Drug elimination was similar to previous studies. Despite all subjects having GRV⬎200 ml, baseline gastric half emptying time (GET1⁄2) varied widely (88 min; 18 –588 min). 040 resulted in a 35% decrease in GET1⁄2, (76vs116 min; p⬍0.07) while placebo resulted in a 37% increase (71vs51 min; p ⫽ 0.36). Secondary analysis, removing the 2 subjects with negligible 040 exposure, resulted in a 46% decrease in GET1⁄2 (65vs121 min; p⬍0.01). The effect of 040 on GE occurred irrespective of baseline GE and was supported by significantly increased absorption of 3OMG from baseline (AUC 0 – 4hrs:1.3vs0.73 mmol.h/l; p⬍0.05). Conclusions: GSK962040 accelerated GE and improved absorption in patients with EF intolerance.


Introduction: Recent evidence suggests severe hyperglycemia is an independent predictor of intensive care unit (ICU) and hospital mortality. Hypothesis: Our aim in this pilot evaluation is to identify predictive factors resulting in glucose values greater than 200 mg/dL in ICU trauma patients as they are being transitioned from an insulin infusion to a basal-bolus subcutaneous insulin regimen. Methods: Trauma patients who were on an insulin infusion for at least 48 hours and transitioned to a basal-bolus regimen were retrospectively identified. Traumatically injured patients admitted to the ICU who received an insulin infusion for greater than 48 hours and at goal tube feeds were included. Patients less than 18 years of age, on parenteral nutrition, vasopressors, renal replacement therapy, or with interruptions in their enteral nutrition were excluded. Patient demographics, glucose values, insulin utilization, caloric intake, and physiologic parameters where extracted from the patient chart. A multivariate regression was performed to determine independent risk factors for development of severe hyperglycemia. Results: Thirty-nine patients were evaluated. Ten patients had hyperglycemic events after transition. Hyperglycemia was significantly associated with increased age (42 ⫾147 vs. 56 ⫾ 13, p ⫽ 0.020), admission glucose (mg/dL) (128 ⫾ 39 vs 214 ⫾ 91, p ⫽ 0.015), and insulin drip rate (units/day) at 48 hours before transition (127 ⫾ 49 vs 87 ⫾ 38, p ⫽ 0.012). There was no difference between the groups with respect to injury severity, demographics, or physiologic parameters. Multiple regression analysis revealed that increased age (OR 1.215 (1.000 –1.477), p ⫽ 0.05), increased admission blood glucose (OR 1.053 (1.006 –1.101), p ⫽ 0.025), and higher insulin infusion rates 48 hours prior to transition (OR 1.061 (1.009 –1.116), p ⫽ 0.020) predisposed patients to severe hyperglycemic episodes. Conclusions: Older trauma patients and patients with higher blood glucose on admission are more likely to experience severe hyperglycemia when transitioned to basal bolus glucose control. In addition, higher insulin infusion rates 48 hours prior to transition are associated with severe hyperglycemia.

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703

PIPERACILLIN/TAZOBACTAM (PTZ) PHARMACOKINETICS (PK) IN CRITICALLY ILL CHILDREN ON EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

NO ASSOCIATION OF ETOMIDATE AND MORTALITY IN PATIENTS WITH SEPSIS AND SEPTIC SHOCK

Jeffrey Cies, St. Christopher’s Hospital For Children, Arun Chopra, Saint Christopher’s Hospital For Children Introduction: There is adult data demonstrating PK parameters such as the volume of distribution (Vd) and clearance (Cl) can be altered for individuals receiving ECMO. Alterations in the Vd and Cl of antibiotics in patients with sepsis have also demonstrated lower than expected serum levels based on standard dosing regimens. Impaired antibiotic distribution into tissue, the target site where most infections occur, is a major concern for clinicians and may explain the high morbidity and mortality in this population. The PK alterations associated with sepsis can be further exacerbated by the PK changes with ECMO. Therefore, an understanding of the PK changes in critically ill children on ECMO is crucial to determining the most appropriate dose and interval selection of PTZ. Hypothesis: PTZ PK is altered in ECMO and current dosing regimens do not achieve appropriate serum concentrations. Methods: A retrospective chart review from 1/1/09 to 7/20/10 of children on ECMO that had ⱖ2 PTZ serum concentrations obtained were included. PTZ serum concentrations were plotted against time, and individual PK parameters were determined by a one-compartmental analysis. Bayesian modeling was used to determine doses that would result in PTZ trough concentrations ⬃ 150 mcg/mL. Results: 6 patients met the inclusion criteria. Ages ranged from 8 days to 7 months. The mean elimination rate constant was 0.22 hr-1 and the mean half-life was 4.3 hrs. The mean Vd was 0.397 L/kg. Intermittent PTZ doses are displayed belowwith resulting troughsDose (mg/kg) Interval (hrs) Trough (mcg/mL)50 2 201100 4 145150 4 218200 4 291200 6 137. Conclusions: Current neonatal and infant PTZ dosing recommendations are not intended to obtain serum PTZ trough concentrations of ⬃ 150 mcg/mL. This ECMO PK data suggests a dosing regimen of 50 mg/kg/dose q2h, 100 mg/kg/dose q4h or 200 mg/kg/dose q6h would obtain serum PTZ trough levels ⬃ 150 mcg/mL to maximize PTZ efficacy for neonates and infants on ECMO. This data needs to be validated prospectively.

Laura McPhee, Maine Medical Center, Omar Badawi, Philips VISICU, Gilles Fraser, Patricia Lerwick, Richard Riker, Maine Medical Center, Ilene Zuckerman, Christine Franey, University of Maryland, David Seder, Maine Medical Center Introduction: The purpose of this study was to evaluate if etomidate use is associated with increased mortality in sepsis and septic shock. Hypothesis: Among septic patients, single-dose etomidate is associated with increased hospital mortality. Methods: In the 2008 –2010 eICU Research Institute database, we identified 2014 adults with sepsis, severe sepsis, or septic shock who had been intubated within 4 –96 hours of ICU admission. 1102 of these patients received etomidate (E) for intubation and 912 did not (NE). We compared demographic and clinical factors, severity of illness, hospital mortality, ICU mortality, ICU length of stay (LOS), hospital LOS, ventilator days, and vasopressor days between the groups, and used a modified Poisson regression model to evaluate the association of etomidate with mortality. Results: Except for age (E ⫽ 62.5 vs NE ⫽ 58.9, p⬍0.001), all demographics and markers of severity of illness were similar. More patients received steroids in the etomidate group before and after intubation (E ⫽ 52.9% vs NE ⫽ 44.5%, p⬍0.0002). Hospital mortality was similar between the groups (E ⫽ 37.2% vs NE ⫽ 37.8%, p ⫽ 0.77), as were ICU mortality (E ⫽ 30.1% vs NE ⫽ 30.2%, p ⫽ 0.99), ICU LOS (E ⫽ 8.7 days vs NE ⫽ 8.9 days, p ⫽ 0.66), hospital LOS (E ⫽ 15.2 days vs NE ⫽ 14.6 days, p ⫽ 0.31), ventilator days (E ⫽ 6.1 vs NE ⫽ 6.5, p ⫽ 0.17), and vasopressor days (E ⫽ 3.5 vs NE ⫽ 3.7, p ⫽ 0.67). Multivariate analysis showed no independent association of etomidate and mortality even when the groups were limited to patients with septic shock (n ⫽ 650). Conclusions: Single-dose etomidate administration for intubation is not associated with higher mortality in patients with sepsis, severe sepsis, and septic shock.This project was funded by the eICU Research Institute, supported by a grant from Philips Healthcare.



705

RETROSPECTIVE ANALYSIS OF AN INSULIN PROTOCOL FOR CRITICAL ILLNESS HYPERGLYCEMIA IN A PEDIATRIC INTENSIVE CARE UNIT

EXPERIENCE WITH DROTRECOGIN ALFA, ACTIVATED IN HEMATAPOIETIC STEM CELL TRANSPLANT PATIENTS

Ashley Nebbia, Cincinnati Children’s Hospital Medical Center, A. Jill Thompson, Medical University Of South Carolina Introduction: Insulin infusion for critical illness hyperglycemia (CIH) in pediatric patients has become more widespread. Increased rates of hypoglycemia associated with tight glucose control prompted the development of an institutionspecific insulin management protocol. Hypothesis: The study purpose was to evaluate an insulin management protocol for CIH in our PICU. We hypothesized that the protocol would reduce the incidence of insulin-induced hypoglycemia (blood glucose [BG] ⬍60 mg/dL). Methods: A 26-month retrospective chart analysis included all patients who received an insulin infusion for CIH in the Medical University of South Carolina Pediatric Intensive Care Unit (PICU) before and after protocol implementation. Protocol violations were also evaluated. All data are presented as medians or percentages. Results: Twenty-eight pre-protocol and nineteen post-protocol patients were included. Patients experiencing one or more hypoglycemic event(s) decreased from 32% to 21% [RRR 35%, p ⫽ 0.51]. Three of the four patients with hypoglycemia in the postprotocol group experienced a protocol violation occurring near the hypoglycemic event. The protocol resulted in a higher initial insulin dose (0.02 unit/kg/h versus 0.05 unit/kg/h, p ⫽ 0.001) and a higher limit of acceptable BG values (150 mg/dL versus 180 mg/dL). The percentage of BG values in the target range improved from 40% to 67%, p ⫽ 0.006. There were fewer daily insulin rate changes following protocol implementation (5 versus 3, p ⫽ 0.01), and patients achieved target BG more quickly (8.2 versus 4.1 hours, p ⫽ 0.030). There were no significant differences in any of the following: BG variability, cumulative insulin infused, infusion duration, daily highest or lowest BG, hospital or PICU length of stay, hospital charges, or days of mechanical ventilation. Conclusions: An intravenous insulin management protocol for CIH was associated with a reduced number of hypoglycemic events in our PICU. Patients achieved target BG values faster and maintained BG values in the target range more effectively while requiring fewer drip rate manipulations.

Krista Wahby, Harper University Hospital, Francois Gregoire, Ayman Soubani, Wayne State University School of Medicine Introduction: Critically ill hematopoietic stem cell transplant (HSCT) patients are one of the most challenging patient populations in the intensive care unit. The PROWESS Study which studied drotrecogin alfa, activated in severe sepsis, excluded HSCT patients. Many institutions still evaluate HSCT patients for use of DAA when they are severely septic. We report our experience with DAA in critically ill HSCT patients. Hypothesis: We report our experience with DAA in critically ill HSCT patients. Methods: This retrospective study assessed all patients treated with DAA for severe sepsis with a cancer diagnosis. Patients were then subdivided into 2 groups, those with a history of HSCT and those with other cancer diagnosis (CAN). Efficacy was measured by survival to ICU and hospital discharge. Safety was assessed by incidence of severe bleeding events, defined as, 1) intracranial bleeding; 2) any life-threatening bleeding event; 3) transfusion of ⬎2 Units of packed red blood cells on 2 consecutive days; or 4) any bleeding classified by the physician as serious. Fisher’s Exact, Student’s t-test and Chi Square testing were used. Results: 41 pts received DAA since 2002 with an active cancer diagnosis. Of these, 8 (20%) patients had HSCT. The HSCT patients were younger (44 ⫾ 10 vs 59 ⫾ 15, p ⫽ 0.01). APACHE II scores were similar (29 ⫾ 5 and 31 ⫾ 5, p ⫽ 0.58) for the HSCT and ONC groups, respectively. Surgery within 2 weeks of DAA was similar (25% vs 45%, p ⫽ 0.43). There was no significant difference in ICU or hospital length of stay (12 ⫾ 12 and 22 ⫾ 16, p ⫽ 0.87 and 23⫾21 vs 37 ⫾ 22, p ⫽ 0.79) respectively. There were no serious bleeding events in the HSCT group (0% vs 18%, p ⫽ 0.56). HSCT patients had a 75% survival to hospital discharge compared with 30% in the ONC group, p ⫽ 0.03. Conclusions: While HSCT patients were excluded from the initial PROWESS trial, our preliminary analysis shows that DAA is safe and efficacious in this patient population. Mortality was lower in HSCT patients than in other cancer populations.

706

707

INFLUENCE OF RENAL IMPAIRMENT ON THE EFFICACY AND SAFETY OF FIXED-DOSE, SUBCUTANEOUS DESIRUDIN IN THE DESIRABLE TRIAL

ALBUTEROL AND IPRATROPIUM ARE ASSOCIATED WITH INCREASED VENTILATOR-ASSOCIATED PNEUMONIA RATES IN INTUBATED TRAUMA PATIENTS

Andrew Shorr, Washington Hospital Center, Amir Jaffer, Univ of Miami Miller School of Medicine, Michael Kurz, Canyon Pharmaceuticals, Inc

Conrad Diven, University of Arizona, Randall Friese, University of Arizona College of Medicine, Julie Wynne, Andrew Tang, University of Arizona, Bellal Joseph, Narong Kulvatunyou, University of Arizona College of Medicine, Peter Rhee, University of Arizona, Terence O’Keeffe, University of Arizona College of Medicine

Introduction: Critically ill patients require venous thromboembolism prophylaxis (VTEP). Patients in the ICU may face an increased risk for bleeding when exposed to injectable anticoagulants. Additionally, renal insufficiency (RI) is common in ICU patients, and VTEP with heparin-based therapies is complicated since their clearance substantially depends on renal mechanisms. Desirudin (D) represents a novel, injectable direct thrombin inhibitor that may have more predictable pharmacokinetics in patients with RI. Hypothesis: D is not associated with significant bleeding in persons with limited renal function. Methods: We examined outcomes for patients with RI from DESIRABLE, a multicenter, open-label, single-arm study of D (15 mg Q 12h SC) which enrolled 516 subjects at 19 centers. Major Bleeding, defined as overt and leading to a ⱖ2 g/dL decrease in hemoglobin and a transfusion of ⱖ2 U at 30 days, was the primary endpoint. Clinically diagnosed VTE at 30 days was the secondary endpoint. Subjects were stratified according to estimated Glomerular filtration rate (eGFR, by CockcroftGault) and we compared subjects with RI to those with normal (N) renal function. We classified subjects with eGFR ⬍60 mL/min as having RI. Results: A majority of subjects had RI (n ⫽ 302, 59% of the entire cohort). Mean eGFRs for RI and N were 46⫾10 and 78⫾15 respectively. Compared to N, those with RI were older (mean age 65 vs 51 years), more likely to be female (81% vs 33%) and to have hypertension (74% vs 58%) and coronary artery disease (28% vs 20%). Treatment duration was similar between groups (⬃ 5 days). There were no major bleeding events in either group. Bleeding-related adverse events considered possibly related to study drug occurred in 1 N and 2 RI subjects (p ⫽ NS). The incidence of VTE was similar between N and RI subjects: 4 (1.9%) vs 5 (1.7%, respectively, p ⫽ NS). Conclusions: RI was not associated with increased bleeding risk in DESIRABLE. The present analysis supports previously published pharmacokinetic analyses suggesting that the dose should not be adjusted for patients with an eGFR ⬎30 mL/min. Additional randomized trials in RI patients, particularly in patients with eGFR ⬍30 mL/min, are needed to confirm these findings.


Introduction: Use of bronchodilators in mechanically ventilated patients has been reported to be an independent risk factor for the development of ventilatorassociated pneumonia (VAP). This has not been examined in trauma patients who represent a significantly different patient population. Hypothesis: We hypothesized that use of either bronchodilators would be associated with increased incidence of ventilator-associated pneumonia in ventilated trauma patients. Methods: A retrospective cohort study was performed in our surgical/trauma ICU over a four-year period, including all trauma patients that required mechanical ventilation for more than 2 days. Ventilator associated pneumonia was defined as those patients who had a positive BAL (insert requirements here). We performed univariate analysis to identify risk factors for the development of VAP, using Chi-square testing for categorical variables and student’s t-test for continuous variables. Data are presented as medians with the interquartile range (IQR) for non-normally distributed data. Results: 766 patients met inclusion criteria for our study, of which 445 (58%) received albuterol as either an inhaler or in nebulized form. There were 56 episodes of VAP in this patient population. The median age was 44 years (IQR 26,61) and 73% were male. The median duration of mechanical ventilation was 5 days (IQR 3,10). The most frequently isolated organisms were coagulase-positive Staphylococcus aureus (36%), Pseudomonas aeruginosa (14%), and Methiciliin Resistant Staphylococcus aureus (11%). There was an increased incidence of VAP in those patients who received albuterol therapy: 9.7% vs. 4.0% (p ⫽ 0.003). Injury severity (23⫾12) and blood transfusions (10.1% vs. 5.4%) were also associated with an increase in VAP rates, while presence of shock on arrival, coma on arrival, alcohol use, and field intubation were not associated with increased VAP. Additionally, we found that the use of ipratropium also increased VAP rates (12.6 vs. 5.8% p ⫽ 0.002). Conclusions: The use of albuterol or ipratropium is associated with an increase in ventilator associated pneumonia rates in a trauma ICU patients. The widespread use of these medications should be reconsidered in this population group.

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709

EXTENDED INFUSION OF MEROPENEM AND PIPERACILLIN IN CRITICALLY ILL PATIENTS: A PHARMACOKINETIC/ PHARMACODYNAMIC ANALYSIS.

EVALUATION OF BUMETANIDE CONTINUOUS INFUSION DOSING IN CRITICALLY-ILL PEDIATRIC PATIENTS

Jan DeWaele, Mieke Carlier, Eric Hoste, Pieter Depuydt, Johan Decruyenaere, Ghent University Hospital, Jeffrey Lipman, University of Queensland, Jason Roberts, Royal Brisbane and Women’S Hospital Introduction: Extended infusion of beta-lactams has been advocated as a viable method of optimizing antibiotic exposures in critically ill patients. Whilst simulation data exists, concentration-time data from critically ill patients are lacking. Hypothesis: Compared to bolus infusion, extended infusion of piperacillin and meropenem changes the pharmacokinetics/pharmacodynamics in critically ill patients. Methods: This was a prospective study in 20 critically ill patients without renal dysfunction. All patients received a loading dose (1 g meropenem or 4 g piperacillin), followed by an extended infusion (3h) of either antibiotic (1 g meropenem or 4 g piperacillin) every 6h for piperacillin and every 8 hours for meropenem. Serial plasma concentrations were obtained at 8 time points during and after the 3h infusion. Results were compared to data from bolus infusion obtained in previous studies (Roberts JA Crit Care Med 2009, 37(3):926 –933, Roberts JA J Antimicrob Chemother 2009, 64(1):142–150). Results: Fifteen patients receiving piperacillin/tazobactam were included and 5 receiving meropenem. The mean age of the patients was 55y, mean APACHE2 and SOFA score on admission 18 and 8 respectively. Twenty-four-hour urinary creatinin clearances ranged from 39 to 304 mL/min. In comparing both methods of administration, significant pharmacokinetic differences were observed in both meropenem and piperacillin groups for Cmax, (higher in bolus group) and Cmin (higher in extended infusion group). Considerable pharmacokinetic variability existed in each group for both drugs. Compared to bolus infusion, T⬎MIC using extended infusion was higher for both drugs: 98% (IQR 75–100%) compared to 58% (IQR 41–92%) for piperacillin and 81% (IQR 69 – 88%) compared to 50% (IQR 47–57%) for meropenem (assuming an MIC of 16 mg/L and 2 mg/L respectively. Conclusions: This study confirms the conclusions of pharmacokinetic simulations, that extended infusion of beta-lactams in critically ill patients results in advantageous pharmacokinetic profiles by increasing the T⬎MIC for piperacillin and meropenem. In a significant sub-population of critically ill patients however, minimum T⬎MIC targets are not reached, even with extended infusion.

Peter Johnson, Christina Bulkley, University of Oklahoma College of Pharmacy, Emilie Henry, Unviversity of Oklahoma College of Medicine, Donald Harrison, Teresa Lewis, Jamie Miller, University of Oklahoma College of Pharmacy Introduction: Loop diuretic continuous infusions (CI) are utilized in children to maintain appropriate fluid balance. Furosemide is most commonly used. Due to drug shortages, other agents including bumetanide (BUM) have been considered. There is no published data of prolonged BUM CI in children. Hypothesis: The objectives of this study were to retrospectively evaluate prolonged BUM CI regimens (⬎24 hours) utilized in children and compare dosing requirements between subgroups. Methods: Children ⬍18 years receiving prolonged BUM CI from July 1, 2008-September 30, 2010 were included. Data collection included demographics, BUM CI regimen, and laboratory data. The primary objective was to describe the median BUM CI dose. Secondary objectives were to describe effectiveness using surrogate markers [i.e., urine output (UOP) and fluid balance] and compare dosing requirements in subgroups [e.g., neonates (NEO) vs nonNEO and cardiothoracic surgery (CTS) patients vs non-CTS patients). Betweengroup analyses were performed using descriptive and inferential statistics. A linear regression model was used to assess the relationship of BUM CI initial dose with independent variables (dose increases, UOP, fluid balance). Results: Forty patients received BUM CI, including seven NEO (17.5%) and 17 CTS patients (42.5%). The initial and maximum median dose (range) was 0.03 mg/kg/hr (0.001– 0.1) and 0.04 mg/kg/hr (0.003– 0.2), respectively, for a median of 99 hrs (36 –263). This cohort required one dose increase (0 –5). The median UOP (ml/kg/hr) pre-, mid-, and post-infusion was 2.3 (0 – 6), 4.9 (0.1–9.8), and 3.7 (1.2–12), respectively and with a fluid balance (ml) of 305 (-383 to 1625), -29 (-1805 to 2004), and 3 (-4311 to 1038), respectively. The only significant differences noted between subgroups were the initial, maximum, and cumulative dose and duration of BUM CI between NEO and non-NEO. There was no significant relationship between the initial BUM CI dose and independent variables. Conclusions: This study provides preliminary evidence for BUM CI dosing; higher doses were utilized in non-NEO. Further prospective studies are needed to define the BUM CI dosing.

710

711

CLEARANCE OF VANCOMYCIN DURING CONTINUOUS INFUSION IN OBESE CRITICALLY ILL PATIENTS

TACHYPHYLAXIS IN POST-CARDIAC SURGICAL PATIENTS RECEIVING BIVALIRUDIN–A RETROSPECTIVE DYNAMIC STUDY USING A PKPD MODEL

Hsin Lin, Iris Faraklas, University of Utah Hospitals and Clinics, Amalia Cochran, University Of Utah Department Of Surgery Introduction: Compared to intermittent dosing, continuous infusion (CI) of vancomycin may better achieve a desired ratio of area under the curve (AUC) to the minimum inhibitory concentration (MIC) and maximize pharmacodynamic parameters. Critically ill obese patients may require higher vancomycin CI dose. Hypothesis: Describe the correlation between vancomycin clearance (CLv) and creatinine clearance (CLcr) in obese critically ill patients. Methods: With IRB approval we reviewed adult obese (Body mass index ⬎30) critically ill patients who were admitted to the Burn Trauma ICU and received vancomycin by continuous infusion for documented or suspected Gram-positive infections between August 10, 2010 and July 1, 2011. All patients included have preserved renal function and at least one vancomycin steady state concentration. In order to avoid underexposure during the first hour of therapy, an initial loading dose (15–25 mg/kg) was administered with the continuous infusion starting immediately afterwards. Target serum vancomycin concentrations were between 20 –30 mcg/ ml. Results: Eighteen patients (fourteen skin soft tissue infection and four acute burn) received vancomycin CI during this period. Median BMI was 38.1 kg/m2 (31– 60); median CLv was 4.2 l/hr (2.6 –11.7); median CLcr was 8 l/hr (3.6 – 13.8); median duration of treatment was 5 days (2–9). The median vancomycin maintenance dose was 25 mg/kg/d (10.2–52); median time to achieve target concentration was 32.7 hr (25.5–71); median steady state level was 24 mcg/ml (16.1– 44); median AUC was 576 mcg*h/ml (386 –1056). The relationship between vancomycin clearance (CLv) and creatinine clearenc (CLcr) was CLv (l/ h) ⫽ 0.68 x CLcr (l/h)– 0.02; (r ⫽ 0.86, p⬍0.001). No patient experienced nephrotoxicty. Conclusions: Our data suggests the ratio of CLv to CLcr is lower in obese critically ill patients who have preserved renal function than non-obese patients. Daily vancomycin requirements were dependant on CLcr. The regression equation generated by this study should be validated through prospective implementation.

Thomas Edrich, Gyorgy Frendl, Brigham and Women’s Hospital/Harvard Medical School, Yannis Paschalidis, Boston University Introduction: Bivalirudin is a direct thrombin inhibitor that serves as an alternative to heparin. Although it is FDA-approved for short-term catheter interventions, it is finding increasing use over longer time-periods in the ICU. Little is known about tachyphylaxis in this setting. Hypothesis: Prolonged exposure to bivalirudin will cause tachyphylaxis. Methods: In a retrospective chart review of 132 post-cardiac surgical ICU patients divided randomly into derivation and validation cohorts, the coagulation parameter PTT and the continuous infusion rate of bivalirudin was collected. A one-compartment model (SM) was designed with an elimination time-constant t_elim and a constant k_PTT to reflect the steady-state response of the patient to bivalirudin. A second model TM has the same structure, except it allows for k_PTT to be reduced slowely over days according to a time constant, t_tachyphyl, depending on the cumulative exposure of the patient to bivalirudin. Both models were fitted to the derivation data and tested in the validation cohort. Results: In the derivation and validation cohorts, the average duration of bivalirudin infusion was similar at 13 and 16 days. For the models SM and TM, the optimal coefficients t_elim/k_PTT were 59/65 minutes and 1705/1680 sec*kg/mg, respectively. In TM, t_tachyphyl was 1.2 days. The resulting errors (root-mean square) between the actual and the simulated PTT were 16.4 and 15.2 seconds, with Pearson’s correlation coefficients of 0.66 and 0.68, respectively. Conclusions: In this patient population in which a steadystate response to bivalirudin can rarely be ascertained because the dosing is changed too frequently, it is challenging to determine a dose-response relationship or to test for tachyphylaxis. Here, the technique of matching a PKPD model to the actual data is useful because steady-state responses are not required-dynamic responses can analyzed. Our model predicts PTT with moderate correlation to the true value. However, the fit of the model does not improve when the mechanism of tachyphylaxis is incorporated. Thus, using data obtained from patients recovering from cardiac surgery and cardiopulmonary bypass, there is no evidence of significant tachyphylaxis to bivalirudin.


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STEROID ADMINISTRATION FOR ADRENAL INSUFFICIENCY IN DECOMPENSATED CIRRHOTICS DOES NOT IMPACT RATE OF FUNGAL INFECTION OR MORTALITY

EARLY INTRAVENOUS IBUPROFEN DECREASES NARCOTIC REQUIREMENT AND LENGTH OF STAY FOLLOWING TRAUMATIC RIB FRACTURES

Stephanie Yi, Kevin Donahue, Howard Monsour, Krista Turner, Jeffrey Hall, Archana Sadhu, Ahmen Gaber, R. Mark Ghobrial, Sherilyn Gordon-Burroughs, The Methodist Hospital

Lilly Bayouth, University of Central Florida College of Medicine, Karen Safcsak, Michael Cheatham, Chadwick Smith, Kara Birrer, John Promes, Orlando Regional Medical Center

Introduction: Symptoms suggestive of adrenal insufficiency (AI) are commonly observed in ICU-bound decompensated cirrhotic patients. The effect of adrenal replacement therapy on critical endpoints such as infection and mortality in this population requiring liver transplantation (LT) remains unclear. We sought to determine whether administration of intravenous steroids in cirrhotic ICU patients with AI affects the rate of peritransplant fungal infection and/or mortality. Hypothesis: The use of steroids in cirrhotic ICU patients with AI is associated with increased fungal infection and mortality. Methods: The records of 85 decompensated cirrhotic patients transferred over a 33-month period to our institution’s surgical ICU with negative admission blood cultures and evidence of AI were reviewed under an IRB-approved protocol. Based on the treating physician, 63 patients were treated with high-dose hydrocortisone (HC⫹), while 22 were not (HC-). Both groups received empiric antibacterials. Admission Model for End Stage Liver Disease (MELD) scores, ICU length of stay (LOS), fungal culture (FC) results, and 90-day outcomes were evaluated. Results: Of the HC⫹ cohort, the median MELD was 26 and median LOS was 21.5 days. 65% expired, and 19% were successfully transplanted with no sepsis-related post-LT mortalities. The others were discharged. Despite nearly universal empiric fungal therapy (61/63), one third demonstrated positive FC. Of the HC- cohort, the median MELD was 25 and median LOS was 22 days. 54% expired (p ⫽ 0.2651 vs. HC⫹), and 31% underwent successful LT (p ⫽ 0.0608 vs. HC⫹). The others were discharged. All HC- patients received antifungal coverage. Again, one-third had positive FC. Conclusions: Decompensated cirrhotic patients receiving steroids for AI are at high risk for fungal sepsis, which may compromise LT candidacy. In this small series, we demonstrated that steroid administration does not impact the rate of fungal infection or mortality; however, the rate of LT is decreased in the group receiving steroids. Further analysis and appropriatelypowered prospective studies are required to determine the factors impacting rate of LT, fungal infection, and mortality in decompensated cirrhotics receiving steroids for AI.

Introduction: Pain control following traumatic rib fractures is essential to avoid respiratory complications and prolonged hospitalization. Narcotics are commonly utilized, but associated with multiple side effects. Adjunctive medications, such as ibuprofen, may be beneficial. Hypothesis: Early IV ibuprofen (IVIb) decreases narcotic requirement following traumatic rib fractures. Methods: A retrospective review of traumatic rib fracture patients managed according to a predefined guideline was performed at a Level I trauma center. Unless contraindicated, patients received IVIb for at least 48 hours following admission before conversion to oral ibuprofen. Patients who received IVIb and narcotics for pain control (Treatment) were matched by age and number of rib fractures to patients who received narcotics alone (Control). Pain medication requirement was evaluated for the first 7 days of hospitalization. All medication dosages were converted to either IV morphine or IVIb equivalent to facilitate comparison. Complications related to ibuprofen administration were collected. Data are reported as mean ⫾ standard deviation and compared using Mann-Whitney U-test. Results: 21 Treatment patients were matched to 21 Control patients with respect to age (52 ⫾ 14 vs. 53 ⫾ 16 years; p ⫽ 0.77) and rib fractures (5 ⫾ 3 vs. 4 ⫾ 2; p ⫽ 0.40). Mean daily IVIb dose was 2070 ⫾ 880 mg. Mean daily IV narcotic dose was 18.9 ⫾ 15.6 vs. 32.1 ⫾ 24.0 mg (p⬍0.0001). Daily narcotic requirement did not differ between Treatment and Control groups on Day 1 or Day 2. However, narcotic requirement was significantly decreased in the Treatment group on each of Days 3 through 7 (p⬍0.05). Hospital days were 4.4 ⫾ 3.3 vs. 5.4 ⫾ 2.9 days (p ⫽ 0.17). There were no significant complications associated with ibuprofen therapy. Conclusions: Early IVIb therapy in patients with traumatic rib fractures significantly decreases narcotic requirement and results in clinically significant decreases in hospital length of stay. It is well tolerated without complications. IVIb should be started upon admission to augment pain control. A prospective study is warranted.



715

ACUTE KIDNEY INJURY IN PATIENTS RECIEVING CONCOMITANT VANCOMYCIN AND PIPERACILLIN/TAZOBACTAM

IMATINIB FOR PULMONARY HYPERTENSION IN CONGENITAL DIAPHRAGMATIC HERNIA, DOES IT MAKE SENSE?

Emily Min, Kevin Box, James Lane, Jose Sanchez, Raul Coimbra, Jay Doucet, Bruce Potenza, Lindsay Wargel, University of California San Diego Medical Center Introduction: Acute kidney injury (AKI) in critically ill patients has been associated with a two to six-fold increased risk of death over non-AKI patients. Nephrotoxic drugs can contribute to the development of AKI. Vancomycin and piperacillin/tazobactam (pip-tazo) are individually considered mildly nephrotoxic; however, the renal insult associated with their concomitant use is currently not described. Hypothesis: We hypothesize that concomitant use of vancomycin and pip-tazo is associated with higher rates of AKI than treatment with vancomycin or pip-tazo alone. Methods: Patients admitted to the surgical intensive care unit (SICU) during a one-year period who received vancomycin and/or pip-tazo for at least 48 hours were studied. The subset of treated patients developing AKI was then identified based on a serum creatinine (SCr) increase to greater than 1.5 times baseline during antibiotic therapy. Data collected from the electronic medical record included patient demographics; antibiotic indication, dose, and course; SCr; and concomitant use of other nephrotoxic agents. The primary endpoint was the incidence of AKI. Results: During the study period, 73 patients were treated concomitantly with vancomycin and pip-tazo, and 67 patients were treated with vancomycin alone. Due to the small sample size, the pip-tazo alone group (N ⫽ 10) was excluded from analysis. Baseline demographic data was well-matched between the groups. Factors potentially contributing to the development of AKI, such as severity of illness as measured by APACHE II score and concomitant use of other nephrotoxic agents, were controlled for in the analysis. The incidence of AKI was higher in the vancomycin/pip-tazo group (40.5%) compared to the vancomycin alone group (9.0%; p⬍0.001). Conclusions: Concomitant use of vancomycin and pip-tazo is associated with a higher incidence of AKI than treatment with vancomycin alone among SICU patients.

Muriel Koninckx, Saskia de Wildt, Ulrike Kraemer, Erik Buijs, Irwin Reiss, Dick Tibboel, Erasmus MC-Sophia Introduction: In neonates with congenital diaphragmatic hernia (CDH), therapy resistant pulmonary hypertension (PH) is associated with high mortality. Platelet derived growth factor (PDGF) stimulates proliferation and migration of smooth muscle cells in pulmonary arteries. Imatinib as an antagonist of the PDGF receptor (a transmembrane receptor tyrosine kinase) can prevent the progression of PH through vascular remodeling. Hypothesis: The aim of this prospective study was to describe our experience with imatinib use for therapy resistant PH in neonatal CDH patients. Methods: We searched our prospective computerized patient database for CDH patients from 2005 until 2011 who received imatinib as a rescue therapy for severe PH. Patients were treated according to a standardized protocol (1. Reiss et al. Neonatology 2010;98(4): 354 – 364). The following clinical parameters were collected: patient demographics, adjuvant therapy for PH at time of start imatinib, age at start imatinib, imatinib dose (mg/m2), blood levels (if available), duration of treatment and outcome. Results: We identified 5 patients (median GA 38 weeks, median birth weight 2.9 kg) with prenatally diagnosed CDH (4 left-sided, 1 right-sided, 2 liver up, 3 liver down) and persistent PH, confirmed by cardiac ultrasound. 4 patients received VA-ECMO successfully. All patients received oxygen, NO, sildenafil and bosentan at start of imatinib. Imatinib [median dose 306 (range 114 –350) mg/m2] was started at median 34 (range 12– 41) days postnatally and was continued for a median of 10 (range 1–142) days. 4 patients died median 6 (range 0 –36) days after start of imatinib treatment. 1 patient received imatinib for 5 months and survived to date (age 11 months). In this patient, imatinib plasma concentration 24 hours after the first dose was 281 ␮g/l. This is within the therapeutic range for oncology treatment. In this patient cardiac ultrasound at the age of 7 months showed no signs of PH. Conclusions: When all other therapies fail, the use of imatinib for persistent PH in neonates with CDH is highly debatable. Its use should be subjected to properly designed multicenter studies with regard to optimal dose, timing and outcome parameters.

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SEROTONIN SYNDROME MIMICKING AS IFOSFAMIDE NEUROTOXICITY

NOVEL THEOPHYLLINE THERAPY FOR PERSISTENT BRADYCARDIA IN SEVERE CERVICAL SPINAL CORD INJURY.

Osman Farooq, Orlando Regional Healthcare, Anand Mohan, Rumi Ahmed Khan, Orlando Regional Medical Center, Rakesh Gupta, OrlandoHealth

Vanessa Gleason, Abby Kordek, Michael Weinstein, Thomas Jefferson University Hospital

Case Reports: Ifosfamide is a chemotherapeutic agent used to treat a variety of malignancies. Neurologic side effects occur in 10 –20% patients ranging from agitation to seizures and coma. Before diagnosing Ifosfamide neurotoxicity, one must exclude other possible life threatening conditions.73 year old female with stage III mullerian cancer admitted for adjuvant chemotherapy. She recently started Sertraline for depression. She developed nausea and vomiting after her first dose of Ifosfamide and was treated with Prochlorazine. Patient’s delirium worsened throughout the day. Diagnosis of CNS toxicity secondary to Ifosfamide was made and treated with Methylene blue with no improvement. Upon transfer to ICU, vitals signs were 104F, HR 160s, BP 170/100s. She was unresponsive with significant dytonic movements with clonus. Troponin, Lactic acid and CPK were normal. She was intubated using Midazolam, Fentanyl and Succinylcholine. Sertraline and Prochlorperazine were discontinued. Within less that 1 hour of initiation of Midazolam infusion, her fever, dystonia and tachycardia resolved. Following morning, she was alert, oriented, following commands and successfully extubated.Serotonin syndrome is a life threatening condition associated with increased serotonergic activity in the CNS. Treatment includes discontinuation of all serotonergic agents, sedation with benzodiazepines and supportive care. Our patient was started on a serotonergic agent 7 days prior to onset of symptoms. The day of her symptons, she also received prochlorperazine. Literature review suggests that serotonin syndrome can present either abruptly after first dose or may initiate after addition of a second agent or change of dose. In our patient, symptoms started abruptly after prochlorperazine was added to Sertraline.With widespread use of serotonergic agents and regular addition of newer drugs with varying side effect profiles, it is important to distinguish clinical features of serotonin syndrome from neurologic side effects of new agents. Diagnosing serotonin syndrome early can potentially be life saving and in this case required knowledge of both serotonin syndrome and Ifosfamide neurologic toxicity.

Case Reports: Severe cervical spinal cord injury (cSCI) is a devastating process associated with various physiologic changes. Neurogenic shock with bradycardia and hypotension is a common sequela of severe cSCI. The incidence of bradycardia in patients with severe cSCI is reported to be as high as 100%, with cardiac arrest in up to 15% of cases. The mainstay of pharmacologic treatment includes atropine, epinephrine, and dopamine. There is sparse literature describing the use of theophylline for bradycardia in this population. Cardiac pacemakers are indicated for patients with persistent bradycardia not responding to medical therapy. Herein, we describe the use of low-dose enteral theophylline to treat bradycardia secondary to severe cSCI in a case series of three patients at Thomas Jefferson University Hospital (TJUH), a model SCI center. Cardiopulmonary parameters and theophylline levels were monitored to measure efficacy and toxicity. After initiation of theophylline, bradycardia resolved within 24 to 72 hours, allowing titration off of intravenous vasopressors in two patients. For each patient theophylline levels were ⬍3 mg/L. Enteral theophylline use in this patient population appears to be an effective therapy to manage persistent bradycardia in patients with severe cSCI. The use of theophylline has the potential to obviate the need for intravenous vasopressors and inotropes, as well as cardiac pacemaker implantation. Further studies, however, are needed to establish the role of theophylline, optimal dose, timing and duration in this patient population.


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COMPUTERIZED DOSE RANGE CHECKING UTILIZING HARD STOPS IMPROVES SAFETY AND REDUCES POTENTIAL FOR MEDICATION ERRORS IN A PEDIATRIC INTENSIVE CARE UNIT

TURN OFF THE LYTE(S): THE ROLE OF MAGNESIUM IN TRAUMATIC BRAIN INJURY

Lilanthi Balasuriya, Paul Bakerman, Vanessa Holton, Pamela Garcia-Filion, Vinay Vaidya, Joan Westdorp, Phoenix Children’s Hospital

Introduction: Traumatic brain injuries (TBI) commonly result in neurologic injury and carry significant morbidity, mortality, societal, and financial impact. In animal models, serum magnesium (Mg2⫹) repletion in severe TBI (sTBI) improves neurologic outcomes. Human studies have shown poor outcomes with supratherapeutic serum Mg2⫹ repletion yet normotherapeutic repletion has been shown to be safe. Hypothesis: The purpose of this study was to test the hypothesis that in sTBI patients serum Mg2⫹ levels were associated with outcome using the modified Rankin scale (good outcome ⫽ mRS 0 – 4, out of bed and poor outcome ⫽ mRS 5– 6, bed bound or dead). Methods: This was an IRB-approved, retrospective analysis of data collected from the prospective, observational, sTBI registry at Northwestern Memorial Hospital (NMH). Patients with consent (or surrogate consent) were enrolled if admitted to NMH with sTBI from 2007–2011. Baseline characteristics were collected for all patients. Patients were categorized via 14-day outcome as good outcome (mRS 0 – 4) or poor outcome (mRS ⬎4) with the primary comparison evaluating mean serum Mg2⫹ level and its association with outcome. Results: Twenty-seven patients were identified during the study period. Ten patients identified had good outcomes and 17 with poor outcomes. Sixty-six percent of our patients were male with a mean age of 48.1 years (⫹/⫺ 23.3). Patients with good outcome had lower mean serum Mg2⫹ level than patients with poor outcome, 2.0 mg/dL (⫹/⫺ 0.2) vs. 2.2 mg/dL (⫹/⫺ 0.2) [p ⫽ 0.01]. A similar trend was seen for the admission serum Mg2⫹ level, 2.0 mg/dL (⫹/⫺ 0.3) vs. 2.3 mg/dL (⫹/⫺ 0.3) [p ⫽ 0.05], respectively. In patients that survived, there was no difference in serum Mg2⫹ levels compared to those that died [p ⫽ 0.22]. Conclusions: In patients with sTBI, lower admission and mean Mg2⫹ levels were associated with improved functional outcomes. The neuro-protective effect of Mg2⫹ seen in animal models does not seem evident in our patients and the harmful neurologic effects seen with supratherapeutic repletion may hold true with normotherapeutic repletion. Further investigation is needed to clarify the relationship of Mg2⫹ levels in sTBI patients and their functional outcomes.

Introduction: Medication errors account for a significant proportion of adverse events and computerized physician order entry (CPOE) has been shown to decrease medication errors. In a pediatric facility computerized dose range checking (DRC) allows for dose confirmation based on weight and absolute limits to prevent medication dosing errors. Hypothesis: Customized computerized dose range checking decreases the potential for serious drug dosing errors in a pediatric critical care setting. Methods: We designed a custom DRC system within the framework of CPOE with soft dose limits (SDL) and hard dose limits (HDL). We measured frequency and response to these alerts. Medication orders for patients admitted to a Pediatric Critical Care Unit (PCCU) were retrospectively reviewed 4-months prior to the “go live” date of 02/15/2011 and compared with orders in the 4-months following the “go live” date. Results: Prior to “go live,” 20.2% (26,205/129,707) of medication orders were entered in the PCCUs. In the 4 months after “go live,” 17.9% (24,710/138/039) of medication orders were entered in the PCCUs, with 83.1% (20,525/24,710) of doses checked by the new DRC program. Prior to “go live,” the frequency of alerts fired increased from 2.8% (n ⫽ 742/26,205) to 3.1% (776/24,710) in the follow-up period (p ⫽ 0.045). With the custom DRC program, there was a statistically significant reduction (p⬍0.001) in the orders submitted in the 4-months following “go live” [52.3% (406/776)] compared to 92.5% (n ⫽ 686/742) in the 4 months prior. Compared to before “go live,” the number of orders modified/cancelled increased from 7.5% (56/742) to 41.9 % (325/776) (p⬍0.001). In 5.7% (n ⫽ 45) a response was not recorded.There were 776 total alerts of which SDL accounted for 73.6% (571/776); HDL accounted for 26.4% (205/776). Conclusions: Alerts prior to customization were often not clinically relevant or meaningful. Following introduction of computerized DRC systems utilizing HDL, the total number of alerts increased from 2.8 to 3.1%, but orders submitted were significantly reduced and orders modified/cancelled were significantly increased. Custom adaptation of CPOE/DRC identified and corrected errors prior to reaching the patient.

Mamta Swaroop, Scott Benken, Geoffrey Chow, Neil Rosenberg, Northwestern Memorial Hospital, Andrew Naidech, Northwestern University

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EVALUATION OF STAPHYLOCOCCUS AUREUS MINIMUM INHIBITORY CONCENTRATIONS IN PATIENTS TREATED WITH VANCOMYCIN AND DRUG-ASSOCIATED RENAL EFFECTS

PREDICTABILITY OF ADJUSTED PHENYTOIN CONCENTRATIONS USING SHEINER-TOZER EQUATION IN CRITICALLY-ILL PATIENTS WITH SEVERE RENAL DYSFUNCTION AND HYPOALBUMINEMIA: A PILOT STUDY

Erin Mancl, Sheila Pedigo, Perry Taylor, VCU Health System

Julie Chen, Nadia Ferguson-Myrthil, Montefiore Medical Center, Arlene Tran, Montefiore Med Ctr

Introduction: There are growing concerns of Staphylococcus aureus vancomycin resistance due to escalating minimum inhibitory concentration (MIC) for vancomycin, a finding known as MIC creep. The aims of this study were to evaluate the following prior to and after implementation of an institution adult vancomycin dosing guideline in patients treated with vancomycin for a S. aureus infection: MIC of S. aureus, adequacy of vancomycin dosing given a particular S. aureus MIC, and incidence of elevated serum creatinine (SCr). Hypothesis: S. aureus MIC creep to vancomycin is occurring, vancomycin dosing after guideline implementation resulted in adequate dosing, and elevated SCr rates occurred within ranges previously reported. Methods: This retrospective review evaluated S. aureus MIC to vancomycin, vancomycin trough levels, SCr data, and concomitant nephrotoxic agents prior to and after the dosing guideline (July 2004 –June 2005 & July 2009 –June 2010). Inpatients (aged ⬎4 months) with a confirmed S. aureus infection, received ⱖ96 hours of vancomycin, and had trough level data were included. Results: In 2004 –5 and 2009 –10, isolates (n ⫽ 1,965) were respiratory (66%), blood (33%), and CSF (1%), with 56% and 52% as MRSA, respectively. There were more isolates with a MIC of ⱕ0.5 mcg/mL in 2004 –5 (66% of total isolates) than in 2009 –10 (56%, p⬍0.001). Significantly more isolates exhibited a MIC of 2 mcg/mL in 2004 –5 (28% vs 4.5%, p⬍0.001). In 2009 –10, isolates with a MIC of 1 mcg/mL were greater compared to 2004 –5 (39% vs 5.5%, p⬍0.001). There was no significant difference in the percentage of isolates with a MIC of 4 mcg/mL (0.5% for both, p ⫽ 0.99). Of patients treated with vancomycin (n ⫽ 391), the majority were treated with a trough of ⬎15 mg/L. There were significantly fewer SCr elevations during vancomycin therapy in 2009 –10 (13% vs 21%, p ⫽ 0.04). In patients with renal toxicity, a vancomycin trough ⬎20 mg/L occurred in 18 patients (40%) and concomitant renal toxic agents were utilized in 64% of patients. Conclusions: A S. aureus MIC creep to vancomycin from ⱕ0.5 to 2 mcg/mL was not present, vancomycin doses were adequate based on trough results, and there was a lower incidence of elevated SCr in 2009 –10 compared to 2004 –5.


Introduction: Sheiner-Tozer (ST) equation has been routinely used to estimate free plasma phenytoin (DPH) levels in critically ill ICU patients with uremia and hypoalbuminemia. To date, only limited clinical data support this practice in the ICU. Hypothesis: ST equation is a valid method for estimating free DPH levels in adult ICU patients with severe renal dysfunction and hypoalbuminemia. Methods: This prospective, observational study included 20 ICU patients (age ⬎18 years) with severe renal dysfunction (CrCl ⬍15 mL/min or on hemodialysis) and hypoalbuminemia (⬍3.5 g/dL) requiring DPH therapy. Concurrent plasma total and free DPH levels, creatinine and albumin levels were measured. Total DPH levels were corrected for uremia and hypoalbuminemia using ST equation (see below). The estimated free DPH levels were derived by “DPHcorrected x0.1” and compared to measured free DPH levels using the paired Student’s t-test. Patients were then divided into two groups, those with albumin levels below 3 g/dL (n ⫽ 10) vs. those with levels of 3–3.5 g/dL (n ⫽ 10) to compare the effect of hypoalbuminemia on the predictability of the free DPH level. Sheiner-Tozer Equation: Cpcorrected ⫽ Cpmeasured/(0.1 x Albmeasured⫹0.1) 䡠 Cpmeasured is the measured total plasma phenytoin concentration 䡠 Alb is the measured albumin 䡠 Cpcorrected is the corrected total plasma phenytoin concentration. Results: A total of 11 patients have been enrolled to date. Six patients had an albumin level below 3 g/dL. The mean measured free DPH level in this group was 2.1 ⫾1.2 mcg/mL and the mean estimated free DPH level was 2.0⫾1.0 mcg/mL (p ⫽ 0.622). Five patients with an albumin level of 3 to 3.5 g/dL had a mean measured free DPH of 1.8 ⫾0.6 mcg/mL and a mean estimated free DPH level of 2.3 ⫾0.6 mcg/mL (p⬍0.01). Conclusions: Based on our preliminary results, ST equation appears to be a viable method for estimating DPH levels in critically ill adults with renal dysfunction and significant hypoalbuminemia (⬍3 g/dL). The use of this equation in the subset of patients with mild hypoalbuminemia (3–3.5 g/dL) shows more variability making clinical recommendations difficult.

722 USE OF METHYLENE BLUE IN REFRACTORY SHOCK Diana Esaian, Amy Dzierba, Mona Patel, NewYork Presbyterian Hospital Introduction: Patients with refractory shock may benefit from the addition of intravenous methylene blue (MB). Hypothesis: The objective of this study was to assess vasopressor (VP) requirements after administration of MB for the management of refractory septic shock (SS) or cardiopulmonary bypass induced vasodilation (CPBIV). Methods: An IRB-approved, retrospective chart review was conducted from January 2008 through September 2010 in adults who received MB in the ICU or OR. Patients were considered responders if VP requirements stayed the same or decreased. Statistical analysis included Fisher’s exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Data are presented as median (IQR). Results: Of the 40 patients included, 53% received MB for CPBIV and 47% for SS. Ninety percent of the CPBIV group were male with an age of 62 (53–74) years as compared to 79% male with an age of 57 (50 – 66) years in the SS group. There was no difference between the CPBIV vs SS groups in APACHE II scores 18 (16 –23) vs 23 (15–26), (p ⫽ 0.139). Both groups received a median of 3 VPs prior to MB. The dose of norepinephrine (NE) was 20 (20 –26) mcg/min in the CPBIV group compared to 25 (20 –30) mcg/min in the SS group prior to MB. The dose of epinephrine (E) was 7 (4 –12) mcg/min and 12 (6 –19) mcg/min, respectively. For the entire cohort, response within the first two hours after MB was observed in 48% of patients; 12 in CPBIV and 7 in SS, p ⫽ 0.225. For patients in the CPBIV group, NE dose decreased from 22 to 21 mcg/min while E remained at 8 mcg/min. In the SS group, NE dose decreased from 28 to 23 mcg/min and E increased from 13 to 14 mcg/min. The most common bolus dose of MB was 2–2.5 mg/kg in the CPBIV group and 1.5 mg/kg in the SS group. Eighty percent of the cohort expired during the hospital stay with the majority of patients not having a VP response. Conclusions: Within two hours after MB approximately 50% of patients had a VP response for the management of refractory shock. A greater decrease in NE was seen in the SS group than the CPBIV group with no change in E.

723 VANCOMYCIN DOSING DURING CORONARY ARTERY BYPASS GRAFT AND/OR AORTIC VALVE REPLACEMENT SURGERY Matthew Hafermann, University of Washington Medical Center Harborview Medical Center, Tyree Kiser, University of Colorado At Denver and Health Sciences Center, Clark Lyda, University of Colorado Hospital, Douglas Fish, University of Colorado, Gerard Barber, University of Colorado Hospital, Joseph Cleveland, UCD Cardiothoraic Surgery Introduction: Vancomycin is commonly given to prevent infections associated with coronary artery bypass graft (CABG) and/or valve replacement surgeries. The purpose of this study was to compare standard dosing vs. weight-based dosing of vancomycin during cardiopulmonary bypass (CPB). Hypothesis: It was hypothesized that compared to a standard 1 gram dose, weight-based vancomycin increases the percentage of time serum concentrations are ⬎15 mcg/ml during CPB. Methods: Patients undergoing CABG and/or valve replacement surgery were randomized to receive either a standard 1 g dose of vancomycin before and after CPB, or a single weight-based 20 mg/kg (max 2 g) dose prior to surgery. Serum samples were obtained before, during, and after CPB. The primary study outcome was the percentage of time patients maintained serum concentrations ⬎15 mcg/ml during CPB and at surgical closure. Results: Baseline characteristics were similar between the study dose group (n ⫽ 10) and the standard dosing group (n ⫽ 10). From post-infusion to the end of bypass, the median percentage of time with a vancomycin concentration ⱖ15 mcg/ml for weight-based dosing vs. standard dosing was 100% (interquartile range [IQR], 72.6 – 100) vs. 43.7% (IQR, 28.7–53.4); P ⫽ 0.0005. From post-infusion to surgical closure, the percentage of time vancomycin concentrations remained ⱖ15 mcg/ml was significantly higher in the weight-based dosing group [100% (IQR 58.3–100) vs. 34.6% (IQR 25.3– 41.6; P ⫽ 0.0005)]. Similarly, there was a significant difference in number of patients who had vancomycin concentrations ⱖ15 mcg/ml after coming off bypass (60% study group vs. 0% standard group, P ⫽ ⬍0.0001) and the median calculated time patients had vancomycin concentrations ⱖ15 mcg/ml [4 hours in the study-dose group (IQR 2.69 –5.49) vs. 1.4 hours in the standard-dose group (IQR 1.20 –1.57; P ⫽ 0.0003)]. Conclusions: This study demonstrates that weight-based dosing of vancomycin is superior to standard doses for the purpose of maintaining therapeutic vancomycin levels for the duration of coronary artery bypass graft (CABG) and/or valve replacement surgeries.



725

PROPOFOL AND OUTCOME IN ACUTE RESPIRATORY DISTRESS SYNDROME

COMPARATIVE IMPACT OF THREE INTRAVENOUS INSULIN INFUSION TITRATION STRATEGIES ON GLYCEMIC VARIABILITY AND CONTROL IN CRITICALLY ILL ONCOLOGY PATIENTS

Farid Sadaka, Chris Chan, Shashi Katukoori, Jacklyn O’Brien, Saint John’s Mercy Medical Center/St. Louis University Introduction: Propofol (PFL) has been commonly used for sedation in critically ill patients. PFL has inhibitory effects on neutrophil migration and activation. In rat models of acute respiratory distress syndrome (ARDS), treatment with PFL abrogated or reversed the pathophysiologic changes of ARDS. The effect of PFL on outcomes of ARDS patients has never been studied. Hypothesis: We hypothesize that patients with ARDS who were sedated with PFL (continuous drips for at least 12 hours, or 24 hours) within the early phase had improved outcomes compared with ARDS patients who did not receive PFL. Methods: This is a retrospective study of patients with ARDS (The American–European Consensus Conference definition) admitted to a 50-bed ICU between July 2006 and February 2009. A total of 47 patients were identified (22 patients received no PFL, 25 patients received PFL[19 received ⬎12 hours of PFL and 15 received ⬎24 hours of PFL]). Results: On Day 1, the PFL group had a median Acute Physiology And Chronic Health Evaluation II (APACHE II) score of 17 and median Lung Injury Score of 2.72 compared with 16 and 2.85 for the nonPFL group respectively. In the whole sample (n ⫽ 47), APACHE II scores were associated with increased ICU length of stay (LOS) in days (0.63, p ⫽ 0.01), and increased hospital LOS in days (0.96, p ⫽ 0.02). Plateau pressures ⬎30 cmH2O were associates with increased 28 day mortality (OR ⫽ 1.38, CI ⫽ 1.1–2.0, p ⫽ 0.01). For patients who received PFL ⬎12 hours, PFL increased ventilator free days at 28 days (1.28 days, p ⫽ 0.6), decreased ICU LOS (2.6 days, p ⫽ 0.4), decreased hospital LOS (1.8 days, p ⫽ 0.78), and decreased 28 day mortality (OR ⫽ 0.46, CI ⫽ 0.04 – 3.9, p ⫽ 0.71) compared with non PFL patients. For patients who received PFL ⬎24 hours, PFL increased ventilator free days at 28 days (3.7 days, p ⫽ 0.1), decreased ICU LOS (4.6 days, p ⫽ 0.1), decreased hospital LOS (9.1 days, p ⫽ 0.05), and decreased 28 day mortality (OR ⫽ 0.54, CI ⫽ 0.04 – 4.6, p ⫽ 0.8) compared to nonPFL patients. Conclusions: PFL, when used early in a small sample of ARDS patients, showed improvement in all outcomes, but did not reach statistical significance. PFL should be studied in a larger sample to evaluate its effect on outcomes in ARDS patients.

Brent Anderegg, Nusrat Harun, Lei Feng, Georgia Lange, Mary Lou Warren, Susan Gaeta, Sajid Haque, The University of Texas MD Anderson Cancer Center Introduction: In an effort to improve glycemic control with IV insulin infusions in our ICU, a computerized insulin protocol (CP), and a manual, calculation-based insulin protocol (MCBP) have been piloted to compare their performance with a standard, continuous IV “sliding-scale” insulin protocol (SP). Hypothesis: Both a CP and a MCBP will perform better than the SP in reducing blood glucose (BG) variability and improving glycemic control in adult, critically ill oncology patients. Methods: A sample of IV insulin infusion cases, insulin protocol types, corresponding infusion times and BG values were retrospectively retrieved from institutional electronic databases. Three protocols were employed in the study sample including a SP (target BG 100 –140 mg/dL), a MCBP (target BG 100 –150 mg/dL), and a CP (BG 100 –140 mg/dl). Glucose variability was measured by mean BG standard deviation (SD) and mean coefficient of variation (CV). Proportion of BG values within protocol target, time to target, and hypoglycemia (BG ⬍70 mg/dL) rates were also analyzed. Results: Of 618 insulin infusion cases identified, 584 were included for analysis with 40646 BG values obtained. Mean BG values for SP, MCBP, and CP were 155 mg/dL, 136 mg/dL, and 128 mg/dL, respectively. The BG variability measured by SD was significantly lower in CP vs SP (33 mg/dL vs 43 mg/dL, p ⫽ 0.0023); however, no difference was noted when measured by CV. Target BG values were achieved in greater proportion with both pilot protocols at 56.1% for MCBP and 56.5% for CP vs 38.1% for SP (ANOVA p⬍0.0001, p⬍0.0001 for MCBP vs SP and CP vs SP). A limited number of hypoglycemic events per case were observed in all groups at 1, 1.2, and 0.5, for MCBP, CP, and SP, respectively. Both MCBP and CP improved time to protocol target but required more daily glucometer measurements per case. Conclusions: Of the three insulin infusion protocols evaluated, CP had lower BG variability than SP when measured by mean SD. However, both MCBP and CP had lower patient mean BG, higher proportion of BGs within target, and shorter time to target achievement than SP. These improvements were achieved at the expense of a slight increase in hypoglycemia and increased resource utilization.

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EVALUATION OF THE DOSE RESPONSE TO RESCUE INTRAVENOUS DEXTROSE ADMINISTRATION FOLLOWING HYPOGLYCEMIC EVENTS WITH AN INSULIN INFUSION PROTOCOL IN CRITICALLY ILL BURN PATIENTS

PROLONGED CONTINUOUS INFUSION OF N-ACETYLCYSTEINE FOR ACETAMINOPHEN TOXICITY

Erin Nagle, Patricia Parker, Jeremiah Duby, University of California Davis Medical Center, Denise Roach, UC Davis Medical Center Introduction: Hypoglycemia and glucose variability are independent risk factors for morbidity and mortality in critically ill patients. The conventional method of blood glucose (BG) correction is administration of IV dextrose 50% (D50W). There is limited evidence establishing the effect of D50W on glucose control. Hypothesis: Intensive insulin protocols result in a high frequency of hypoglycemia, and hypoglycemic correction induces a high level of glucose variability. Methods: All adult subjects admitted to the Burn ICU (8/2008 – 8/2009) that were initiated on an insulin infusion were included. Data was collected from electronic records and included age, sex, history of diabetes, hypoglycemic events (BG ⬍70 mg/dL), D50W dose, BG levels, and insulin infusion rate. Descriptive statistics were utilized. Results: Twenty-eight patients were identified. The mean age was 50.4 ⫾ 14.3 years, 67% were male, and 20% had a history of diabetes. Hypoglycemia occurred in 20 (71%) patients; 15 (75%) patients required D50W for 80 separate hypoglycemic events. The mean and median delta glucose response were 5.84 ⫾ 4.02 and 5.2 (3.83, 6.87) mg/dL per gram of D50W administered, respectively. The mean delta blood glucose ranged from 1.37 to 12.09 mg/dL per gram of dextrose. A mean of 5.17 (4.16) and 7.21 (4.87) interventions were required to maintain BG levels at goal for 2 and 3 consecutive BG readings. Use of the protocol for hypoglycemia resulted in 69.7%, 58.2%, and 44.3% of patients returning to goal glycemic control at 1, 2, and 3 hours, respectively. Conclusions: Understanding the effect of D50W on BG response may guide the development of protocols for hypoglycemic correction. Critically ill burn patients that received an insulin infusion appeared to experience a high occurrence and frequency of hypoglycemia. The central point of tendency for BG response appears to be approximately 6 mg/dL per gram of dextrose administered; there is wide intra- and inter-patient variability. The rate of hypoglycemia and number of interventions to achieve goal glycemic control may be used to assess protocol safety.These findings suggest suboptimal management of hypoglycemic events.


Charles Hunley, Orlando Health, Rakesh Gupta, OrlandoHealth Case Reports: Acetaminophen poisoning is responsible for 70,000 visits to health care facilities and approximately 300 deaths per year in the U.S. Acetaminophen poisoning can be due to a single overdose, excessive repeated doses or ingestion of too frequent therapeutic doses. Repeated supratherapeutic ingestion is increasingly recognized as a significant clinical problem. Duration of treatment in patients with clinical or laboratory evidence of hepatotoxicity is debated. We present a case of continuous N-acetylcysteine infusion for 90 hours until LFT normalized and acetaminophen levels were below toxic levels.46 year old male with PMH of alcohol abuse, multiple acetaminophen intoxication and cirrhosis presents with 1 day history of hematemesis, confusion and lethargy. Patient admits taking 10 –12 Excedrin per day times 2 weeks for pain. Complains of RUQ pain with nausea. PE: Temp 101.2, BP 140/60, RR 35. Patient appears malnourished, tachycardic with scleral icterus. Abdominal exam reveals tenderness over RUQ with hepatomegaly. Laboratory findings: WBC 15.7, Hb 14.2, Platelet 217, AST 6000, ALT 7000, INR 3.5 and acetaminophen level 350.Pt. treated with lactulose for hepatic encephalopathy. Coagulopathy corrected with FFP and Vitamin K. I.V. N-acetylcysteine given as 150 mg/kg over 1 hour then 50 mg/kg over 4 hours followed by 100 mg/kg over 16 hours. Pt’s acetaminophen level remained elevated (toxic) for 4 days and he was placed on continuous N-acetylcysteine infusion for 90 hours until AST/ALT normalized and acetaminophen levels cleared. Pt’s mental status improved, INR normalized and he was discharged to floor and then home.The definition of acetaminophen induced hepatotoxicity is AST and/or ALT ⬎1000 IU/L, or other evidence of hepatic failure. Maximal hepatotoxicity occurs at 72–96 hours. Many patients with hepatic damage after repeated ingestion may exhibit a more prolonged acetaminophen half-life. Thus, the original nomogram to treat acetaminaphen toxicity may not apply in chronic repeated ingestions. This case demonstrates the need for tailored therapy with N-acetylcysteine for acute liver failure from chronic ingestion with acetaminophen.

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EVALUATION OF RESISTANCE PATTERNS OF GRAM-NEGATIVE ISOLATES IN A MEDICAL RESPIRATORY INTENSIVE CARE UNIT

EVALUATION OF VANCOMYCIN DOSING AND MONITORING IN OBESE ADULT MEDICAL INTENSIVE CARE UNIT PATIENTS

Kelly Ennis, Katie Muzevich, Virginia Commonwealth University Health System

Connie Yoon, Jeffrey Gonzales, University of Maryland School of Pharmacy, Asha Tata, Siu Yan Yeung, University of Maryland Medical Center, Ada Offurum, Mangla Gulati, University of Maryland

Introduction: Treatment of nosocomial infections is a challenge for healthcare practitioners. Selection of antimicrobial therapy is paramount, as delay in appropriate antimicrobial therapy is associated with increased mortality in both sepsis and hospital-acquired pneumonia. Hypothesis: At Virginia Commonwealth University Health System (VCUHS), an antibiogram is used to provide hospitalwide susceptibility data, but unit-specific data is not available, nor does this antibiogram provide guidance about combination therapy susceptibility. In the Medical Respiratory Intensive Care Unit (MRICU) at VCUHS, the preferred empiric antimicrobial regimen for suspected infection due to a MDR pathogen includes both piperacillin/tazobactam and a fluoroquinolone. We hypothesize that a small percentage of gram-negative organisms resistant to a given betalactam antibiotic are then sensitive to a fluoroquinolone; therefore, alternative agents may need consideration. Methods: An IRB approved, retrospective, single-center evaluation assessed the resistance patterns of gram-negative organisms isolated in the MRICU at VCUHS. Susceptibility information was reported consistent with the Clinical and Laboratory Standards Institute (CLSI) antimicrobial susceptibility testing standards. Descriptive statistics were used to analyze all data. Results: A total of 283 isolates and susceptibility data were collected for analysis. Overall, when a given beta-lactam antibiotic was resistant, addition of a fluoroquinolone resulted in additional coverage in less than 10% of isolates. Out of 278 isolates tested to a fluoroquinolone, 43.5% were susceptible. A secondary objective was to determine the antibiotic combination most likely to provide at least one susceptible antibiotic. At our institution the combination of a carbapenem and gentamicin provided at least one susceptible antibiotic 80.2% of the time. Conclusions: Based on the rate of fluroquinolone resistance found, it has been concluded that the addition of a fluoroquinolone to empiric therapy with a beta-lactam may not be providing additional gram-negative coverage. This conclusion has prompted discussion about adjusting empiric treatment of suspected gram-negative infections in the MRICU at VCUHS.

Introduction: ASHP/IDSA/SIDP guidelines recommend initial vancomycin doses of 15–20 mg/kg of actual body weight (ABW) in all patients. Loading doses of 25–30 mg/kg are also recommended in the critically ill population. Inadequate dosing of vancomycin has raised questions regarding treatment failure. Obese patients are at a considerable risk for inadequate dosing of vancomycin due to lack of research and dosing guidelines. Vancomycin also displays altered pharmacokinetics (clearance and volume of distribution) in the obese population, which may influence therapeutic levels. The primary objective of this study was to evaluate the initial vancomycin doses administered in obese patients. The secondary objectives included assessing the frequency of a loading dose and the frequency of obtaining vancomycin trough levels. Hypothesis: We hypothesized that initial vancomycin doses are inadequate in obese critically ill patients at our institution. Methods: A retrospective chart review was conducted for patients admitted to the adult medical intensive care unit between June 2009 and June 2010 at a tertiary care center. Patients were included in the study if they were: ⫽ 18 years of age, body mass index ⫽ 30 kg/m2, and received at least one dose of vancomycin. Subjects were excluded if they did not have a recorded height, weight, or were receiving renal replacement therapy. A loading dose was defined as at least 25 mg/kg of ABW, initial dose was defined as 15 mg/kg of ABW, and therapeutic trough level was defined as 10 –20 mcg/mL. Descriptive statistics were used. Results: Fifty patients were included in the study. The mean initial dose of vancomycin per kg of ABW administered was 10.95 ⫾ 3.30 mg/kg/dose. None of the patients received a loading dose. Initial vancomycin trough levels were drawn in 23 (46%) patients, with a mean serum trough level of 12.74 ⫾ 5.63 mg/L. Conclusions: Initial vancomycin dosing at our institution does not meet the recommendations of the ASHP/IDSA/SIDP guidelines. Loading doses were not utilized and initial vancomycin trough levels were drawn in less than half of the population. Further education on the proper loading and initial doses are required in the obese critically ill population.

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OFF LABEL USE OF GASTROINTESTINAL MEDICATIONS IN THE INTENSIVE CARE UNIT

STUDY ON THE CURRENT TRENDS OF STRESS-RELATED GASTRIC MUCOSAL DISEASE PREVENTION IN THE CANADIAN PAEDIATRIC INTENSIVE CARE UNITS

Jeffrey Barletta, Midwestern University, College of Pharmacy-Glendale, Ishaq Lat, University of Chicago Hospitals Critical Care, Scott Micek, Barnes-Jewish Hosptial, Henry Cohen, Kingsbrook Jewish Medical Center, Keith Olsen, University of Nebraska Medical Center, Curtis Haas, University of Rochester Medical Center Introduction: Off-label medication use is common in ICU patients but practices specific to gastrointestinal (GI) medications remains unknown. Hypothesis: The purpose of this study was to evaluate off-label GI medication use, identify the medication class and indication whereby off-label use was most common and determine the level of evidence supporting their use. Methods: A prospective, multi-centered observational study evaluated all medication orders written in 37 ICU’s in the United States over a 24 hour period. All medications for gastrointestinal related indications were identified and information pertaining to demographics, medication class, dose, frequency, indication, strength of evidence and strength of recommendation were collected. Medication class, strength of evidence (A, B, C, none) and recommendation (1, 2A, 2B, 3, indeterminate) were defined using a nationally recognized drug information database (DRUGDEX). The medication class and indication whereby off-label use was most prominent was identified and the respective level of evidence was described. Results: There were 774 medication orders evaluated from 363 individual patients. 63% (489/ 774) of medication orders were off-label; 88% (429/489) were first initiated in the ICU. Proton pump inhibitors (PPI) accounted for most of the off-label usage [55% (271/489)] followed by laxatives [16% (77/489)] and histamine-2-receptor antagonists (H2RA) [15% (71/489)]. When prescribed, 99% (271/274) of PPI use, 99% (71/72) of H2RA use and 79% (30/38) of promotility use was off-label. Stress ulcer prophylaxis [100% (309/309)], GI bleeding [18/18 (100%)] and gastric motility [88% (30/34)] were the most common off-label indications encountered. The most common strength of recommendation and level of evidence for off-label use was indeterminate [58%(282/489)] and none [57% (280/489)], respectively. Conclusions: Acid-suppressive agents have both the highest prevalence and incidence of off-label use in the ICU. Stress ulcer prophylaxis accounts for the most common indication for off-label use. The level of evidence supporting off-label GI medication use is poor.

Jerome Ouellet, Marie-Eve Samson, Dennis Bailey, Laval University Introduction: Stress-related mucosal disease (SRMD) is a frequent comorbidity occurring in paediatric intensive care units (PICU). It’s prevention has changed significantly in the past 20 years, but there is no data on current prophylaxis use in children. Hypothesis: To describe current trends in SRMD prophylaxis in Canadian PICU. Methods: A standardized validated questionnaire about SRMD prophylaxis was sent to every paediatric intensivist in Canada. Each intensivist was identified by electronically contacting PICU directors to inform them of the project and ask them for current staff information. Intensivists received a copy of the questionnaire (with information about the study) via postal and electronic route twice in a 1 month interval to ensure a better response rate. Confidentiality was guaranteed by an anonymous questionnaire and postal material and by email received and anonymized by a third person (our research nurse). Results: Of the 95 PICU attendings listed in Canada, 59 (62%) answered our questionnaire. Thirty seven percent of them were based in Quebec, 29% in Alberta and the rest from other provinces. Both for their residency and subspecialty trainings, they were mainly trained in Quebec (27% and 31%), Ontario (19% and 36%) and Alberta (15% and 8%). A majority of attendings (78%) had 6 or more years of work experience. When asked about risk factors for prescribing UGIB prophylaxis, the 3 most frequent responses were prior history of gastric ulceration/ bleeding (53%), coagulopathy (46%) and major neurologic insult (31%). More than half of the attendings (53%) said that they prescribe UGIB prophylaxis directly upon PICU admission. Among Canadian PICU, reported incidence of clinically significant UGIB by PICU attendings is very low (86% said that the incidence is below 3% of patients). Ninety three percent of respondents use ranitidine as a first-line therapy. The choice for second-line therapy was more diverse: 53% used pantoprazole and 22% used omeprazole. Conclusions: A majority of patients receive SRMD prophylaxis during a PICU hospitalization despite the low occurrence of clinically significant UGIB. The preferred treatment among attendings is ranitidine.


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EARLY ADMINISTRATION OF INTRAVENOUS TERBUTALINE IN SEVERE PEDIATRIC ASTHMA MAY REDUCE THE INCIDENCE OF ACUTE RESPIRATORY FAILURE

EARLY BIOMARKER ACTIVITY AND IMMUNOTHERAPY TRIALS

Sule Doymaz, James Schneider, Cohen’s Children Medical Center, North Shore LIJ MC, New Hyde Park, NY, Mayer Sagy, New York University Medical Center Introduction: Severe pediatric asthma, if not immediately and aggressively treated, may progress to acute respiratory failure requiring mechanical ventilation in the PICU. Hypothesis: Timely initiation of IV terbutaline infusion in severe asthma reduces the incidence of acute respiratory failure. Methods: A retrospective chart review of patients admitted to the PICU with severe asthma and received continuous intravenous infusion of terbutaline was conducted. The patients were divided into 2 categories; patients who were transported to our PICU from outlying emergency departments (ED) and patients who were transferred from our ED to the PICU. We evaluated these patients’ responses to terbutaline and outcome. Results: One hundred and twenty (120) patients were studied, 42 females and 78 males with a mean age of 6.8 y ⫾ 4.2 y. One hundred eighteen (118) patients survived and 2 patients died (brain death) in the PICU from an earlier episode of cardiac arrest at home. Thirty-five (35) patients were transferred from outlying ED(s) and 85 patients from our own ED. Seventy-six patients (76) had their terbutaline infusion started prior to their arrival in PICU and 44 patients had it started after. Seventy-six patients (63%) did not require respiratory mechanical support and were breathing spontaneously throughout their course, 21 patients (17%) received BiPAP and 23 patients (19%) required tracheal intubation and mechanical ventilation. The periods of Pre-PICU terbutaline infusion were 2.61 h ⫾ 2.47 h, 2.04 h ⫾ 2.54 h and 0.97 h ⫾ 1.59 h, respectively (p ⫽ 0.015). Patients transported from outlying hospitals’ ED(s) had shorter mean durations of IV terbutaline than those transferred from our ED, measuring 0.69 h ⫾ 1.38 h and 2.91 h ⫾ 2.47 h, respectively (p ⫽ 0.000). Conclusions: Early administration of continuous infusion of terbutaline in ED may reduce the need for mechanical respiratory (invasive and non-invasive) support in severe pediatric asthma. Patients who were transferred from outlying, non-tertiary care hospitals’ ED(s) to our PICU, showed a higher incidence of progression to respiratory failure in association with shorter durations of pre-PICU intravenous terbutaline treatments.


Anja Jaehne, Henry Ford Hospital, Department of Emergency Medicine, Demosthenes Papamatheakis, Ayman Saad, Loma Linda University Medical Center, Daniel Singer, Mount Sinai School of Medicine, James Yang, Henry Ford Hospital, H. Nguyen, Loma Linda University Medical Center, Samantha Brown, Howard Klausner, Emanuel Rivers, Henry Ford Hospital Introduction: Improving time to diagnosis and interventions based on better understanding of early disease pathogenesis have made a significant impact on directing therapy and improving outcomes for acute myocardial infarction, stroke and trauma. Is there pathogenic evidence for a similar approach to severe sepsis and septic shock with modulation of inflammation? Hypothesis: Purpose of this study was to prospectively examine early natural history of circulatory biomarker activity commonly targeted by immunotherapy trials in patients presenting at the most proximal presentation. These findings are examined in reference to prior immunotherapy trials which have been mainly negative to date. Methods: Samples were obtained from adult patients with severe sepsis and septic shock beginning upon hospital arrival with follow-up samples at 3, 6, 12, 24, 48, 60, and 72 hours. Interleukin(IL)1␤, IL6, IL10, D-Dimer, HMG-1, VEGF, MMP, and MPO were examined. These findings were combined with previous reported data on IL1receptor antagonist, IL8, ICAM, and TNF-␣, and Caspase-3 to provide a comprehensive characterization of early biomarker activity. These findings were then examined in reference to study design of prior immunotherapy trials. Results: Elevated circulatory biomarker levels are commonly seen during the first hours of hospital presentation. These circulatory biomarkers overlap; have bimodal patterns and generally peak between 3 and 36 hours while diminishing over the subsequent 72 hours of observation. These are findings consistent with published experimental human and animal data. Conclusions: Based on the findings of this study, prior sepsis immunotherapy trials generally have enrolled patients with severe sepsis and septic shock after peak circulatory biomarker concentrations are reached. In these clinical trials, generally the time frame from identification to enrollment ranges from 12 to 72 hours after the patients are in the ICU. Based on these study findings, there is a need to recalibrate the timing of enrollment and intervention in these trials. By taking advantage of this optimal interventional window, these therapies may still hold great promise for a deadly disease.


735

ALBUMIN USE FOR ACUTE RENAL FAILURE AND NONHEMORRHAGIC SHOCK IN CRITICALLY ILL PATIENTS IN THE MEDICAL AND SURGICAL INTENSIVE CARE UNITS

IMPLEMENTATION OF GLUCOSE MANAGEMENT SOFTWARE (ENDOTOOL®

Basi Sanuth, Mount Sinai Hospital, Rose Jung, University of Toledo College of Pharmacy Introduction: Evaluation of renal function with albumin use according to the 2004 American Thoracic Society Consensus Statement (ATS-CS) and 2000 University HealthSystem Consortium Guidelines (UHC-G) in acute renal failure (ARF) and non-hemorrhagic shock (NHS) patients. Hypothesis: Appropriate albumin use according to ATS-CS and UHC-G for ARF and NHS results in improved serum creatinine (SCr), urine output (UO) and decreased need for hemodialysis initiation. Methods: Data was retrospectively collected in patients who received albumin for ARF and NHS in both MICU and SICU of our community teaching hospital. The primary outcome measure was change in SCr, UO and decreased need for hemodialysis initiation with appropriate albumin use per ATS-CS and UHC-G. Results: Sixty-two patients were enrolled in the study. Albumin was used appropriately in 14 patients (53.8%) with ARF and 12 patients (46.2%) with NHS compared to inappropriately used in 19 patients (52.8%) with ARF and 17 patients (47.2%) with NHS (p ⫽ 0.14). The albumin level in both groups on albumin initiation and discontinuation was unchanged. The mean SCr was higher in the appropriate use group on albumin initiation 3.32⫹2.27 mg/dl compared to 1.97⫹1.70 mg/dl in the inappropriate use group (p ⫽ 0.004). However, on albumin discontinuation, the mean Scr was 3.27⫹2.06 mg/dl in the appropriate use and 2.42⫹1.93 mg/dl (p ⫽ 0.04) in the inappropriate use groups. Urine output with albumin initiation was unchanged at 0.45⫹0.51 ml/kg/hr in the appropriate use and 0.64⫹0.77 ml/kg/hr in the inappropriate use groups (p ⫽ 0.33) compared to urine output on albumin discontinuation of 0.47⫹0.76 ml/kg/hr in the appropriate use and 0.70⫹0.82 ml/kg/hr (p ⫽ 0.12) in the inappropriate use groups. Hemodialysis was initiated in 11 (42.3%) patients in the appropriate use group compared to 6 patients (16.67%) in the inappropriate use group (p ⫽ 0.03). Conclusions: Appropriate albumin use for ARF and NHS resulted in a greater rate of hemodialysis initiation despite insignificant change in creatinine or urine output compared to inappropriate use in which a lower rate of hemodialysis initiation was seen despite an increase in serum creatinine and an unchanged urine output.

Amanda Zomp, Earnest Alexander, Maresa Glass, Tampa General Hospital, Ren Chen, University of South Florida Introduction: The Surgical Care Improvement Project (SCIP) was developed in an effort to decrease the incidence of surgical site infections. SCIP measure INF-4 requires that cardiac surgery patients have a controlled blood glucose (less than or equal to 200 mg/dL) at 6am on postoperative days one and two (POD1 and POD2). In January 2010, our institution implemented a blood glucose management system (Endotool) to increase SCIP measure compliance. Hypothesis: This study was conducted to analyze the impact of the Endotool program on compliance with SCIP measure INF-4 for patients on continuous intravenous insulin for blood glucose management on POD1 and POD2. Methods: A retrospective chart review was conducted from August 2010 to April 2011 on all cardiac surgery patients at our institution, evaluating 5 months pre-implementation and 4 months post-implementation of Endotool. The primary outcome was the overall percentage of patients meeting the SCIP measure. Secondary outcomes were percentage of patients meeting the SCIP measure on POD1 and percentage meeting it on POD2. We evaluated the following factors for potential influence on SCIP measure compliance: duration of Endotool, adherence to Endotool instructions, and concomitant steroid use. Results: A total of 275 patients were included in the analysis (n ⫽ 145 pre-Endotool, n ⫽ 130 post-Endotool). The mean overall percentage that met the SCIP measure was higher post-implementation of Endotool compared with pre-implementation, at 89.9% and 86.1%, respectively. On POD1, the mean percentage was also higher post-implementation at 96.1%, compared with 88.9% pre-implementation. All of the patients in the post-Endotool group that met the SCIP measure on POD1 and did not meet on POD2 were taken off Endotool at ⬍30 hours duration. Conclusions: The use of Endotool to manage blood glucose in postoperative cardiac surgery patients increased our compliance with SCIP measure INF-4. This improvement may be further augmented by the continuation of Endotool for the full 48 hours postoperatively, rather than early discontinuation. Improvement in compliance with this measure may decrease surgical site infections, improve patient outcomes, and help ensure reimbursement for hospital stays.

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YALE INSULIN PROTOCOL INFUSION IN SEPSIS PATIENTS

PHARMACOKINETIC ANALYSIS OF MEDICATION CLEARANCE FOR CRITICALLY ILL PATIENTS RECEIVING CONTINUOUS RENAL REPLACEMENT THERAPY

Sandro Oliveira, Fabio Dessa, Marcelo Fernandes, Carlos Molica, Fernanda Oliveira, Hospital Bangu Introduction: Actually tight glycemic control is a major concern in critical care. Hyperglycemia occurs frequently in critically ill diabetic and nondiabetic patients and strict control of blood glucose has been considered ideal behavior with the use of continuous intravenous insulin generalizing in intensive care units in worldwide. Hypothesis: This study aimed to evaluate the effectiveness and safety of Yale insulin therapy protocol, used to maintain blood glucose between 100 and 150 mg/dL, in critically ill patients admitted to general intensive care unit. Methods: Retrospective, before-after cohort study. Selected end-points were mean blood glucose levels, time-to-reach target range of 100 –150 mg/dL, and per– cent of blood glucose in target range and hypoglyce–mia incidence. Results: Were studied 78 patients: 42 in control group (CG) and 36 in protocol group (PG). Bedside blood glucose was measured 3755 times for a mean value of 134.1 ⫾ 15.4 mg/dL in the PG versus 1730 ti–mes for a mean value of 172.7 ⫾ 33.6 mg/dL in the CG. Blood glucose values were in the target range 63% and 37% of the times, respectively for PG and CG groups (p⬍0.001). The median time to reach glucose target range was 8 hours (range 5 -17 hours) for PG and 53 hours (range 23–218 hours) for CG (p⬍0.001). Incidence of severe hy–poglycemia reaches a difference statistically signifi– cant: 1 patient in PG versus 4 patients in CG (p⬍0.01). All patients reached the target in 72 hours of insulin infusion in the PG while only 29 patients in CG reached. Conclusions: This study showed that the Yale protocol was effective and safe for handling the continuous intravenous insulin therapy, aimed at strict glycemic control for medical and surgical critical ill patients admitted to the intensive care unit.

Lynn Anliker, University of MIssouri Kansas City, Tyree Kiser, University of Colorado At Denver and Health Sciences Center, Douglas Fish, University of Colorado, Robert MacLaren, University of Colorado School of Medicine Introduction: Evaluation of continuous renal replacement therapy (CRRT) ultrafiltration (UFR), dialysis rates (DFR), and residual renal function is commonly used to estimate drug clearance (CL) during CRRT. Hypothesis: We hypothesized that urine output (UOP), CRRT UFR and DFR correlate well with drug CL and can be utilized for developing dosing recommendations for specific antibiotics during CRRT. Methods: This retrospective study included critically ill patients, 18 to 89 years of age, with at least 2 antibiotic concentrations reported while undergoing CRRT. Pharmacokinetic analyses were performed utilizing ADAPT for the following antibiotics: tobramycin, amikacin, vancomycin, cefepime, ciprofloxacin, and levofloxacin. Correlation of CL (ml/min) with UOP, UFR, and DFR (all reported as ml/min), if applicable, were performed for individual drugs and for the aminoglycosides as a drug class. Results: Eighty-one patients were enrolled in this study (2 tobramycin, 3 amikacin, 50 vancomycin, 6 levofloxacin, 8 ciprofloxacin, and 10 cefepime). 65.4%, 24.7%, 8.6%, and 1.2% were on CVVH, CVVHDF, CVVHF, and CVVHD, respectively. Correlation of individual drug CL and UOP, UFR, and DFR were: aminoglycoside class R2 ⫽ 0.0396, R2 ⫽ 0.0000, and N/A (p ⫽ 0.67, p ⫽ 0.99, respectively); vancomycin R2 ⫽ 0.0001, R2 ⫽ 0.0002, and R2 ⫽ 0.5413 (p ⫽ 0.94, p ⫽ 0.92, p ⫽ 0.038, respectively); cefepime R2 ⫽ 0.2422, R2 ⫽ 0.0786, and R2 ⫽ 0.0297 (p ⫽ 0.39, p ⫽ 0.43, p ⫽ 0.63, respectively); ciprofloxacin R2 ⫽ 0.0343, R2 ⫽ 0.2338, and R2 ⫽ 0.0000 (p ⫽ 0.66, p ⫽ 0.22, p ⫽ 0.99, respectively); and levofloxacin R2 ⫽ 0.0074, R2 ⫽ 0.0000, and R2 ⫽ 0.0905 (p ⫽ 0.87, p ⫽ 0.99, p ⫽ 0.69, respectively). Conclusions: This study demonstrated overall poor correlation between drug CL and UOP, UFR, or DFR during CRRT for the specified antibiotics. Based upon these results, UOP, UFR, or DFR may not sufficiently predict dosing requirements in critically ill patients undergoing CRRT. In this study, DFR was the strongest predictor of drug CL; however, this parameter accounted for only a small portion of variability in drug CL during CRRT.


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OPTIMIZING PHARMACOTHERAPEUTIC INTERVENTIONS IN CRITICALLY ILL NEUROSURGICAL PATIENTS: A RETROSPECTIVE CLINICAL AND ECONOMIC ANALYSIS

THE ESTIMATING OF THE INFLUENCE OF HELIOX AND SALBUTAMOL TREATMENTS HISTOPATHOLOGICALLY IN A RAT-MODEL ARDS

Julie Chen, Richard Savel, Danny Lizano, Montefiore Medical Center

SEMA YILMAZ, Dincer Yildizdas, Kenan Daglioglu, Cukurova University Medical Faculty, Arbil Acikalin, University Medical Faculty, Yurdun Kuyucu, Cukurova University Medical Faculty, Derya Gumurdulu, Ibrahim Bayram, University Medical Faculty

Introduction: To evaluate the use of antihypertensive and antiepileptic therapy in a neurosurgical (NS) ICU and to determine if pharmacotherapeutic interventions can be implemented to improve the quality and cost of patient care. Hypothesis: A properly conducted medication usage review could help identify important patient care issues for future quality improvement initiatives. Methods: Electronic medical records for patients admitted to NSICU from June 1, 2010 to August 31, 2010 were reviewed retrospectively. Data on antihypertensive and antiepileptic usage were collected in addition to general demographic data. Results: A total of 74 patient records were reviewed. The mean length of ICU stay was 5.5⫾4.5 days. The two most common diagnoses were intracranial hemorrhage (N ⫽ 33) and brain mass (n ⫽ 24). An order for nicardipine infusion was placed in 55 patients (74%) with 71% of those patients (39 patients) actually requiring the drug for BP control. The infusion was discontinued in 25 patients (64%) within 24 hours, with a mean duration of 22⫾30 hours. Prolonged infusion (⬎24 hours) occurred in 14 patients, with the majority of the prolonged infusions (11 patients [79%]) occurring on weekends or holidays. Although 23 patients (59%) who received nicardipine had a history of hypertension, only 4 patients (10%) received concurrent oral antihypertensives. The cost of nicardipine use during this review was $14,400. Seizure prophylaxis was initiated in 42 patients (60%) with a mean duration of 9.5⫾6.8 days. Empiric therapy was started in 88% of patients with ICB and 46% of patients with brain mass. Phenytoin (DPH), the most common agent, was used in 29 patients (63%) with148 levels monitored per 154 DPH days (mean: 1 level/day). Conclusions: Our review indicated that nicardipine infusion was used properly in most NS patients, with an average duration less than 24 hours. Nicardipine use on weekends and holidays (no clinical pharmacist participating on rounds) could potentially be optimized. We also documented excessive DPH levels obtained for monitoring purposes. Implementing weight-based phenytoin dosing and monitoring guidelines can potentially optimize patient management in this area.

Hypothesis: To describe the histopathological changes in the lungs of rats with acute respiratory distress syndrome (ARDS) after using salbutamol and heliox. Methods: Anesthezied and tracheotomized rats with ARDS were ventilated with 100% oxygen at a respiratory rate of 30 breaths/min, inspiration– expiration ratio of 1:2, peak inspiratory pressure of 28 cm H2O at positive end-expiratory pressure of 8 cm H2O. There were four group: Control group, salbutamol 0,2 mg/kg/dose, heliox (He:O2 ⫽ 50:50) group and salbutamol 2.5 mg/dose group. Control group was applied only physiological saline solution. Ventolin nebules inhalation was given in dosage of 0,2 mg/kg and 2,5 mg/dose intratracheally in four cycle with 15 minutes breaks in the second and fourth group, respectively. The third goup received 50:50 heliox:O2 for one hour continously. Grading was performed with respect to the severity of the following parameters as grade 1(25% of lung paranchyma), 2(50%), 3(75%) and 4(100%): hyaline membrane (HM) formation, intraalveolar edema, infiltration of leukocytes into the lung alveoli and itraalveolar hemorrhage. Results: The control group showed similarities to the histopathological appearance occuring during the acute phase of ARDS in humans (Figure 1). We found a significant difference statistically between heliox and the dosage of 0,2 mg/kg of salbutamol group according to hyaline membrane formation (p ⫽ 0,008). The difference was significant statistically between second and fourth group in terms of hemorrhage (p ⫽ 0,0001) (Figure 2 and 3). While the mean grade of HM was lower in heliox group, the grade of hemorrhage was high. But in fourth group, the mean grade of hemorrhage was low (Figure 4). The using of heliox and the dose of 2,5 mg/dose ventolin nebules inhalation showed statistical difference for HM and hemorrhage grades, respectively. Conclusions: The formation of hyalen membrane has been decreasing after using heliox:02. The inhalation of ventolin nebules in 2,5 mg/dose showed that it can be helpful to decrease the hemorrhage of lung paranchyma during the menegament of ARDS in practice. Besides known effects of salbutamol, this result should be emphasized with regard to dosage of salbutamol in ARDS.

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EFFECT OF BODY MASS INDEX ON ANALGESIC RESPONSE TO MORPHINE

EFFICACY AND SAFETY OF SUBCUTANEOUS DESIRUDIN IN MEDICALLY ILL PATIENTS

Karen Holmes, Maricopa Integrated Health System, Asad Patanwala, Brian Erstad, University of Arizona

David Rosenberg, North Shore University Hospital, Jerrold Levy, Emory University School of Medicine, Michael Kurz, Canyon Pharmaceuticals, Inc

Introduction: The dosing and analgesic response to opioids is not well studied in obese and morbidly obese patients. Weight-based dosing in these patients could result in the administration of very high doses, putting them at risk for respiratory depression and other complications. It is unknown if these patients require a higher opioid dose for a similar analgesic response compared to non-obese patients. Hypothesis: We hypothesize that there is no difference in analgesic response after administration of the same fixed dose of morphine between nonobese, obese and morbidly obese patients. Methods: This was a retrospective cohort study conducted in a tertiary care emergency department. Consecutive adult patients who received a fixed dose of morphine 4 mg intravenously for acute pain were categorized by body mass index into three groups: non-obese (18.5– 29.9 kg/m2), obese (30.0 –39.9 kg/m2), and morbidly obese (ⱖ40 kg/m2). Baseline and post-dose pain scores were recorded on a numerical rating scale (0 ⫽ no pain, 10 ⫽ worst possible pain). The analgesic response, defined as the difference between baseline and post-dose pain scores, was compared between the groups using a Kruskal-Wallis test. Adverse effects related to the morphine administration were also collected and compared between groups. Results: Median baseline pain scores were similar between groups: 8.5, 8 and 8.5 for the non-obese, obese and morbidly obese groups, respectively (p ⫽ 0.46). There was no significant difference in median analgesic response between the groups: 2, 3 and 2 point reduction in the non-obese, obese and morbidly obese groups, respectively (p ⫽ 0.16). The number of adverse effects such as nausea or vomiting, pruritis, respiratory depression or hypotension was similar between the groups. Conclusions: There is no difference in analgesic response to the same fixed dose of morphine in non-obese, obese and morbidly obese patients in acute pain. Factors other than body mass index may influence analgesic response.

Introduction: DESIRABLE, a multicenter, open-label, single-arm study which enrolled 516 subjects at 19 centers, was designed to examine the safety profile of desirudin, the only parenteral heparin alternative approved for venous thromboembolism prophylaxis (VTEP) in the US, in a broad range of perioperative and critically ill patients requiring VTEP. The primary endpoint was Major Bleeding; secondary endpoints included incidence of new symptomatic VTE. Previous studies have evaluated desirudin only in surgical populations. The present analysis was performed to evaluate the efficacy and safety of desirudin in medically ill subjects from the DESIRABLE trial. Methods: Case report forms were reviewed to identify subjects receiving VTEP for perioperative (P) or medical (M) indications. Demographic characteristics, incidence of Major Bleeding, VTE, and serious bleeding-related adverse events were determined for comparison between groups. The desirudin dose was 15 mg SC q12h. Results: 138 subjects were identified as having M indications for prophylaxis [prolonged immobility (128), stroke (2) or cancer (8)]. P indications included orthopedic (93), cardiothoracic/ vascular (76), abdominal (132) and cancer (77). P and M groups were wellmatched for age, sex, weight and renal function. P subjects were more likely to have suspected heparin-induced thrombocytopenia (7.4% vs 0.0%) or malignancy (29% vs 9.4%). M subjects were more likely to have diabetes (36% vs 25%) and CHF (15% vs 7.1%). Treatment duration was similar between groups (⬃5 days). The incidence of new VTE was not different between P and M subjects: 5 (1.3%) vs 4 (2.9%, respectively, p ⫽ NS). There were no Major bleeding events in either group. Bleeding-related adverse events considered possibly related to study drug occurred in 2 (0.5%) of P and 1 (0.7%) of M subjects (p ⫽ NS). Conclusions: DESIRABLE demonstrated the clinical utility and safety of fixeddose SC desirudin in a broad population of critically ill perioperative and medical patients. The present analysis is the first to describe the safety and efficacy of desirudin in a medically ill (non-surgical) population. Randomized trials in M patients are needed to confirm these findings.


742

743

PIPERACILLIN/TAZOBACTAM (PTZ) PHARMACOKINETICS (PK) IN CRITICALLY ILL CHILDREN

DETECTION OF POTENCIAL DRUG INTERACTION IN PRESCRIPTIONS IN THE ICU-CONTRIBUTING TO THE DEVELOPMENT OF CLINICAL PHARMACY MODELS IN BRAZIL

Jeffrey Cies, St. Christopher’s Hospital For Children Introduction: Current evidence suggests early and appropriate antimicrobial (AM) therapy reduces morbidity and mortality in sepsis. Alterations in the Vd and clearance (Cl) of AMs in patients with sepsis have been documented in the literature. Impaired AM distribution to the site of infection is a major concern and may explain the high morbidity and mortality. Children between 6 months-6 years typically have larger Vds and faster Cl which can impact the dose and interval selection. Therefore, an understanding of PK and pharmacodynamic (PD) changes in critically ill children is crucial to determining the most appropriate PTZ dose and interval in critically ill children. Hypothesis: Current dosing dose not achieve appropriate PTZ serum concentrations in critically ill children. Methods: This was a retrospective chart review from 1/1/09 to 7/30/10. Children between 6 months-6 years admitted to the ICU with ⱖ2 PTZ serum concentrations were eligible for inclusion. PTZ serum concentrations were plotted against time, and individual PK parameters were determined by a one-compartmental analysis. Bayesian modeling was used to determine doses that would result in PTZ trough concentrations ⬃ 150 mcg/mL. Results: 8 patients met the inclusion criteria. The mean elimination rate constant was 0.59 hr-1 and the mean half-life was 1.4 hours which is similar to thevalues in the package insert for healthy volunteers. The mean volume of distributionwas 0.71 L/kg compared with 0.24 L/kg as reported in the package insert. Intermittentdoses of PTZ are displayed below with resultant troughsDose (mg/kg) Interval (hrs) Trough (mcg/mL)100 4 138150 4 208200 4 277200 6 127. Conclusions: Critically ill children have Vds that are significantly larger than currently published values for healthy volunteers. Appropriate PTZ serum concentrations may not be achieved in critically ill children based on current dosing recommendations. This data needs to be further evaluated to determine if appropriate PK/PD targets are achieved.

Aline Teot␮␮␮ Rodrigues, Ana Paula Devite Cardoso Gasparotto, Antonio Luis Eiras Falcao Me´™a de Marialva, Patr␮␮a Moriel, Priscila Gava Mazzola, UNICAMP Introduction: The chances of Adverse Drug Reactions (ADR) occurrence can be correlated to the presence of Potential Drug Interactions (PDI) in medical prescriptions, which makes PDIs one of the main concerns for a Clinical Pharmacist in the Intensive Care Unit. Hypothesis: There is a high incidence of PDI in prescriptions of the Intensive Care Unit (ICU) patients. Methods: The present study is a longitudinal, prospective and uncontrolled clinic trial conducted from January to June of 2011 in a public hospital (Hospital de Cl␮␮cas-University of Campinas-UNICAMP) in Brazil, . Prescriptions of 195 patients under 18 yearsold were evaluated. All of them remained hospitalized in the ICU for more than 24 hours. Results: In the study period, 172 different types of medication were prescribed, with an average of 12.9 ⫾ 4.3 per prescription. Among the evaluated prescriptions, 88.2% presented Potential Drug Interactions, resulting in an average of 4.7 ⫾ 4.9 PDI per prescription. It was observed 915 PDIs in the prescriptions which were classified according to the Micromedex® database as contraindicated (20), major (257), moderate (516) and minor (122). The medical team was warned according to the PDI severity and about the necessity of clinical management. Conclusions: This study helps to design the Drug Therapy Profile used in ICU of Brazilian public hospitals, showing that there is a high incidence of Potential Drug Interactions in prescriptions, which highlights the necessity of knowledge improvement to the medical staff for better clinical management, of PDIs. In addition, this work contributes to the initial development of Clinical Pharmacy for Intensive Care in Brazil, suggesting the participation of Clinical Pharmacists in the multidisciplinary team to reduce risks of drug therapy.

744 A COMPARISON OF EARLY AND LATE DUAL VASOPRESSOR THERAPY FOR INITIAL RESUSCITATION OF SEPTIC SHOCK Mitchell Daley, Ishaq Lat, Sarah Adriance, Nishil Patel, Jesse Hall, John Kress, University of Chicago Medical Center Introduction: The Surviving Sepsis Campaign (SSC) guidelines do not make specific recommendations regarding optimal timing for the addition of dual vasopressor therapy in the resuscitation of septic shock. The primary objective of this study is to evaluate if early initiation of dual vasopressor therapy is superior to late initiation of dual vasopressor therapy in the attainment of hemodynamic success. Methods: This retrospective cohort evaluated all adult medical and surgical ICU patients who received norepinephrine plus an additional vasopressor agent for the management of septic shock from December 2008 through July 2010. Patients were excluded if they were transferred from an outside hospital, norepinephrine was not the initial vasopressor agent utilized, or norepinephrine was monotherapy. Results: A total of 152 patients were included. The median time until a second vasopressor agent was added was one hour, defining the upper limit for early dual vasopressor therapy group (n ⫽ 74). There was no statistically significant difference in the proportion of patients who achieved hemodynamic success when utilizing an early dual vasopressor strategy compared to late dual vasopressor therapy (45.9% and 30.8%; p ⫽ 0.054; 95% CI 20% to 41% and 34% to 58% respectively). The proportion of patients who achieved hemodynamic success had a quicker interruption of vasopressor therapy with early compared to late dual therapy (HR 2.36, 95% CI 1.3 to 4.3), however, those who did not achieve hemodynamic success had a quicker progression to death with early compared to late dual vasopressor therapy (HR 1.65; 95% CI 1.13 to 2.43; p ⫽ 0.01). Conclusions: In this retrospective analysis, there was no difference between early and late dual vasopressor therapy on the achievement of hemodynamic success in septic shock. Further prospective analysis is warranted.


Posters: Therapeutics-Other-1 745

746

DOES BLOOD PURIFICATION IMPROVE SURVIVAL IN SEPSIS? A META-ANALYSIS OF PUBLISHED TRIALS

ORAL GLUTAMINE IMPROVES OUTCOMES AND REDUCES MYOCARDIAL INJURY IN CARDIAC SURGERY PATIENTS: A RANDOMIZED PILOT TRIAL

Feihu Zhou, Zhiyong Peng, Raghavan Murugan, John Kellum, University of Pittsburgh Medical Center Introduction: We sought to determine if pooled results from multiple published trials would provide a better estimate of the overall effect of blood purification on clinical outcomes for patients with sepsis. Hypothesis: We hypothesized that blood purification would decrease mortality in patients with sepsis or septic shock. Methods: PubMed, EMBASE, and the Cochrane Library database from database inception until July 1, 2011, including bibliographies of all relevant studies were searched. We selected randomized controlled trials in adults with sepsis that compared any blood purification technique including hemofiltration, hemoperfusion, plasma exchange, or dialysis against no blood purification (conventional treatment). We extracted data on outcomes and study quality and rated each study using the Jadad score. After assessing for heterogeneity of treatment effect across trials using the I2-statitic, we used a fixed effect model and expressed results as risk ratio (RR) for dichotomous outcomes. Results: Sixteen trials (n ⫽ 827) met inclusion criteria and the mean Jadad score was 2.75 indicating moderate study quality. Overall, blood purification decreased mortality in patients with sepsis or septic shock compared to no blood purification (RR, 0.69; 95% CI, 0.59 – 0.80; p⬍0.00001; 16 trials, n ⫽ 827), including 28-day mortality (RR, 0.80; 95% CI, 0.67– 0.96; p ⫽ 0.01; 8 trials, n ⫽ 588) and hospital mortality (RR, 0.56; 95% CI, 0.43– 0.73; p⬍0.0001; 6 trials, n ⫽ 262). Of individual blood purification modalities, hemoperfusion (RR, 0.64; 95% CI, 0.53– 0.76; p⬍0.00001; 10 trials, n ⫽ 557), plasma exchange (RR, 0.63; 95% CI, 0.42– 0.96; p ⫽ 0.03; 2 trials, n ⫽ 128), and hemofiltration combined with hemoperfusion (RR, 0.70; 95% CI, 0.59 – 0.82; p⬍0.0001; 14 trials, n ⫽ 699) decreased mortality. However, hemofiltration alone did not reduce mortality (RR, 1.08; 95% CI, 0.71–1.64; p ⫽ 0.72; 4 trials, n ⫽ 142). Funnel plot analysis ruled out significant publication bias. Conclusions: Blood purification techniques including hemoperfusion, plasma exchange, and hemofiltration combined with hemoperfusion appear to decrease mortality in patients with sepsis or septic shock.

Lindsay Weitzel, University of Colorado-Denver, Alexandra Sufit, University of Colorado SOM, Christine Hamiel Baird, Kelly Queensland, University of Colorado, Ira Dauber, South Denver Cardiology Associates, Olav Rooyackers, Karolinska University Hospital, Paul Wischmeyer, University of Colorado At Denver School of Medicine Introduction: Ischemia/reperfusion (I/R) injury during cardiac surgery is associated with increased morbidity and mortality. Glutamine (GLN) has been shown to protect against myocardial I/R injury both in vitro and in vivo. GLN’s potential to protect the myocardium in cardiac surgery patients is unknown. Hypothesis: Our hypothesis for this pilot trial was that GLN would attenuate myocardial injury and clinical complications in cardiac surgery patients. Methods: Patients undergoing elective cardiac surgery, requiring cardiopulmonary bypass, were enrolled in a randomized, placebo controlled, double-blind pilot trial to receive oral Alanyl-GLN (GLN) (25 g twice daily) (n ⫽ 7) or maltodextran (CONT) (n ⫽ 7) daily for 3 days pre-operatively. Serum troponin (TROP I) and creatine kinase (CK-MB) were measured at multiple peri-operative timepoints. Peri-operative clinical outcomes were also assessed. Results: GLN therapy significantly decreased TROP I at 24, 48, and 72 hours post-operatively (all p⬍0.05) versus CONT. GLN also reduced CK-MB at 24 and 48 h (p⬍0.05, p⬍0.001 respectively) versus CONT. GLN significantly reduced pooled clinical complications versus CONT (p ⫽ 0.03). Conclusions: This pilot study showed that high dose oral GLN therapy prior to cardiac surgery was feasible, and that it reduced myocardial injury and clinical complications. A larger trial of pre-operative GLN therapy in cardiac surgery patients is warranted.

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748

DEVELOPMENT OF AN EQUATION ESTIMATING RESTING ENERGY EXPENDITURE AFTER ICH

THIAMINE BLOOD LEVELS ARE ASSOCIATED WITH ILLNESS SEVERITY BUT NOT DELIRIUM IN CRITICAL ILLNESS

Teresa May, Maine Medical Center, Aimee Monohan, Amanda Carpenter, Columbia University College of Physicians and Surgeons, chunhao tu, New England University, Michael Schmidt, COlumbia University, Stephan Mayer, Neurological Institute of New York, Kiwon Lee, The Neurological Institute-New York Presby. Hosp., Columbia Univ. Med. Ctr, Jan Claassen, Columbia University, David Seder, Maine Medical Center, Neeraj Badjatia, Columbia University Medical Center

Mary Lough, Stanford Hospital And Clinics, Edith Sullivan, Stanford University, Bruce Cooper, University of California San Francisco, Bradley Aouizerat, University of California at San Francisco, Kathleen Puntillo, University of California San Francisco

Introduction: Determining nutritional needs is difficult in patients with acute illness, and incorrect calculation may result in over- or underfeeding. Hypothesis: No existing equation to estimate resting energy expenditure (eREE) has been validated in the intracerebral hemorrhage (ICH) population. An equation based on measured REE in patients with ICH may be more accurate than current estimation equations, derived from other populations. Methods: Between May 2008 –June 2011, we prospectively assessed resting energy expenditure (REE) from 30 minute indirect calorimetry (IDC) measurements performed every 48 –72 hours for the first 14 days after ICH. Patients were excluded if they arrived late (⬎48 hours after bleed), did not survive ⬎3 days post bleed, or were unable to tolerate IDC testing. Factors predicting mean 14 day REE were analyzed using multivariable linear regression. These factors were used to create a new equation estimating REE (eREE ICH). REE estimates from this equation, along with estimates from seven established eREE equations were compared to the IDC measured mean 14 day REE using a Bland Altman analysis. Results: 71 ICH patients (198 IDC measurements) met study criteria. Admission characteristics were mean age was 62 ⫹/⫺ 15 years, 39% men, mean BMI of 29⫹/ ⫺7.5 kg/m2, median ICH score of 2 (IQR: 2,3), mean intraventricular (IVH) volume of 18⫹/⫺3 ml and mean Apache II score of 17⫹/⫺8. The mean 14 day REE was 1530 ⫹/⫺ 379 calories/day. Higher mean 14 day REE was associated male sex (P ⫽ 0.008), higher body mass index (kg/m2) (P ⫽ 0.003), younger age (p ⫽ 0.052) with a trend for association with IVH volume on admission (p ⫽ 0.063). The eREE-ICH (Bias: 32 calories, 95% CI: -91, 166) was significantly better at estimating REE than the most accurate established eREE equation, the Ireton-Jones 92 equation (Bias: 261 calories, 95% CI: 160, 361). Conclusions: Higher 14 day mean REE after ICH is associated with male sex, higher BMI, younger age, and higher IVH volume on admission. These factors together provide a better estimation of REE requirements for ICH patients than currently established equations.


Introduction: Thiamine deficiency is a recognized risk factor for delirium, yet thiamine levels and delirium have not been studied in tandem in critical illness. Hypothesis: The aim of this study was to examine associations between whole blood thiamine diphosphate and delirium across time in critically ill patients. Methods: Fifty mechanically ventilated adults were prospectively enrolled in an observational study within 48 hours of intensive care unit (ICU) admission, between June 2009 and June 2010. Whole blood thiamine diphosphate levels and delirium status using the Confusion Assessment Method for the ICU (CAMICU) were obtained daily. Multilevel regression models were developed to examine associations between thiamine and delirium at baseline and across time. Results: Adult participants (n ⫽ 50) were in the study an average of four days (range 1–10 days); 262 thiamine samples were drawn. Mean whole blood thiamine diphosphate was 124.3 nmol/L, range 33–354 nmol/L (normal 80 –150 nmol/ L). Delirium decreased over linear time (p ⫽ .016) but delirium was not associated with thiamine levels at baseline or across time. Thiamine deficiency was identified in 6 patients (12%) when the blood thiamine level was below 60 nmol/L on multiple days; 5 were admitted with critically low thiamine and one developed thiamine deficiency in ICU. The interclass correlation coefficient (ICC) for blood thiamine was 0.56 indicating that 56% of total thiamine variance was from differences between patients; the remaining 44% represented withinpatient trajectory differences over time. Thiamine levels initially decrease then increase back to baseline (quadratic effect) over several days (p ⫽ .001). The quadratic effect on whole blood thiamine was statistically significant for patients with greater illness severity (higher APACHE II) scores (p ⫽ .016), patients with sepsis (p ⫽ .013) and patients who died in the hospital (p ⫽ .002). Conclusions: Whole blood thiamine diphosphate levels were not associated with delirium either at study baseline or across time. Thiamine levels vary significantly over time and thiamine deficiency may be underestimated in critical illness.Funded by the SCCM Normal J. Shoemaker Grant for Critical Care Nursing Research.

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750

MOLECULAR MECHANISMS UNDERLYING SMALL INTESTINAL GLUCOSE SENSING AND ABSORPTION IN CRITICAL ILLNESS

ENDOGENOUS GHRELIN, AMYLIN AND GLUCAGON-LIKE PEPTIDE-1 AND THEIR ASSOCIATIONS WITH GASTRIC EMPTYING IN THE CRITICALLY ILL

Adam Deane, Chris Rayner, University of Adelaide, Alex Keeshan, Royal Adelaide Hospital, Nam Nguyen, Bridgette Chia, Jennifer Sim, Marianne Chapman, Michael Horowitz, Richard Young, University of Adelaide

Matthew Summers, Antony Zaknic, Anna Di Bartolomeo, Adam Deane, Marianne Chapman, Michael Horowitz, University of Adelaide

Introduction: Glucose absorption is markedly diminished in the critically ill. In health, dietary glucose is predominantly absorbed via the intestinal sodium-dependent glucose transporter-1 (SGLT-1). The sweet taste receptor, T1R2, which is expressed in the human intestine, may link the presence of luminal glucose to upregulation of SGLT-1 transporter capacity. Hypothesis: Critical illness is associated with reduced levels of intestinal T1R2 and SGLT-1 during fasting, and following intestinal glucose exposure. Methods: This was a study of critically ill patients and healthy volunteers. Following an 8 hour fast, subjects underwent ultra-thin endoscopy and mucosal biopsies were collected from the second part of the duodenum at baseline and after a 30 min endoscopic infusion with glucose (4 kcal/min). RNA was extracted from biopsies and quantitative PCR performed to measure transcript levels of T1R2 and SGLT-1. Data are median (range). The local research ethics committee approved the protocol. Written consent was obtained from subjects, or their surrogate. Results: Nine mechanically ventilated, non-diabetic, critically ill patients [51(33–76) y; 8 M:1F; HbA1C 5.8 (5.1– 6.7)%; BMI 27 (20 –36)kg/m2; Days in ICU 4 (2–10); APACHE II 19 (7–26)] and 9 healthy volunteers [35 (24 –78) y; 8 M:1F; HbA1C 5.7 (5.2– 6.4)%; BMI 24 (21–39) kg/m2] were studied (P ⬎ 0.15 for all variables). During fasting the number of SGLT-1 transcripts in the duodenum of the critically ill was markedly reduced when compared to health (50%; p⬍0.001), and a trend for reduced T1R2 transcripts was also evident (46%; P ⫽ 0.12). These differences in expression persisted following luminal glucose exposure for both SGLT-1 (61% reduction, critical illness vs.health; p⬍0.001) and T1R2 (53% reduction; p⬍0.05). Conclusions: Critical illness is associated with markedly reduced transcript levels of both intestinal SGLT-1 transporter and the putative intestinal glucose sensor T1R2. These changes may represent the molecular basis of carbohydrate malabsorption in critically ill patients. Novel therapies that target the regulation of these molecules may offer new approaches to clinical management in this setting.

Introduction: Gastric emptying is controlled by a number of gastrointestinal hormones, but the concentrations of these hormones, and their relative importance to emptying in the critically ill, are yet to be quantified. Hypothesis: (i) In the critically ill fasting plasma ghrelin concentrations would be reduced and amylin and GLP-1 concentrations would be increased.(ii) Plasma concentrations of these hormones would be associated with rate of gastric emptying. Methods: Following a 6h fast, 106kcal of nutrient liquid, containing 0.1 g 13C-sodium octanoate, was administered to subjects via a naso-gastric tube. Fasting (t0) and postprandial (t30 & t60) blood samples were assayed for ghrelin, amylin and GLP-1. Breath samples were collected and analysed for 13CO2 to calculate the gastric emptying coefficient (GEC), with lesser numbers reflecting slower emptying. Data are median (range) and analysed using Mann-Whitney U tests. Results: 26 patients [20 m:6F; Age 50(20 – 85)years; BMI 26(16 –36)kg/m2; APACHE II 21(11–38)] and 23 healthy subjects [19 M:4F; 46(18 – 88)years; 24(18 –30)kg/m2] were studied. Gastric emptying was slower in the critically ill [GEC: 2.9(0.6 – 4.0)vs. 3.4(2.9 –3.8); P⬍0.01]. Ghrelin concentrations were comparable during fasting [6.7(0.4 – 69.7)vs. 8.7(1.4 – 46.2)pmol/l; P ⫽ 0.63] and postprandial [data not shown] periods. Amylin concentrations were similar during fasting [12.1(2.7–124.6)vs. 7.8(4.1–18.7)pmol/l; P ⫽ 0.25] and at t30, but in the critically ill these were increased at t60 [30.0(7.2–191.3)vs. 13.4(6.7– 36.2)pmol/l; P ⫽ 0.04]. GLP-1 concentrations were increased in the critically ill during fasting [1.7(0.4 –7.2) vs. 0.7 (0.3–32.0)pmol/l; p⬍0.01] and at t30 [3.0(0.4 – 8.5)vs. 0.8(0.4 –32.0)pmol/l; P⬍0.01], but not at t60. There were no linear relationships between GEC and fasting ghrelin, amylin or GLP-1 concentrations in critically ill patients. Conclusions: Critical illness increased fasting plasma GLP-1 concentrations, but had no apparent effect on fasting concentrations of ghrelin and amylin. Ghrelin, amylin and GLP-1 do not appear to be important endogenous modulators of gastric emptying rate in the critically ill.

751

752

THE USE OF TRANSCAPILLARY ALBUMIN LEAK RATE AS AN EARLY MARKER IN A LPS INDUCED SEPSIS MODEL

EVALUATING THE EFFECT OF AQUAPHORESIS ON TISSUE OXYGENATION IN ACUTE DECOMPENSATED HEART FAILURE PATIENTS USING NEAR-INFRARED SPECTROSCOPY

Carsten Bandt, Andre Shih, University of Florida, Naveen Thuramalla, Transonic Systems Inc, Gareth Buckley, Hunter Schrank, UF Introduction: Normal endothelial function provides an excellent barrier against the loss of plasma proteins such as albumin. In inflammatory states vascular permeability increases due to the loss of endothelial integrity and leads to an increased losses of intravascular fluid as well as plasma albumin. In systemic inflammatory response syndrome (SIRS) and sepsis, the increased vascular permeability is believed to occur in all organ beds. A new method to measure the vascular albumin leak rate is available through the Blood Volume Analyzer (BVA100, Daxor, NY). Hypothesis: Albumin transendothelial leakage increases early in the process of a LPS induced porcine sepsis model. Methods: Twelve 10 kg 1 month old piglet were anesthetized and instrumented with central venous catheter, femoral arterial catheter and pulmonary artery blood flow probe (CO) placed through a thoracotomy approach. I-131 labeled albumin was injected intravenously with 4 sequential blood draws at timed intervals to measure tracer levels. The intravascular I-131 labeled albumin leak rate was then calculated. Data was collected after anesthesia (baseline), after thoracotomy (control) and 15 min after 0.02 mg/kg of IV LPS administration (Sepsis). Data was analyzed by one way Anova and pair wise comparison with Fisher test. P less 0.05 was considered significant. Results: LPS induced Sepsis induced significant reduction in CO, systolic and mean arterial pressure. Albumin slope at baseline was 0.45%⫾1.3, 0.38%⫾1.9 in control stage and 1.38%⫾2.5 at sepsis stage. Albumin slope was statistically significant when baseline was compared to sepsis (p ⫽ 0.001) but not to control (p ⫽ 0.81). Control stage was statistically significant different than Sepsis stage (p ⫽ 0.003). Conclusions: Endothelial albumin leak rate increases significantly in the early process of sepsis. Further studies are necessary to evaluate if albumin leak can be used as an early marker, a prognostic indicator and/or as objective marker for responds to treatment.

Farid Sadaka, RaviKumar AgguSher, Sumi Prakash, Jocelyn Hawthorne, Saint John’s Mercy Medical Center/St. Louis University Introduction: Microvascular alterations and Tissue Oxygen consumption play a major role in the pathophysiology and outcome of acute decompensated heart failure (ADHF) patients. The Food and Drug Administration recently approved the Aquadex system (CHF Solutions, Brooklyn Park, Minn) for the clinical treatment of ADHF. In the 2009 update to the American College of Cardiology/American Heart Association Heart Failure diagnosis and management guidelines, Ultrafiltration (Aquaphoresis [AQ]) received a class IIa recommendation for the treatment of ADHF. Hypothesis: The aim of this study is to evaluate the effect of AQ on muscle tissue oxygenation, oxygen consumption and microvascular reactivity in ADHF patients using near-infrared Spectroscopy (NIRS). Methods: This prospective, observational study included 8 ADHF patients treated with AQ in the coronary ICU. Thenar tissue oxygen saturation (StO2) and muscle tissue hemoglobin index (THI) were measured using a tissue spectrometer (InSpectra™ Model 650; Hutchinson Technology). A vaso-occlusive test was performed before (T1), during (T2) and after (T3) AQ by rapid inflation of a pneumatic cuff around the upper arm for 3 min. The following variables were recorded: StO2, THI, the StO2 desaturation slope during the occlusion (%/minute) and the StO2 upslope of the reperfusion phase following the ischemic period (%/second). Muscle oxygen consumption (NIRVO2) was calculated as the product of the inverse StO2 desaturation slope and the mean THI over the first minute of arterial occlusion. Results: AQ did not globally affect NIRS-derived variables. Mean NIRVO2 increased from 155.6 at T1 to 174.3 at T2 (p ⫽ 0.36), to 170.3 at T3 (p ⫽ 0.41). However, Percent Change in NIRVO2-T2([NIRVO2-T2- NIRVO2-T1]/NIRVO2-T1) was negatively correlated with NIRVO2-T1(R2 ⫽ 0.66, p ⫽ 0.038). Percent Change in NIRVO2-T3 ([NIRVO2-T3- NIRVO2-T1]/NIRVO2-T1) was negatively correlated with NIRVO2-T1 (R2 ⫽ 0.70, p ⫽ 0.027). Conclusions: Muscle tissue oxygenation, and microvascular reactivity were globally unaltered by AQ in ADHF patients. Muscle oxygen consumption improved with AQ, but did not reach statistical significance. However, muscle oxygen consumption significantly improved in patients with low baseline.


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754

EFFECTS OF HYPERTONIC SALINE ON INTRACRANIAL PRESSURE IN PATIENTS WITH TRAUMATIC BRAIN INJURY

RETRIEVAL OF PATIENTS WITH SEVERE RESPIRATORY FAILURE ON VENO-VENOUS EXTRA-CORPOREAL MEMBRANE OXYGENATION: A CRITICAL CARE PHYSICIAN-LED MODEL

Diana Wells, Auburn University Harrison School of Pharmacy, G. Christopher Wood, Bradley Boucher, Joseph Swanson, Charles Harrison, Martin Croce, University of Tennessee Health Science Center Introduction: Hypertonic saline (HTS) is used in some centers for managing traumatic brain injury (TBI) patients with elevated intracranial pressure (ICP). Small retrospective studies suggest that a serum sodium of 145–155 mEq/L is associated with lower ICP in patients with TBI; however, this has not been demonstrated in a larger population. The goal serum sodium for most patients with TBI in the study center is 145–155 mEq/L. The purpose of this study was to determine the effects of serum sodium values on ICP in patients with TBI. Hypothesis: Serum sodium concentrations of 145–155 mEq/L correlate with lower ICP values compared to serum sodium values outside of this range. Methods: This retrospective review enrolled adult patients with TBI and an ICP monitor who received at least one dose of HTS. Data were collected for up to 120 hours after ICP monitor placement. The primary outcome was the relationship between serum sodium and maximum ICP. The secondary outcomes were the acute change in ICP during the six hours after HTS administration and the percentage of patients with any ICP reduction after administration. Linear regression was used for the primary outcome analysis. Repeated measures ANOVA was used to evaluate the acute effect of HTS on ICP. Results: Eighty-one patients were enrolled with a mean age of 36 ⫾ 15 years and median Glasgow Coma Score of 7 (interquartile range, 4 –7). Twelve hundred thirty sodium (range, 118 –174 mEq/L) and 7483 ICP values (range, 0 –159 mmHg) were collected. There was no correlation between serum sodium and maximum ICP (R-squared ⫽ 0.0052). Regarding the acute effect of HTS on ICP, there was no statistical difference in mean ICP change during hours one through six following HTS doses (Hr 1: 0.12 ⫾ 6.8 mmHg, Hr 2: -0.06 ⫾ 6.93, Hr 3: -0.05 ⫾ 7.59, Hr 4: -0.42 ⫾ 7.22, Hr 5: -0.53 ⫾ 6.87, Hr 6: -0.09 ⫾ 7.28; p ⫽ 0.693). However, HTS acutely reduced ICP within the first hour in 66% of patients (mean, -3.89 mmHg). Conclusions: Serum sodium concentrations did not correlate with ICP values. These results warrant further evaluation and possible reassessment of sodium goals for ICP management in patients with TBI.


Aidan Burrell, Vincent Pellegrino, David Pilcher, Stephen Bernard, The Alfred Hospital Introduction: Patients with severe respiratory failure may require veno-venous extra-corporeal membrane oxygenation (vv-ECMO). However, this treatment is only available in specialized centres. Previous reports of vv-ECMO cannula insertion and retrieval have described staffing by a surgeon/perfusionist as part of an ECMO team. Hypothesis: We hypothesized that a critical care physician-led model for rapid response to a referring hospital, the insertion of vv-ECMO cannulae and subsequent retrieval would be safe and feasible. Methods: The Alfred Hospital Intensive Care Unit is the specialist centre for ECMO services for the states of Victoria and Tasmania in Australia. The critical care physicians in our ICU are trained to insert ECMO cannulae using a percutaneous femoral approach and manage the ECMO circuit during transport. The retrieval team comprises two critical care physicians to insert femoral cannulae and manage the ECMO circuit, a third physician to manage the ventilator and infusion pumps and a paramedic to manage the logistics of the patient transfer. We reviewed our vv-ECMO retrieval experience during 2008 –2011 for patients with severe respiratory failure. Results: There were 23 patients with severe respiratory failure who were placed on vv-ECMO and then retrieved back to The Alfred Hospital. All cannulations were successfully performed percutaneously by the critical care physicians. The underlying condition was H1N1 in 11 patients, bacterial pneumonia in 6, acute lung injury in 4, metastatic seminoma in 1 and multiple lung abscesses in 1. The average age was 36 yrs (range 17– 60 years). Males were 61%. Transport was by fixed wing aircraft in 35% and road ambulance in 65%. The retrieval distance averaged 76km (range 7 to1770km). During transport, there were 2 transient pump failures requiring hand cranking and one monitor failure. The average ICU length of stay was 14 days. Overall survival was 17/23 (74%). Conclusions: A critical care physician-led model of vv-ECMO cannulation and retrieval appears to be a safe and effective model for vv-ECMO retrieval. This model may lead to a more rapid and cost-effective response than the requirement for a surgeon/perfusionist and larger team.


756

DIFFERENCES IN PAO2/FIO2 RATIOS AND CHEST WALL COMPLIANCE (CCW) IN A 24 HOUR PORCINE ARDS MODEL USING TWEEN 20

LIMITATIONS OF PREALBUMIN AS A MARKER OF THE ADEQUACY OF NUTRITIONAL SUPPORT IN CRITICALLY ILL SURGICAL PATIENTS

Charles Hunley, Orlando Health, Hugo Silva, Edgar Jimenez, Mai Vo, Orlando Regional Medical Center, Ewa Jaruga-Killeen, OHMERTC, Jay Falk, Orlando Regional Medical Center, Jorge Barba, Orlando Health, Hugo Ramon, Orlando Regional Healthcare, Cesar Bertolotti, Orlando Regional Medical Center, Gary Nieman, SUNY

Fahim Habib, Salma Hernandez, Kellie Henderson, Christine Stinson, Zara Khan, Sharyce Gonzalez, Anabel Anon, George Garcia, Nicholas Namias, University of Miami-Jackson Memorial Hospital

Introduction: Talmor et al. (1) showed that PaO2/FiO2 (P/F) ratios improved in ARDS patients when PEEP was set keeping the transpulmonary pressure at end-expiration (PtpPEEP) above 0 cm H2O. Criticism of the study (2) calls into question if improved oxygenation was due to overcoming decreased Ccw from potential increased abdominal pressure. This study investigates whether P/F ratios and Ccw increase in a 24 hour porcine ARDS model with normal bladder pressures. Hypothesis: In a porcine ARDS model setting PtpPEEP above 0 cm H2O will improve oxygenation and Ccw as compared with PEEP set using the ARDSNet protocol (3) in animals with bladder pressures within normal limits. Methods: Lung injury was induced with 5% Tween-20 in 6 yorkshire pigs, anesthetized and ventilated on a comprehensive Avea ventilator. When P/F ratios of ⱕ200 mm Hg were obtained (T0) a recruitment maneuver was preformed and the animals randomized into ARDSNet protocol (n ⫽ 4) and Talmor’s PtpPEEP protocol (n ⫽ 2) and followed for 24 hours (T24). Hourly measurements of Ptp, P/F ratio, inspiratory plateau pressure, lung compliance, Ccw, bladder pressure and hemodynamics were obtained. Results: As reported by Talmor et al, the PtpPEEP controlled group (PG), compared to ARDSNet protocol group (AG) had higher P/F ratios (T5 to T24: PG: 373⫾16 vs. AG: 275⫾77, p⬍0.0001), improved Ccw (T5 to T24: PG: 69⫾16 vs. AG: 57⫾16 mL/cm H2O, p⬍0.001) with all groups having bladder pressures that were consistently below 7 mm Hg throughout the study. Conclusions: Talmor et al. (1) had 39% of individuals studied with abdominal pathology that could potentially affect the PtpPEEP guided protocol. This swine lung injury model suggests that keeping the PtpPEEP greater than 0 results in improved P/F ratios and Ccw with abdominal pressures within normal range throughout the study. Further studies are necessary to determine the inflammatory response of these strategies and its effect on atelectrauma. References1. References: 1. Talmor D, et al.: N Engl J Med. 2008; 359(20):20952. Bernard G: N Engl J Med 2008; 359:21663. Acute Respiratory Distress Syndrome Network: N Engl J Med 2000; 342:1301

Introduction: Prealbumin, the most widely used indicator of adequacy of nutritional support in critically ill patients, is reportedly influenced by the pro-inflammatory state characterized by increased levels of acute phase proteins, notably C-reactive protein (CRP). The exact relationship between changing levels of CRP and prealbumin levels in adequately fed critically ill patients remains poorly defined. Hypothesis: We hypothesized that rising CRP levels would preclude increases in prealbumin despite adequate nutritional support. Further, beyond a threshold CRP value, expected increases in prealbumin would not be observed. Methods: With IRB approval, weekly CRP and prealbumin levels were prospectively obtained in critically ill surgical patients admitted to our ICU. Data on demographics, steroid use, and presence of renal failure were also collected. Statistical analysis was performed using Spearman and Pearson tests of correlation, linear regression, and ROC analysis as appropriate. Results: Paired measurements of CRP and prealbumin (n ⫽ 215) were obtained in 67 patients (66% male, 34% female). Renal failure was present in 31% of patients and 24% were receiving steroids. There was a significant negative correlation between ⌬CRP and ⌬Prealbumin (r ⫽ -0.50). However, only weak associations between ⌬prealbumin and initial/final CRP levels were detected (r ⫽ 0.28 and 0.30, respectively). These findings were replicated in regression analysis; ⌬CRP and steroid use were significant predictors of ⌬Prealbumin (␤ ⫽ 0.569, p⬍0.001 and ␤ ⫽ 0.140, p ⫽ 0.040, respectively) while overall CRP level and renal failure were not significant (␤ ⫽ 0.159, p ⫽ 0.064 and ␤ ⫽ 0.005, p ⫽ 0.943, respectively). ROC analysis revealed an AUC of 0.339 precluding identification of cutoff values for CRP with adequate sensitivity and specificity. Conclusions: Rising CRP levels were associated with a failure of prealbumin levels to rise despite adequate nutritional support in critically ill surgical patients. However, no threshold CRP value could be identified that reliably predicted the direction of prealbumin change. Further studies are needed to identify additional predictor variables and/or alternative markers for adequacy of nutritional support.

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PROCALCITONIN KINETICS IN A HETEROGENEOUS GROUP OF CRITICALLY ILL PATIENTS

AIRWAY RESCUE STRATEGIES FOR PEDIATRIC DIFFICULT AIRWAY: A REPORT FROM THE NATIONAL EMERGENCY AIRWAY REGISTRY FOR KIDS (NEAR-4-KIDS)

Steven Reynolds, Royal Columbian Hospital, Andrew Shorr, Washington Hospital Center, John Muscedere, Department of Medicine, Queen’s University, Xuran Jiang, Clinical Evaluation and Research Unit, Kingston General Hospital, Daren Heyland, Kingston General Hospital Introduction: The utility of Procalcitonin (PCT) for the diagnosis of infection in the critical care setting has been extensively investigated with conflicting results. A potential source of variability may be the variable populations and clinical syndromes studied. Herein, we report PCT values relative to baseline patient characteristics, ICU time course, infectious status and infecting organism. Hypothesis: PCT kinetics will show variability depending upon the patient population evaluated. Methods: A prospective, multicenter, observational study of critically ill patients admitted to 3 mixed medical-surgical Tertiary Care ICUs for more than 24 hours. Patients who had elective surgery, overdoses, and who were expected to stay less than 24 hours were excluded. Patients were followed prospectively to ascertain the presence of prevalent or nosocomial infections and clinical outcomes. PCT levels were measured daily for 10 days and were analyzed as function of the underlying patient characteristics, time of infection and pathogen isolated. Results: 598 patients were enrolled. Medical and surgical infected cohorts were similar with respect to baseline PCT values (3.0 [0.7 to 15.3] vs. 3.7 [0.6 to 9.8] p ⫽ 0.68) and peak PCT (4.5[1.0 to 22.9] vs. 5.0[0.9 to 16.0], p ⫽ 0.91). Infected patients were sicker than their non-infected counterparts (APACHEII 22.9 vs 19.3, p⬍0.001); those with infection on admission had higher peak PCT values than did those whose infection developed in the ICU (4.9 vs. 1.9, p ⫽ 0.08). PCT levels in patients with incident infections tended to decay quicker than in those patients who had a prevalent infection. There were no significant differences in the PCT values when analyzed as a function of gram stain or culture negative vs. positive status. Conclusions: Significant differences in PCT values were seen in patients who had incident vs. prevalent infections. Further study is required on the dynamics of PCT response in patients who develop a nosocomial infection.

Akira Nishisaki, The Children’s Hospital of Philadelphia, Jessica Leffelman, Children’s Hospital of Philadelphia, Susan Ferry, Abhijit Karwa, The Children’s Hospital of Philadelphia, Calvin Brown, Brigham’ and Women’s Hospital, Robert Berg, The Children’s Hospital of Philadelphia, Ron Walls, Brigham and Women’s Hospital, Vinay Nadkarni, The Children’s Hospital of Philadelphia, John McCloskey, Children’s Hosp. of Philadelphia Introduction: Scarce epidemiological data are reported for the incidence and difficult airway rescue strategies in PICU. Hypothesis: Orotracheal intubation in PICU requiring more than one approach is associated with more adverse Tracheal Intubation Associated Events (TIAEs) and indirect laryngoscope (Airtraq, Glidescope) rescue device use. Methods: With IRB approval, we analyzed consecutive orotracheal intubations reported to our local tertiary PICU NEAR-4-KIDS airway management database. Primary nasal intubations were excluded. Fisher’s exact and Wilcoxon rank-sum were used for univariate analysis. Two-tailed alpha ⫽ 0.05 as statistically significant. Results: Of 586 ICU patients requiring orotracheal intubation in the PICU from 8/2008 –7/2011, 47 patients required ⬎1 approach (airway rescue). Compared to patients requiring only one approach, patients requiring ⬎1 approach were younger (median 1 vs.4 yrs, p ⫽ 0.01), commonly had history of difficult airway (23% vs. 5%, p⬍0.001), required more attempts (median [IQR]: 3 [2–5] vs.1 [1–2], p⬍0.001),and with higher incidence of TIAEs (34% vs.14%, p⬍0.001). . Patients requiring ⬎1 approach were associated with more Laryngeal mask airway: LMA (19% vs.4%, p⬍0.001), Flexible fiberoptic bronchoscope (4% vs.0%, p⬍0.001), Airtraq (15% vs.1%, p⬍0.001), and Glidescope (19% vs. 0%, p⬍0.001) use. The successful rescue devices were Direct laryngoscope (72%), Airtraq (11%), Glidescope (7%), LMA (4%) and Flexible fiberoptic bronchoscope (4%). Conclusions: Orotracheal intubation in PICU requiring more than one approach is associated with more adverse Tracheal Intubation Associated Events (TIAEs) and indirect laryngoscope (Airtraq, Glidescope) rescue device use. Supported by Endowed Chair, Anesth/CCM, CHOP, and Laerdal Foundation for Acute Medicine. Dr. Walls has provided testimony in a patent infringement suit in Scotland on behalf of Verathon, Inc., manufacturer of the GlideScope video laryngoscope.


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THE INCIDENCE OF ACUTE RENAL FAILURE (ARF) WITH INTRAVENOUS COLISTIN (COLISTIMETHATE SODIUM) AND POLYMYXIN B AT A TERTIARY CARE MEDICAL CENTER

INDICATIONS AND OUTCOMES IN CHILDREN RECEIVING RENAL REPLACEMENT THERAPY IN A CANADIAN PEDIATRIC INTENSIVE CARE UNIT

Darowan Akajagbor, Sharon Wilson, University of Maryland Medical Center, Kalpana Shere-Wolfe, Paul Dakum, Manhattan Charurat, Bruce Gilliam, University of Maryland School of Medicine Introduction: Intravenous (IV) polymyxin B and colistin use has been associated with acute renal failure (ARF), but due to lack of standardized definitions and comparative studies, the true incidence of nephrotoxicity is unknown. We sought to evaluate the incidence of and risk factors for nephrotoxicity associated with colistin and polymyxin B. Hypothesis: The risk of nephrotoxicity would be higher with IV colistin when compared to polymyxin B. Methods: This was a retrospective cohort study of adult inpatients receiving IV colistin or polymyxin B for ⱖ72 hours between 01/2008 and 06/2010, excluding all who received continuous renal replacement therapy or intermittent hemodialysis prior to initiation of treatment. Nephrotoxicity was defined using the validated Risk Injury, Failure, Loss, and End-stage renal disease (ESRD) (RIFLE) criteria based on changes in serum creatinine from baseline. Risk, injury and failure were considered reversible, loss and ESRD were considered irreversible ARF. Time to the development of nephrotoxicity was determined using Kaplan-Meier estimates with multivariate analysis using Cox proportional regression to estimate hazard ratio (HR). Results: A total of 173 patients met our study criteria. 106 patients received colistin and 67 patients received polymyxin B. The incidence of nephrotoxicity was in 60.4% in the colistin group and 41.8% in the polymyxin B group (p ⫽ 0.017), HR ⫽ 1.98, (p ⫽ 0.003). Most patients experiencing ARF fell into the reversible kidney injury category (92.5% and 100%) in the colistin and polymyxin B arm respectively. Majority of the patients were ICU patients (90.2%) with mean APACHE II score of 22.6⫾6.4 and 22.7⫾5.3 (p ⫽ 0.918) for colistin and polymyxin B respectively. Other independent risk factors associated with increased nephrotoxicity were older age, APACHE score, and baseline renal dysfunction. Conclusions: The combined incidence of ARF was 53.2% and patients receiving IV colistin had a significantly higher incidence of nephrotoxicity compared to polymyxin B. This data supports the need for close monitoring of renal function for patients receiving these agents. Further investigation is needed to determine the etiology of the differences in nephrotoxicity observed.

Erin Boschee, University of Alberta, Dominic Cave, Daniel Garros, Don Granoski, Lindsay Ryerson, Stollery Children’s Hospital Introduction: Our aim was to describe patient characteristics, indications for renal replacement therapy (RRT), and outcomes in a Canadian quarternary pediatric ICU. Hypothesis: We hypothesized that fluid overload, not blood chemistry indications, would be the most frequent reason for RRT initiation. Methods: We performed a retrospective chart review on all patients receiving RRT between 2004 and 2008 at Stollery Children’s Hospital Edmonton, Canada. Data was collected on patient demographics, PRISM score, pRIFLE criteria, indications for initiating RRT, RRT modality, length of stay and mortality. Results: 105 patients had RRT initiated in the PICU. Eight patients admitted with end-stage renal disease were excluded. Median age was 9 months (IQR 2–112 months). Median PRISM-III score was 14 (IQR 8 –19). 41% were post cardiac surgery, 9% were admitted with sepsis, 6% post cardiac arrest, 5% post liver transplant. 29% were on extracorporal life support (ECLS) at the time of RRT initiation. Prior to RRT, 65.6% had renal failure by pRIFLE score and 10.8% had injury. The most common cause of AKI was hemodynamic instability (81%), followed by multi-organ dysfunction syndrome (MODS) 25.3%. The most common indication for RRT initiation was fluid overload (62%) with a mean percent fluid overload of 12.1% (IQR 4.1–22.3%) with a median urea of 15 mmol/L (IQR 9.7–28.7 mmol/L). Median duration of RRT was 6 days (IQR 3–15) and 28-day mortality was 9.3%. 75.3% of patients survived to hospital discharge. 9.3% of patients required dialysis at hospital discharge. Conclusions: Hemodynamic instability and MODS are the most significant causes of AKI in the PICU population. The commonest indication for RRT was management of fluid overload, with a median urea of only 15 mmol/L. The paucity of conventional indications of acid base, electrolyte disturbance or uremia in the presence of significant renal dysfunction as assessed by pRIFLE criteria suggests that renal impairment is being recognized early and managed aggressively. In the population studied, the mortality was lower than previously reported in children and much lower than in the adult population. The use of RRT was associated with a renal recovery greater than 90%.

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EARLY GOAL DIRECTED THERAPY IN PEDIATRIC SEPTIC SHOCK: COMPARISON OF OUTCOMES WITH AND WITHOUT INTERMITTENT CENTRAL VENOUS OXYGEN SATURATION MONITORING

DIURNAL VARIATION IN PLASMA SODIUM CONCENTRATIONS IN NEUROCRITICAL CARE PATIENTS

Jhuma Sankar, PGIMER, DR RML Hospital, M Jeeva Sankar, All India Institute of Medical Sciences, Narendra Bagri, Yogiraj Chopra, Nandkishore Dubey, PGIMER, Dr RML Hospital Introduction: The surviving sepsis campaign guidelines (SSC) for management of septic shock advocates the use of early goal directed therapy (EGDT) with continuous monitoring of central venous oxygen saturation (ScvO2) being one of the major resuscitation end-points. However, continuous or even intermittent monitoring of ScvO2 may not be feasible in most resource-restricted settings. Hypothesis: The primary objective of this study was to evaluate the effect of intermittent ScvO2 monitoring on critical outcomes in children with septic shock. Methods: In this ongoing prospective cohort study, we enroll children aged 2 months to 17 years who are admitted in our ICU with fluid refractory septic shock. Children in whom superior vena caval line insertion is successful form the ‘exposed’ group (Group 1) while the rest constitute the ‘control’ group (Group 2). Management in both groups is as per the SSC guidelines with the only exception being intermittent ScvO2 monitoring at 1, 3 and 6 hours after initiation of therapy that is used as an additional therapeutic end point in Group 1. The major outcomes are the in-hospital mortality and achievement of therapeutic goals within 6 hours. Results: A total of 34 children have been enrolled till date-19 in Group 1 and 15 in Group 2. Baseline characteristics were comparable between the groups except for the number of dysfunctional organs at admission (mean [SD]: 2.1 [0.7] vs.3.1 [1.1]; p ⫽ 0.008]. The Pediatric Logistic Organ Dysfunction (PELOD) scores were, however, comparable between the groups (p ⫽ 0.13). ScvO2 directed therapy was associated with reduced in-hospital mortality (26.3% vs. 60%, RR: 0.44; CI: 0.19 –1.03, p ⫽ 0.047) and greater proportion of patients achieving the therapeutic goals within the first 6 hours (84% vs. 40%, RR: 2.9; CI: 1.1– 8, p ⫽ 0.01). Patients in the exposed group received inotropes earlier and in increased doses than those in the control group. However, there was no difference in the use of blood products, ventilation or dialysis between the groups. Conclusions: Early goal directed therapy using intermittent central venous oxygen monitoring seems to decrease the in-hospital mortality in children admitted with septic shock in resource restricted settings.


Jane Dickerson, University of Washington, Aaron Joffe, University of Washington, Harborview Medical Center, Matthew Hallman, University of Washington Medical Center, Geoffrey Baird, University of Washington Introduction: Abrupt changes in plasma tonicity can cause brain swelling and malignant elevations in intracranial pressure. Plasma sodium concentration [Na] is the main determinant of tonicity and is thus checked frequently. Hypothesis: [Na] in Neurocritical Care Patients will be lowest during the evening and early morning hours, reflecting a diurnal variation. Methods: [Na] results from all adults admitted to two large academic medical centers for the years 2004 –2009 were extracted from the laboratory information systems, along with patient location and time of collection for each result. Results were compared between the neurointensivecare unit (NICU) and all other inpatients (including all ICU and hospitalwards). Plasma was collected in heparinized tubes and analyzed with ion-selective electrodes on the Beckman DxC platform. Pairwise comparisons between analyte means at multiple times of the day were made using t-tests with Bonferroni correction. [Na] is reported as mean⫾SD in mEq/L. Significance was defined as a P-value⬍0.001. Results: 1.07 million inpatient [Na] results were retrieved, 22,953 of which originated from the NICU. Overall, [Na] was 140.8⫾6.3 in the NICU and 137.7⫾4.7 for all other inpatients. In NICU patients, a [Na] nadir was found between 0200 – 0600 (140.3⫾5.7) and a peak between 0800 –1000 (143.4⫾8.4). [Na] for each hour 0200 – 0600 was significantly lower than each hour 0800 –1000. In all other inpatients, the magnitude of diurnal variation was smaller, with [Na] 138.1⫾5.0 between 0200 – 0600 and 137.6⫾4.6 between 0800 –1000. All comparisons were statistically significant. Conclusions: [Na] is routinely and frequently monitored in NICU patients to allow early diagnosis and treatment of sudden changes in plasma tonicity. The time of day chosen to assay blood, particularly the “morning draw,” is largely a matter ofconvenience. Our data suggests that low [Na] results from early morning draws, depending on their magnitude, could represent normal physiologic variation. Future investigation including paired nursing and pharmacy data is warranted, to examine the possible contribution of therapeutic interventions started in the early morning hours on later morning [Na].

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RESIDUAL LESIONS IN POST-OPERATIVE PEDIATRIC CARDIAC SURGERY PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION

A COMPARISON OF VASOPRESSIN AND NOREPINEPHRINE ON RENAL OUTCOMES IN PATIENTS WITH SEPTIC SHOCK.

Hemant Agarwal, Daphne Hardison, Karla Christian, David Bichell, Zena Harris, Vanderbilt Children’s Hospital

Hira Shafeeq, St. John’s University, Elena Santayana, University of Chicago Hospitals, Ishaq Lat, University of Chicago Hospitals, Critical Care, Jesse Hall, Pritzker School of Medicine, University of Chicago Hospitals, John Kress, University of Chicago Hospitals

Introduction: Pediatric cardiac surgery patients on extracorporeal membrane oxygenation (ECMO) have poor outcome. Hypothesis: To evaluate residual lesions in pediatric cardiac surgery patients placed postoperatively on ECMO and assess their outcome. Methods: Single institution retrospective review of postoperative pediatric cardiac surgery patients placed on ECMO within 7 days of surgery in time period of January 2005 to June 2011. Demographics, ventricle physiology, surgical details, ECMO details were studied. Residual lesions defined as hemodynamically significant lesions on ECMO that needed intervention were investigated. Role of cardiac imaging to detect residual lesions was studied. Time interval from placement on ECMO to detection of residual lesion was reviewed and subdivided as early diagnosis (detection in ⱕ3 days of ECMO) and late diagnosis (⬎3 days of ECMO). Outcomes including successful decannulation and survival to hospital discharge were studied. Chi-square and Wilcoxon rank sum tests were used for analysis. Results: Residual lesions were detected in 27 (25%) of the 110 post-operative patients placed on ECMO. No significant difference in demogrephics, cardiopulmonary bypass time, ventricle physiology, and indications for ECMO was seen in 27 patients with residual lesions as compared with the remaining 83 patients. Residual lesions were detected by transthoracic echocardiography in 6 of 26 patients and by cardiac catheterization in all 24 patients studied (p⬍0.001). 15 patients were diagnosed early and 12 patients were diagnosed late. 12 of 15 patients diagnosed early were decannulated from ECMO as compared to 4 of 12 patients diagnosed late (p ⫽ 0.022) and 9 of 15 patients diagnosed early survived as compared to 2 of 12 patients (p ⫽ 0.047) diagnosed late. Early diagnosis was also associated with improved survival to hospital discharge (12 of 15 patients) when compared to 30 of 83 patients not known to have residual lesions, although not reaching statistical significance (p ⫽ 0.09). Conclusions: Evaluation for residual lesions should be undertaken in post cardiac surgery patients that are not successfully weaned off ECMO. Early diagnosis of residual lesions may improve their outcome.

Introduction: Acute kidney injury (AKI) is a common complication of septic shock. Vasopressin’s effect on renal vasculature and urine output (UOP) suggests potential renal protective effects. However, there is limited clinical evidence to validate these findings in the setting of septic shock. Hypothesis: Vasopressin monotherapy for initial treatment of septic shock leads to improved renal outcomes compared to norepinephrine monotherapy. Methods: This was a retrospective, cohort, single-center, IRB approved study. All adult patients admitted from June 2008 to June 2010 receiving vasopressin or norepinephrine monotherapy for the initial 6 hours of septic shock were included in the analysis. Patients presenting with AKI or history of end-stage renal disease were excluded from the analysis. Patients were evaluated for development of AKI during the initial 48 hours of vasopressor treatment. Using the Acute Kidney Injury Network criteria, AKI was defined as an absolute rise in serum creatinine of 0.5 mg/dL or UOp⬍0.5 ml/kg/hr for ⱖ12 hours. Data was analyzed using Chisquare or Fischer exact test for categorical variables and student’s t-test or Wilcoxon rank-sum test for continuous data. Results: A total of 109 patients were included in the analysis of which 78 received norepinephrine and 31 received vasopressin. Patients in the two treatment groups were similar in all measured baseline characteristics except a greater proportion of patients in the vasopressin treatment group received aminoglycosides (3.9% vs. 19.4%, p ⫽ 0.02). The incidence of AKI was similar between the norepinephrine and vasopressin groups (37% vs. 48%, RR 1.3, 95% CI, 0.82–2.07, p ⫽ 0.28). Patients treated with norepinephrine demonstrated greater goal hemodynamic stability (83.3% vs. 64.5%, p ⫽ 0.03) and UOP (65.4% vs. 41.9%, p ⫽ 0.03), during the initial 6 hours of vasopressor therapy. Conclusions: There was no difference between vasopressin and norepinephrine monotherapy for preventing AKI as the initial vasopressor for treatment of septic shock. Inability to detect a treatment difference among the two groups may be subject to type II error.



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AIRWAY PRESSURE RELEASE VENTILATION IS ASSOCIATED WITH LOWER UTILIZATION OF PARALYTICS AND CHEST TUBES THAN HIGH FREQUENCY OSCILLATORY VENTILATION FOR PEDIATRIC RESPIRATORY FAILURE

CAN WE PREDICT WEANING-INDUCED LEFT VENTRICULAR DYSFUNCTION? INVASIVE AND ECHOCARDIOGRAPHIC EVALUATION

Nadir Yehya, Alexis Topjian, Richard Lin, Robert Berg, Stuart Friess, Children’s Hospital of Philadelphia Introduction: High frequency oscillatory ventilation (HFOV) is widely used for respiratory failure when conventional ventilation (CV) fails. Airway pressure release ventilation (APRV) represents an alternative nonconventional ventilation (NCV) mode which offers theoretical advantages over HFOV, such as reduced need for sedation and paralysis, and less cardiovascular compromise. Hypothesis: APRV is associated with decreased use of paralytics but increased use of chest tubes compared to HFOV for pediatric respiratory failure. Methods: A retrospective review of children ⱖ1 month of age managed with either HFOV or APRV for ⱖ4 hours in a single tertiary care pediatric intensive care unit between 1/2004 and 6/2009. Patients were classified as receiving HFOV, APRV, or both. Results: 114 patients received NCV ⱖ4 hours (HFOV n ⫽ 42, APRV n ⫽ 41, BOTH n ⫽ 31). HFOV patients were younger (median 24 months [IQR 8–76]) than those receiving APRV (81 months [30–164], p ⫽ 0.002). Compared to patients on APRV, patients receiving HFOV had higher oxygenation indexes (OI) prior to transition from CV (31 [24–37] vs. 20 [13–23], p ⫽ 0.0003), higher peak OI during NCV (37 [20–51] vs. 28 [17–39], p ⫽ 0.03), and higher use of nitric oxide (86% vs. 39%, p ⫽ 0.001). After controlling for mean airway pressure prior to transition to NCV, HFOV was associated with greater paralytic use (OR 89 [95% CI 16–499], p⬍0.001) and chest tube placement (OR 3.98 [95% CI 1.05–15.15], p ⫽ 0.04) compared to APRV. Seven patients (4 in HFOV and 3 in BOTH) failed NCV and required extracorporeal support. Overall survival was 60.5%. HFOV was associated with lower survival (48% vs. 76%, p ⫽ 0.03); however, there was no difference in survival between NCV modes after controlling for OI prior to transition to NCV (OR 0.46 [95% CI 0.15–1.47], p ⫽ 0.19). Conclusions: Use of HFOV compared to APRV was associated with younger age, more severe lung disease, and more frequent use of paralytics and chest tubes. When controlling for severity of lung disease, mode of ventilation was not associated with mortality. These results support the exploration of APRV as an alternative to HFOV for failure of conventional ventilation because of fewer complications and similar outcomes.

Wael Ayoub, Cairo University Medical School, Akram Abdelbary, Khaled Hussein, Yasser Nassar, Cairo University Medical School Introduction: Weaning-induced left ventricular dysfunction is a cause of weaning failure in high-risk patients. The diagnosis may require pulmonary artery catheterization to demonstrate increased pulmonary artery occlusion pressure (PAOP) during weaning. Transthoracic echocardiography can estimate left ventricular filling pressures using tissue Doppler imaging of mitral annulus velocities including early (E‘) peak diastolic velocity. Hypothesis: We tested the hypothesis that E/E‘ could be used to detect weaning-induced PAOP elevation defined by a PAOP ⬎18 mm Hg during a spontaneous breathing trial (SBT). Methods: We included thirty invasively mechanically ventilated patients fulfilling criteria of weaning from mechanical ventilation & Shifted to SBT (using low PSV (8 cmH2O)) for 30 minutes. 2 sets of variables were measured at the beginning & end of the SBT. Weaning failure was defined as; Failed SBT, Reintubation &/or ventilation or death within 48 h following extubation. Swan Ganz catheter was used to get the right atrial (RAP), pulmonary artery (PAP), pulmonary artery occlusion (PAOP) pressures. Transthoracic Echocardiography was used to get The LV internal diameter at end diastole (LVIDd) & end systole (LVIDs), Ejection fraction (LVEF), E/A ratio& E/E‘ ratio. Results: LVEF was ⬎50% in all included subjects. Weaning-induced PAOP elevation occurred in 7 patients. There was weak correlation between E/A ratio and PAOP at the end of the trial (r: 0.2, p: 0.02), while E/E‘ ratio correlated well with PAOP at the end of the trial (r: 0.6, p⬍0.001). We found a value of septal E/E‘ ⬎10.4 at the end of the SBT predicted weaning induced PAOP elevationⱖ18 mmHg with a sensitivity of 100%, and a specificity of 78%. Conclusions: At the end of an SBT, a value of septal E/E‘ ⬎10.4 allows noninvasive detection of weaning-induced PAOP elevation.

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PHARMACOLOGIC VENOUS THROMBOSIS PROPHYLAXIS IN TRAUMATIC BRAIN INJURY PATIENTS: HOW AGGRESSIVE SHOULD WE BE?

CELL SAVER SALVAGED BLOOD CAN SAFELY BE TRANSFUSED FOR UP TO 24 HOURS POST-COLLECTION

Xi Liu-DeRyke, Orlando Regional Medical Center, Joseph Trang, UF School of Pharmacy, Matthew Lube, Orlando Regional Medical Center, Denise Rhoney, Wayne State University Introduction: The incidence of venous thromboembolism (VTE) following traumatic brain injury (TBI) varies in the literature. Furthermore, phamacologic prophylaxis against VTE in TBI patients remains controversial. Hypothesis: This study is to evaluate bleeding complications with pharmacologic VTE prophylaxis and incidence of clinical important VTE in TBI patients. Methods: A retrospective review in two Level I trauma centers compared no pharmacologic prophylaxis to pharmacologic prophylaxis [(low dose heparin (UFH) or low molecular weight heparin (LMWH)] in consecutive patients with documented traumatic intracranial bleed. Variables collected included demographics, time of initiation of UFH/LWMH, VTE risk factors, bleeding complications, and clinical important VTE. Results: 124 TBI patients were included: 40% did not receive pharmacologic prophylaxis and 60% received UFH/LMWH. There were no differences in baseline characteristics, VTE risk factors, laboratory values, or severity of TBI between groups. Nonpharmacologic VTE prophylaxis was received by ⬎80% of patients in each group. The incidence of any bleeding were 33% in non-treatment group vs. 40% in UFH/LMWH group (p ⫽ 0.41). Major bleeding was also similar between the groups (27% vs. 24%; p ⫽ 0.83) including intracranial bleeding. The overall incidence of clinical important VTE was 7% (2% in non-treatment vs. 11% in UFH/LMWH group; p ⫽ 0.11). However, more patients in non-treatment group died compared to UFH/LMWH group (24% vs. 12%; p ⫽ 0.01) and hospital LOS is longer in UFH/LMWH group (p⬍0.01). Of patients who received UFH/LMWH 60% received treatment ⱕ48 hr from admission and 40% received treatment ⬎48 hr. More VTE was detected in patients treated ⬎48 hr compared to ⱕ48 hr (23% vs. 2%; p ⫽ 0.01). Logistic regression revealed that UFH/LMWH initiated ⬎48 hr was an independent predictor for VTE development (OR 15.6; 95% CI 1.2–202.3). Conclusions: Pharmacologic VTE prophylaxis was not associated with increased bleeding in this cohort. The low VTE rate in non-treatment group may be due to the higher mortality. In patients received treatment, delayed initiation appears to be associated with increased risk of VTE. This finding need to be further elucidated in a prospective trial.


Jill Cholette, University of Rochester Medical Center, Karen Powers, Ronald Angona, George Alfieris, Kelly Henrichs, Debra Masel, Neil Blumberg, University of Rochester Introduction: Cell saver devices that remove heparin and inflammatory cytokines from salvaged blood are commonly used in adults, but until recently were not available for small volume collection necessary in pediatrics. There is little literature describing the re-infusion of cell saver blood in pediatrics, but it appears that most centers utilize cell saver for only 4 – 6 hours post-collection. We describe our experience with post-operative reinfusion of cell saver blood stored at the bedside for up to 24 hours post-collection. Hypothesis: Cell saver blood can safely be infused for up to 24 hours post-collection and drawn off aseptically in aliquots for multiple transfusions without increases in post-operative infectious or inflammatory complications. Methods: Single center experience describing the use of bedside-stored cell saver blood for up to 24 hours post-collection in pediatric cardiac surgery. Subjects: children ⬍20 kg undergoing cardiopulmonary bypass (CPB). Residual CPB volume was washed and processed by the Fresenius Continuous Auto Transfusion System® and transferred into a collection bag as cell salvage. Cell salvage was stored in a bedside cooler at 1– 6° managed by blood bank staff, from which aliquots were drawn off aseptically and transfused as needed for up to 24 hours post-collection. Wide-range C-reactive protein (wrCRP) was measured post-operative days (POD) 1 and 2. The incidence of infections occuring within 72 hours post-op was determined by chart review and culture data. Results: 34 subjects received cell saver salvaged blood during the first 24 hours following CPB. No infections occurred. There was no significant difference in wrCRP levels compared to patients managed per standard of care without salvaged blood infusion (POD#1: p ⫽ 0.32; POD#2 p ⫽ 0.95). Conclusions: Cell saver salvaged blood can be safely stored at the bedside, and transfused in multiple aliquots for up to 24 hours post-collection. This strategy for maintenance of cell saver blood is highly desirable as it allows a washed red blood cell product to be immediately available, without additional donor exposure, to correct for anemia or volume replacement without an increase in infectious complications or inflammation.

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COMPARISON OF UNFRACTIONATED HEPARIN, LOW MOLECULAR WEIGHT HEPARIN AND GRADUATED COMPRESSION STOCKINGS TO PREVENT THROMBOEMBOLIC EVENTS IN MECHANICALLY VENTILATED MEDICAL PATIENTS

OROPHARYNGEAL OXYGEN CONCENTRATION DURING ADENOTONSILLECTOMY IN THE PEDIATRIC POPULATION

Dany Gaspard, Utkal Patel, Krystal Hunter, Karen Vito, Barry Milcarek, David Gerber, Cooper Hospital/UMC

Introduction: Current clinical practice recommends that the inspired oxygen concentration (FiO2) should be as low as possible during tonsillectomy to avoid contamination of the oropharynx and the risk of airway fire. As there has been a trend toward the use of cuffed endotracheal (ETTs) in infants and children, the cuff may prevent the contamination of the oropharynx and thereby negate the need to wean the FiO2. The current study prospectively evaluated the impact of using a cuffed ETT on the oropharynx oxygen concentration with positive pressure ventilation (PPV) and spontaneous ventilation (SV) during adenotonsillectomy. Hypothesis: With the use of a cuffed ETT, the oxygen concentration in the oropharynx is independent on the FiO2. Methods: The use of a cuffed or uncuffed ETT as well as the use of SV or PPV was at the discretion of the anesthesiologist. After endotracheal intubation and placement of the mouth gag for the surgical procedure, a catheter was placed into the oropharynx and the concentration of oxygen and anesthetic agent measured using an infrared device. All measurements were made during the delivery of 100% oxygen. Results: The study cohort included 122 pediatric patients who ranged in age from 2 to 8 years. With a cuffed ETT and PPV (n ⫽ 52) or SV (n ⫽ 36), there was no anesthetic agent measured in the oropharynx and the oxygen concentration was 20 –23%. With the use of an uncuffed ETT with either PPV (n ⫽ 22) or SV (n ⫽ 12), there was significant contamination of the oropharynx with both oxygen and the inhalational agent. The oxygen concentration of the oropharynx exceeded 80% in 27 of 34 (79%) cases with an uncuffed ETT. Conclusions: With the cuff inflated to a pressure of 20 –25 cmH2O, there was no contamination of the oropharynx with either oxygen or inhalational agent. Therefore, if needed, a high FiO2 may be used. When an uncuffed ETT is used, the FiO2 should be kept at a minimal value to avoid contamination of the oropharynx with oxygen and the risk of an airway fire.

Introduction: Thromboembolic events (deep vein thrombosis (DVT) and pulmonary embolism (PE)) are significant medical problems and major causes of morbidity and mortality. We aimed to compare Unfractionnated Heparin (UFH), Low Molecular Weight Heparin (LMWH) and Graduated Compression Stockings (GCS) as methods of DVT and PE prophylaxis in mechanically ventilated (MV), non-surgical patients. Hypothesis: We hypothesized that chemical prophylaxis (UFH, LMWH) and mechanical prophylaxis (GCS) had equivalent efficacy in preventing thromboembolic events. Methods: In a retrospective study of adult patients in the Cooper University Hospital Intensive Care Unit from November 2002-June 2010, 1998 medical patients on MV were identified. 748 of those met the inclusion criteria of being on only one modality of DVT/PE prophylaxis. These were divided into 3 groups: 267 were treated with UFH, 62 with LMWH and 419 with GCS. Results: APACHE ii score was comparable in all 3 groups (p ⫽ 0.304). Results of univariate analysis showed no DVT/PE in the UFH group (0%), 1 DVT in the LMWH group (1.6%) and 12 DVTs/1 PE in the GCS group (3.1%), this difference was significant by Chi Square (p ⫽ 0.014). Overall mortality in the UFH, LMWH and GCS groups was 32.6%, 41.9% and 50.6% respectively, a difference that was also significant by Chi Square (p⬍0.001). ICU length of stay (LOS) in the three groups was not statistically significant (Mann-Whitney-U test, p ⫽ 0.650). Overall Hospital LOS was 16 days, 14.5 days and 13 days in the UFH, LMWH and GCS groups respectively; difference was significant (Mann-Whitney-U test, p ⫽ 0.022). Patients in the GCS group received significantly more blood transfusions (Pearson Chi Square test, p ⫽ 0.01). Multivariate analysis with correction for risk factors including age, APACHE ii score, comorbidities (HTN, CAD, CHF, cerebrovascular accidents, COPD, diabetes mellitus) and PRBC transfusion showed a 90% reduction of DVT/PE development risk with chemical prophylaxis (UFH and LMWH) as compared to GCS (95% confidence interval 0.01– 0.79). Conclusions: We conclude that chemical methods for DVT/PE prophylaxis are superior to mechanical prophylaxis in non-surgical patients on mechanical ventilation and should be used when possible.

Joseph Tobias, Nationwide Children’s Hospital

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PICU BLOOD CONSERVATION PROGRAM INITIATION: BLOOD OVERDRAW FINDINGS

VALIDATION OF FASTHUG-MAIDENS: A MNEMONIC FOR DRUG RELATED PROBLEM IDENTIFICATION IN THE INTENSIVE CARE UNIT

Jennifer York, Washington University Dept. of Pediatrics Introduction: This study documents the need for a Blood Conservation Program in a Pediatric Intensive Care Unit (PICU). Monitoring critically ill children includes repeated phlebotomy, putting patients at risk for anemia and transfusions. Upon admission, 33% of children are anemic and 41% more become anemic. Hypothesis: We aim to demonstrate need, implement and evaluate the effectiveness of a Blood Conservation Program on blood waste. This pre-implementation phase data documents baseline blood removal, anemia and transfusions. Methods: This is a single center, prospective, observational study. Inclusion criteria: ⬍18 years old, PICU stay ⬎48 hours and English speaking. Exclusion criteria: premature neonates, wards of the state, prior participation in the study, refusal of blood transfusions, involvement in other transfusion research, pregnancy, impending brain death, recent PICU stay, or ECMO. The six month pre-implementation phase characterized blood draws on 112 patients. Overdraw was calculated after determining the minimal volume for the 23 most frequent lab groups, representing ⬎50% of blood draws. These results inform the development of blood conservation guidelines and implementation strategies. Subsequently, blood draws, anemia incidence and transfusion frequency will be re-characterized for comparison. Results: During the pre-implementation phase, 3.3 ⫾2.5 ml blood/kg was removed (0.5 ⫾0.2 ml blood/kg/day). Blood overdraw was identified in 89% of samples with a mean of 0.6 ⫾ 0.7 ml, varying by site (capillary ⫽ 0.28 ⫾ 0.31 ml, peripheral venous ⫽ 0.76 ⫾ 0.85 ml, arterial line ⫽ 0.61 ⫾ 0.52 ml, central venous catheter ⫽ 1.08 ⫾ 1.36 ml). Overdraw volume also varied with test number (1 test ⫽ 0.58 ⫾ 0.69 ml, 2 tests ⫽ 0.69 ⫾ 0.64 ml, 3 tests ⫽ 0.77 ⫾ 1.05 ml). Of the 32% of transfused study patients, the median (interquartile range) of hemoglobin from admission to transfusion decreased from 9.8(7.9 –11.6) to 7.0(6.3–7.8) g/dl. Conclusions: These results indicate that blood overdraw is common and the decrease in hemoglobin appears sufficient to cross a conservative transfusion threshold, supporting the need for a Blood Conservation Program. UL1 RR024992.

Sarah Masson, Abbotsford Regional Hospital, Vincent Mabasa, Burnaby Hospital, Douglas Malyuk, Jerrold Perrott, Royal Columbian Hospital Introduction: The mnemonic FASTHUG (Feeding; Analgesia; Sedation; Thromboembolic prophylaxis; Head of bed elevation; stress Ulcer prophylaxis; Glucose control) was developed by intensive care unit (ICU) physicians to ensure that several key aspects of care are addressed by the ICU team in every patient encounter. However, this tool did not specifically target pharmacotherapy assessments. To provide a standardized approach for identifying drug related problems (DRPs) in the ICU, we further modified this mnemonic to FASTHUG-MAIDENS (Changing the H to Hypo/hyperactive delirium and adding Medication reconciliation; Anti-infectives; assess for Indications; Drug dosing; Electrolytes/ laboratory results; No duplications, interactions, allergies or side effects; Stop dates). The purpose of this study was to validate the benefit of this mnemonic for identifying DRPs. Hypothesis: Our hypothesis was that the use of the FASTHUG-MAIDENS mnemonic by pharmacy residents would increase their identification of DRPs in ICU patients compared to standard monitoring practice (SMP). Methods: This randomized, prospective validation study took place from January to May 2011 in the ICUs of four hospitals within the Fraser Health Authority in British Columbia, Canada: two community level and two tertiary referral ICUs. Six Pharmacy Residents completing ICU rotations were randomized to assess patients using the mnemonic FASTHUG-MAIDENS or employing SMP. The DRPs identified from these assessments were then compared with those identified by the ICU Pharmacists. The proportion of DRPs per patient encounter (the primary outcome) was calculated for each group using the Mann Whitney U test. The proportion of total DRPs identified in each group was assessed as a secondary endpoint using the Chi squared test. Results: Pharmacy Residents using the FASTHUG-MAIDENS mnemonic identified a statistically significant greater mean proportion of DRPs per patient encounter (73.2% vs 52.4%, p ⫽ 0.008) and a greater proportion of total DRPs (77.1% vs 52.5%, p⬍0.0001) than those assessing patients using SMP. Conclusions: The mnemonic FASTHUG-MAIDENS is a useful tool to increase the capture of DRPs by Pharmacy Residents in ICU patients.


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THE USE OF DROTRECOGIN ALFA IN SURGICAL PATIENTS WITH AN OPEN ABDOMEN

INTRACUFF PRESSURES DURING ROUTINE INTRAOPERATIVE USE OF CUFFED ENDOTRACHEAL TUBES IN INFANTS AND CHILDREN

Kelli Rumbaugh, Marcus Dortch, Addison May, Vanderbilt University Medical Center Introduction: There is limited data on the use of drotrecogin alfa (DA) in surgical patients, particularly those with peritonitis, requiring laparostomies. Bleeding risks associated with DA in patients with an open abdomen (OA) are unknown. Hypothesis: The objective of this study is to assess markers of blood loss and transfusion requirements pre and post-DA administration in critically-ill patients with an OA. Methods: A single center, retrospective cohort study was conducted in trauma and surgical intensive care unit (ICU) patients with a laparostomy and concurrently administered DA. The primary outcome was to assess changes in hemoglobin (Hgb)/hematocrit (Hct) levels and blood products pre/ post- DA administration. Secondary outcomes were the presence of intracranial hemorrhage (ICH), bleeding events that required discontinuation of DA, or a transfusion requirement of ⱖ3 units of packed red blood cells(PRBCs) on two consecutive days. A paired T-test was used to assess changes in Hgb/Hct and units of blood products given pre/post DA. Results: Twenty-five patients were included in the analysis. Mean ICU length of stay was 15 days and mean APACHE II score at DA initiation was 26. All patients were diagnosed as primarily having peritonitis, and secondary infection sites were blood stream (40%) and pulmonary (12%). Overall mortality was 32% (8/25). There was a significant decrease in Hgb (mean change:1.26 gm/dL,95% CI: 0.282–2.246, p ⫽ 0.014) and Hct (mean change:4.04%,95% CI: 1.118 – 6.962, p ⫽ 0.009) from pre/post-DA administration. Patients received significantly more PRBCs post-DA administration with a mean difference of 1.5 units (95% CI: -2.503–-0.537, p ⫽ 0.006). There was not a statistically significant decrease in FFP (mean: -1.0 unit; 95% CI: -3.098 –1.098, p ⫽ 0.414) and platelets (mean: -0.320 units; 95% CI: -1.193– 0.553, p ⫽ 0.457) given after DA administration. No reports of major bleeding were noted. Three patients required discontinuation of DA. Two of these patients had thrombocytopenia (⬍30,000␮L), and the third patient developed an intraabdominal hematoma. Conclusions: Patients with a laparostomy and concurrent DA use require more PRBCs and have decreased Hgb/Hct levels post-DA use.


Joseph Tobias, Nationwide Children’s Hospital Introduction: There has been a change in the practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETT) in infants and children. Although several advantages of such a practice have been suggested, there are few studies evaluating the current practices of inflation of the cuff of the ETT and the intracuff pressures. Hypothesis: Intracuff pressures during the use of cuffed ETT’s in infants and chidlren for intraoperative anesthetic care exceed current recommendations. Methods: There was no change dictated in clinical management for these patients during the induction or maintenance of anesthesia. During the first 30 minutes of the case, the intracuff pressure of the ETT was measured using a hand-held manometer. Additional data collected included the patient’s demographic information (age, weight, and gender), the size of the ETT, whether nitrous oxide was in use, whether the patient was breathing spontaneously or undergoing positive pressure ventilation, and the type of anesthesia provider (resident, fellow, CRNA or SRNA). Results: The cohort for the study included 200 patients ranging in age from 1 month to 17 years and in weight from 3.5 to 99.1 kilograms. The average intracuff pressure was 23 ⫾ 22 cmH2O in the cohort of 200 patients. The intracuff pressure was ⱖ30 cmH2O in 47 of the 200 patients (23.5%). The mean intracuff pressure was significantly higher in patients who were 8 years of age or older compared to younger patients. Additionally, there were significantly more patients with an intracuff pressure ⱖ30 cmH2O in the ⱖ8 year old age group. Although no difference in the mean intracuff pressure was noted when comparing staff anesthesia providers versus trainees (SRNA, anesthesiology resident, medical student or pediatric anesthesiology fellow), the incidence of significantly excessive cuff pressures (ⱖ60 cmH2O) was higher in the trainee group (12 of 99 versus 2 of 101, p⬍0.0001). Conclusions: Using current clinical practice to inflate the cuff of the ETT during intraoperative anesthetic care, a significant percentage of pediatric patients have an intracuff pressure greater than the generally recommended upper limit of 30 cm H2O.


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EFFECT OF THE CRITICAL-CARE PAIN OBSERVATION TOOL ON PAIN ASSESSMENT AND MANAGEMENT: BEFORE AND AFTER STUDY

A NOVEL 24 HOURS PORCINE MODEL OF TWEEN 20-INDUCED ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) TO TEST STRATEGIES OF PROTECTIVE MECHANICAL VENTILATION

Louise Rose, University of Toronto, Lynn Haslam, Sunnybrook Health Sciences Centre, Craig Dale, University of Toronto, Leasa Knechtel, Sunnybrook Health Sciences Centre, Michael McGillion, University of Toronto Introduction: Our goal was to determine the effect of a behavioural pain assessment tool (critical-care pain observation tool [CPOT]) on: (1) pain assessment documentation (narrative and numeric) frequency; and (2) analgesia and sedation administration for critically ill patients unable to self-report pain. Hypothesis: CPOT would increase documentation and influence analgesic administration. Methods: Before and after study in 2 intensive care units (ICUs) of a university-affiliated hospital providing services to a mixed ICU population including trauma and cardiovascular (CV) surgery specialties. Eligible patients were those unable to communicate verbally or via other means, confirmed by documented failure to follow commands or a Glasgow Coma Scale Motor Score of ⱕ5. We excluded patients receiving neuromuscular blockade. Institutional guidelines for pain assessment frequency were 6 X 1-hourly for immediately postoperative CV patients, 4-hourly thereafter for all patients. Results: Data were recorded for a maximum of 72 hours on 130 patients before and 132 patients after CPOT implementation in the CVICU; 59 and 52 patients respectively in the mixed med/surg/trauma (MST)ICU. In the CVICU, the proportion of pain assessment intervals (PAIs) with pain assessment documented increased from 15.2% to 64.2% (P⬍0.0001). In the MSTICU, PAIs with pain assessment documented increased from 21.9% to 79.7% (P⬍0.0001). The median total dose of opioid analgesia during study eligibility decreased from 5 mg to 4 mg in the CVICU patients (P ⫽ 0.02). In the MSTICU, the total dose of opioid analgesia increased from 27 mg to 75 mg (P ⫽ 0.002). Benzodiazepine median total dose decreased from 12 mg to 2 mg (P⬍0.0001) in the CVICU but remained similar in the MSTICU. Older age, medical diagnoses, higher severity of illness (SOFAmax), and male gender were associated with more frequent pain assessment. Conclusions: Implementation of the CPOT was effective in increasing the frequency of pain assessment and may have influenced opioid analgesic administration in the 2 ICUs. The effectiveness of the CPOT for optimizing appropriate analgesic administration for critically ill patients unable to self-report needs to be evaluated in randomized controlled trials.

Hugo Silva, Edgar Jimenez, Orlando Regional Medical Center, Ewa Jaruga-Killeen, OHMERTC, Jorge Barba, Orlando Health, Charles Hunley, Cesar Bertolotti, Mai Vo, Orlando Regional Medical Center, Nathan Wooding, OHMERTC, Mauricio Lafuente, Medical Education Research and Teaching Center, Gary Nieman, SUNY Introduction: Intratracheal instillation of Tween-20 causes lung injury secondary to surfactant deactivation and histopathological features associated with ARDS. Small animal models studied for a few hours are limited in their translation capabilities to ARDS patients. Hypothesis: To develop a large animal, 24 hr ARDS model to better understand ventilator strategies in the preclinical setting. Methods: An intratracheal dose (3 mL/kg) of 5% Tween-20 was given to 5 yorkshire pigs, followed by 30-minutes of non-protective ventilation (Vt ⫽ 10 mL/kg, PEEP ⫽ 3 cm H2O, FiO2 ⫽ 1.0). T0 was defined when a PaO2/FiO2 (P/F) ratio of ⱕ200 was obtained. Followed by a single recruitment maneuver (40 cm H2O for 30 sec) and mechanical ventilation for 24 hours (T24) with the ARDSNet protocol (1). Hemodynamics, lung mechanics, bladder pressures, fluid balance were measured hourly. Blood samples for cytokines, caspase 3, complete blood counts were taken at baseline (BL) and hourly for the first six hours and then every three hours until T24. Lung tissue samples were obtained at necropsy for histologic evaluation. Bronchoalveolar lavage fluid was taken at BL and T24 for flow-cytometry, cytokines and matrix metalloproteinase analysis. Results: Data reported as Mean ⫾ SEM. P/F ratio BL: 450.0⫾42.16, T0: 161.9⫾14.01, T24: 205.2⫾19.17; Static compliance BL: 31.25 ⫾1.8; T0: 16.5⫾0.64; T24:13.4 ⫾1.44; lung compliance: BL: 42.5⫾7.64; T0: 23.25⫾1.10; T24: 18.5⫾2.06; Plateau pressure BL: 18.5⫾0.64; T0: 25.25⫾1.10, T24: 24.25⫾0.75; Histology: Both dependant and non-dependant lung showed hemorrhage in air spaces (grade 1), fibrinous deposit (grade 2), vessel congestion (grade 2), leukocyte infiltration (grade 3), and alveolar wall thickness (grade 4) (2). Conclusions: Tween-20 caused an immediate lung injury consistent with ARDS that persisted for 24hrs when followed with mechanical ventilation by the ARDSNet protocol. These data suggest that this is an applicable model to study ventilator strategies such in a translational setting. References: 1). Acute Respiratory Distress Syndrome Network: N Engl J Med 2000; 342:13012). Kubiak B, et al.: Shock. 2010 Vol. 34, No. 5, pp. 525

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THAWED PLASMA WITHIN 30 MINUTES OF ED ARRIVAL ACHIEVES 1:1 RATIO MORE QUICKLY THAN LATE PLASMA TRANSFUSIONS BUT DOES NOT EFFECT OVERALL SURVIVAL

ABSOLUTE HUMIDITY AND ORAL DRYNESS DURING NONINVASIVE POSITIVE PRESSURE VENTILATION

Erica Moran, Mayo Clinic, Nicole Krumrei, University of Pennsylvania Health System, Pamela Johnson, James Stubbs, Donald Jenkins, Henry Schiller, Martin Zielinski, Mayo Clinic Introduction: Our trauma center employs thawed plasma during resuscitation of patients with trauma induced coagulopathy (TIC). We aimed to determine whether early plasma transfusion (EPT) was associated with higher plasma:RBC ratios at 6 and 24 hours and its effect on survival. Hypothesis: Early plasma transfusion will be associated with higher plasma:RBC transfusion ratios with lower overall RBC units required and improved survival outcomes. Methods: All level 1 trauma patients from 2008 –2009 were reviewed. EPT was defined as plasma ⱕ30 minutes from arrival, late plasma (LPT) as ⬎30 minutes but ⬍24 hours, massive transfusion (MT) as ⱖ10 RBC units in 24 hours, and significance as p⬍0.05. Results: Three hundred ninety-four patients were identified, 23 EPT, 65 LPT, and 36 MT. EPT was equivalent in Injury Severity Score (ISS; 22 vs 29), TRISS (0.90 vs 0.67), MT (48% vs 46%) and mortality (22% vs 18%) compared to LPT. In the subgroup of MT patients surviving to 24 hours, there were 9 EPT and 27 LPT patients. Of these, EPT achieved a higher plasma:RBC at 6 (0.95 vs 0.40) and 24 hours (0.95 vs 0.5) despite equivalent ISS (22 vs 14), TRISS (0.37 vs 0.56) and mortality (33% vs 11%). RBC usage was equal at 6 (12 vs 12 units) and 24 hours (17 vs 9 units), but plasma usage was greater in the EPT group (15 vs 8 and 17 vs 9 units, respectively). Conclusions: Achieving a 1:1 ratio within 6 hours is possible but does not change RBC transfusion quantities or survival. By reducing survivor bias, EPT’s effect in clinical trials should elucidate whether achieving a 1:1 ratio is best for correction of TIC.

Jun Oto, Hideaki Imanaka, University of Tokushima Graduate School, Mutsuo Onodera, University of Tokushima Graduate School, Masaji Nishimura, University of Tokushima Graduate School Introduction: Non-invasive positive pressure ventilation (NPPV) delivers medical gas at high flow. Although heated humidifier (HH) is usually used during NPPV, few data have been reported about absolute humidity (AH) of inspired gas and oral dryness. Hypothesis: Humidification is inappropriate during NPPV, and it leads to oral dryness and patient’s discomfort. Methods: We measured AH within a full face mask of patients supported by NPPV for 24h continuously by hygrometer (Hygrocron, KN Laboratories, Inc., Osaka, Japan). We also measured moisture of oral mucosa by an oral moisture-checking device (Moisture Checker Mucus; Scalar, Tokyo, Japan; the values less than 25% as sever dryness) every 8 hours. Feeling of dryness was evaluated with a 0 –10 numerical rating scale (NRS; 10 was the most severe dryness) simultaneously. Water vapor was added via HH (MR850 Humidifier, Fisher and Paykel, New Zealand). Results: Sixteen patients with acute respiratory failure were recruited. Median values of AH was 30.5 mgH2O/L (inter-quartile range (IQR): 28.1–32.2 mgH2O/L). Median value of oral moistness was 19.2% (IQR: 4.4 –24%) and NRS of 5.5 (IQR: 4 –7). The values of oral moistness and NRS correlated with the values of AH (oral moistness; rs ⫽ 0.34, P ⫽ 0.03, NRS; rs ⫽ – 0.29, P ⫽ 0.04, respectively). Conclusions: The patients supported with NPPV felt oral dryness and discomfort even with HH. Not only adequate humidification but also other integrated strategies were needed to prevent oral dryness and improve patient’s discomfort during NPPV.


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AEROSOL DRUG DELIVERY USING AEROGENTM NEBULIZER VIA VAPOTHERMTM HUMIDIFIED HIGH-FLOW NASAL CANNULA SYSTEM: AN IN VITRO STUDY

DOES AN INITIAL TROPONIN I VALUE OF ZERO PREDICT NO NSTEMI ON ACUTE EMERGENCY PRESENTATION OF CHEST PAIN?

Sarah Perry, Alfred I. duPont Hospital For Children, Kenneth Kesser, Nemours Children’s Clinic, Orlando, FL, Dawn Selhorst, Alfed I. duPont Hospital for Children, John Rendle, Alfred I. duPont Hospital for Children, David Geller, Nemours Children’s Clinic, Orlando, FL, James Hertzog, Alfred I. duPont Hospital for Children

David Milzman, Georgetown University

Introduction: The delivery of aerosolized medications during humidified, high-flow nasal cannula (HHFNC) use is often necessary; however the optimal way to deliver these medications is unknown. Hypothesis: We investigated the in vitro inspired drug dose and particle size distribution of albuterol delivered by a vibrating mesh nebulizer through the Vapotherm (VT) HHFNC system at clinically relevant flow rates and nasal cannula (NC) sizes. Methods: An Aerogen SoloTM nebulizer was set up downstream from the Vapotherm 2000iTM unit using a VT aerosol adaptor. Albuterol (2.5 mg/3 ml) was used in all trials. The total “inspired dose” (ID) of albuterol was collected onto a filter mounted to the inlet of a breath simulator programmed to simulate age-appropriate, normal breathing patterns. Particle sizing was completed by cascade impaction. Measurements were made with the following NC sizes and flow rates: adult (5, 10, 20 and 40 liters per minute (lpm)), pediatric (3, 5, 10, and 20 lpm), and infant (3, 5, and 8 lpm). Albuterol was quantified using UV spectometry. Results: The % ID for each NC size and flow rate was: 2.5, 0.8, 0.4, and 0.2% for the adult NC at 5, 10, 20 and 40 lpm, respectively; 1.2, 0.6, 0.1, and 0.0% for the pediatric NC at 3, 5, 10, and 20 lpm, respectively; and 0.6, 0.6, and 0.5% for the infant NC at 3, 5, and 8 lpm, respectively. 62– 80% of the loaded albuterol dose accumulated within the adaptor. For the adult and pediatric trials, there was a statistically significant decrease in the ID with increasing flow rates, p⬍0.001 and p ⫽ 0.001, respectively. There was also a significant increase in the ID with increasing NC size for 5, 10 and 20 lpm, p ⫽ 0.007, p ⫽ 0.004, p ⫽ 0.005, respectively. The mass median aerodynamic diameter (MMAD) for all trials was ⬍5␮m. Conclusions: The quantity of albuterol delivered through the VT system was very small, likely due to impaction of aerosol particles in the circuit due to the high flow rates Further studies investigating changes to the VT set-up for aerosol delivery and in vivo studies quantifying intrapulmonary drug delivery and systemic effect are needed before instituting routine delivery of aerosolized albuterol through VT.Funded by Nemours Foundation grant.

Introduction: Rapid biomarkers to rule out NSTEMI havebeen based solely on Troponin I now for almost a decade. There are many papersreporting various testing protocls with regard to timing of cardiac markerdraws. No study has identified a level of below detection on first marker as aprognosticator to rule out any infarction. Hypothesis: To determine if a single negative marker, negative as in non detected can safely predict no NSTEMI on ED presentation irregardless of timing of chest pain prior to arrival. Methods: Retrospective chart review of over 5 years and 4 hospitals for all patients arriving with a complaint of chest pain and no STEMI on initial ECG. Inclusion ED workup of CP with at least 2 consecutive Trop I drawn within 8 hours of arrival and follow up obtained. The Timing of chest pain onset, and interventions including PTCA, CABG and other interventions were reviewed. In-hospital and all cause 30 day mortality are also noted. NON-cardiac causes on ICD-9 discharge were excluded from analysis. (PE, Pneumonia). Results: 5409-chest pain patients with at least 2 consecutive Trop I were entered in study. 5409 pts with initial trop I ⬍0.012 ng.dl: 215 had next lab draw of ⬎0.60 ng/dl ( positive for MI) and 256 had indeterminate next draw b/w 0.1- 0.6 ng/dl and 5,244 had next draw negative b/w 0.012– 0.01 ng/dl.Pts had a mean age: 55.4 years (SD 5.6) 88.2% Black, and 60% male. 215 pts had an elevated next draw positive level of Troponin I for MI: ⬎0.6 ng/dl on lab draw without EKG findings c/w AMI. with a mean age 62.7 (SD 5.3) 72.1% black, 57% male . Of these with a 2nd or 3rd elevated Trop I: 34.3% were diagnosed with NSTEMI, 37% went to PTCA, 14.2% had CABG in -hospital and 4.4% suffered in-hospital mortality. NSTEMI rates was: 2.8% for these pts vs. 0.9% for the all chest patient having a positive NSTMI on 2nd or 3rd blood draw but not ⬍0.012ng/dl p⬍0.03. Conclusions: There is no level on initial analysis, not even a none detected value of ⬍0.12 ng/dl, that a single troponin I can safely rule out an NSTEMI; Although a non-detectable first troponin value is more likely to rule out than usual low level first draw of chest pain patients.

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SIMULATION OF SPONTANEOUS BREATHING SYNCHRONIZATION UNDER NON-INVASIVE POSITIVE PRESSURE VENTILATION WITH A HELMET TYPE INTERFACE; COMPARISON OF TWO RESPIRATORS

REVERSIBLE MRI ABNORMALITIES IN ETHYLENE GLYCOL POISONING MANAGED WITH ICP MONITORING, PENTOBARBITAL COMA, HYPERCALCEMIA AND HYPEROSMOLAR THERAPIES.

Tadahiro Kobayashi, Nozomi Momose, Ayuka Narisawa, Shinya Oda, Masaki Nakane, Kaneyuki Kawamae, Yamagata University Faculty of Medicine

Erin Owen, University of Louisville, Aaron Calhoun, Mark McDonald, University of Louisville

Introduction: Few reports have investigated synchronization with spontaneous breathing under non-invasive positive pressure ventilation (NPPV) with a helmet type interface. Our objective was to investigate a respirator’s synchronization with spontaneous breathing under various conditions testing the trigger sensitivity of an NPPV respirator (V60, Philips-Respitronics) compared with an ordinary respirator (Benett840, Covidien). Hypothesis: The Benett840 is superior to the V60 with regard to synchronization because of its closed respiratory circuit. Methods: A spontaneous breathing simulator, LUNGOO (Air Water Inc.), was used to simulate a normal lung using compliance (C) of 50 mL/cmH2O and airway resistance (R) of 5cmH2O/L/sec. We used 2 types of morbid lung conditions, obstructive (C50, R20) and restrictive (C20, R5), total pressure of respiratory muscles (Pmus) of 5cmH2O, inspiratory time of 1.0 sec, and respiratory rate of 15 breaths per minutes. To test trigger sensitivity, the S/T mode (V60) and the PSV mode (Benett840) were used, and their settings included PEEP (5, 10, 15 cmH2O) and pressure support (PS: 5, 10, 15 cmH2O). We recorded the time to trigger inspiration, which is considered to be increased work of breathing if prolonged, and the time to terminate PS for the lung conditions. Results: The Benett840 had 0.15– 0.25 sec delays in inspiratory triggers, which were not significantly affected by PEEP and PS, and earlier PS terminations under restrictive conditions, which were less affected by PEEP and PS compared with the V60. During obstructive simulation, it had trivial delayed PS terminations. In contrast, for the V60, auto-triggers were frequently recorded for some combinations of PS and lung conditions under 5cmH2O of PEEP, its inspiratory trigger delay worsened when peak inspiratory pressure was ⱖ25 cmH2O, and for its PS termination more delay was found when PS was increased during obstructive simulation. Conclusions: Our results suggest that the Benett840 is superior to the V60 with regard to synchronization with spontaneous breathing especially in obstructive conditions and with combinations of low PEEP and higher PS. It may be better to choose an ordinary respirator like the Benett840 in such situations.

Case Reports: Ethylene glycol (EG) ingestions cause significant morbidity and mortality amongst all age groups. Management strategies include gastric aspiration and lavage, alcohol dehydrogenase inhibition, and hemodialysis (HD). Routine intracranial pressure (ICP) monitoring is not currently considered standard of care in the management of EG poisoning. We report a case of a 17-year-old healthy white male who presented after ingesting an unknown quantity of EG 2–3 days prior to admission. Admission exam was significant for obtunded mental status, respiratory failure, tachycardia, and hypertension. Laboratory studies revealed an EG level of 179 mg/dL, metabolic acidosis, an osmolar gap of 57 and creatinine of 1.3 g/dL. An initial brain MRI was normal. Initial treatment included fomepizole, HD and labatolol. On hospital day 1, he developed seizure activity and head CT demonstrated diffuse cerebral edema. A subarachnoid bolt was placed, and progressive ICP elevation (up to 52 mm Hg), despite hyperosmolar therapies, prompted a pentobarbital coma through day 5. On days 5 through 8, the patient had intermittent rises in ICP (up to 63 mm Hg) with a worrisome neurological exam that required frequent boluses of mannitol and pentobarbital. On day 8, the bolt was removed and a brain MRI demonstrated multiple areas of swelling and signal abnormality consistent with toxic injury. He was again placed in a pentobarbital coma, started on a continuous 3% saline infusion, and calcium was administered to keep ionized calcium levels greater than 1.3 mmol/L to theoretically chelate oxalate crystals within brain parenchyma. On day 13, a repeat MRI revealed normal brain with resolution of all abnormalities, and pentobarbital was discontinued. He steadily improved and was ultimately extubated and discharged home with normal neurological and mental status exams. While cerebral edema has been noted with EG ingestions, we believe this is the first case to demonstrate that intracranial hypertension associated with EG ingestion can be successfully managed with ICP monitoring, hyperosmolar therapies, therapeutic hypercalcemia, and barbituate-induced coma; concluding with reversible MRI abnormalities.


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ISOLATED TRANSVERSE PROCESS FRACTURES: INSIGNIFICANT INJURY OR MARKER OF COMPLEX INJURY PATTERN

BICARBONATE THERAPY IN SEVERE COMBINED ACIDOSIS OF TRAUMA INCREASES MORTALITY

Gary Lombardo, David Cho, Pramodh Krishnamurthy, Tom Sullivan, Donald Risucci, Jay Yelon, Corrado Marini, Westchester Medical Center/New York Medical College Introduction: This study reviews our experience and examines associated injury patterns with isolated transverse process fractures (ITPFx). Results are discussed in terms of their implications for further evaluation of spinal injuries via advanced radiologic imaging. Hypothesis: Helical CT scanning of the torso provides sufficient imaging for identifying isolated fractures of transverse processes and these injuries are markers for additional injury. Methods: Retrospective review of a Level 1 trauma center registry from 11/2004 –12/2008. Data collected included patient demographics, ISS, type of imaging obtained and concomitant injuries. Results: Of 881 patients with spinal fractures, 214 (24%) had ITPFx. 100% of these patients underwent dedicated spinal CT imaging; 26 patients had MRI. Dedicated spinal CT revealed no additional injury compared with torso CT in 213 patients (99%) and detected 1 additional ITPFx. MRI revealed no additional injuries. The incidence of rib fractures was higher with ITPFx at Levels T1– 4 than those without T1– 4 injuries (63% vs. 32%; p⬍0.001) and among those with ITPFx at T5– 8 than those without T5– 8 injuries (59% vs. 33%; p ⫽ 0.004) . The incidence of pelvic fractures was significantly higher with ITPFx at Level L5 than those without L5 injuries (48% vs. 11%; p⬍0.001) Multiple logistic regression analyses identified T1– 4 fractures (OR: 2.6, 95% CI: 1.1–5.8) as a significant predictor of rib fracture independent of ISS and L5 fracture (6.8, 3.1–14.8) as a significant predictor of pelvic fracture independent of ISS. Conclusions: Helical CT scanning of the torso may provide sufficient imaging and dedicated spinal CT reconstruction and MRI may not be necessary for identifying isolated fractures of transverse processes. Further, these injuries are associated with and may be markers for rib and pelvic fractures.

Amy Spencer, Wayne State University, Heather Dolman, Alfred Baylor, Wayne State University, Detroit Receiving Hospital, Lisa Hall Zimmerman, Detroit Receiving Hospital, James Tyburski, Robert Wilson, Wayne State University, Detroit Receiving Hospital Introduction: The use of bicarbonate (HCO3) to treat metabolic acidosis has come under increasing scrutiny. Even though HCO3 tends to raise arterial pH, the increased dissolved carbon dioxide (CO2) which is generated, especially if the PaCO2 is not appropriately reduced (Winter’s Formula), can rapidly diffuse into tissue cells causing severe cellular respiratory acidosis. Hypothesis: To review the effect of bicarbonate (HCO3) therapy in trauma patients with severe acidosis (pH ⱕ7.10) during their emergency surgery. Methods: A retrospective evaluation was performed on trauma patients with severe acidosis in the OR (pH ⱕ7.10). Winter’s Formula (PaCO2 ⫽ (HCO3)(1.5)⫹8 ⫾4) was used to determine a patient’s appropriate ventilatory response to the acidosis. Results: Of the 209 patients, 114 (55%) died within 48 hours (“early deaths”-ED) and 95 (45%) survived ⬎48 hours (“early survivors”-ES). The mean initial arterial blood gas (ABG) included pH ⫽ 6.92⫾0.16, PaCO2 ⫽ 50⫾14 mmHg, HCO3 ⫽ 10.9⫾3.5 mEq, and a base deficit ⫽ 22⫾6 (suggesting combined metabolic/respiratory acidosis). In 65 patients given 2– 4 amps HCO3 over 20 – 60 minutes with no other management changes, the mean response was increases in pH (⫹0.15), PaCO2 (⫹6 mmHg), HCO3 (⫹6.0 mEq/L), and a decrease in base deficit (-9). The mean total amps of HCO3 (1amp ⫽ 44.6 mEq NaHCO3) given was higher in ED vs ES, 6.7⫾5.0vs3.7⫾3.5, p⬍0.001, even though pre-treatment ABGs were similar. Following resuscitation, ES vs ED had a higher pH (7.15⫾0.09 vs7.21⫾0.09, p⬍0.001) and a lower PaCO2 (46⫾12vs38⫾7 mmHg, p⬍0.001) with no significant difference in arterial HCO3 levels or base excess. Patients who had a PaCO2 ⱕ41 mmHg vs ⬎42 mmHg after OR resuscitation (with HCO3 therapy) had a lower mortality rate, (39%vs74%, p⬍0.001). In patients with a PaCO2 that was appropriate (ie. XS PaCO2 ⫽ 0 or negative), only 30% died, whereas patients with an XS PCO2 ⱖ11 mmHg, 79% died (p⬍0.001). Conclusions: Administration of HCO3 can cause an abrupt increase in PaCO2, which is associated with increased mortality in severely acidotic patients. Therefore, before and during HCO3 administration, the PaCO2 should be maintained at appropriate low levels by mechanical ventilation, as determined by Winter’s formula.



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VALIDATION OF A PREDICTIVE MODEL FOR THE DEVELOPMENT OF ABDOMINAL COMPARTMENT SYNDROME

CORRELATION OF CARDIAC CHAMBER VOLUMES AND COMPARISON OF EJECTION FRACTION AS MEASURED BY PULMONARY ARTERY CATHETER AND ULTRASOUND DILUTION METHOD

Corrado Marini, Westchester Medical Center, Anthony Policastro, N.Y.M.C., Dmitriy Karev, Gary Lombardo, Carlo Gwardschaladse, WMC Introduction: In a retrospective case-matched control study, we have previously shown that the development of abdominal compartment syndrome (ACS) can be predicted by the equation p ⫽ 1/(1⫹e-z) where p is the probability of developing ACS and z is the product of [-18.6763⫹(0.1671x peak inspiratory pressure)⫹(0.0009 x fluid balance at 24 hours)]. This study was designed to validate predictive model intrauma, burn, liver transplant and general surgery patients. Hypothesis: The development of ACS can be predicted by an equation that includes PIP and fluid balance at 24 hours. Methods: Patients at risk of ACS defined by the need for fluid requirements ⱖ8,000 ml in 24 hours after general surgery, burn, trauma and liver transplant were included in the study. Data ncluded demographic, hemodynamic,laboratory, fluid balance, PIP, bladder pressure (BP), development of ACS and decompressive laparotomy (DL) data. Results: O15 patients were at risk of ACS over 6 months. 10/15 patients (66.6%) developed ACS. The model predicted that 62% of the patients would develop ACS. Variable ACS (n ⫽ 10) No ACS (n ⫽ 5) P Age 50 ⫾ 16 50 ⫾ 30 1Fluid in L 16.2 ⫾ 12.6 7.9 ⫾ 5.3 0.18Fluid out L 2.0 ⫾ 3.3 1.5 ⫾ 1.2 0.75Fluid 24hr 14.1 ⫾ 12.3 6.0 ⫾ 5.8 0.18PIP cmH2O 48 ⫾ 11 25 ⫾ 15 0.005BP mmHg 29 ⫾ 12 10 ⫾ 5 0.005Probability % 90 ⫾ 20 0DL 10 0 mortality 1/10 0 1. Conclusions: Based on the results of this study we confirm the validity of PIP and fluid balance at 24 hours as predictive variables for the development of ACS. Furthermore, we suggest that our model can be used to calculate the probability of development of ACS.

787 SEVERE TBI OUTCOMES ASSOCIATED WITH IMPLEMENTATION OF COMPREHENSIVE GUIDELINES IN A CHILDREN’S HOSPITAL Natalie Tillman, Karen Walson, Toni Petrillo-Albarano, Andrew Reisner, Thomas Burns, Elizabeth Atkins, Chuck Cochran, Children’s Healthcare of Atlanta, Atul Vats, Emory University School of Medicine and Children’s Healthcare of Atlanta Introduction: Pediatric traumatic brain injury (pTBI) is a major cause of morbidity and mortality in children. In adults, using guidelines to manage TBI patients is well established, resulting in improved outcomes. Since the 2003 publication of national guidelines for the acute management of severe pTBI, data is lacking on the impact of the guidelines on physician compliance and effect on patient outcomes. Hypothesis: A hospital-specific severe pTBI guideline based on the 2003 guidelines along with a guideline-specific computerized order set will decrease practice variation, and be associated with positive patient outcomes in a pediatric institution. Methods: In 2008, a pTBI guideline at Children’s Healthcare of Atlanta was initiated by a multidisciplinary team; however, there was noticeable practice variation and the guideline was not consistently utilized. The guideline was further refined in 2010. The patient population was defined and data collection standardized. Electronic medical record tools were developed to “hardwire” the guideline usage and report outcome measures. Specific guideline improvements included defined ranges & response for ICP/CPP, panic values & time for response, ranges for temp and CO2 control, documentation of GCS, and monitoring parameters for hyperosmolar therapy and EEG use. Education efforts included combined physician and nursing quality meetings. The updated guideline was implemented in March 2011 along with a guideline-specific order set. Scorecard measures from the first quarter of implementation (Apr-Jun 2011) were compared to the same time period one year prior (Apr-Jun 2010), as a historical control. Results: Patients ⬍18 years old that suffered a TBI with GCS ⬍9 and admitted to the PICU were retrospectively identified for each quarter (n ⫽ 28, 2010, n ⫽ 24, 2011). Compliance with ordering the guideline increased from 7.1% to 54.0% (100% for patients with an ICP monitor). Average LOS (non-rehab) decreased from 9.5 to 7.4 days. Avg ICU LOS decreased from 7.9 to 6.7 days. Conclusions: A multidisciplinary effort to develop, educate and implement a comprehensive severe TBI guideline led to increased compliance and was associated with improved outcome measures.


Erin Suydam, University of Hawaii, Sho Furuta, University of Hawaii Department of Surgery, Uy Vu, Keilla Schmidt, University of Hawaii, Michael Hayashi, David Inouye, University of Hawaii At Manoa John A Burns School of Medicine, Maimona Ghows, University of Hawaii, Danny Takanishi, University of Hawaii At Manoa John A Burns School of Medicine, Mihae Yu, University of Hawaii School of Medicine Introduction: Optimal management of critically ill patients requires clinical assessment of volume status and cardiac function. Ideal tools to provide this information have yet to be identified. Pulmonary artery catheters (PACs) (Edwards Lifesciences, Irvine, CA) provide information on right end-diastolic volume index (REDVI) and right ventricular ejection fraction (RVEF), allowing estimation of preload and contractility. An ultrasound dilution method (COstatus system, Transonic Systems Inc., Ithaca, NY) provides information on total end-diastolic volume index (TEDVI), central blood volume index (CBVI) and total ejection fraction (TEF) and is less invasive than the PAC. Hypothesis: REDVI correlates with TEDVI and EF obtained from PAC agrees with EF values obtained from ultrasound dilution method. Methods: Critically ill surgical patients with PAC and an arterial line had COstatus connected to the arterial and central venous line. Values of REDVI and RVEF were obtained from the PAC. COstatus gave information on 1) TEDV, defined as the blood volume in the four chambers of the heart at end-diastole, 2)CBV, defined as the blood volume in the heart, lungs and major vessels including aorta, pulmonary artery and vein, and 3)TEF, defined as the combined ejection fraction of the right and left ventricles. Correlation and regression analysis was done between a) REDVI and TEDVI or CBVI, and b) between RVEF and TEF. Results: Eleven patients contributed 24 data points. Demographics were: age 68⫾12, male:female 7:4, and APACHE II ⫽ 23.2⫾7.6 with diagnoses of severe sepsis/septic shock (n ⫽ 9) and ALI/ARDS (n ⫽ 2). No significant correlation was found between REDVI and TEDVI (r ⫽ -0.205, R2 ⫽ 0.01, p ⫽ 0.336), between REDVI and CBVI (r ⫽ 0.017, R2 ⫽ 0.022, p ⫽ 0.937) or between RVEF and TEF (r ⫽ 0.379, R2 ⫽ 0.116, p ⫽ 0.068). Conclusions: In this preliminary study of critically ill patients with PAC, the RVEDVI did not correlate with total cardiac volume (TEDV) nor thoracic volume (CBV). RVEF and total EF also did not correlate, although the p value was 0.068 and the sample size was small. Further studies need to determine which volumes (RVEDV, TEDV, CBV) are predictive of improving cardiac function and EF.

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IMPACT OF NEBULIZED TOBRAMYCIN ON OUTCOMES ASSOCIATED WITH VENTILATOR ASSOCIATED PNEUMONIA

GLUCOSE METER TOTAL ANALYTICAL ERROR ASSOCIATED WITH THE HEMATOCRIT LEVELS COMMONLY SEEN IN AN ADULT INTENSIVE CARE UNIT

Jason Ferreira, Shands Jacksonville, Audis Bethea, Charleston Area Medical Center Introduction: Pneumonia frequently complicates care of the critically ill with 90% of nosocomial pneumonias occurring during mechanical ventilation (MV). Frequent use of antibiotics to treat infectious complications of critical illness contributes to the evolution of microbial resistance. Accordingly, IDSA/ATS guidelines recommend empiric double coverage for gram negatives using a betalactam in conjunction with a fluoroquinolone or aminoglycoside. There has been interest in the use of nebulized aminoglycosides for the treatment of ventilator associated pneumonia (VAP) in order to improve pulmonary concentrations while avoiding potential toxicities. This study compares nebulized tobramycin (NT) in conjunction with a beta-lactam agent versus regimens consistent with IDSA/ATS recommendations (Control). Hypothesis: Combination therapy for gram negatives with NT will result in clinical cure rates similar to regimens consistent with IDSA/ATS recommendations. Methods: This was a retrospective chart review of surgical trauma ICU patients diagnosed with VAP between January 1, 2004 and December 31, 2010. Diagnosis was supported by a Clinical Pulmonary Infection Score (CPIS) greater than 6. Primary outcome of clinical response, defined as 50% decrease in CPIS, was performed by comparing patients’ CPIS on days 1, 5, 8 and 14 of therapy. Secondary outcomes included the rate of CPIS improvement, length of MV, hospital and ICU stays, and mortality. Results: Seventy-seven patients were included in the analysis (NT ⫽ 39, control ⫽ 38). Demographics were similar in both study arms, however, patients in the NT arm were of greater age (53.31 vs. 40.53 years, p ⫽ 0.004) and BMI (30.24 kg/m2 vs. 26.29 kg/m2, p ⫽ 0.034). Twenty-five (control) and 24 (NT) met the primary endpoint (p ⫽ 0.88). Secondary outcomes were not significant, except ICU stay (days) was longer in the NT arm (19.5 vs. 15.91, p ⫽ 0.038). Conclusions: Clinical response was similar in the study groups suggesting the combination of a beta-lactam and NT are a viable alternative for empiric coverage of gram negative pathogens. ICU stay was found to be longer in the NT arm; however, this may have been influenced by the differences in age and obesity rates noted between the study arms.

Kaoru Koyama, Saitama Medical Center and University, Hideki Miyao, Saitama Medical Center/School, Hitoshi Ikeda, Noriko Harashima, Masanori Tamura, Saitama Medical Center and University, Mark Heinz, Nova Biomedical, Martha Lyon, Alberta Children’s Hospital, Jeffrey DuBois, Nova Biomedical Introduction: To determine the impact of hematocrit on total analytical error associated with five glucose meters commonly used in the adult intensive care setting. Hypothesis: Glucose meters that measure and correct or compensate for hematocrit will demonstrate less total analytical error than meters that do not. Methods: The bias caused by hematocrit (hematocrit ranges 20 –30%, 31– 40%, 41–50%, 51– 60% and 61–70%) was evaluated at five glucose concentrations with five different glucose meters. Multivariate regression analysis was used to estimate the combinatorial effects of the interferences on bias. The precision of each glucose meter was determined by consecutive analysis (n ⫽ 20) of a whole blood specimen at three levels of glucose. Total analytical error was estimated as % bias ⫹1.645 (% imprecision). Results: Four of the five glucose meters demonstrated a significant hematocrit bias that was dependent upon glucose concentration. Among these four glucose meters, estimates of total analytical error ranged from 2 to 40% depending upon the conditions evaluated. The largest total errors were observed with specimens in the hematocrit ranges of 20 –30% and 61–70%. One glucose meter demonstrated minimal bias (-0.03% to 6.5%) to the hematocrit and glucose concentrations tested. Estimates of total analytical error for this meter ranged from 5 to 14%. Conclusions: The extent to which hematocrit and glucose concentration influence the measurement of glucose is highly meter specific. A total analytical error of 40% in glucose measurement could have profound influence of clinical decision making.

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THE IMPACT OF FLEXIBLE VISITING HOURS ON NURSE JOB SATISFACTION IN AN ADULT SURGICAL ICU

A RETROSPECTIVE STUDY OF DROTRECOGIN ALFA (ACTIVATED) IN ADULTS WITH SEVERE SEPSIS: A COMPARISON WITH THE PROWESS STUDY

Stephanie Keeth, Loma Linda University Medical Center, Andrea Mason, Sharmel Weerasinghe, Loma Linda University Heart and Surgical Hospital, Patti Radovich, Loma Linda University Medical Center, Grenith Zimmerman, Loma Linda University Introduction: Flexible visiting hours in an ICU still creates apprehension from the critical care nurses in regards to patient privacy, adverse physiologic changes, and direct impact on nursing care. Hypothesis: The implementation of a flexible visitation policy would not affect nurse job satisfaction. Methods: Prospective descriptive observational study done from March 2008 to March 2009 in a 22 bed university hospital SICU that changed from restrictive to flexible visitation. Registered nurses were surveyed at baseline, 3, 6, 9, & 12 months utilizing Torres’ (1998) Nurse Job Satisfaction Scale and Berti & Ferdinandi’s (2007) Beliefs and Attitudes Towards Visitation in ICU Questionnaire (BAVIQ). The Therapeutic Intervention Scoring System 28 (TISS-28) and Acute Physiology and Chronic Health Evaluation (APACHE II) defined patient acuity. Results: Mean TISS-28 score for nurse-patient ratios of 1:1 was 34 and of 1:2 was 56. During the course of the study 82% was staffed as 1:2. The mean APACHE II score was 17. Overall, 81% were against an open visiting policy, 68% believed open visiting infringes upon patients’ privacy, and 53% believed that open visiting increased the risk of errors. Strong opposition was statistically significant among the groups “years of experience.” Nurses with more than 10 years of experience answered in opposition. There was no change in nurse job satisfaction or BAVIQ with the implementation of flexible visiting hours. Nurses rated a fair degree of job satisfaction, mean score of 61. Mean score of the BAVIQ was 2.81 indicating that nurses tended to be in opposition of unrestricted visiting hours. Conclusions: Implementation of flexible visiting hours did not affect nurse job satisfaction. The high workload (TISS-28) likely is a variable of nurse job satisfaction. Evaluating the impact of policy changes to patient care and sequelae will lend to a higher success rate of implementation.

Meredith Hollinger, Jamie Rosini, Christiana Care Health System Introduction: The setting of randomized controlled trials (RCTs) may not mimic that observed in clinical practice due to the strict inclusion and exclusion criteria, as well as stringent protocols utilized in RCTs. The purpose of this study is to compare the baseline characteristics and in-hospital mortality rate of Christiana Care Health System (CCHS) severe sepsis patients who have received drotrecogin alfa (activated) (DrotAA) to the established mortality rates demonstrated in the PROWESS trial. Hypothesis: The patient population studied in the PROWESS trial is different than that seen with our clinical use of DrotAA which will result in different outcomes. Methods: Retrospective case series conducted on patients who had received DrotAA between January 1, 2005 and October 31, 2008 within the health system. Patients who had received DrotAA were identified through pharmacy and hospital databases. Variables collected were similar to PROWESS and included baseline demographics, preexisting conditions, mechanical ventilation and vasopressor use during DrotAA infusion, number of dysfunctional organ systems, APACHE II score, duration of DrotAA therapy, anticoagulant use, incidence of serious bleeding, and in-hospital mortality rates. Results: There was no difference observed with CCHS in-hospital mortality rates (36.7% vs. 37%, p ⫽ 0.967) when compared to PROWESS patients. CCHS patients had a higher incidence of vasopressor usage (96.8% vs. 70%, p ⫽ 0.001), organ dysfunction systems including cardiovascular (96.9 vs. 80%, p⬍0.001), metabolic acidosis (70.4 vs. 46%, p ⫽ 0.001), and severity of illness of patients with the overall number of dysfunctional organ systems (3.2 vs. 2.7, p ⫽ 0.001) and APACHE II scores (33.9 vs. 31, p ⫽ 0.001). Conclusions: Patients at CCHS had higher APACHE II scores and number of dysfunctional organs when compared to PROWESS patients indicating that these patients had a higher risk for mortality, however there was no observed difference in overall hospital mortality.


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IMPACT OF BRONCHOSCOPY DURING BEDSIDE PERCUTANEOUS TRACHEOSTOMY TRAINING

THERAPEUTIC HYPOTHERMIA AFTER IN-HOSPITAL PEA AND ASYSTOLIC CARDIAC ARREST

Jennifer Palminteri, John Dziodzio, Richard Riker, Thomas Van Der Kloot, Jason Yahwak, Maine Medical Center, Lonny Yarmus, Johns Hopkins Hospital, David Seder, Maine Medical Center

Rebecca Anderson, Marlena Fox, Jason Brady, Orlando Regional Medical Center, Valerie Danesh, Orlando Health, Jeffrey Sadowsky, Orlando Regional Medical Center

Introduction: Flexible bronchoscopic guidance (FB) adds cost and complexity to percutaneous tracheostomy (PT), and may interfere with ventilation, but may facilitate accurate placement, reduce injury to posterior wall of trachea, and improve airway management during the procedure. Our center traditionally performed PT without FB; we introduced a FB protocol for training PT procedures to confirm appropriate guidewire placement before stomal dilation. The purpose of this study was to evaluate the utility of FB in the procedure. Hypothesis: The routine use of FOB during PT performed by trainees facilitates tracheal cannulation and decreases potential misplacement of tracheostomy tubes. Methods: A prospective database of PT procedures performed between 2009 –2011 was retrospectively evaluated. Procedures were performed by board-certified critical care physicians learning PT under the supervision of an experienced proceduralist. After tracheal cannulation and guidewire placement, FB verified midline insertion at the appropriate level, and facilitated puncture if it could not be performed blindly after 2 attempts. Demographics, clinical features, and details of PT were prospectively recorded at the time of the procedure. Results: Among 47 procedures, FB influenced PT performed by trainees in 20 (43%) instances, including recannulation at a more appropriate insertion site (high or lateral puncture) in 13 (28%), and facilitating tracheal puncture after failure to perform blind cannulation in 7 (15%). Among demographic and clinical factors analyzed, only BMI ⬎30 (60% vs 29.6%, P ⫽ 0.04) was associated with FB influencing the course of the procedure. Conclusions: Bronchoscopic guidance frequently influenced percutaneous tracheostomy procedures performed by trainees, facilitating difficult tracheal cannulation and preventing misplacement. This was particularly true when BMI⬎30. Bronchoscopy should be routinely employed in PT training.

Introduction: Therapeutic hypothermia (TH) is recommended after out-ofhospital ventricular fibrillation cardiac arrest to prevent anoxic encephalopathy. There is limited data supporting safety and efficacy of its use in patients who experience pulseless electrical activity (PEA) or asystolic cardiac arrest. Hypothesis: TH can be used safely after PEA or asystolic cardiac arrest but will not result in significant improvement in neurologic outcomes. Methods: We retrospectively identified in-hospital PEA and asystolic cardiac arrest patients ⱖ18 years of age with return of spontaneous circulation (ROSC) and persistent coma admitted to ICU from 1/2006 to 1/2010. TH patients were case matched with patients who did not receive TH based on age, gender, and CPR duration. Demographics, cardiac arrest rhythm, time to ROSC, time from ROSC to initiation of TH, time from initiation of TH to desired temperature, duration of hypothermia, and time to rewarm were recorded. Development of complications including infection, coagulopathy, arrhythmias, seizures, and acute renal failure (ARF) was assessed. Clinical outcomes were compared. Results: Seven patients who received TH were identified and case matched to 7 patients who did not receive TH. Age range was 38 to 84 years. Total CPR duration was 12 (1–27) minutes in no TH group compared to 11 (7–20) minutes in TH group. Complications occurring in no TH group included: 6 infection, 2 arrhythmias, 2 ARF, 1 coagulopathy and in TH group: 6 infection, 4 arrhythmias, 2 ARF, 1 coagulopathy, 1 seizure. Hospital LOS was longer in no TH (44 vs. 26 days); however, ICU LOS and duration of MV was longer in TH group (19 vs. 11 days, 14 vs. 8 days, respectively). Neurologic recovery, defined by discharge disposition, was favorable (home or rehabilitation facility) in 2 patients in each group. One person expired in each group. The remaining 4 in each group where discharged to long term care facility. Conclusions: More patients in TH group experienced arrhythmias; however, there was no difference in other complication rates. No difference was seen in neurologic recovery with TH. The clinical impact of TH in this population needs to be further investigated.

794 ASSESSMENT OF A HEPARIN NOMOGRAM UTILIZING ANTI-XA MONITORING IN CRITICALLY ILL PATIENTS WITH ACUTE DVT/PE Dachelle Johnson, Johns Hopkins Bayview Medical Center, Shilta Subhas, Annette Rowden, The Johns Hopkins Hospital Introduction: The use of weight-based heparin nomograms (WBHN) to optimize heparin dosing is well established. An accurate method of nomogram development has not been elucidated. Evaluating the use of an institutional derived, WBHN is essential to assess if this strategy adequately leads to early therapeutic anticoagulation. Hypothesis: Evaluate a newly implemented anti-xa WBHN and assess what proportion of patients achieve therapeutic anticoagulation at 24 hours (h). Methods: Our institution converted from WBHN based on activated partial thromboplastin time (aPTT) to one that utilizes anti-xa heparin activity. Patients with a new DVT or PE who had heparin initiated in the MICU or no more than 12 h prior to their admission within a 6 month period were included. Outcome data were collected through retrospective review of the electronic medical record. Results: 45 patients were identified. 87% of patients attained a therapeutic anti-xa within 24 h. 67% of patients attained 2 consecutive therapeutic levels within 24 h. 10 of the 45 patients received heparin boluses. In patients who achieved 2 consecutive therapeutic levels in 24 h, the mean units/kg/h infusion rates were similar between patients with PE v. DVT (14 v. 13). Patients who were ⬎105 kg received less units/kg/h of heparin than those ⬍105 kg as designed by the protocol (12 v. 15). Yet the time to first 2 consecutive therapeutic levels in this group was similar (22 h v. 23 h). 3 of the 6 patients admitted for a new PE had 2 consecutive therapeutic levels in 24 h. 34 of the 45 patients were noted to have at least 1 documented incident of protocol noncompliance. There were no recurrent thromboembolic events and 4 bleeding events during the study. Conclusions: A lower proportion of patients achieved therapeutic anticoagulation within 24 h compared to similar trials. However, these studies utilized the aPTT for monitoring and were not conducted in ICU patients. Noncompliance with the nomograms was a factor in failing to maintain therapeutic anticoagulation. Our institution recently switched back to aPTT for the primary method of heparin monitoring due to observations of discordance between individual’s anti-xa and aPTT levels and concerns of excess bleeding risk.


Posters: Therapeutics-Other- 6 795

796

FEBRILE NEUTROPENIA RESULTING IN SEVERE SEPSIS AND SEPTIC SHOCK: DRUG UTILIZATION PATTERN AND ASSOCIATED COST

EARLY (24HR) JEJUNAL FEEDING INITIATION IN CRITICALLY ILL PATIENTS

Lama Nazer, Mohammad Al-Shaer, Taghreed Al Najjar, Feras Hawari, King Hussein Cancer Center

Yoichi Katayama, Toru Hifumi, Takashi Kanemura, Hiroshi Kato, Junichi Inoue, Yuichi Koido, National Disaster Medical Center, Yasufumi Asai, Sapporo Medical University

Introduction: Febrile neutropenia that results in admission to the intensive care unit (ICU) requires the use of multiple medications. The purpose of this study was to describe the medications utilized and the associated cost in patients admitted to the ICU with chemotherapy-induced febrile neutropenia (CIFN) and severe sepsis or septic shock. Hypothesis: Severe sepsis and septic shock in patients with CIFN is associated with high medication costs. Methods: This was a retrospective cohort study of patients admitted to the ICU of a comprehensive academic cancer center. Patients with CIFN and severe sepsis or septic shock admitted to the ICU between Jan 1st, 2010 and Dec 31, 2010 were identified through the ICU sepsis database. Data regarding prescribed medications, total patient charges for each medication, demographics, culture results, length of stay and mortality were recorded. Results: Thirty cases were identified: 17 were males (56.7%), mean age was 48.7⫾13.4 (SD) years, mean APACHE II score was 20.8⫾7.27 (SD) and the mortality rate was 33.3%. The mean number of medications prescribed and the mean patient charges were 12.5⫾3.32 (SD) (range 8 –18) and $4,690⫾4,566 (SD) (range 437–23,881), respectively. The most common medication classes prescribed were: acid suppressive therapy (n ⫽ 30, 100%), glycopeptides (n ⫽ 29, 96.7%), penicillins/cephalosporins (n ⫽ 26, 86.7%), and aminoglycosides (n ⫽ 25, 83.3%). The highest patient charges were associated with antifungals (average $2,117/patient) and colony stimulating factors (average $1,199/patient), prescribed in 21 (70%) and 23 (76.7%) patients, respectively. Patient charges were higher in non-survivors, compared to survivors and in patients with positive microbiological cultures, compared to those with negative cultures ($7,996 vs $3,037, p ⫽ 0.036) and (6,005 vs $2,968, p ⫽ 0.047), respectively. Conclusions: To our knowledge, this is the first economic analysis of CIFN resulting in severe sepsis and septic shock. Multiple medications are prescribed in this patient population, which are associated with significant cost.

Introduction: ASPEN/SCCM guidelines suggest that enteral feeding should be started within the first 24 – 48 hours following admission in critically ill patients. There are no data showing improvement in relevant outcome parameters using early EN in critically ill patients. Hypothesis: We hypothesized that early jejunal feeding was associated with better outcome in critically ill patients, and conducted this study to evaluate the outcome of early jejunal feeding. Methods: We retrospectively reviewed the records of critically ill patients fed by jejunal route from January 1st in 2009 to August 31st in 2011. Based on the time from admission to initiation of feeding, patients were divided into two groups: early (⬍24hr) group and conventional (⬎24hr) group. Twenty eight-day mortality rate was compared as a primary outcome between the two groups. Other parameters, such as age, gender,diagnosis, APACHE II, SOFA score, catecholamine index on initiation of feeding, volume of infusion for a week, ventilator days, ICU days, and CRRT initiation were examined. Results: A total of 20 patients were analyzed. Baseline characteristics were gender (male/female 16/4), age (median [IQR], 65.5 years [37– 88] ), APACHE II score (16[12.25–29.75] ), SOFA score ( 6 [4 –7.75] ), and 28-day mortality rate (35%). Diagnoses included: ARDS(n ⫽ 10), severe sepsis (n ⫽ 9), the others (n ⫽ 1). Eight cases were categorized in early group, 12 cases were conventional group. The time from admission to initiation of feeding in the early group was 11 hours [3.25–22.5]. Twenty eight-day mortality rate is significantly higher in the early group than in the conventional group (62.5% vs. 16.6%, p ⫽ 0.027). Duration of stay in the ICU were significantly shorter in the early group than in the conventional group (12.6 days vs. 24.7 days, p ⫽ 0.02). No significant difference between the two groups was observed with respect to age, gender, APACHE II, SOFA score, catecholamine index, volume of infusion for a week, CRRT initiation, or ventilator days. Conclusions: Early jejunal feeding was associated with poor outcome in critically ill patients. Further large study is required to establish appropriate time to start feeding.

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EVALUATION OF TWENTY-FOUR HOUR COMPLIANCE OF HEAD OF BED ELEVATION

THE SAFETY OF HIGH FLOW NASAL CANNULA AT WOMEN AND CHILDREN’S HOSPITAL OF BUFFALO

Frank Acevedo, Jonas DeMuro, Adel Hanna, John McNelis, Winthrop University Hospital

Bree Kramer, Women & Children’s Hosp of Buffalo, Maude Dull, Children’s Hospital of Buffalo

Introduction: Ventilator Associated Pneumonia (VAP) is the most common hospital acquired infection in the ICU. Positioning of the head of bed (HOB) in a semirecumbant (SR) position ⬎30° helps to prevent VAP. Hypothesis: Objective was to evaluate time spent in the ⬎30° elevation position for any given 24-hour period. A literature search could not find any previous study documenting this data. Methods: This is a prospective cohort study performed over 60 days on all ventilated patients admitted to a 15 bed surgical ICU. HOB data from the In Touch Critical Care Bed manufactured by Stryker® was collected on 26 patients. Staff was not informed of the study efforts and a single physician assistant collected the data. HOB data was entered onto a collection form and then transferred onto an Excel® spreadsheet where total hours and minutes spent both ⬎30° and ⬍30° were tabulated. Calculations were made for average number of ventilator days, total hours ⬎30° and ⬍30°, and average times ⬎30° and ⬍30°. Data was collected during times when nursing staff was unavailable so as to avoid a potential Hawthorne effect. Results: Twenty-six ventilated patients studied during this 60 day time frame spent a total of 194 ventilator days, average 7.46 vent days/patient. Average time spent with the HOB ⬍30° was 14.2 hours while time spent by patients with HOB ⬎30° was 9.5 hours (discrepancy from 24 hour total result of partial ventilator days). Patients spent 59.9% of their time in less than optimal SR positions while only 40.1% of the time was spent in the recommended, or greater than recommended position. Of note, a review of the completed ventilator bundles for the unit revealed a ⬎95% compliance rate. Conclusions: Though it has been clearly established that the optimal position for ventilated patients is a SR position of ⬎30° analysis revealed a lack of consistently during any given 24 hour period. Despite compliant ventilator bundles it would appear that bundle compliance figures can be misleading as patient position may change adversely after bundle data has been completed. A further pilot study is required to assess compliance with 24 hour positioning of ventilated patients after appropriate educational interventions.

Introduction: High Flow Nasal Cannula (HFNC) therapy is a novel interventional approach in the pediatric population. It has been used at The Women and Children’s Hospital of Buffalo (WCHOB) since 2006 for respiratory support of infants and toddlers with primarily respiratory disease. The application of HFNC, the appropriate patient population, safety of feeding while in use, and efficacy have not been established. Hypothesis: Our hypothesis is that it is safe to initiate and continue patients on HFNC on the pediatrics wards. Additionally, it is safe to feed patients while on HFNC, if not clinically contraindicated. Methods: 302 charts were reviewed for HFNC patients between July 2009 and June 2010. Demographics, diagnoses, and comorbidities were recorded. Details regarding initiation, discontinuation, vital signs, feeding parameters, PICU transfers, intubations and modality regulation were noted. Results: Of the 302 charts reviewed the population was primarily composed of children under the age of 2 years, the majority less than 1 year of age (65%). Utilization decreased as age increased. The primary indication for HFNC application was Bronchiolitis snd then pneumonia. The data revealed that one third of the patients were started in the emergency room and another one third on the general pediatric ward with the remaining one third in the PICU. 40% of patients who started on HFNC in the ED or wards required PICU transfer during their admission, 10% requiring intubation. 46% of all patients were allowed to feed while on HFNC, 4% of these required an increase in settings and only 1 patient had a documented complication (choking and vomiting). Conclusions: HFNC has been safely used at WCHOB. The largest demographic has been children less than 2 years admitted for a respiratory condition. Escalating support suggests clinical deterioration. Only one fifth of the patients started on HFNC on the ward required PICU transfer. We conclude it is safe to both initiate and maintain patients on HFNC on the general pediatrics ward. The data also supports that it is safe to feed patients if they are clinically stable.


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EVALUATION OF GLUCOSE METER PERFORMANCE IN AN ADULT INTENSIVE CARE UNIT: COMPARISON OF TOTAL ANALYTICAL ERROR VERSUS ISO 15197:2003

CLINICIAN CHEST RADIOGRAPHIC INTERPRETATION VARIES WIDELY IN SUSPECTED ACUTE LUNG INJURY

Kaoru Koyama, Saitama Medical Center and University, Hideki Miyao, Saitama Medical Center/School, Hitoshi Ikeda, Noriko Harashima, Masanori Tamura, Saitama Medical Center and University, Mark Heinz, Nova Biomedical, Martha Lyon, Alberta Children’s Hospital, Jeffrey DuBois, Nova Biomedical Introduction: To compare the assessment of glucose meter performance using total analytical error versus ISO 15197:2003 expectations with patient specimens obtained from an adult intensive care setting. Hypothesis: Total analytical error will compliment ISO 15197:2003 expectations to provide a better understanding of glucose meter performance. Methods: Bias caused by patient hemoglobin was evaluated with two different glucose meters. Multivariate regression analysis was used to estimate the combinatorial effects of patient hemoglobin and glucose concentration on bias. The precision of each glucose meter was determined by consecutive analysis (n ⫽ 20) of a whole blood specimen at two levels of glucose. Total analytical error was estimated as % bias ⫹1.645 (% imprecision). The performance of the two glucose meters were also compared with the clinical laboratory plasma hexokinase results according to protocol described in the ISO 15197:2003 document. ISO 15197:2003 expect that 95% of the individual glucose results should fall within ⫾15 mg/dl at low glucose concentrations (⬍75 mg/dl) and within ⫾20% when glucose concentrations are higher. Results: Hemoglobin influenced the performance of one glucose meter. Estimates of total analytical error for this glucose meter ranged from 6.7 to 27.7% while 90.7% of the glucose meter results compared within 20% of the clinical laboratory plasma hexokinase result. Total analytical error of 27% at a 100 mg/dL glucose concentration would translate into a potential reported glucose ranging from 73 mg/dL to 127 mg/dL. The second glucose meter evaluated was not influenced by hemoglobin concentration, demonstrated 100% of the results met ISO 15197 expectations and the estimated total analytical error ranged from 5.6 to 8.1%. Conclusions: Achievement of ISO 15197:2003 performance expectations for glucose meters can translate into a total analytical error up to 8%. The clinical impact of a total analytical error of 27% in glucose measurement could be significant.

Thomas Iden, Jared Shipley, Cecilia Bergh, Mark Parker, Kristin Miller, Curtis Sessler, Medical College of Virginia/Virginia Commonwealth University Introduction: Clinicians vary in use of low tidal volume (Vt) ventilation (LTVV) in acute lung injury (ALI)/ARDS. Since the chest radiographic (CXR) component of the American European Consensus Criteria (AJRCCM 1994) for ALI requires only bilateral infiltrates on frontal CXR, we sought to examine the consistency of clinician interpretation of CXRs and relationship to ventilator management in suspected ALI. Hypothesis: We postulate that clinicians’ level of confidence in diagnosing ALI is based in part on their CXR interpretation and thus influences ventilator management. Methods: We identified 30 ICU patients (2007– 8) who met consensus criteria for ALI. 19 critical care clinicians viewed day 1 CXRs for the 30 cases and recorded their confidence of radiographic compatibility with ALI using a 5-level Lykert scale anchored by “certain” (1) and “not at all confident” (5). While viewing the CXR and corresponding PaO2/ FiO2 (mean 154⫹68 mmHg (SD)), the clinicians selected a target Vt from 5 levels (4.5 to 10.5 ml/kg PBW in increments of 1.5). We correlated the clinician CXR confidence score and clinician target Vt with actual Vt applied. Results: The median CXR confidence for ALI for all cases was 3 “somewhat confident” (IQR 2,4) with “certain” or “very confident” scores in 40% of cases and “not very confident” (4) in 30%. There was wide variability, with all 5 levels of confidence selected in 5 cases (17%), 4 levels in 11 cases (37%), and no cases with complete agreement. Median Vt selected was 6 ml/kg PBW, however clinician choices varied widely with 8 cases (27%) having 4 different target Vts, 13 cases having 3 different targets, and no cases with complete agreement. Both CXR confidence and PaO2/FiO2 correlated highly with Vt selected (p⬍0.001). Neither clinician CXR confidence score, nor clinician target Vt correlated with actual Vt at 24hrs post-intubation (8.5⫹1.6 ml/kg PBW). Conclusions: Although all cases met consensus criteria for ALI, we observed wide variation in clinician confidence of CXR compatibility with ALI. Both CXR interpretation and PaO2/FiO2 influenced Vt selection. We found no correlation between clinician CXR assessment and actual Vt applied, suggesting other factors influence adherence to LTVV.

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EFFICACY AND SAFETY OF ENOXAPARIN 20 MG SUBCUTANEOUSLY IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGES 4 AND 5 FOR DEEP VEIN THROMBOSIS PROPHYLAXIS

ESTIMATES OF GLUCOSE METER TOTAL ANALYTICAL ERROR ASSOCIATED WITH CHEMICAL INTERFERENCES COMMONLY SEEN IN AN ADULT INTENSIVE CARE UNIT

Lamis Karaoui, Samah Tawil, Lebanese American University Introduction: Uncertainties still surround LWMH use in patients with severe chronic kidney disease (CKD), for DVT prophylaxis at CrCl less than 30 mL/ min. Hypothesis: The objective of this study was to assess the efficacy and safety of enoxaparin 20 mg SC daily for DVT prophylaxis in patients with severe CKD. Methods: This is a retrospective, IRB approved cohort study of 216 inpatients conducted in a tertiary care teaching hospital. Included patients were older than 40 years, hospitalized for ⱖ3 days, with CKD stages 4 and 5, at moderate to high risk for VTE, and prescribed enoxaparin 20 mg SC daily for VTE prevention. Baseline characteristics, relevant medical history, concurrent antithrombotic therapy, laboratory values and clinical symptoms for VTE or any bleeding episode were all obtained from medical charts. Exclusion criteria: treatment doses of enoxaparin, pregnancy and breast-feeding. The primary efficacy endpoint was a VTE event defined as DVT, pulmonary embolism (PE), or both at any time during hospital stay. The secondary safety endpoints were overall mortality and incidence of major or minor bleeding events. Results: Between October 22 and November 30, 2010, a total of 216 patient charts (130 males, mean age 77.1 ⫾ 9.24 years) were reviewed. Of the 216 patients, 167 (77.31 %) had CKD stage 4, 49 (22.69%) had CKD stage 5, and 62 (28.7 %) were on hemodialysis. Of those 216 patients receiving prophylactic enoxaparin, VTE occurred in 14 (6.48 %). Of those 14 patients, 9 (4.16 %) had a DVT detected clinically, 4 (1.85 %) had a DVT detected by Duplex Ultrasound, and only one had a non-fatal PE. Overall mortality (death from any cause) occurred in 43 patients (19.90 %) with the risk of death more clinically-associated with patients comorbidities than with enoxaparin therapy. A total of 31 patients (14.35 %) experienced nonfatal bleeding episodes. Of the 51 cases (23.61 %) of thrombocytopenia observed, 9 (4.1 %) were probably related to enoxaparin. Conclusions: Prophylactic enoxaparin 20 mg SC daily in hospitalized patients with CKD stages 4 and 5 appears to prevent VTE risk with no major side effects or bleeding. A randomized controlled trial is warranted to further confirm these findings.


Kaoru Koyama, Saitama Medical Center and University, Hideki Miyao, Saitama Medical Center/School, Hitoshi Ikeda, Noriko Harashima, Masanori Tamura, Saitama Medical Center and University, Mark Heinz, Nova Biomedical, Martha Lyon, Alberta Children’s Hospital, Jeffrey DuBois, Nova Biomedical Introduction: To estimate total analytical error with five different glucose meters associated with chemical interferences commonly seen in the adult intensive care unit. Hypothesis: Glucose meter total analytical error will be dependent upon the conditions under evaluation and whether the glucose meter utilizes glucose oxidase or glucose dehydrogenase based technology. Methods: The bias caused by maltose (100, 200 mg/dL), acetaminophen (5, 10 mg/dL), ascorbic acid (5, 10 mg/dL) and uric acid (8, 20 mg/dL) was evaluated at five glucose concentrations with five different glucose meters. Multivariate regression analysis was used to estimate the combinatorial effects of the interferences on bias. The precision of each glucose meter was determined by consecutive analysis (n ⫽ 20) of a whole blood specimen at three levels of glucose. Total analytical error was estimated as % bias ⫹1.645 (% imprecision). Results: Glucose oxidase based glucose meters demonstrated greater estimates of total analytical error (up to 33%) in the presence of uric acid than the meter with glucose dehydrogenase based technology. In contrast, the glucose dehydrogenase based meter demonstrated profound susceptibility to maltose interference (up to 117% total error) whereas the glucose oxidase meters were much less influenced (.up to 20% total error). Estimates of total analytical error in glucose measurement ranged from 3 to 117% under the various conditions tested. Conclusions: The impact of chemical interferences on the performance of glucose meters is highly device and technology dependent.

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TWO CASES OF COMBAT CASUALTIES WHO DEVELOPED TACHYCARDIA INDUCED CARDIOMYOPATHY SECONDARY TO PROLONGED SINUS TACHYCARDIA FROM IMPROVISED EXPLOSIVE DEVICE (IED) ATTACKS.

PROSPECTIVE COMPARISON OF THE INTEGRATED PULMONARY INDEX (IPI™) TO RESULTS FROM WEANING EVALUATIONS IN CARDIAC SURGERY PATIENTS

Michael Kavanaugh, Jonathan McDivitt, Anthony Nations, Andrew Philip, Walter Reed National Military Medical Center Bethesda

Manuel Castresana, Susan Whiddon, Georgia Health Sciences University, Ramona Herrington, Georgia Health Sciences Medical Center, Jennifer Waller, Arthur Taft, Georgia Health Sciences University

Case Reports: BACKGROUND: Tachycardia induced Cardiomyopathy (TICM) is generally associated with atrial tachycardias as well as ventricular arrhythmias. Typically, TICM has been attributed to duration of tachycardia as opposed to magnitude, likely because higher rates are symptomatic and result in earlier treatment. This condition is considered reversible when the rate is corrected. CASE 1: 25 year old Marine injured by an Improvised Explosive Device (IED) resulting in loss of consciousness, multiple fractures and a left Below the Knee Amputation. His course included rhabdomyolysis, acute renal failure and bilateral pulmonary emboli. He also received a partial orchiectomy and had external fixators placed on his pelvis and right upper extremity. His pulse averaged ⬎110 beats per minute (BPM) with maximum 146 BPM. His initial echocardiogram showed an ejection fraction of 75%. His course was complicated by bacteremia and multiple wound infections. After 2 months, his repeat echocardiogram showed an ejection fraction 35– 40%. CASE 2: 26 year old Marine injured by IED resulting in a bilateral Total Knee Amputations. He also had a retroperitoneal hematoma, right testicular rupture and a pubic symphisis avulsion fracture requiring a pelvic external fixator. His pulse averaged 113 BPM with maximum 151 BPM. His course was complicated by pneumonia which responded to antibiotics. His echocardiogram showed an ejection fraction of 20 – 25%. Cardiac enzymes were negative and TICM was diagnosed. DISCUSSION: Generally, sinus tachycardia associated with trauma or critical illness is not treated with rate controlling medications. The normal physiologic response to these extrinsic factors demands a higher output. Thus, the tachycardia is compensatory and suppressing the tachycardia would be detrimental to the patient. In burn patients, there is evidence to support early beta blockade. The data is weaker for trauma patients, and rate control is still not the standard of care. Our patients had no prior cardiac history or thoracic trauma but displayed severe decline in left ventricular function. These cases are examples of the adverse outcomes which can occur from persistent tachycardia.

Introduction: Rapidly removing patients from mechanical ventilation after surgery decreases costs and complications. Currently, the best predictors of readiness to wean are the RSBI in conjunction with a spontaneous breathing trial (SBT) and clinician judgment. However, some patients pass the weaning evaluation, yet fail removal from mechanical ventilatory support, and some may fail the evaluation yet successfully wean. The IPI is an index of respiratory status derived from capnography and pulse oximetry data (PETCO2, RR, SPO2, and PR). Hypothesis: This study tested the hypothesis that average IPI is higher during successful SBTs than unsuccessful SBTs. Methods: This IRB approved, prospective, observational trial was performed on mechanically ventilated patients after cardiac surgery (CABG with cardiopulmonary bypass). All patients received standard of care, no intervention was performed for the purpose of this study. All subjects had an RSBI evaluation, followed by an SBT, per hospital protocol. IPI was continuously recorded immediately before and during the SBT. Clinicians were blinded to IPI. At the end of each SBT, the staff RT determined the outcome (pass or fail). Recorded IPI data was averaged over the first 30 minutes of the SBT, and analyzed to determine the ability of IPI to predict weaning evaluation outcome. Statistical analysis was performed (SAS 9.2) using a one-tailed t-test. Results: Eleven subjects (6 males) were studied. Results from 14 SBTs were evaluated, with 8 subjects performing a single SBT and 3 subjects having multiple SBTs. Twelve SBTs were performed using pressure support and 2 using CPAP. Of the 14 SBTs, 11 were rated by the staff RT as passing and 3 failing. Although no statistically significant difference in mean values was found, failing SBTs tended to have a lower mean IPI (7.63 ⫾ 1.25) than those passing (8.64 ⫾ 0.96) p ⫽ 0.075. Conclusions: In post-operative CABG patients, IPI demonstrates reasonable agreement with clinical evaluation of SBTs by RT staff and may be useful in predicting readiness to discontinue mechanical ventilation. Further study and a larger sample size are needed to more clearly define the value of IPI during the weaning process in this patient population.

805 ASSESSING A SAFE INTERVAL FOR SUBSEQUENT NEGATIVE PRESSURE WOUND THERAPY AFTER INITIAL PLACEMENT IN CONTAMINATED WOUNDS Ehyal Shweiki, Christiana Care Health Services, Kathy Gallagher, Christiana Care Health Systems Introduction: Limited data exists with negative pressure wound therapy (NPWT) in acutely contaminated wounds and decreased bacterial load has not been definitively shown with its use. Despite lack of data in contaminated wounds, NPWT is empirically expanding across the globe. Yet, currently there is no defined time interval in the literature specifying when NPWT should be changed after its initial placement in contaminated wounds. We aim to study this paradigm in order to guide evidence-based practice. Hypothesis: We hypothesize that safe NPWT practice allows a 1–3 day interval for subsequent NPWT application after initial placement in contaminated wounds. Methods: We retrospectively reviewed 86 consecutive patients, totalling 97 contaminated wounds. Sepsis criteria were present in 78/86 (91%) of patients. All patients were managed with NPWT. Wound type, degree of tissue destruction, presence of infection, wound dimension, timing of initial NPWT, type and timing of wound closure, and patient comorbidities were recorded. Outcome endpoints included durability of wound closure and death. Results: Wound location was 41/97 (42%) in the torso; 56/97 (58%) at the extremities. Tissue necrosis was present in 84/97 (87%) of wounds. Infection was present in 86/97 (89%) of wounds. Average wound size was 619 cm2 when square surface area measured; 786 cm3 when volume measurements taken. Average time between initial and subsequent placement of NPWT was 2.7 days. Durability of wound closure was 73/79, (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT. Conclusions: Based on these findings using NPWT in the largest known patient cohort of this type, a time interval of 1–3 days between initial and subsequent placement of NPWT is safe and effective in managing contaminated wounds including patients meeting sepsis criteria.



807

THE RISK OF ASPIRATION POST-EXTUBATION IN SURGICAL PATIENTS IS INDEPENDENT OF THE DURATION OF INTUBATION

ADVERSE EVENTS OF FLUID THERAPY AFTER ABDOMINAL SURGERY

Erin McMurrer, Westchester Medical Cennter, Carlo Gwardschaladse, Dmitriy Karev, Gary Lombardo, WMC, Corrado Marini, Westchester Medical Center, Anthony Policastro, N.Y.M.C. Introduction: Studies suggest that patients extubated after short period of intubation (ⱕ3 days, SI) do not require fiberoptic endoscopic evaluation of swallowing (FEES) since only patients intubated ⬎3 days (PI) are at risk of aspiration from dysfunction of swallowing. Hypothesis: In this study we assessed whether the risk of aspiration is dependent on the duration of intubation. Methods: 32 patients underwent FEES after extubation. Silent aspiration was defined as the entry of liquid or puree material below the true vocal cords without cough, whereas clinical aspiration as removal of enteral content. Data acquired included age, duration of intubation (DI), sex, presence of traumatic brain injury and FEES failiure. Patients were compared with respect to FEES failure vs no failure and SI vs PI. Results: Aspiration was documented in 20/32 (62%) of patients.Variable FEES Failure (n ⫽ 20) No FEES Failure (N ⫽ 12) PAge 51 ⫾ 22 45 ⫾ 21 0.45DI 11 ⫾ 8 7 ⫾ 6 0.14Sex 12/8 9/3 0.46TBI 6/20 4/12 1Variable SI (N ⫽ 6) PI (N ⫽ 26) PAge 64 ⫾ 19 45 ⫾ 21 0.68DI 2 ⫾ 1 10 ⫾ 6 0.64Sex 4/2 17/9 0.44TBI 4/6 7/19 0.35FEES Failure 3/6 (50%) 17/26 (65%) 0.64. Conclusions: We conclude: 1. The risk of aspipration is independent of the duration of intubation; 2. All patients should be assessed with FEES after extubation.

Arkadiy Makaron, Upstate University Hospital, Karina Muzykovsky, John Mitchell, William Vincent, The Brooklyn Hospital Center Introduction: The purpose of this study was to identify the prevalence of sodium disturbances and maximum fluid volume and daily rate, which are associated with adverse events (AE). Hypothesis: Higher rates of administration and total volumes of fluid would result in a higher prevalence of sodium disturbances. Methods: This study was a retrospective chart review of adult patients admitted to the surgical intensive care unit who underwent colorectal surgery, received perioperative fluids and had a length of stay (LOS) greater than five days. The primary outcome was the rate of sodium disturbances. Secondary outcomes included association of body weight/BMI with sodium disturbance, use of furosemide, and hospital LOS. Odds ratio (OR) was used to compare the primary endpoint and the chi-square test was used to analyze categorical data. The student’s t-test and Wilcoxon rank sum tests were used to analyze furosemide administration and lengths of stay, respectively. Results: Seventy-five patients were enrolled into our retrospective chart review. The mean volume of fluid administered in mL/kg ⫾ SD of total body weight on post-operative days 0, 1, 2, and 3 was 78.3 ⫾ 40.1, 48.1 ⫾ 23.1, 34.2 ⫾ 17.8, and 27.5 ⫾ 21.1, respectively. A total of 33 (44%) patients developed hyponatremia, which occurred on post-operative day two (p ⫽ 0.0237). Patients who had a BMI of 25 kg/m2 or less had higher rates of sodium disturbance versus patients who were overweight or obese: 100% and 76% versus 36% and 50%, respectively. Patients receiving more than 58.25 mL/kg/day had an OR of 4.33 (95% CI: 1.32–13.9) for development of a sodium disturbance, p ⫽ 0.0139. Less furosemide was given to patients who received less than 58.25 mL/kg/day of fluid versus patients who received more, 7.5 ⫾ 21.64 mg versus 36.11 ⫾ 62.24 mg, respectively (p ⫽ 0.0039). Patients who received less than 45.94 mL/kg/day had a mean hospital LOS that was 10 days shorter (p⬍0.05). Conclusions: High volumes of fluid administered to post-abdominal surgery patients may result in high rates of sodium disturbances. Weight is an important determinant of the risk of developing a sodium disturbance. Fluids dosed based on body weight may help avoid sodium abnormalities.

808

809

AB THERA VACUUM ASSISTED TEMPORAY CLOSURE IN ABDOMINAL COMPARTMENT SYNDROME

EVALUATION OF ETOMIDATE INDUCED ADRENAL INSUFFICIENCY IN ADULT PATIENTS IN THE SURGICAL INTENSIVE CARE UNIT

Jacqueline Morano, Winthrop University Hospital, Adel Hanna, Withrop University Hospital, Jonas DeMuro, John McNelis, Winthrop University Hospital Introduction: To determine the efficacy of the Ab-thera Vacuum Assisted Abdominal (AbVAC)closure system in the treatment of Abdominal Compartment Syndrome(ACS). Hypothesis: Ab-thera is a safe and effective method for temporary abdominal closure in ACS. Methods: The AbVAC (KCI industries San Antonio Texas) was introduced into our unit as the primary method of abdominal closure A retrospective medical record review was undertaken examining patients receiving temporary closure with the AbVAC between January 2010 and May 2011 for the treatment of ACS at a tertiary care center. Data inquire included demographics, Patient age, procedure, time to ACS diagnosis (hours), duration of AbVAC (days), number of AbVACS used per patient, method of closure, complications and overall outcome. Data is reported as means ⫾ standard deviation. Results: AbVAC was employed in 19 patients. Mean age: 62 ⫾ 10 years, average duration of AbVAC use: 9.74 ⫾ 10.4 days, number of AbVACs used: 2.37 ⫾ 1.92 per patient . No patients developed fistulas, evisceration, or AbVAC failure during this study interval. A 53% survival rate was observed in the group. A Subgroup analysis revealed an overall survival rate of 46.0% in patients developing ACS intra-operatively. In those diagnosed with ACS in the post-op period, survival dropped to 40.0% . Those who received multiple AbVAC therapy for second look surgeries and prolonged closure had a survival rate of 62.5% compared to those who received only one AbVAC resulting in a survival rate of 22.2%. Conclusions: Our data indicate that AbVAC is a safe method to achieve temporary closure in patients with ACS with no complications or therapeutic failures. Multiple applications were also found to be safe with this group actually having an improved survival when compared to patients requiring a single application. This is most likely reflective of disease severity, but does demonstrate the safety of multiple applications. Conventional VAC therapy has been associated with a 30% complication rate with a reported fistula rate of 19.5%. Based on our experience, AbVAC provides a superior modality than previous available modalities of Temporary Abdominal Closure. Our evaluation is ongoing.


Shailesh Garg, NSLIJ, Kaity Wan, STJ, Manuel Villa, NSLIJ, Candace Smith, Wenchen Wu, STJ, Rafael Barrera, NSLIJ Introduction: According to the National Emergency Airway Registry study, etomidate is the most frequently used induction agent for rapid sequence intubation (RSI) in adults. Etomidate inhibits an enzyme necessary for adrenal steroid production, which may result in reduction of cortisol plasma levels. A comparison between adult patients who received etomidate and subsequently developed adrenal insufficiency versus those who did not develop this condition in the surgical intensive care unit (SICU) was evaluated. Hypothesis: To assess the prevalence of etomidate associated adrenal insufficiency in adult SICU patients. Methods: A retrospective chart review of 47 SICU patients was evaluated. The following data from medical records covering the period of 2007 to 2011 were retrieved: etomidate use, dose, date, and time of administration, potential risk factors for adrenal insufficiency (i.e., adrenal injury, coagulopathy, hemorrhagic shock, vasopressor dependence), and signs and symptoms of adrenal insufficiency; defined as hypotension (MAP ⬍65 mm Hg) and cortisol level less than 25 mg/dl. Results: Of the 47 adult SICU patients included in our study, 34 patients received etomidate. The average age for the total population and etomidate patients was 71 ⫾ 15 and 73 ⫾ 14, respectively. The total number of patients who developed adrenal insufficiency was 48.94%, had septic shock was 55.32%, and had adrenal insufficiency and septic shock was 34.04%. Of the patients who received etomidate, 44.12% developed adrenal insufficiency, 61.76% had septic shock, and 38.24% had adrenal insufficiency and septic shock. The comparison of patients who developed adrenal insufficiency and received etomidate (44.12%) versus those who did not (61.54%) was not statistically significant (p ⫽ 0.29). However, a comparison of patients who developed adrenal insufficiency and had septic shock (61.54%) versus those who did not (33.33%) was statistically significant (p⬍0.05). Conclusions: There is no association with etomidate and adrenal insufficiency in adult SICU patients. Our study suggests that there is a relationship between septic shock and the development of adrenal insufficiency in adult SICU patients.

810

811

ASSESSMENT WITH INDIRECT CALORIMETRY IS ESSENTIAL TO OPTIMIZE NUTRITIONAL SUPPORT IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY

PROCESS-RELATED DETERMINANTS OF HYPOGLYCEMIA IN CRITICALLY ILL PATIENTS AFTER TRANSITION FROM AN INTRAVENOUS TO A SUBCUTANEOUS INSULIN REGIMEN

Jackie Maxell, Westecher Medical Center, Anthony Policastro, N.Y.M.C., Kaliani Bhuta, Westchester Medical Center, Francis Baccay, Westchester University Medical Center, Heena Rajdeo, Corrado Marini, Westchester Medical Center Introduction: Patients with severe traumatic brain injury (STBI-Glasgow Coma Score ⱕ8) are hypermetabolic and remain catabolic even when given calories/kg (kcal/Kg) and proteins adjusted to their increased metabolic rate. Hypothesis: Assessment with indirect calorimetry (IC) in STBI patients improves the ability to achieve nitrogen balance (NB). Methods: 11 STBI patients on mechanical ventilation received nutrition (25% protein, 35% fat, 45% carbohydrate) targeted to achieve 140% of their basal energy expenditure (BEE) by the Harris-Bennidict equation within 72 hours. IC and 24 hour urine urea nitrogen were evaluated at 72 hours and at day 7. Patients were divided into 2 groups; a negative and positive nitrogen balance group (-NB, ⫹NB). Data acquired included age, BMI, temperature, Kcals/kg received, REE/kg, minute ventilation (Ve), % of substrate utilization (PSU), RQ and NB. The two groups were compared to respect of all valuables. Results: 4/11 (36%) of patients achieved ⫹NBVariable ⫹NB (n ⫽ 4) -NB(n ⫽ 7) PValueAge 32⫾14 24⫾8 0.25BMI 28⫾8 23⫾4 0.19Temp 37.6⫾0.2 37.4⫾0.3 .026Kcal/kg 35⫾9 31⫾10 0.52REE/kg 26⫾3 32⫾8 0.19Ve 11⫾2 12⫾3 0.57PSU-CHO 35⫾10 11⫾3 0.002PSU-FAT 36⫾3 52⫾7 0.002PSU-PRO 30⫾7 38⫾5 0.05RQ 0.84⫾0.01 0.74⫾0.05 0.003NB 1⫾2 -10⫾2 0.0001. Conclusions: We conclude: 1. STBI patients with RQ ⬍0.75 require and increase in 25% above REE/kg; 2. IC is essential to optimize nutritional support in STBI patients.

812 INTESTINAL DEROTATION IN THE TRAUMA PATIENT Sarah Cate, Gary Lombardo, Vincent Blood, Corrado Marini, Westchester Medical Center/New York Medical College Case Reports: Duodenal trauma remains a challenging injury. Mortality rates for duodenal injuries range from 17%-20. We describe a patient in whom an intestinal derotation procedure was successfully utilized as a primary treatment modality in the setting of trauma.The patient is a 19 year old female who was involved in a motor vehicle collision. She had liver, spleen and renal laceration, rib fractures, and a fracture of the 1st lumbar vertebrae. She was taken to the operating room for peritonitis. Intraoperative findings revealed devitalized fourth portion of the duodenum and jejunum with a perforation of the mid jejunum. The perforation was repaired primarily and intestinal derotation was performed. The right colon was mobilized to the midline, the ligament of Treitz was divided and the small bowel was mobilized to the level of the superior mesenteric artery. The duodenum was mobilized and the small bowel was rotated in a clockwise fashion along the superior mesenteric artery axis allowing a tension free anastomosis between the jejunum and duodenum. The third and fourth portions of the duodenum were resected and a hand sewn duodenal-jejunal anastomosis was created. A feeding jejunostomy was inserted and the abdomen was closed primarily. Postoperatively, her diet was advanced rapidly and the jejunostomy was removed and she was discharged home. Out patient follow up at 6 weeks revealed no sequelae.Intestinal derotation was first described by Cattel, Braasch, and Valdoni in 1950s. It is based on the normal embryological development of the intestine, and has been widely described in the repair of intestinal atresia in neonates and in the repair of superior mesenteric artery syndrome, and in oncologic resections. This case illustrates the use of intestinal derotation as a primary treatment modality in the management of injury resulting from trauma. Intestinal derotation is a viable option for repair of duodenal injuries in the trauma setting. It is safe, allows for enteral nutrition, and should be part of the trauma surgeon’s skill set in the management of duodenal injuries.

Kimberley Harris, Nichole Allen, Kelly Rafferty, Pitt County Memorial Hospital, Eric Toschlog, Michael Bard, East Carolina University/Brody School of Medicine Introduction: The issue of glycemic control in critically ill patients has been studied extensively, however, there are limited data concerning the incidence and potential causes of hypoglycemia after transition from an intravenous to a subcutaneous insulin regimen. Hypothesis: Hypoglycemic episodes after transition from intravenous to subcutaneous insulin differ from those on intravenous insulin alone and are due to identifiable factors related to processes of care. Methods: A single-center, retrospective chart review was conducted in all adult inpatients that were initiated on an intravenous insulin protocol in the surgical intensive care unit and transitioned to subcutaneous insulin between February 2009 and September 2010. Data collected include patient demographics, rate of hypoglycemia with intravenous insulin, rate of hypoglycemia with subcutaneous insulin, blood glucose measurements with subcutaneous insulin, and process-related factors that may be associated with hypoglycemia as documented in the medical record. Results: The rate of hypoglycemia on intravenous compared to subcutaneous insulin was 0.162 vs. 0.133 values ⬍70 mg/dL per day and 0.014 vs. 0.011 values ⬍40 mg/dL per day. The main process-related factors identified as contributing to hypoglycemia include an interruption of the nutrition source, a reduction or discontinuation of the corticosteroid dose, and an inappropriate administration of insulin. Conclusions: Rates of hypoglycemia are lower after patients are transitioned to subcutaneous insulin compared to management on an intravenous insulin protocol. However, there are still a number of process-related factors that are associated with hypoglycemia in the transitioned population. Actions taken to prevent hypoglycemia when the nutritional source is interrupted or discontinued, including restarting intravenous dextrose therapy and adjusting the insulin regimen may further lower the rate of hypoglycemia in the critically ill.

813 NET FLUID BALANCE IS A IMPORTANT FACTOR AFFECTING THE OUTCOME OF THE CRITICALLY ILL SURGICAL PATIENTS Hongjin Shim, Jae Gil Lee, Yonsei University College of Medicine Introduction: Recently, restrictive fluid management showed the better outcome in perioperative period. However, there are no consensus how many fluid is required and what is the optimal goals in critically ill surgical patients. Hypothesis: The fluid amount may affect the outcome of the critically ill surgical patients. Methods: We retrospectively reviewed the medical records of the patient who cared in the surgical intensive care unit (SICU) more than 48 hours in postoperative period from Jan. 2010 to Feb. 2011. The pediatric and posttransplant patients were excluded. We checked the demographic data, and APACHE II score, length of stay of ICU and hospital, in-hospital mortality, values of the fluid resuscitation (intake, output and net balance) during operating room and initial 2 days of SICU. Results: Total 149 patients were enrolled. The overall mortality was 20.8 % in this group. Length of stay of hospital and ICU were 38.5 ⫾ 28.3 and 10.0 ⫾ 12.9 days respectively. In operating room, fluid intake and output were 79.1 ⫾ 64.2 ml/kg and 30.9 ⫾ 40.1 ml/kg respectively, and fluid balance was 48.2 ⫾ 36.1 ml/kg. In ICU, fluid intake and output were 64.1 ⫾ 30.6 ml/kg/day and 47. ⫾ 22.3 ml/kg/day respectively, and net fluid balance was 16.5 ⫾ 19.1 ml/kg/day.In univariate analysis, APACHE II score (p⬍0.001), use of inotropics in ICU (p ⫽ 0.044), output of OR (p ⫽ 0.019), fluid intake in ICU (p ⫽ 0.004), fluid output in ICU (p ⫽ 0.04), and net fluid balance of ICU (p ⫽ 0.008) were significant factors affecting the mortality.In multivariate analysis, net fluid balance of ICU (p ⫽ 0.001) and output in OR (p ⫽ 0.002 ) were significant factors affecting the mortality. Conclusions: In fluid resuscitation of the critically ill surgical patients, net fluid balance is the most important factors affecting the mortality. Regardless of the amount of fluid intake, balance of intake and output is more important. And then we have to consider less positive fluid balance during fluid resuscitation. However, further prospective study is required.


814

815

PROTOCOL-BASED TRACHEAL EXTUBATION FOLLOWING A SPONTANEOUS BREATHING TRIAL IN EMERGENCY PATIENTS

APPROPRIATENESS OF CARBAPENEM INITIATION AND DE-ESCALATION IN A TERTIARY HOSPITAL’S MEDICAL, SURGICAL AND CARDIOTHORACIC INTENSIVE CARE UNITS.

Kenichi Nitta, Kazufumi Okamoto, Shinshu University School of Medicine Introduction: Spontaneous breathing trial (SBT) has been recommended as the best way to assess the need for continued mechanical ventilatory support in patients with acute respiratory failure (ARF). Although SBT is useful, it has the considerable reintubation rate, which is associated with increased risk for mortality. Hypothesis: We hypothesized that the protocol-based tracheal extubation following the SBT wouldreduce reintubation rate and result in decreased mortality rate in emergency patients with ARF. Methods: To guide decision-making regarding the tracheal extubation following SBT, we developed the extubation protocol including the preventive use of noninvasive positive pressure ventilation (NPPV). Observational data was collected after protocol implementation in consecutive patients with ARF. In addition, the ARF patients were divided to compare between patients with acute lung injury (ALI group) and with non-ALI (non-ALI group). Moreover, the patients who received the preventive NPPV after tracheal extubation (NPPV group) were compared with those who received conventional oxygen mask(conventional group). Results: The overall reintubation rate of the ARF patients (n ⫽ 161) was only 3.1%. The 28-day mortality rate was 0% and and the hospital mortality rate 0.6%. The reintubation rates of the ALI group (n ⫽ 104) and the non-ALI group (n ⫽ 57) were 3.8% and 1.7%, respectively(p ⫽ 0.20). The 28-day mortality rates of the both groups were 0% and 0%, respectively(p ⫽ 1.00).The rapid shallow breathing index score at extubation were significantly higher in the non-ALI group than in the ALI group(p ⫽ 0.01 ). The acute physologic and chronic health evaluation II score and the rapid shallow breathing index score at extubation were significantly higher in the NPPV group than in the conventional group. However, the reintubation rates and the 28-day mortality rate were similar in the the two groups (p ⫽ 0.42 and p ⫽ 1.00, respectively). Conclusions: The present study suggests that the protocol-based tracheal extubation is likely effective to reduce the reintubation and the reintubation-induced mortality of emergency patients with ARF.

816 IMPACT OF CONTINUOUS HYPERTONIC SALINE INFUSION ON INTRACRANIAL PRESSURE IN ANEURYSMAL SUBARACHNOID HEMORRHAGE PATIENTS Eugene Gu, Benjamin Boudreaux, Daniel Klinger, Kim Rickert, Christopher Madden, Babu Welch, Wengui Yu, Jonathan White, UT Southwestern Medical Center Introduction: Hyponatremia is frequently encountered in patients following aneurysmal subarachnoid hemorrhage (SAH). The likely causes of hyponatremia are the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cerebral salt wasting. Currently, the treatment for hyponatremia in patients with aneurysmal SAH is salt repletion, either in the forms of salt tablet or hypertonic saline infusion. Delayed cerebral ischemic injury caused by cerebral vasospasm in SAH may lead to elevation of ICP. Bolus injection of hypertonic saline is commonly used as a hyperosmolar agent for treatment of elevated ICP. Hypothesis: The hypothesis of this study is continuous infusion of 3% hypertonic saline will not have effect on ICP in aneurysmal SAH. Methods: A retrospective chart review at an academic hospital from July 1st 2010 to December 31st 2010 yielded 9 patients with the diagnosis of aneurysmal SAH and with External Ventricular Drain (EVD) placement. Use of 3% hypertonic saline infusion, daily serum sodium level and ICP were recorded. A student’s T test was used for statistical analysis. Results: A total of 9 patients were included in this study. All patients were started on 3% hypertonic saline infusion at some time after their aneurysmal SAH due to hyponatremia. There was no significant change in average daily ICP before, during and after 3% hypertonic saline infusion (p⬎0.05). There was no further worsening of their hyponatremia after initiation of 3% hypertonic saline infusion. Conclusions: Continuous infusion of 3% hypertonic saline for the purpose of hyponatremia treatment will not decrease ICP in aneurysmal SAH patients, but it may prevent further serum sodium drop. Bolus injection of 3% hypertonic saline, however, may be a better option for the treatment of elevated ICP.


Chern Yih Lee, Janice Li, National University Hospital Introduction: Carbapenems are used widely in intensive care units (ICUs). Appropriate use of these broad-spectrum antibiotics is important to maximise patient outcomes and prevent resistance.The aim of this study is to evaluate the appropriateness of empiric carbapenem initiation and de-escalation rates in the hospital’s medical, surgical and cardiothoracic ICUs. Hypothesis: It is hypothesized that carbapenems are initiated appropriately in the ICUs and non-de-escalation is mainly due to non-conclusive cultures. Methods: A retrospective chart review was conducted. All adult patients who were initiated on carbapenems in the 3 ICUs between January 2009 to January 2010 were identified. Exclusion criteria: 1) Directed carbapenem therapy. 2) Death within 72 hours. The appropriateness of carbapenem use were evaluated based on criteria for initiation and de-ecalation after 72 hours. Chi-square tests and Student’s T-test were used to determine factors associated with appropriateness. Statistical analyses were done using SPSS v19.0 Results: A total of 30 patients were included in the final analysis. Empiric carbapenems were initiated in the ICU mainly for ventilator/ healthcare-associated pneumonia (66.7%) and sepsis/septic shock (16.67%). All initiations were accompanied by clinical/laboratory signs of infection. Appropriate cultures taken in all cases. Thirty-three percent of the therapies (33%) were de-escalated. No conclusive cultures were available for the 39.1% of patients in whom de-escalation was not done. Infection with ESBL bacteria (40.0%) and deterioration of patients’ conditions (40.0%) were also frequently associated with non-de-escalation. Patients in the non-de-escalated group have significantly higher APACHE II scores of the patients before ( 25.26 ⫾ 6.61 vs 17.71 ⫾ 7.57; p ⫽ 0.016) and 72 hours after (23.17 ⫾ 8.00 vs 16.43 ⫾ 5.88 ; p ⫽ 0.049) the administration of carbapenems compared to the de-escalated group. Conclusions: We observed that carbapenems were initiated appropriately in the ICU. However, the practice of de-escalation can be improved. We propose interventions to improve review rates of de-escalation as well as the need for guidance on deescalation when cultures are non-conclusive.


818

EVALUATION OF THE TREATMENT OF DIABETIC KETOACIDOSIS IN THE MEDICAL INTENSIVE CARE UNIT

THE TIME-COURSE OF HEAT SHOCK PROTEIN 70 EXPRESSION AND THE RELATIONSHIP TO GLUTAMINE IN THE CRITICALLY ILL CHILD

Nicholas Fusco, University of Maryland School of Pharmacy, Siu Yan Yeung, University of Maryland Medical Center, Jeffrey Gonzales, University of Maryland School of Pharmacy Introduction: The American Diabetes Association (ADA) has published clinical guidelines for the treatment of diabetic ketoacidosis (DKA). Studies have demonstrated that non-compliance with these recommendations can lead to worsening outcomes. The objective of this study is to determine if the treatment of DKA in patients admitted to the medical intensive care unit (MICU) of a tertiary medical center is consistent with the 2006 ADA Hyperglycemic Crisis in Adults Patients with Diabetes Clinical Guidelines. Hypothesis: The treatment of DKA in our MICU is not consistent with the 2006 ADA recommendations. Methods: This is a retrospective evaluation of all adult patients admitted to the MICU with a diagnosis of DKA between July 2007 and June 2010. Patients who received insulin for indications other than DKA or initiated DKA treatment at transferring institution were excluded. The primary endpoint was compliance with the 2006 ADA recommendations and patients were deemed to be compliant if they received 4 –14 ml/kg/hour of IV replacement fluids during the first 24 hours of treatment, an insulin bolus of 0.1 unit/kg and subsequent insulin infusion of 0.1 unit/kg/hour. Compliant and non-compliant cases were assessed for: time to resolution of DKA, ICU length of stay (LOS), frequency of rebound DKA and hypoglycemia within 48 hours. Results: Sixty patients met the inclusion criteria. Twelve patients (20%) received DKA treatment compliant to the 2006 ADA recommendations. The mean time to resolution of DKA in compliant cases was 13.1⫾ 9.0 hrs vs. 15.0 ⫾ 11.0 hrs in non-compliant cases (p ⫽ 0.53). The mean ICU LOS in compliant cases was 45.8 ⫾ 22.7 hrs vs. 57.1 ⫾ 58.9 hrs (p ⫽ 0.67). Five patients (41.7%) had rebound DKA in compliant group vs. 11 (22.6%) in non-compliant group (p ⫽ 0.34). One patient (8.3%) had hypoglycemia in compliant group vs. 7 (14.7%) in non-compliant group (p ⫽ 1.0). Conclusions: Compliance with 2006 ADA Clinical Guidelines for treatment of DKA in our MICU is low. Patients treated in compliance with the recommendation have a trend towards shorter time to resolution of DKA and ICU LOS. Education should be performed to improve compliance and possibly outcomes.

Luise Marino, Imperial College London, Nazima Pathan, National Heart and Lung Institute, Rosan Meyer, Parviz Habibi, Imperial College London Introduction: To describe the time course of HSP70 expression and effect of glutamine in-vitro. To investigate the hypothesis that during times of stress, glutamine upregulates the expression of HSP70. Glutamine supplementation is believed to mediate a beneficial effect on outcome in adult critical illness via upregulation of Heat shock protein70 (HSP70).There is paucity of data regarding HSP70 expression in children and the role of glutamine supplementation in paediatric critical illness. Whole blood endotoxin stimulation (LPS) assay in healthy children; analysis of supernatant from children with meningococcal septicaemia (MS). Assay over time; HSP70 expression by ELISA [Stressgen: PA,USA], inflammatory cytokines [Meso Scale MA;USA], serum glutamine levels [AminoTac500JLC500/V]. Illumina.SingleColor.HumanRef-8,total Prep RNA amplification kit for genome wide associations [GWA]. Genespring and Ingenuity for transcriptome analysis.HSP 70 was upregulated linearly over time in whole blood stimulation assay. Glutamine significantly increased HSP 70 at 24hours/1␮gLPS [p ⫽ ⬍0.0001]. Cytokines; IL 6, TNF␣, IL10 were increased, although not significantly, with GS. In MS HSP70 was significantly increased p ⫽ ⬍0.0001 in the acute phase [n ⫽ 135] compared to convalescence [n ⫽ 58]. Glutamine in acute phase [n ⫽ 133] was significantly depleted ⫽ 0.0001 [median:264 mMol/l, CI:260.5–304.2] compared to convalescence [n ⫽ 58] [median:485 mMol CI:454.1– 496.3]. Significant differences between acute and convalescent cytokines [IL6, IL1␤, TNF␣, IL8 and IL10], and a positive correlation between IL6:IL10 ratio p⬍0.0001, r ⫽ 1.00. GWA show HSP70 is positively upregulated [fold change ⬎-2] acute vs. convalescent. Glutamine enhances HSP70 expression in a whole blood endotoxin stimulation model, with a proinflammatory response. Septic children have significant glutamine depletion in addition to increased serum levels HSP70 and enrichment of genes associated with HSP70. Further work is required to determine whether supplementing glutamine parenterally during critical illness is of benefit relative to HSP70 and markers of inflammatory response.

819

820

ENDOSCOPIC PLACEMENT OF NASOJEJUNAL FEEDING TUBE IN MECHANICALLY VENTILATED PATIENTS IN INTENSIVE CARE UNIT

HIGH PEEP VENTILATION DELIVERED BY ARPV-BIPAP MODE ASSOCIATED WITH SEMI-LIBERAL FLUID BALANCE TO PREVENT RENAL FAILURE IN H1N1 A VIRAL INFECTION RELATED ALI AND ARDS.

Hiroshi Kamura, Musashino Red Cross Hospital, Norio Sato, Kyoto University Hospital, Hideto Yasuda, Musashino Red Cross Hospital Introduction: Although early initiation of enteral nutrition significantly reduces the incidence of septic complications, mortality and shortens hospital stay and is considered one of the keys for the critically ill patients, the occurrence of ventilator associated pneumonia may increase. One of the reasons is that gastric atony or gastric paresis often occur in mechanically ventilated patients in an intensive care unit (ICU) and restrict the use of nasogastric enteral tube feeding. To solve the problem, nasojejunal tube feeding is considered the accepted method of nutrition support for those patients. Methods: This was a prospective cohort study. 42 patients requiring mechanical ventilation more than three days and hemodynamically stable in our ICU were received nasojejunal tube replacement by endoscopic technique. All procedures were performed at the bedside in the ICU by the intensive care physician and all patients were properly sedated. A 12Fr. feeding tube was used in all cases. The placement was considered successful when a tip of the tube was placed beyond the ligament of Treitz, which was confirmed by an abdominal x-ray. This study was conducted to assess the safety, success rate, and time required to establish postpyloric nutrition by the endoscopic technique in our ICU. Results: Out of 41 patients, nasojejunal feeding tubes were successfully placed in 40 patients (97%). One patient was excluded because multiple gastric ulcers were found accidentally. The average time of successful placement was 11.8⫹/⫺6 mins. (range 2.8- 32.3). In 4 cases (10%) out of 40 success patients, the procedure required forceps and took more than 20 mis. No adverse events such as bleeding, aspiration and hemodynamic change were observed. Conclusions: Endoscopic placement of nasojejunal feeding tubes can safely and accurately be performed at the bedside in critically ill patients. The average of 12 min. procedure is considered feasible in our daily ICU work. The endoscopic placement technique facilitates the insertion of the nasojejunal feeding tube and early enteral feeding.

Noureddine Nciri, Welcare Hospital, EHL Group, Aamir Yusafzai, Muna Shakir, Basel Kret, Athar Safi, Samira nawaz, Rajesh Sadanand, Susan John, Azmat Ali, Welcare Hospital Introduction: Patients with influenza A (H1N1) virus infection have developed rapidly progressive lower respiratory tract disease resulting in respiratory failure, acute renal failure (ARF) and multi-organ failure (MOF). Hypothesis: A strategy on ventilator management and a semi-liberal fluid balance to prevent ARF, MOF and mortality. Methods: 42 patients with confirmed or suspected H1N1 viral infections were admitted to the ICU during the study period. Thirty-two of them required mechanical ventilation assistance: 10 patients on invasive ventilation and 22 managed by Non Invasive Ventilation (NIV). All intubated patients were ventilated Biphasic Positive Airway Pressure (APRV/BIPAP) mode; with preventive ventilation and a high PEEP. Recruitment maneuvers and prolonged prone position (20 hours) were used early in case of SpO2 less than 90% on FiO2 of 1. Albumin infusion was given to patients with serum albumin ⱕ35 g/l. A semiliberal fluid strategy was implemented to deliver a parenteral nutrition of 25 to 30 Kcal/kg and crystalloids’ infusion in case of hemodynamic instability. Results: 27 patients (64%) had associated risk factor and 7 women were pregnant. The mean Apache2 score was 18. Sixteen patients were ARDS, 18 ALI and 8 patients had unilateral pneumonia. The PaO2 to FiO2 ratio was 89 for ALI and ARDS patients. Only two patients were intubated initially and 8 patients failed on NIV, all of them were ARDS. Eight patients required recruitment manoeuvres and prone positioning. The mean level of PEEP was 18 cm H2O in intubated patients and 12.8 cmH2O was the mean PEEP in NIV. Duration of mechanical ventilation was 6.8 days, ICU LOS was 9.7 days and Hospital LOS was 12.7 days. The daily mean intake volume was 2070 ml, the mean output volume was 1793 ml and the mean balance was 275 ml. Albumin infusion was administrated to 10 patients.No patient develops any stage of renal failure (RIFLE)All patients were discharged home without oxygen supplementation. Conclusions: A strategy based on preventive ventilation with a high PEEP delivered by APRV/BIPAP mode associated with a semi-liberal fluid balance is effective to prevent renal impairment, MOF and mortality.


821 HYPONATREMIA ASSOCIATED ADMINISTRATION

822 WITH

VASOPRESSIN

Amy Dzierba, NewYork-Presbyterian, Joseph Dasta, University of Texas Introduction: Hyponatremia is the most common hospital-acquired electrolyte disturbance associated with high morbidity and mortality. Recently, we observed an increased frequency of hyponatremia in patients receiving arginine vasopressin (AV) for septic shock in our Medical Intensive Care Unit (MICU). Hypothesis: The objective of this study was to quantitate the incidence of hyponatremia associated with AV administration in septic shock. Methods: An IRB-approved, retrospective chart review was conducted from January through March 2011 in all patients admitted to the MICU initiated on AV for septic shock. Changes in serum sodium concentrations before, during, and at discontinuation of AV were evaluated. Data are presented as median (IQR). Differences in sodium concentrations compared to baseline were determined by t-test. Results: Of the 162 admissions, 29 received AV, and eight patients met inclusion criteria receiving AV for 62 (56 –97) hours. Fifty percent of patients were male with an age of 69 (62–71) years and APACHE II score of 27 (20 –29). ICU mortality was 50%. Baseline sodium concentrations, obtained 67 (23–270) minutes before AV administration was 137 (134 –140) mEq/L. Serum sodium concentrations decreased at 24 hours by 2.5 mEq/L (4.3– 0.3; p ⫽ 0.6) and at 48 hours (n ⫽ 7) by 2 mEq/L (3.5–2.0; p ⫽ 0.8). Two patients had an increase in sodium concentrations at 24 hours and both expired in the ICU. Severe hyponatremia (sodium ⱕ130 mEq/L) developed at 24 and 48 hours in two patients, and one died in the ICU. The median proportion of D5W administered at 24 hours was 0.39 (0.32– 0.54) and 0.4 (0.35– 0.61) at 48 hours. The majority of D5W was from intermittent drug administration, whereas most NS administration occurred from fluid boluses (25L at 24 hours and 34L at 48 hours). Five patients had serum sodium concentrations evaluated after AV discontinuation. Sodium increased in all patients at 24 and 48 hours by 2 mEq/L (2– 4; p ⫽ 0.10) and 8 mEq/L (6 –10; p ⫽ 0.06), respectively. Conclusions: Most patients receiving AV for septic shock had a decline in sodium concentrations which often increases following discontinuation.

SURVIVAL AFTER HEART TRANSPLANTATION: A SINGLECENTER EXPERIENCE OF 25 YEARS. Lucas Petersen, Carla Saldanha, ULBRA, Marcio Menezes, HCPA, Ilmar Kohler, Luiz Claudio Danzmann, ULBRA, Lidia Lima, Paulo Prates, Renato Kalil, Solange Bordignon, Ivo Nesralla, IC/FUC Introduction: Besides the advances in the therapeutics of Heart Failure (HF), Heart Transplantation (HT) remains the best option for the treatment of refractory HF. Many variables correlate with the prognosis of the transplanted patient. Hypothesis: The objective of the present study was to analyze the survival and epidemiological profile of patients who underwent cardiac transplantation from 1984 to 2009 in a Medical Center specialized in Cardiology in south Brazil, and correlate with donor (sex and age) and recipient (sex, age, heart failure etiology, extracorporeal circulation time, ischemia time, surgical technique used, reoperation, and pacemaker implant) variables. Methods: Retrospective analysis of 25 years through a databank and medical chart reviews on a total sum of 174 transplants. The Log-Rank was used to compare the Kaplan-Meier curves. Results: A total of 169 patients were analyzed. The overall survival was 63% on the first year and 46% after five years of cardiac transplant. When the last decade was analyzed separately, the survival was 66% on the first year and 51% until the fifth year, respectively. The majority of patient were adult males (68%)(p ⫽ 0,027) from non-ischemic etiology (64,5%)(p ⫽ 0,02). Nowadays, the bicaval technique is preferred, and Shumway was applied in all HT until 1997. The mean extracorporeal circulation (ECC) and ischemia time was 134 (⫹58) and 183 (⫹94) minutes, respectively. Most of donors were below 30 years of age (62,5%). The Kaplan-Meier curves showed better survival among patients with non-ischemic etiology with a mean of 8,6 (CI 95% 6,8 –10,6) years (p ⫽ 0,032) when compared with ischemic etiology, and a ECC time below 130 minutes with a mean of 8,4 (CI 95% 6,5–10,2) years (p ⫽ 0,028) when compared with a ECC time above 130 minutes. There was no statistical significance when the other variables were compared and analyzed. Conclusions: The overall survival of patients post cardiac transplantation is similar to the national data and the epidemiological profile is similar to the international literature. The non-ischemic etiology and the ECC time below 130 minutes showed better survival among the variables compared and analyzed.

823

824

FOMEPIZOLE FOR TOXIC ALCOHOL INTOXICATION AT TERTIARY ACADEMIC MEDICAL CENTER

REVERSAL OF WARFARIN INDUCED COAGULOPATHY IN PATIENTS WITH INTRACRANIAL HEMORRHAGES (ICH): A SINGLE CENTER EXPERIENCE

Kevin Anger, Kelly Babcock, Jeremy DeGrado, Paul Szumita, Brigham and Women’s Hospital Introduction: Toxic alcohol intoxication is associated with metabolic acidosis, acute tissue damage, and death if not managed acutely with pharmacological antidotes and dialysis in severe cases. With the removal of commercially available intravenous ethanol therapy from the U.S. market, fomepizole is the only commercially available pharmacological antidote for toxic alcohol ingestions. Hypothesis: The purpose of this study was to evaluate the baseline characteristics, pharmacological management, and outcomes of patients who received fomepizole for treatment of toxic alcohol ingestion. Methods: Adult patients receiving at least one dose of intravenous fomepizole therapy from January 1, 2004 to October 29, 2010 were retrospectively evaluated. Data included APACHE II score, comorbidities, and laboratory variables. Outcomes included pharmacotherapy administration, time to anion gap closure, toxin associated morbidities, length of stay, and hospital mortality. Results: Thirty-eight patients were included with a mean age of 46 ⫾ 14 years and APACHE II score of 16.4 ⫾ 8.2. Twenty eight (74%) patients required admission to an ICU and 11 (29%) received emergent hemodialysis. Seventeen patients (45%) had laboratory confirmed toxic alcohol ingestion, with ethylene glycol (n ⫽ 6) being the most common alcohol ingested. The mean time from hospital admission to first dose of fomepizole was 7 ⫾ 6.7 hours. The average number of doses administered per patient was 2 ⫾ 1.5. Median time to anion gap closure was 12 hours. Mean length of stay was 3.2 ⫾ 3.3 days in the ICU and 5.7 ⫾ 6.7 days in the hospital. In-hospital mortality was 13%. The incidence of toxin associated morbidities including new onset renal failure (2.6%), permanent vision impairment (2.6%), and seizure (7.8%). Conclusions: Physiological variables and outcomes were favorable suggesting that fomepizole administration provided antidotal therapy to patients presenting with toxic alcohol ingestion.


Tamer Abdelhak, Abdul Kader Tabbara, katherine Gwinn, Tracey Lasak-Myall, kathleen Mays-Wilson, Joseph Miller, Henry Ford Hospital, Panayiotis Varelas, Henry Ford Hospital & Henry Ford West Bloomfield Hospital Introduction: The risk of bleeding is estimated to be 0.3– 0.5% per year for patients on warfarin therapy. Currently, there is no standard of practice concerning reversal of warfarin in ICH. The goal of this study was to retrospectively review our institution warfarin reversal methods in these patients, identify areas of weakness to help improve our facility current practice and maybe improve outcomes. Hypothesis: Therapies employed for reversal of warfarin in ICH will be extremely variable and inconsistent. Methods: Retrospective analysis of patients’ records who were admitted to our institution with ICH while being anticoagulated with warfarin. Results: Between 2001 and 2011, 2971 patients were admitted to our hospital with intracranial hemorrhage, interim analysis show 41 patients were on warfarin. The type of bleeding was Subdural hemorrhage (19 patients, 46%), Intraparenchymal (6 patients, 14.6%) Intraventricular (8 patients, 19.5%) and subarachnoid (3 patients, 7.3%). Trauma was the cause of bleeding in 19 patients; the other 22 patients were considered spontaneous ICH. Mean admission GCS was 10 (range 3–15), mean pre-therapy INR 4.20 (range 1.65–18.78) and mean INR post therapy 1.25 (0.95–1.82). Mean time elapsed before a post therapy repeat INR check was 155 minutes (7–1090 min). Reversal agents used included: vitamin K in 36 patients (87.8%), FFP in 34 patients (82.9%), activated factor 7 in 19 patients (46.3%) and prothrombin concentrate complex in 20 patients (48.7%). 30 patients (73%) received 3 reversal agents. Average ICU length of stay was 12.5 days, mean GOS upon discharge was 2 (range 1–5). 16 patients died (39%). Thromboembolic events were encountered in 4 patients (9.7%). Anticoagulation was resumed in 12 patients. The mean return to anticoagulation 15.6 days (range 2–58 days). Conclusions: Intracranial hemorrhage with anticoagulation carries a high mortality. There is a significant variability in the practice within our health system. Most patients received a combination of agents. We created a standardized protocol for reversal with strict follow up of INR. We will study in a prospective manner the outcomes related to the implementation of the new protocol across the whole health system.

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826

TRAUMA TIMEOUT: PERIODIC REASSESSMENT OF TRAUMA PATIENTS DURING INITIAL STABILIZATION

VOLUMETRIC DIFFUSIVE RESPIRATOR IMPROVES OXYGENATION IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: ONE YEAR’S EXPERIENCE IN A COMMUNITY HOSPITAL

James Miner, william heegaard, Chad Richardson, John Hitt, Arthur Ney, Hennepin County Medical Center Introduction: To develop a method to conduct a periodic reassessment of the rapidly changing clinical condition of critically ill trauma patients during their initial stabilization, the trauma time out (TTO) was developed as a checklist reviewing essential clinical, laboratory, and imaging results to ensure trauma care providers are aware of critical information during transfers of care. Hypothesis: The TTO will assist decision making and reduce error due to omitted or miscommunicated information in the high stress, rapidly evolving clinical situation of the critically injured trauma patient. Methods: This is an observational study of the implementation of the TTO. The TTO was developed through consensus by trauma surgeons and emergency physicians at an Urban, level 1 trauma center, as a checklist to prompt physicians to complete a rapid periodic assessment of clinical, laboratory and imaging studies in trauma patients that occurs after initial stabilization during transfers of care. The TTO includes elements concerning airway, breathing, circulation, mental status, E-FAST findings, hemorrhage control, laboratory findings, resuscitation measures, outputs, reductions and external fixations, and imaging findings. Trauma care was observed by trained research associates who recorded whether the TTO was performed and which elements were covered. Subsequent to the patients care, the Emergency Physician and Surgeon leading the case were asked whether or not information was conveyed during the TTO and whether or not the information was helpful. Results: Thirty critically ill trauma patients were included in the study. Some element of the TTO was incorporated in all 30 cases. All of its elements were completed in only 1 case. In all cases, the Emergency Physician and Surgeon leading the case felt that information was conveyed by the TTO and that the information was helpful. Conclusions: The TTO is a tool to assist in communication and decision making in the care of critically ill trauma patients. It has been successfully incorporated into clinical practice at our hospital. We will perform further studies to determine the effect of the TTO on patient outcomes.

827 HYBRID APPROACH TO CRITICAL COR TRIATRIATUM Jennifer Milner, Thivakorn Kasemsri, Texas Tech University Health Sciences Center, Andrew Robinson, James Harrell, Covenant Women’s and Children’s Hospital Case Reports: A 27 day old infant born at term and who required CPAP for 1 week was seen in the emergency department for heart murmur, jaundice, and failure to thrive. Physical examination revealed weight of 2.75 kg, IV/VI holosystolic murmur, and hepatomegaly. Blood analysis revealed total bilirubin of 21.8, an INR of 2.1, fibrinogen of 87 mg/dL, lactate of 5 mmol/L, and NT-pro-BNP of 58,000 pg/mL. Critical care ultrasound demonstrated small left-sided structures, a membrane in the left atrium, and a small atrial septal defect. PGE1 and mechanical ventilation were started. He was transferred to a facility with pediatric cardiothoracic surgery and interventional cardiology where the patient was diagnosed with core triatriatum, restrictive atrial septal defect, and arterial duct (PDA). He underwent emergent balloon atrial septostomy and angioplasty and stenting of the PDA. Subsequently, his shock resolved. He then underwent surgical repair without complications one week later. Cor triatriatum may be associated with major congenital cardiac abnormalities or may also be an incidental, isolated finding in childhood and adulthood. However as many as 13% of patients may present critically and not survive to surgical repair especially when low cardiac output is a presenting symptom (1). In such a case, the ability to improve cardiac output and resolve shock via interventional techniques can be life-saving. Reference: (1)Humpl T et al. Can J Cardio 2010;26(7): 371– 6

Chirag Chavda, Hetal Patel, Kristin Fless, Paul Yodice, Fariborz Rezai, Mikhail Litinski, Saint Barnabas Medical Center Introduction: Strategies to improve oxygenation during ARDS are limited. We reviewed our experience after introduction of the Volumetric Diffusive Respirator (VDR). Methods: Retrospective chart review of adult patients demonstrating persistent, life-threatening hypoxia due to Acute Respiratory Distress Syndrome (ARDS) despite maximal ARDSNET management strategies utilizing volume or pressure control modes ultimately requiring institution of VDR rescue. Arterial blood gas (ABG) data, PaO2/FiO2 before and after rescue attempt were compared and mortality data was collected. Results: 14 patients (mean age 59 years) escalated from Servo i to VDR over a 12 month period:12 medical, 1 postoperative and 1 thermal injury. 12 patients had normal systolic function by 2D-echocardiography. Co-morbidities were: cancer (n ⫽ 3), renal transplant (n ⫽ 1) cirrhosis (n ⫽ 1), renal insufficiency (n ⫽ 5), diabetes (n ⫽ 2). Primary ARDS existed in 10 patients: Pneumonia (n ⫽ 6), aspiration (n ⫽ 3), thermal injury (n ⫽ 1) while secondary ARDS existed in the remaining 5: sepsis (n ⫽ 2), pancreatitis (n ⫽ 1), post-operative (n ⫽ 1).Available microbiological data (Blood, tracheal aspirate or BAL) revealed Gram positive organisms (3), Gram negative organisms ( 2), Influenza A (2) and Candida (1). Improvement in oxygenation and CO2 elimination was observed after initiation of VDR within 6 hours (range 1– 6 hours). The mean PaO2/FIO2 pre-VDR was 77 vs. mean post-VDR PaO2/FiO2 of 100. The pre- VDR CO2 was 47 mm Hg vs. postVDR PaCO2 of 38 mm Hg. 24 hours after initiation of VDR ventilation the mean PaO2/FiO2 was 105 and mean PaCO2 was 40 mm Hg.This data was not available for 5 patients who were terminally extubated. 5 of the 14 patients survived to discharge. Airway pressures were similar on both modalities. Conclusions: VDR demonstrated immediate and sustained improvement in oxygenation and ventilation in our patients who remained hypoxic despite maximal support with servo i ventilation. Limitations: Our study was uncontrolled and retrospective. Fluid balance and other modalities such as Nitric Oxide were not considered.

828 VASOPRESSIN IN SEPTIC SHOCK: EARLY VERSUS LATE ADMINISTRATION Danielle Holowecky, Lisa Hall Zimmerman, Detroit Receiving Hospital, Tahuanty Pena, Wayne State University School of Medicine, Linda Browning, Detroit Receiving Hospital Introduction: Septic shock has mortality rates as high as 80%. Vasopressin (VP) is often used as a second-line vasopressor in septic shock as a relative VP deficiency has been described during the first 24 to 36 hours (hrs) of onset of septic shock. Hence, the timing of VP administration is crucial. Hypothesis: To assess whether VP before or after 24 hours of onset of septic shock effects the resolution of shock. Methods: This retrospective study evaluated 35 critically ill patients from 3/10 to 6/11. Patients were included if they were in septic shock and received VP for at least 6 hours. Septic shock was defined as hypotension (systolic blood pressure⬍90 mmHg) secondary to sepsis refractory to fluid resuscitation in addition to signs of organ hypoperfusion. Groups were defined as the Early (E) group (VP administered ⬍24 hrs from onset of sepsis) and the Late group (L) (VP ⱖ24 hrs after onset of sepsis). p-value ⬍0.05 was considered significant. Results: Of the 35 patients (16 E vs19 L), mean age was 57⫾15 years, 51% were male, 71% patients were bacteremic. The overall score for APACHE II was 29⫾10, and SOFA was 10⫾5. Steroids were more likely utilized in the E vs L, [62% vs 31%, p ⫽ 0.08]. In patients surviving ⬎48 hours, sepsis onset to last vasopressor being discontinued was faster with E vs L, [2.1⫾1.2 vs 4.3⫾2.5 days, p ⫽ 0.03]. The magnitude of change in SBP tended to be greater with E vs L, [27⫾22 vs 17⫾12 mmHg, p ⫽ 0.15]. The resolution of shock (4 consecutive SBP measurements ⬎90 mmHg) tended to be higher with E vs L, [31% vs 10%, p ⫽ 0.12]. Mortality was associated with the following characteristics: gram negative infection (p ⫽ 0.03) and arterial pH ⱕ7.20 at VP initiation (p ⫽ 0.10). Overall mortality was not different between E vs L, [75% vs 57%, p ⫽ 0.47]. In addition, mortality was not affected if the patient was on 1 vs ⱖ2 vasopressors at the time vasopressin was initiated, [68% vs 100%, p ⫽ 0.27]. Conclusions: Early administration of VP in the setting of septic shock resulted in a faster time from sepsis onset to vasopressor discontinuation, a higher magnitude of SBP change and higher rates of shock resolution. More studies are needed to address the relationship between the timing of VP and the onset of sepsis.


Posters: Therapeutics-Sedation-1 829

830

INFLUENCE OF PATIENT-DIRECTED MUSIC ON PATTERNS OF SEDATIVE THERAPY IN MECHANICALLY VENTILATED PATIENTS

COMPARING DAY AND NIGHT UTILIZATION OF SEDATION FOR MECHANICALLY VENTILATED CHILDREN IN A PEDIATRIC INTENSIVE CARE UNIT

Nesreen Mughrabi-Jenad, Debra Skaar, University of Minnesota College of Pharmacy, Linda Chlan, Kay Savik, University of Minnesota School of Nursing, Mary Fran Tracy, University of Minnesota Medical Center, Fairview, Craig Weinert, University of Minnesota School of Medicine

Mihaela Damian, Jason Arimura, Lucile Packard Children’s Hospital, Camelia Sima, Memorial Sloan-Kettering Cancer Center, Madelyn Kahana, Stanford -Lucile Packard Children’s Hospital

Introduction: Sedation and analgesia in mechanically ventilated patients are associated with adverse effects. Music is a non-pharmacologic therapy that may affect sedative exposure. Hypothesis: We hypothesized that patients who use adjunctive music intervention will require different patterns of sedative and analgesic therapy than patients who receive noise-canceling headphones or usual ICU nursing care. Methods: Patients requiring acute mechanical ventilation for a primary pulmonary cause from 12 ICUs were randomized to: patient-directed music (PDM), noise-canceling headphones (HP) only (control 1), or usual care (UC, control 2). Patients in the PDM group listened to self-selected music (tailored to patient preference by a music therapist) for a minimum of 30 minutes twice daily. We examined patterns of drug administration for 8 sedative/opioid medications using mixed models logistic regression. Results: Patients (N ⫽ 373, 86% Caucasian; 52% female; age 59 ⫹/⫺14, APACHE III 64 ⫹/⫺22) mean time on protocol was 5.7 ⫹/⫺6.4 days and the PDM group listened to music a mean of 79 minutes/day. Frequency of opioid use decreased over time in all groups; the PDM group was less likely to receive analgesics than the HP or UC groups [OR (95% CI): .75 (.58, .96); p ⫽ .007] and [.77 (.60, .98); p ⫽ .01] respectively. PDM patients were less likely to receive midazolam than the HP or UC groups [OR (95% CI): .64(.44, .91); p ⫽ .004 for HP and .61 (.42, .86); p ⫽ .001 for UC] but more likely to receive lorazepam than the HP group [1.3 (.98, 1.7); p ⫽ .03] as well as a trend toward using more lorazepam than the UC group [OR 1.2 (.93, 1.6)]. PDM patients were less likely to receive haloperidol than the UC group [OR .65 (.46, .91); p ⫽ .003]; there was no difference between the PDM and and HP groups [OR .77 (.54, 1.1)]. Conclusions: PDM is associated with a shift from short- to longer acting benzodiazepine therapy. PDM reduces the frequency of analgesic and neuroleptic drug use. Because music therapy has no adverse effects and reduces the need for medications commonly administered to patients with anxiety, pain and delirium, ICUs should consider implementing a music therapy program for mechanically ventilated patients. Supported by grant R01-NR009295.


Introduction: Children admitted to the pediatric intensive care unit require sedation to facilitate mechanical ventilation. Hypothesis: Significantly higher doses of sedatives and analgesics are administered during night shift versus day shift. Methods: This is a retrospective descriptive study of critically ill children requiring mechanical ventilation and continuous sedation for ⬎24 hours and ⬍30 days. The total quantity of sedatives administered was calculated for the day shift (7 AM to 7 PM) and for the night shift (7 PM to 7 AM). All opioids and benzodiazepines were converted to IV morphine and IV midazolam equivalents. The total quantity of sedatives and analgesics included continuous infusions and “as needed” (PRN) doses. The number of PRN doses was also quantified. To minimize any bias due to development of tolerance and dependence, sedation was evaluated for the following time periods: 0 –30 days, 0 –5 days, 6 –10 days, and 11–30 days. Results: 84 children admitted May 1st-December 31st, 2010 were included in the study. 920 day and night shifts were analyzed. 84 children received sedation for at least 0 –5 days, 71 children for at least 6 –10 days, and 48 children for 11–30 days. During the night shift, the total amount of opioid and benzodiazepine equivalents administered was significantly higher for the total time of intubation and for the first 5 days of sedation (mg, not adjusting for weight); Opioids: Days 0 –30: 38.2⫾109.1 (AM) vs 45.8⫾139.72 (PM), p⬍0.01; Days 0 –5: 17.6⫾38.2 (AM) vs 23.5⫾46.4 (PM), p⬍0.01; Benzodiazepines: Days 0 –30: 104.1⫾190.8 (AM) vs 112.7⫾197.7 (PM), p⬍0.001; Days 0 –5: 50.4⫾87.4 mg (AM) vs 61.1⫾92.2 mg (PM), p⬍0.001. The total number of PRN doses of opioids given during the night was significantly higher for all of the time intervals: Opioids (mean count): Days 0 –30: 7.29 (AM) vs 13.70 (PM), p⬍0.00001; Days 0 –5: 9.42 (AM) vs 14.25 (PM), p⬍0.000001; Days 6 –10: 6.26 (AM) vs 14.51 (PM), p⬍0.0000000001; Days 11–30: 8.44 (AM) vs 12.7 (PM), p⬍0.00001. Sign rank test was used for analysis. Conclusions: Children requiring continuous sedation for mechanical ventilation receive more sedation during the night. A prospective study is needed to address the issues that contribute to this discrepancy.

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THE IMPACT OF OBESITY ON SEDATION-RELATED PRACTICE AND OUTCOMES–RESULTS FROM THE PEDIATRIC SEDATION RESEARCH CONSORTIUM (PSRC)

LONG TERM DEXMEDETOMIDINE USE AND ITS SAFETY PROFILE IN THE PICU: A SYSTEMATIC REVIEW

John Berkenbosch, University of Louisville/Kosair Children’s Hospital, Michael Mallory, Children’s Healthcare Of Atlanta at Scottish Rite Hospital, Joseph Cravero, Dartmouth Hitchcock Medical Center, Lia Lowrie, St Louis University, James Hertzog, A.I. DuPont Hospital for Children, Mark Buckmaster, University Of Alabama Birmingham, Anne Stormorken, Rainbow Babies & Children’s Hosp., Avind Rampersad, Rainbow Babies and Childrens Hospital, Patricia Scherrer, Children’s Hospitals and Clinics of Minnesota Introduction: Obesity is an increasing problem in North America. Obese patients undergoing general anesthesia are at higher risk for adverse events, especially respiratory. The impact of obesity during pediatric procedural sedation has not been evaluated. Hypothesis: That obese patients would experience more sedation-related adverse events and require more respiratory interventions. Methods: The PSRC is a multidisciplinary group of Institutions dedicated to evaluating pediatric sedation practices and outcomes. The PSRC database was queried to identify patients for whom BMI could be calculated. Obesity was defined as BMI ⱖ95 percentile for age. Sedationrelated outcomes, adverse events, and required interventions were compared between obese and non-obese patients. A p value ⬍0.05 was significant. Results: 28792 records were analyzed. 5153 patients (17.9%) were obese. Obese patients were more often male, slightly older, and had higher ASA scores (p⬍0.0001). Obese patients were more often sedated for Hem Onc and surgical/invasive procedures but less frequently for Radiology and GI procedures (p⬍0.0001 for all). Adverse events overall were more common in obese patients (6.1 vs 4.1%, p⬍0.001). Obese patients specifically experienced more respiratory events (airway obstruction-2.1 vs 1.1%, oxygen desaturation-1.3 vs 0.7%, and laryngospasm 0.4 vs 0.2%; p⬍0.005 for all), prolonged sedation/recovery events (0.35 vs 0.13%; p⬍0.05), and sedation failures (0.39 vs 0.2%, p⬍0.05). In multivariate logistic regression analysis, obesity was independently associated with minor (OR 1.28; 95% CI 1.15–1.54) and moderate (OR 1.83; 95% CI 1.51–2.21) but not major adverse events. Obese patients also required more airway interventions including repositioning (40.5 vs 34.3%), jaw thrust (22.1 vs 17.0%), suctioning (16.3 vs 13.2%), oral/NP airway placement (15.8 vs 12.1%), and BVM ventilation (4.2 vs 3.4%; p⬍0.01 for all). Conclusions: Obesity has significant impact on pediatric procedural sedation. Obese patients are at increased risk for adverse events, especially respiratory events, and require more airway interventions than non-obese patients. While few major events occurred, additional vigilance is required when sedating these patients.

Lesta Whalen, Gretchen Irby, Ofer Yanay, Jerry Zimmerman, Seattle Children’s Hospital and Medical Center Introduction: Sedation in the pediatric ICU is vital for patient comfort and to facilitate care delivery. Dexmedetomidine (DEX) has been studied for short term procedural sedation, however DEX use for long term sedation in children is reported, despite lack of data. This study evaluates the safety and efficacy of long term DEX use in the PICU. Hypothesis: In children, DEX infusions longer than 72h decreases the use of opioid and benzodiazepine medication and is not associated with increased risk of hemodynamic changes or withdrawal symptoms when compared to use of less than 24h. Methods: Single institution chart review of children ages 0 –21yr who received DEX infusion for ⱖ72h. Bedside charts were extracted for blood pressure, heart rate, comfort scores and benzodiazepine and opioid dosing. Baseline values for patients before DEX initiation were compared with changes utilizing a paired t-test. Results: Among 48 patients who received DEX for ⱖ72 h, 33 met study criteria. In those patients, systolic (SBP) and diastolic (DBP) blood pressure changes at 0.5, 1, 2 and 72h post initiation as well as 1, 2 and 4 h post discontinuation were not statistically significant. SBP at 0.5h after stopping was significantly increased (8.3 mmhg p0.02). Heart rate decreased at 1 and 72h after start of DEX (6bpm p0.04, 24bpm p0.0001). At 4h post discontinuation heart rate increased (7bpm p0.05). Benzodiazepine dose decreased on day of DEX initiation and the next 24h (0.2 mg/kg/d p0.02, 0.14 mg/kg/d p0.02). Opioid use decreased significantly at both 24h after starting and 24h after stopping DEX (1 mg/kg/d p0.03, 0.5 mg/kg/d p0.03). Comfort scores improved 0.5h after starting DEX (0.6 p0.04), but had no significant change after discontinuation. Conclusions: These data suggest that the hemodynamic effects of DEX should not limit long term use, although rebound hypertension and tachycardia may be a factor after discontinuation. We found evidence that DEX infusion can decrease opioid and benzodiazepine burden for patients. With improved comfort score, a role for Dex in augmenting sedation is suggested. Continued work is directed at further chart review to increase patient numbers, at DEX effects on vasoactive medications, and at withdrawal symptoms.

833 SAFETY OF PROPOFOL SEDATION IN CHILDREN WITH KNOWN FOOD ALLERGIES Richard Lambert, Frank Maffei, Heather Wadams, Janet Weis Children’s Hospital at Geisinger, John Boker, Geisinger Medical Center, Allison Freeman, Janet Weis Children’s Hospital at Geisinger Introduction: To describe our institutions experience with propofol related allergic reactions in children with known food allergies. Hypothesis: We hypothesize that the use of intravenous propofol for sedation in children with known food allergies is not associated with an increased risk of allergic reaction including anaphylaxis. Methods: We reviewed the electronic medical record of all children aged 0 –17 years with a personal history of life threatening allergic reaction to egg, soy or peanuts or a positive skin prick test or blood allergy test to these foods. Of these children, we further identified those who underwent procedural sedation from 1/1/06 –12/31/09. A life threatening allergic reaction was defined as a reaction to food causing anaphylaxis in the last three years, a ⫹3 or higher skin test response to the food allergen, or an age based (IgE) level of ⬎95% likelihood of reaction to the food. Data were collected on demographics, procedure performed, medications used, adverse events, rescue therapies, primary illness and any existing allergy related diagnoses. Results: There were 94 children with document food allergies. Eight of these were excluded for incomplete data. A majority of children 59/86 (68.6%) received propofol for procedural deep sedation. Of these children, 11/59 (18.6%) had either a personal history of anaphylactic reaction to egg, soy or peanut or had an IgE or RAST level correlating with high risk for anaphylaxis. The remaining 48 children had history or laboratory testing consistent with non-anaphylactic food allergy. There were no reported cases of anaphylactic or allergic reaction during exposure to propofol in either the anaphylactic or non-anaphylactic risk group. Non allergic adverse events occurred in 4/86 (4.7%) of the total study population. Conclusions: We found no cases of allergic reaction to propofol in children with known food allergies, including those at risk for anaphylaxis. We believe this to be the first study in children to report no incidence of allergic reaction or anaphylaxis in a previously recognized high risk population. The avoidance of propofol in this patient population may not be warranted.


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METHADONE/LORAZEPAM WEANING PROTOCOL REDUCES SEDATIVE/ANALGESIA WITHDRAWAL SYMPTOMS IN PEDIATRIC ICU PATIENTS

DELIRIUM EDUCATION IN A SURGICAL INTENSIVE CARE UNIT DECREASES THE USE OF SEDATION IN CRITICALLY ILL PATIENTS

Sangita Basnet, Shakila Mathew, David Willman, Jennifer Andoh, Southern Illinois University School of Medicine

Christopher LaFond, Amanda Yang, Stefan Leichtle, Wendy Nieman, MaryMargaret Brandt, Joseph Bander, Harry Anderson, Patricia Posa, Mary-Anne Purtill, St. Joseph Mercy Health System-Ann Arbor

Introduction: Abrupt cessation of sedation medications including opiates and benzodiazepines can cause withdrawal syndrome in children. Hypothesis: Standardized opiate/bezodiazepine weaning protocol using enteral methadone and lorazepam prevents withdrawal in PICU patients. Methods: In November 2009, a systematic 7 day sedation weaning protocol was prepared and implemented based on calculations of total doses of opiates and midazolam used. A retrospective chart review of children admitted to the PICU from October 2008 to October 2010 was done. Inclusion criteria included patients on ventilator and sedation for 5 or more days. Patients with extensive head trauma or requiring narcotic medications post extubation for pain were excluded. Statistical analysis was done to compare pre-protocol and post-protocol groups by Independent-Sample t test (SPSS 19.0). Results: Thirteen patients in each group met criteria. Both groups were similar in age, sex, weight, mechanical ventilation and sedation days, opiate and benzodiazepine cumulative doses, and additional sedative medication use (ketamine, chloral hydrate, pentobarbital, demetomidine). Six patients (46.2%) in the pre protocol group had withdrawal symptoms including tremor, irritability, hallucinations, diarrhea, vomiting while none in the post protocol group did (p⬍0.01). Although days on methadone (mean 8.08 ⫾ 2.72 vs. 4.29 ⫾ 4.76 days, p ⫽ 0.02) and lorazepam (mean 7.77 ⫾ 2.86 vs. 1.07 ⫾ 2.70 days, p⬍0.01) were significantly greater in the post protocol group, the hospital length of stay was similar (p ⫽ 0.94). Mean dose of methadone used was actually less in the post protocol group (1.11 ⫾ 0.43 vs. 1.88 ⫾ 2.16 mg/kg, p⬍0.01) while mean dose of lorazepam use was greater (2.82 ⫾ 1.96 vs 0.11 ⫾ 0.29 mg/kg, p⬍0.01). Both groups had similar requirement for speech therapy, nasogastric tube feeds, and occupational and physical therapy (p ⬎0.1). Conclusions: Sedation weaning protocol using enteral methadone and lorazepam optimized care in children recieving prolonged sedation in the PICU. It decreased withdrawal symptoms without affecting hospital length of stay or time to return to baseline preadmission status as compared to children not on the protocol.

Introduction: The objective of this study was to investigate the impact of a delirium prevention program on the use of continuous intravenous sedatives and analgesics in a surgical intensive care unit (SICU). Hypothesis: A delirium prevention program will lead to a decrease in continuous, intravenous sedation (measured as average sedative days, SAD) without an increase in self-extubation or inadvertent line removal. Methods: Review of a prospectively collected database including all patients hospitalized in the SICU who were mechanically ventilated and had at least one continuous infusion of a sedative for the year before (Y0) and after (Y1) implementation of a delirium prevention program. Results: One hundred eighty-four patients with a mean APACHE III score of 64 were recorded in the database in Y0, and two hundred fourteen patients with a mean APACHE III score of 65 were recorded in Y1. The number of SAD decreased from 3.2 to 2.6 following implementation of the program (p⬍.05). The reduction of average days on propofol was significant (Y0: 2.8 days, Y1: 2.0 days; p⬍.01). There was no significant difference between Y0 and Y1 in regards to the risk of inadvertent line removal (4% versus 3%, P ⬎ .05) or self-extubation (3% versus 6%, P ⬎ .05). Patients did not require an increased amount of analgesic infusions (mean number of days on continuous IV analgesics, Y0: 4.8, Y1: 4.0, P ⬎ .05). There was no statistically significant difference between Y0 and Y1 in days of mechanical ventilation, length of stay in the SICU, and hospital length of stay (P ⬎ .05). Mortality was 14% (26/184 patients) in Y0, and 15% (33/214 patients) in Y1 (P ⬎ .05). Conclusions: An ongoing delirium prevention program in a SICU significantly reduced the use of continuously infused sedatives. This reduction did not increase the number of adverse events. The program did not change the use of analgesic infusions, days of mechanical ventilation per patient, length of stay in the SICU, hospital length of stay, or mortality.

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A COMPARISON OF SEDATION AND NEUROMUSCULAR BLOCKADE REQUIREMENTS BETWEEN HIGH FREQUENCY OSCILLATORY VENTILATION AND CONVENTIONAL MECHANICAL VENTILATION

ETOMIDATE DOSING VARIABILITY BASED ON WEIGHT FOR RAPID SEQUENCE INTUBATION IN THE EMERGENCY DEPARTMENT

Lindsay Pell Ryder, The Ohio State University Medical Center, Roy Brower, Johns Hopkins Hospital, Bruce Doepker, Anthony Gerlach, Kari Mount, Claire Murphy, Jennifer Severing, James O’Brien, The Ohio State University Medical Center Introduction: High Frequency Oscillatory Ventilation (HFOV) is an alternative mode of mechanical ventilation in patients with Acute Respiratory Distress Syndrome (ARDS). However, patients on HFOV may require more sedation and neuromuscular blockade (NMB). Hypothesis: HFOV patients receive more sedation and NMB than those on conventional ventilation (CV). Methods: A retrospective cohort study was performed in the medical intensive care unit of patients with ARDS between August 2007 and May 2009. The data collection period was the first 48 hours of HFOV or CV after diagnosis of ARDS. We compared sedation and NMB requirements between the groups, time on continuous infusion (CI) NMB, and RASS scores while not receiving CI NMB. Intermittent and CI doses of benzodiazepines (BZD) and opioids were converted to midazolam equivalents (ME) and fentanyl equivalents (FE) respectively. Categorical data were evaluated using Chi-square test and continuous variables were analyzed using the Students t-test for normally distributed and Mann-Whitney U test for non-normally distributed variables. Results: 75 patients were reviewed, 42 HFOV and 33 CV. The groups had similar baseline demographics. For both groups, the median amount of time spent on continuous sedation or analgesia was 100%. For the first 24 hours of data collection, median total BZD dose per hour was 3.8 mg ME (HFOV) vs. 2.3 mg ME (CV) (p ⫽ 0.045) and median total opioid dose per hour was 43.1 mcg FE (HFOV) vs. 31.1 mcg FE (CV) (p ⫽ 0.026). The same data for the time period from 24 – 48 hours was BZD: 4.0 mg ME (HFOV) vs. 1.1 mg ME (CV) (p ⫽ 0.040) and opioid: 63.1 mcg FE (HFOV) vs. 22.8 mcg FE (CV) (p ⫽ 0.020). The median percentage of RASS scores that were -4 or -5 (deep sedation) was 66% (HFOV) and 20% (CV) (p ⫽ 0.018). 7.1% of HFOV patients and 9.1% of CV patients received CI NMB at any time during the data collection period (p ⫽ 1.000). Conclusions: HFOV patients received significantly higher doses of BZD and opioids and achieved deeper sedation than those on CV, but there was no difference in CI NMB use between the groups.


Brittany Traylor, Asad Patanwala, John Sakles, Brian Erstad, University of Arizona Introduction: Etomidate is one of the most commonly used sedatives for rapid sequence intubation (RSI) in the emergency department (ED). The recommended dose required for induction of sedation prior to intubation is 0.3 mg/kg. Although there may be some inter-patient variability, patients given less than 0.2 mg/kg would fall outside the recommended dosage range and would be at risk for inadequate sedation for this invasive procedure. Hypothesis: We hypothesize that patients who weigh ⱖ100 kg are more likely to receive sub-therapeutic doses of etomidate compared to those who weigh ⬍100 kg for RSI in the ED. Methods: This was a retrospective cohort study conducted in an academic ED in the United States. Consecutive adult patients who received etomidate for rapid sequence intubation during a 2-year time frame were evaluated. Patients were categorized a priori into two groups based on weight: 1) ⬍100 kg or 2) ⱖ100 kg. The mean dose of etomidate (mg/kg) was compared between the groups using an unpaired Student’s t-test. The percentage of patients who received at least 0.2 mg/kg in each group was compared using a chi-square test. Results: A total of 200 patients were included in the final analyses (100 patients in the ⬍100 kg group and 100 patients in the ⱖ100 kg group). All patients were successfully intubated, without the requirement for a surgical airway. There were no baseline differences in age, sex or type of paralytic used between the treatment groups. There was a significant difference in the mean etomidate dose given to patients in the ⬍100 kg and ⱖ100 kg groups, 0.28 mg/kg versus 0.18 mg/kg, respectively (p⬍0.001). Only 2% of patients in the ⬍100 kg group received less than 0.2 mg/kg of etomidate compared to 68% in the ⱖ100kg group (p⬍0.001). Conclusions: Patients who weigh ⱖ100 kg are more likely to receive less than recommended doses of etomidate for RSI in the ED. These patients may be at risk for being awake while being paralyzed during the procedure.

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EVALUATION OF A NURSE IMPLEMENTED SEDATION AND ANALGESIA PROTOCOL IN MECHANICALLY VENTILATED CRITICALLY ILL PATIENTS AT A COMMUNITY HOSPITAL

SLEEP QUALITY SEDATED WITH DEXMEDETOMIDINE DURING MECHANICAL VENTILATION

Richard Woerndle, Southeastern Regional Medical Center Introduction: A nurse implemented sedation and analgesia protocol for mechanically ventilated critically ill patients was developed and used in our 12 bed medical/surgical ICU. This study evaluates the protocol for safety, efficacy and nursing satisfaction. Hypothesis: The protocol is safe and effective. Methods: From June 2009 to June 2010 mechanically ventilated patients received protocolized or standard care sedation and analgesia, at the discretion of the admitting physician. All patients were evaluated for parameters of safety. After predetermined exclusion criteria designed to isolate a protocol effect, a subgroup analysis evaluated length of mechanical ventilation (LOMV), ICU length of stay (ICULOS), and dosage of sedatives and analgesics administered. An anonymous survey to elicit nursing staff perceptions was conducted after one year. Results: 365 consecutive patients were enrolled, 116 or 32% received the protocol, 240 or 68% received standard care. There was not a significant difference in incidence of unexpected tracheotomy, unplanned extubation, extubation failure, or ventilator associated pneumonia. Incidence of pressure ulcer development in the protocol group was higher, 10 or 8% vs. 5 or 2% in the standard care group, P ⫽ 0.0008. In subgroup analysis, 34 protocol and 39 standard care patients remained after exclusion criteria. There was no significant difference in LOMV or ICULOS measured in hours. Protocol LOMV 149⫾86.4; 95% CI 123.7 to 173.9 vs. 118⫾68.6; 95% CI 91.0 to 144.8 in the standard care group, P ⫽ 0.098. ICULOS in the protocol group 181⫾90.0; 95% CI 149.9 to 221.2 vs. 165⫾103; 95% CI 131.5 to 198.3 in the standard care group, P ⫽ 0.48. Dosages of benzodiazepine and fentanyl were 3 and 5.5 times higher respectively in the protocol group with a 6 fold increase in use of a continuous infusion. Profofol dosage was similar. The nursing survey indicated uniform satisfaction. Conclusions: Use of a nurse implemented sedation and analgesia protocol was safe, effective and associated with a high degree of nursing satisfaction. Higher doses of sedatives and analgesics were used in the protocol group without a significant difference in length of mechanical ventilation or ICU length of stay.

Jun Oto, Hideaki Imanaka, University of Tokushima Graduate School, Mutsuo Onodera, University of Tokushima Graduate School, Masaji Nishimura, University of Tokushima Graduate School Introduction: Dexmedetomidine (DEX) is considered to activate natural nonrapid eye movement (NREM) sleep-promoting pathway in healthy human beings. However, there has been few data of sleep characteristics during DEX infusion in mechanically ventilated (MV) patients. Hypothesis: DEX induces restorative sleep; NREM stage 3, 4 (slow wave sleep; SWS) or sleep continuity in MV patients. Methods: We recorded polysomnography (PSG) for 24 hours in MV patients sedated with DEX. We administered DEX (0.2– 0.7 mcg/kg/hr) intravenously to maintain the Richmond Agitation-Sedation Scale between -1- -4 only during nighttime (PM 9:00 to AM 6:00). Opioid was administered when patients expressed pain as needed. In the daytime, we interrupted the sedatives and analgesics until the patients awoke and expressed discomfort. When patients expressed discomfort, midazolam or opioids was administered intermittently. Sleep stages and the frequency of arousals during nighttime were analyzed with Rechtschaffen and Kales criteria. Results: Ten adult MV patients were recruited in the study. Median total sleep time (TST) during nighttime was 4.7 hrs (IQR; 4.2– 8.1 hrs). The sleep architecture consisted of NREM sleep stage 1 (median 28.9 % of TST), stage 2 (median 71.2 % of TST). Neither SWS (median 0 % of TST) nor REM sleep (median 0 % of TST) were observed. Median frequency of arousal was 9.3/hrs (IQR; 3–19.5/hrs). Conclusions: In MV patients, DEX induced neither restorative SWS nor REM.


Posters: Therapeutics-Sedation-2 840 VOLATILE-BASED SADATION. WHERE IS THE BENEFIT? Marcin Wasowicz, Angela Jerath, George Djaiani, Vivek Sharma, Toronto General Hospital, Warren Luksun, University of Toronto, Rita Katznelson, Jacek Karski, Toronto General Hospital Introduction: No intravenous agent possesses the features of an ideal medication used for ICU sedation; side effects are considerable. Theoretically, volatile anesthetics offer better sedation profile: precise control over their action, rapid emerge, minimal accumulation. Until recently their use in ICU was not practical due to technical requirements. Introduction of anesthetic conserving device (Anaconda, Sedana Med., Sweden) allows use of volatile-based sedation in any ICU setting. Our recent study showed that use of volatile based sedation (VS) is safe and feasible when used for surgical patients (SCCM 2011 Abs. 908). Hypothesis: Volatile sedation results in better outcomes when compared to intravenous sedation protocol using propofol. Methods: Study protocol was designed as a randomized, prospective, evaluator blinded study and approved by REB. 139 patients scheduled for elective CABG were randomized to receive VS or propofolbased sedation (PS). VS was provided with use of Anaconda device. Perioperative procedures were standardized. Primary outcomes: length of mechanical ventilation and ICU stay, hemodynamic profile. Secondary outcomes: degree of myocardial injury (Troponin leak) use of inotropic support and incidence of arrhythmias. Continuous variables were described by median and interquartile range values and 2 groups were compared with the use of Wilcoxon non-parametric test. Categorical variables were described with frequencies and percentages, while the two groups were compared using Fisher’s Exact test. Results: 70 patients received VS and 69 PS. Patient characteristics were similar for 2 groups. VS resulted in shorter readiness/extubation time when compared to PS group (138 vs209 min/185 vs. 291 min, p⬍0.001). Both groups have similar readiness/ discharge time from ICU. Use of inotropic support was similar in 2 groups, however hemodynamic profile was better in VS.Troponin leak and incidence of arrhythmias were similar in both groups. Conclusions: VS offers better sedation profile when compared to short-acting intravenous agent propofol. Based on these findings analyzing short term VS we suggest that potential of this novel sedation technique should be explored in patients requiring prolonged ICU stay.

841 EFFECT OF PARALYTIC TYPE ON TIME TO POST-INTUBATION SEDATIVE USE IN THE EMERGENCY DEPARTMENT John Watt, Albert Amini, Brittany Traylor, Richard Amini, John Sakles, Asad Patanwala, University of Arizona Introduction: The most common paralytic agents used for rapid sequence intubation in the emergency department (ED) are succinylcholine and rocuronium. Patients require continued sedation after intubation in order to tolerate mechanical ventilation. Since rocuronium has a longer duration of effect compared to succinylcholine, level of sedation is difficult to assess for a longer duration after administration of rocuronium. This could lead to delays in post-intubation sedative use and put patients at risk for paralysis without sedation. Hypothesis: We hypothesize that patients intubated with rocuronium will have greater delays in initiation of post-intubation sedation compared to those patients intubated with succinylcholine. Methods: This was a retrospective cohort study conducted in a tertiary care ED. Consecutive adult patients intubated in the ED between August 2007 to October 2008, using succinylcholine or rocuronium for paralysis in combination with etomidate for induction of sedation were included. Data collected included patient demographics, vital signs, medications used post-intubation, and times of drug administration. Time between intubation and postintubation sedative use was compared between the two groups using a student’s t-test. Results: A total of 200 patients were included in the final analyses (100 patients in each group). There were no significant differences between the groups with regard to patient demographics, vital signs, or other baseline characteristics. After intubation, 77.5% (n ⫽ 155) of patients were initiated on a sedative infusion of propofol (n ⫽ 148) or midazolam (n ⫽ 7). The remaining patients received sedation as bolus doses only. Mean time between intubation and postintubation sedative use was significantly greater in the rocuronium group compared to the succinylcholine group (33 ⫾ 6 vs. 15 ⫾ 1 min, p ⫽ 0.008). Conclusions: Patients intubated with rocuronium have greater delays in postintubation sedative initiation compared to succinylcholine.

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EVALUATION OF THE SAFETY AND EFFICACY OF ANTISHIVERING THERAPY IN PATIENTS ON A THERAPEUTIC NORMOTHERMIA PROTOCOL

EVOLUTION OF CEREBRAL ATROPHY IN PATIENTS WITH PROLONGED STATUS EPILEPTICUS: THREE CASES

Megan Rech, Henry Ford Hospital Introduction: In neurologically injured patients, fever is associated with increased metabolic demand and oxygen consumption, inflammation and excitotoxic injury, and free radical damage. Neurosciences intensive care unit (NSICU) patients with acetaminophen-refractory fever are placed on a therapeutic normothermia (TN) protocol. Shivering increases energy and oxygen consumption and propagates a stress response that counteracts cooling. The objective of this study is to determine the efficacy and safety of dexmedetomidine (DEX) versus propofol (PROP) for anti-shivering therapy. Hypothesis: There is no difference in the percentage of patients that received meperidine for anti-shivering therapy between the DEX and PROP groups in patients on the TN protocol. Methods: This is a retrospective evaluation of patients on a TN protocol in a 25 bed NSICU. Patients received buspirone plus DEX or PROP for at least 12 hours. Patients were excluded if they were on more than one vasopressor, had broken or inflamed skin, or if sedation was changed more than once during the study duration. Efficacy was defined as the percentage of patients in each group that had persistence of shivering requiring the administration of meperidine. Safety endpoints included hypotension, bradycardia, or hypertriglyceridemia. Shivering was assessed using the Bedside Shivering Assessment Scale (BSAS). Results: Fortyone patients were enrolled (DEX n ⫽ 15, PROP n ⫽ 26; male ⫽ 60%; median age ⫽ 60; diagnosis: subarachnoid hemorrhage 47%, intracerebral hemorrhage 43%). There was no difference in meperidine use between the groups (47.6% DEX vs. 53.8% propofol, P ⫽ 0.196). There was no difference in adverse effects (13.3% DEX vs. 11.5% PROP, P⬎0.99). Patients in the DEX group had higher median incidence of agitation, defined as a Richmond Sedation Agitation Score (RASS) score of ⫹1 to ⫹4 (P ⫽ 0.036), while patients in the PROP group had higher median incidence of deep sedation, defined as a RASS score of -3 to -5 (P ⫽ 0.003). Conclusions: This study examined anti-shivering in patients on a TN protocol in the NSICU. DEX and PROP appear to have similar safety and efficacy when used for anti-shivering therapy. Further evaluation is necessary to explore these results.


Christopher Newey, Cleveland Clinic-Neurological Institute, Aarti Sarwal, Wake Forest, Joao Gomes, Cleveland Clinic-Neurological Institute Case Reports: Introduction: The progression of cerebral atrophy in patients with refractory status epilepticus is unclear. Cross-sectional studying of these patients is complicated by actual damage of the initial insult, nonlesional MRI, progression of underlying brain abnormalities independent of the status epilepticus, and difficulty to determine with MRI if the atrophy is a result of status epilepticus or another process such as critical illness or antiepileptic used to treat the status epilepticus. The purpose of this case series is to illustrate the utility of monitoring patients in prolonged status epilepticus with neuro-imaging to determine etiology but also complications such as cerebral atrophy. Methods: Case series. Results: Three patients –19 year-old male, 20 year-old female, and 22 year-old male–were admitted with refractory status epilepticus arising from the left hemisphere. Etiologies were viral encephalitis, NMDA-antibody encephalitis, and idiopathic. All were placed in pentobarbital coma (average 11.3 days after seizure onset) and maintained in burst suppression (mean duration 65.3 days). Initial MRI brain (performed on an average 6 days after seizure onset) did not show cerebral atrophy. Subsequent imaging (mean 84.2 days from seizure onset; range 11– 421 days) showed persistent generalized cerebral atrophy. At the time of image acquisition, all three patients were on 4 to 6 antiepilpetics. Mean osmolality during the hospital stay was 297 mosm/kg. Only one patient developed sepsis and acute respiratory distress syndrome (ARDs) during hospitalization. Discussion: This case series illustrates generalized cerebral atrophy associated with prolonged pentobarbital coma for medically refractory status epilepticus, and highlights the urgency of aggressive intervention in patients who present with status epilepticus. Future studies should determine if changes in brain volume are secondary to the primary insult, effect of pentobarbital, depth of burst suppression, and/or duration of burst suppression.

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THE IMPACT OF DEXMEDETOMIDINE USE ON DURATION OF MECHANICAL VENTILATION IN CRITICALLY ILL MEDICAL PATIENTS

MANAGEMENT OF ALCOHOL WITHDRAWAL SYNDROME (AWS) THAT COMPLICATES THE COURSE OF CRITICALLY ILL PATIENTS

Leena Kansagra, Quinn Czosnowski, Craig Whitman, University of the Sciences, Jackie Sutton, Christa Schorr, Barry Milcarek, David Gerber, Cooper University Hospital

Andrew Berry, Christine Cocanour, Jeremiah Duby, University of California Davis Medical Center

Introduction: Large clinical trials suggest early initiation of dexmedetomidine is associated with decreased durations of mechanical ventilation (MV) compared to traditional sedation regimens in intensive care unit (ICU) patients. The purpose of this study was to assess the impact of dexmedetomidine on duration of MV compared to traditional ICU sedation regimens. Hypothesis: Dexmedetomidine does not decrease the duration of MV when use differs from available clinical trials. Methods: A retrospective chart review of patients admitted to the medical/ surgical ICU between August 1, 2006 to March 1, 2010. IRB approval was granted with a waiver of informed consent. Patients were included if they received sedation and were mechanically ventilated for ⬎24 hours. Sedation regimens contained either dexmedetomidine (D) or no dexmedetomidine (ND). The primary objective was duration of mechanical ventilation. Mann-whitney U test, pearson chi square, and independent t test were used as appropriate. Results: A total of 147 patients were included in the analysis: 73 D and 74 ND. Patients in the D group had significantly more pulmonary disease and substance abuse in their medical history. Other baseline characteristics were similar between groups. The mean (⫾SD) number of ICU days to initiation of dexmedetomidine was 6.3 (⫾ 5) days. A higher percentage of patients in the D group received fentanyl (75% vs 58%, p ⫽ 0.03) and antipsychotics (55% vs 22%, p⬍0.01). Midazolam use was similar between groups while more patients received propofol in the ND group (82% vs 33%, p⬍0.01). The D group had a longer median (IQR) duration of MV [7.4 days (3.5–14.2) vs 3.6 (1.9 – 6.0), p⬍0.01] hospital LOS [22 days (15–30) vs 11.5, (7–21.3), p⬍0.01], and mean (⫾SD) ICU LOS (12.9 ⫾ 9.4 days vs 6.7 ⫾ 4.8, p⬍0.01). Conclusions: Dexmedetomidine was started late in the ICU stay as an adjunct to other sedatives or to assist with weaning and extubation, which may not shorten duration of mechanical ventilation and ICU length of stay compared to traditional sedation regimens.

Introduction: Symptom-triggered dosing of benzodiazepines (BZP) using doseescalating strategies have shown promise in critically ill patients with AWS, but these principals are not consistently utilized. The purpose of this single-center, retrospective, observational study is to characterize the management of AWS that complicates the course of critically ill patients. Hypothesis: Treatment of AWS in the absence of a protocol leads to suboptimal sedation. Methods: Subjects were identified using the ICD-9 (291.81) code for AWS and concomitant use of BZP/thiamine/folic acid. Adults admitted to an ICU (02/2008 – 02/2010) were considered for inclusion; those with severe brain injury were excluded. Demographics, severity of illness, and history of AWS were documented. Total daily BZP requirement was recorded until the patient expired, was discharged from the ICU, or for a maximum of 28 days. All reported RASS scores during the ICU stay were recorded to track sedation levels and determine treatment adequacy. Results: Sixty separate encounters of AWS in 57 patients were analyzed. The mean age was 56⫾8.7 with 80% male. Mean SOFA score was 6.2⫾3.7. History of AWS was reported in 35% of cases. Median ICU length of stay was 6.4 (2.6, 11.9) days and median duration of sedation was 7.5 (4.4, 14.9) days. Overall, 58% of RASS scores were within the target goal of -2 to 0. In cases for which agitation was reported (n ⫽ 39, 65%), the median time from admission to onset of agitation was 1.6 (0.6, 4.4) days. Resolution of agitation occurred a median of 12.0 (4.0, 27.6) hours later. 53% were treated with continuous sedative infusion with a median duration of 3.0 (1.4, 5.2) days. Although BZP requirements were highest on ICU days 2– 4, a second spike in BZP use was noted on ICU day 9. 62% of cases required mechanical ventilation; the indication for intubation in 35% was AWS. Conclusions: Optimal sedation for treatment of AWS in critically ill patients was not consistently achieved. The the late spike of BZP use may signal a delayed complication of AWS or an adverse effect of therapy. A protocol featuring a rapid dose escalation of BZP that targets clearly defined RASS goals may improve control of sedation in this patient population.

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DEXMEDETOMIDINE ENABLES NOT ONLY OPTIMAL SEDATION BUT ALSO MINIMIZING LIFE-THREATENING MORBIDITIES IN INTENSIVE CARE MANAGEMENT AFTER PEDIATRIC CARDIOVASCULAR SURGERY

ASSESSMENT OF DAILY SEDATION INTERRUPTION PERCEPTIONS AND PRACTICES IN THE INTENSIVE CARE UNIT

Shintaro Nemoto, Tomoyasu Sasaki, Hideki Ozawa, Takahiro Katsumata, Maiko Asano, Yusuke Kusaka, Osamu Umegaki, Osaka Medical College Hospital Introduction: Dexmedetomidine (DEX) is a ␣2A-adrenergic agonist widely used as a unique postoperative sedative and known to blunt excess sympathetic stimuli caused by surgical stress in adult. Hypothesis: An open-label observational study was performed to assess the potential and benefits of scale-targeted sedation with DEX in combination with conventional sedatives after pediatric cardiovascular surgery. Methods: Intravenous administration of DEX was started at 0.4 – 0.7 ␮g/kg/hr in combination with midazolam (0.5–1.0 ␮g/kg/min) and fentanyl (5–10 ␮g/kg/hr) at admission to the ICU. With careful hemodynamic monitoring, the doses were adjusted to achieve an optimal sedation level based on scores on the State Behavioral Scale for infants and young children of -3 (unresponsive) to ⫹2 (agitated) (Pediatr Crit Care Med 2006; 7: 107–114). After successful weaning from ventilator support, the doses were gradually reduced and the drugs were discontinued before ICU discharge. Consecutive 312 children (212 open and 100 closed heart surgeries) without mechanical circulatory assist were enrolled in this study. Results: The age distribution was ⫽ 64), 1-⬍6 months (n ⫽ 78), 6-⬍12 months (n ⫽ 36), 1–3 years (n ⫽ 75), 4 – 6 years (n ⫽ 30) and ⬎7 years (n ⫽ 35). The optimal sedation (SBS score -1 to 0) was successfully achieved at a rate of 93.8⫾1.7% in the first 24 hours. Blood pressure did not change significantly. Heart rate decreased predictably but insignificantly, with a maximum change of -4.5%. Supraventricular tachyarrhythmia deteriorating hemodynamics occurred in only 2 cases (0.64%). Postoperative severe pulmonary hypertension crisis occurred in only 7 patients (2.2%) but was well managed by pulmonary vasodilators without a use of muscle relaxant and prolonged ventilator support. Respiration was well maintained in all patients with no significant changes in blood gas analysis throughout the clinical course. No abnormal findings in biological parameters occur relating to the combination sedation. Conclusions: Our results suggest that DEX-based combination therapy not only provides optimal sedation but also prevents and ameliorates life-threatening morbidities after pediatric cardiovascular surgery as seen in adults.

Christopher Adams, Brigham & Women’s Hospital, Paul Szumita, Heather Torbic, Lisa Rubino, Brigham and Women’s Hospital, Mary Antonelli, New England Baptist Hospital, Carol Pierce, Anthony Massaro, Brigham and Women’s Hospital Introduction: Daily sedation interruptions are incorporated in intensive care unit (ICU) ventilator bundles to reduce ventilator associated complications. We conducted a survey to evaluate the current practice and perceptions among the ICU fellows, attending and nurses. Hypothesis: To determine educational needs and barriers to performing daily interruptions in ICU patients on continuous sedation. Methods: A single center, web based survey was administered to 558 ICU nurses and 57 physicians (fellows and attendings) in 7 ICUs (medical, surgical, burn/trauma, thoracic, coronary, cardiac surgery, and neuroscience) in a tertiary, urban, academic medical center. From February 2011 to March 2011 all ICU nurses, fellows and attending physicians were emailed the survey and data was collected electronically. Results: Overall, 299 (53.6%) nurses (RN) and 43 (75.4%) physicians (MD) responded. An active discussion regarding sedation interruptions occur during rounds ⬎75% of the time by 61% RN and 71% MD respondents. If a patient is on a continuous sedative and is comfortable at a goal Richmond Agitation Sedation Scale of 0 to -1, 68% of MD respondents would most commonly perform a sedation interruption. When a sedation interruption was performed, 36% RN and 65% MD would restart the continuous sedation at half of the previous rate. Sedation interruptions were reported to increase workload in 75% RN respondents and had no effect on workload in 69% MD respondents. Fifty percent RN and 94% MD respondents felt the sedation interruption decreases the length of mechanical ventilation. Most reported safety concerns included rebound agitation (RN 68%, MD 25%), self extubation/removal of invasive catheters (RN 70%, MD 47%), and risk of pain and patient discomfort (RN 60%, MD 43%). Conclusions: Several educational needs and barriers to performing daily interruptions in ICU patients on continuous sedation were identified. These results support the need for targeted quality improvement projects to address these barriers.


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COMPARISON OF SEDATION AND ANALGESIA ACROSS THE DAY AND NIGHT SHIFTS IN THE MEDICAL INTENSIVE CARE UNIT

PERCEPTIONS AND PRACTICES OF ON-CALL MEDICAL HOUSESTAFF TO ICU NURSE CONCERNS PERTAINING TO PAIN, AGITATION AND DELIRIUM

Heather Bockheim, Jennifer Lunger, Michael Harrison, Wendy Thomas, Melissa VandenBerg, Spectrum Health

Jana Hoffmeister, Tufts Med Ctr, Nada Al-Qadheeb, Northeastern Univ, Russ Roberts, Erik Garpestad, Tufts Med Ctr, John Devlin, Northeastern Univ

Introduction: A perception exists that intensive care unit (ICU) patients are oversedated during the nighttime hours. Inappropriate titration of sedatives is of great concern due to the potential for poorer patient outcomes and increased costs to the healthcare system. Patients who do not undergo daily reassessment of sedative regimens are at risk for prolonged ICU length of stay and increased mortality. Drug accumulation and oversedation may also prevent successful weaning from mechanical ventilation. In addition, oversedation may impair neurologic assessment and lead to unnecessary diagnostic testing. Lastly, implementation of sedation protocols has been shown to decrease ventilator associated pneumonia. Unfortunately, limited studies have examined sedation practices across the day and night shifts. Hypothesis: Drug accumulation and oversedation can prolong duration of mechanical ventilation and ICU length of stay. Whether drug doses utilized for sedation and analgesia differ between the day and night shift in mechanically ventilated patients is unclear. Methods: One-hundred adult patients ventilated ⬎48 hours in the medical ICU between January-September 2009 who received intravenous propofol and/or benzodiazepines were retrospectively identified. The average dose of intravenous propofol, lorazepam equivalents, and/or fentanyl equivalents utilized was calculated for three time blocks of the day. Sedation scores and performance of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) were analyzed. Results: The average dose of propofol administered during the 2300 – 0659 time block was 36.9 (14.4 –97.9) mcg/kg/min, compared to 34.7 (0 –102.8) mcg/kg/min during the 1500 –2259 time block (p⬍0.01). There was no difference in drug utilization across time blocks for benzodiazepines or opioids. Sedation scores did not differ across time blocks. SATs were performed during 57% of assessments, and SBTs were performed during 39% of assessments. Conclusions: A significant difference was found in propofol utilization across the day and night shifts, however the clinical significance is uncertain. No difference was found in benzodiazepine or opioid dosing across the day and night shifts.

Introduction: Addressing ICU nurse (RN) concerns regarding pain, agitation and delirium (PAD) is an important responsibility of medical housestaff (MDH) when on-call (5pm-7am) in the ICU. Hypothesis: Perceptions and practices of MDH surrounding PAD-related interactions with the ICU RN when on-call in the ICU are unknown. Methods: A validated, self-administered, written survey was distributed to MDH (n ⫽ 75) who had completed ⱖ1 MICU rotation in the past year at a 330-bed academic center. Results: Of the 75 MDH surveyed, 56 (75%) responded. Most were year-2 (45%) or year-3 (44%) and had completed ⱖ3 prior ICU rotations (68%). When on-call (census 11⫾8 patients), the MDH perceived receiving 17⫾8 pages and 14⫾8 face-to-face concerns from a MICU RN each shift of which 30% and 31%, respectively, were related to PAD. Among PAD-related pages received, 58 ⫾18% were felt to accurately portray the situation. MDH prefer pages with a text phrase (100%) rather than an ICU phone # (0%) and 70% agreed (either strongly or moderately) that the RN uses good judgement when paging the MDH re: PAD issues. A high degree of MDH urgency (ⱖ4/5) existed for some text page phrases [i.e., “pt has RR of 22/decreasing SaO2”(98%), “pt self-extubated”(93%) and “pt unresponsive to painful stimuli”(92%)] but not for others [“pt agitated despite IVP sedation” (27%) or “pt has delirium”(14%)]. Of the total PAD-related pages/face-to-face concerns received from a RN during an average on-call shift, 52⫾21% represented a new RN recommendation of which 35⫾11% were accepted by the MDH. Among PAD recommendations made by the MDH to the RN, the RN was perceived to question 32⫾24%. MDH (41%) agreed (either moderately or strongly) that the RN sometimes makes PAD-related changes that the on-call MDH is not aware of. Conclusions: Realizing the limitations of an opinion-based survey, ICU RNs frequently communicate PAD-related issues to on-call MDHs that are sometimes perceived not to be urgent, not accurately portrayed and that contain a RN recommendation that may not be supported by the MDH. Future studies should investigate the impact of a better communicated PAD plan during RN and MDH hand-offs and the perception of the night RN surrounding these issues.

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ASSOCIATION BETWEEN USE OF SCHEDULED ANTIPSYCHOTIC THERAPY IN LONG TERM ACUTE CARE HOSPITAL (LTACH) PATIENTS AND RELATED OUTCOMES: A CASE-CONTROL STUDY

SAFETY AND EFFICACY OF VALPROIC ACID FOR TREATMENT OF DELIRIUM IN CRITICALLY ILL PATIENTS

Nada Al-Qadheeb, Aura Neidhardt, Mark Albizati, Northeastern Univ, Heidi O’Connor, Alexander White, Bernard Joseph, Rose Kalman Research Center, New England Sinai Hospital, Russ Roberts, Robin Ruthazer, Tufts Med Ctr, John Devlin, Northeastern Univ Introduction: While scheduled antipsychotic therapy (SAT) is frequently administered to mechanically ventilated patients in the LTACH setting, the association between SAT use and both SAT-related appropriateness and safety remains unclear. Hypothesis: Patients undergoing prolonged mechanical ventilation in the LTACH setting and receiving SAT, have more documented delirium symptoms, receive more agitation-related management strategies (e.g., anxiolytics, restraints) and experience more SAT-related adverse effects than those not receiving SAT. Methods: Pertinent data from the medical records of consecutive, mechanically ventilated patients admitted to a 200-bed, academic LTACH over a 1 year period, without a history of a major psychiatric disorder or severe dementia, were extracted by a trained reviewer and compared (all as a % of LTACH days) between patients administered ⱖ24hrs of SAT and those who were not. Results: Demographics and both LTACH stay duration and disposition were similar between SAT (31/80; 39%) and non-SAT (49/80; 61%) groups. The words confusion (P ⫽ 0.02) and agitation (P ⫽ 0.0002) were more likely to be documented in the patient record of the SAT group but delirium (P ⫽ 0.13), inattention (P ⫽ 0.17) or disorientation (P ⫽ 0.34) were not. A psychiatrist (P ⫽ 0.03) provided more evaluations to the SAT group. Use of an ‘as needed’ antipsychotic (P ⫽ 0.008) or anxiolytic (P ⫽ 0.016) was greater in the SAT group but restraint therapy (P ⫽ 0.33) was not. Days of enteral nutrition (P ⫽ 0.69), the weekly increase in the blood glucose (P ⫽ 0.78) and days of insulin therapy (P ⫽ 0.64) were similar between SAT and non-SAT groups. Neither the weekly change in the QTc interval (P ⫽ 0.79), the days where the SBP was ⱕ90 (P ⫽ 0.75) or a patient fell (P ⫽ 0.73) differed. LTAC days with ⱖ1 extrapyramidal symptom were greater in the SAT group (P ⫽ 0.06). Conclusions: Mechanically ventilated LTAC patients prescribed SAT are more likely to undergo a psychiatric examination, have the word confusion or agitation (but not other symptoms of delirium) documented in their record and receive anxiolytic and ‘as needed’ antipsychotic therapy. Future investigations need to evaluate the factors associated with SAT use in the LTACH setting.


Katherine Fitz, Angela Harding, Riverside Methodist Hospital of OhioHealth Introduction: While valproic acid (VPA) is prescribed for the treatment of delirium at our institution, little data exists regarding the efficacy of the drug for this indication. Hypothesis: This study evaluated the hypothesis that VPA may be used as an alternative for critically ill patients experiencing delirium. Methods: A single-center retrospective review compared VPA and olanzapine (OLZ) for time to resolution of delirium as defined by CAM-ICU assessments. Secondary outcomes included: delirium-free days as measured by CAM-ICU assessments; average daily dose of study medication; duration of study drug therapy; rationale for discontinuation of study drug; length of mechanical ventilation; overall length of stay; ICU length of stay; episodes of recurrent delirium; use of adjunctive antipsychotics; and safety. Results: A total of 40 patients were included: 18 patients were treated with VPA and 22 were treated with OLZ. Overall rates of resolution of delirium were similar: 72.2% in the VPA group compared with 72.7% in the OLZ group. Average time to resolution of delirium was also similar between groups: 7.0 days for VPA and 6.0 days for OLZ. This study was not sufficiently powered to achieve statistical significance, so the implication of the variation in time to resolution is unknown. Hospital length of stay (21.6 ⫾ 12.5 vs. 23.1 ⫾ 18.5 days), ICU length of stay (17.2 ⫾ 9.3 vs. 17.5 ⫾ 18.3 days), and mechanical ventilator days (12.4 ⫾ 11.6 vs. 14.7 ⫾ 19.1 days) were similar between VPA and OLZ. Recurrent delirium occurred slightly more frequently in patients treated with VPA (27.8% vs. 18.2%). In patients experiencing recurrent delirium, those treated with OLZ experienced more delirium free days. Adjunctive antipsychotics were used more commonly in the patients treated with VPA than the patients treated with OLZ. Rates of medication-related adverse events were similar between groups. Conclusions: Preliminary data suggests the feasibility of prospective research exploring the role of VPA for the treatment of delirium.

Posters: Case Reports 852

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B-TYPE NATURETIC PEPTIDE PREDICTING ALVEOLAR OVER-DISTENTION DUE TO HIGH FREQUENCY OSCILLATORY VENTILATION THERAPY

INTRAVENTRICULAR DAPTOMYCIN FOR VANCOMYCINRESISTANT ENTEROCOCCUS VENTRICULITIS

Aaron Godshall, Florida Hospital for Children Case Reports: A 6-year old patient, who sustained severe hypoxic ischemic encephalopathy following cardiopulmonary arrest at 2 years of age, presented to the emergency department with increased respiratory distress. Her condition progressed requiring high frequency oscillatory ventilation (HFOV). Due to mildly depressed blood pressures and dampened pulses in all extremities, a B-type Naturetic Peptide (BNP) level was assessed and found to be elevated at 1,212 pg/mL (0 – 450 pg/mL). This level continued to escalate reaching a height of 6,367 pg/mL. The mean airway pressure (MAP) required to maintain sufficient oxygenation rose from 17 to 28 cmH2O, approximately 6 hours prior to the initial BNP assessment, and remained elevated between 29 and 34 cmH2O during which time BNP levels progressively escalated to a maximum of 6,367 pg/mL. Chest radiograph showed mild distention with the diaphragm between 11–12 ribs. A rapid wean of her MAP to 20 cmH2O was initiated and well tolerated. BNP levels fell to 2,196 pg/mL within 20 hours of reduced MAP without any appreciable difference in other clinical factors. DISCUSSION: BNP has been consistently shown to be a reliable marker for heart failure and often indicates a worse prognosis. Some studies have shown that BNP can be a strong indicator of increased pressures to the right ventricle. Specifically, cases associated with persistent pulmonary hypertension of the Newborn, pulmonary thromboembolism, and a strong association with right sided heart pressures as noted during cardiac catherterization have shown a positive correlation to BNP levels. This case represents a positive correlation of BNP with MAP induced by HFOV. Alveolar over-distention produces increased pulmonary vascular resistence, consequently transmiting increased afterload to the right ventricle that stimulates BNP release. Monitoring of BNP levels may facilitate HFOV adjustments in patients with significant pulmonary disease, potentially expediting ventilator weaning.

Scott Mueller, Tyree Kiser, University of Colorado-Denver School of Pharmacy, Robert Neumann, University of Colorado School of Medicine Case Reports: Vancomycin-resistant Enterococcus faecium (VRE) is an important hospital acquired infection. We present the successful treatment of VRE ventriculitis with intraventricular (IVT) daptomycin and resulting cerebral spinal fluid (CSF) concentrations from each extraventricular drain (EVD) in a complex neurosurgical patient.The patient was a 64 year old white male with a complex past medical history significant for eosinophilic pneumonia treated with high dose steroids, cyclosphosphamide and mycophenolate. After treatment with multiple courses of antibiotics for recurrent meningitis and cerebritis at an outside hospital, he was transferred to our institution for management of hydrocephalus and raising intracranial pressure (ICP). An EVD was placed and diagnostic biopsy revealed Scedosporium apiospermum. A second EVD was required and the patient slowly improved with antifungal therapy. On day 28, CSF cultures from his EVD became positive for VRE, susceptible to linezolid, daptomycin (Etest MIC ⫽ 4 mcg/mL), quinupristin/dalfopristin, and high level gentamicin. After two days of linezolid therapy, CSF cultures remained positive for VRE. Daptomycin 5 mg IVT daily for 5 days was added. First dose daptomycin CSF concentrations varied 3–3.6 fold between the right and left EVD, with similar EVD outputs of 75 and 89 mL within the sampling period, respectively. Initial mean Cmax from the combined right and left EVD was 74.83 mcg/mL. CSF concentrations 7 hours post dose from the right and left EVD were 7.71 and 2.55 mcg/mL and 18 hours post were 1.34 and 0.37 mcg/mL, respectively. After the third dose, CSF concentrations at 16.5 hours were 11.42 and 0.51 mcg/mL from the right and left EVD, respectively, demonstrating potential drug accumulation. Surveillance CSF cultures remained negative and no daptomycin toxicity was demonstrated at follow-up.In this patient, daily administration of IVT daptomycin with intravenous linezolid successfully treated VRE ventriculitis. Interestingly, intraventricular drug administration did not result in equal distribution between lateral ventricles and therefore questions the adequacy of this assumption when designing IVT dosing regimens.

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CASE REPORT: ASPERGILLUS FUMIGATUS NECROTIZING PSEUDOMEBRANOUS TRACHEOBRONCHITIS AND INVASIVE PULMONARY ASPERGILLOSIS IN AN IMMUNOCOMPETENT HOST, USE OF COMBINATION ANTIFUNGAL THERAPY

A CASE SERIES DESCRIBING THE USE OF BIVALIRUDIN IN PEDIATRIC PATIENTS MAINTAINED ON EXTRACORPOREAL LIFE SUPPORT

Ashley Stinnett, University of Arkansas For Medical Sciences, Eduardo MirelesCabodevila, UAMS

Introduction: Anticoagulation with heparin is the current standard of care for patients maintained on extracorporeal life support (ECLS); however, this strategy is not without limitations. Very limited evidence exists for the use of alternative anticoagulants in ECLS. Patients with heparin-induced thrombocytopenia (HIT), heparin resistance, and treatment failure may be candidates for anticoagulation with bivalirudin. Methods: Subjects were identified by ECLS program records. Consecutive patients (⬍18 years old) that received bivalirudin during their ECLS course were enrolled (05/2006 – 02/2011). Data was extracted from the electronic and written records, and included demographic information, laboratory values, indication and duration of ECLS, and bivalirudin dosing. Descriptive statistics were utilized. Results: Twelve patients received bivalirudin during their ECLS course. Eight of the 12 patients were neonates with a mean age of 361 days (1 day to 6 years). Eight patients were male. Nine patients were supported with veno-arterial ECLS. Median duration on ECLS was 226 (175,463) hours, and median time on bivalirudin was 92 (77,190) hours. Bolus doses ranged from 0.04 to 0.14 mg/kg. The bolus dose did not appear to affect subsequent aPTT.The maintenance dose that corresponded with initial target aPTT ranged from 0.045 to 0.48 mg/kg/hr with a median rate of 0.16 mg/kg/hr (0.098,0.199). The median dose for days 1, 3 and 5 was 0.135 (0.078,0.238), 0.175 (0.115,0.239) and 0.267 (0.098,0.410) mg/kg/hr, respectively. There appeared to be a weak correlation between dose adjustment and aPTT response (r2 ⫽ 0.264). Conclusions: This is the first report of the use of bivalirudin in pediatric patients maintained on ECLS. There was not a clear advantage in the use of a bolus dose in achieving target aPTT. This finding is likely confounded by aPTT sample time, disparate clinical endpoints, and potentially sub-therapeutic dosing. The wide maintenance dose range reflected high inter-patient variability. There appeared to be a dose creep with time. Additionally, it is difficult to predict the aPTT response for dose adjustments; therefore, close monitoring and adjustment are critical to maintain target anticoagulation.

Case Reports: We present the case of invasive pulmonary aspergillosis and necrotizing pseudomembranous tracheobronchitis treated successfully with systemic antifungals and inhaled liposomal amphotericin B (LAMB). A 56 year-old man was transferred from an outside hospital for respiratory failure requiring intubation. His past medical history was significant for osteoarthritis and alcohol abuse. He was admitted to an outside hospital where he had a course consistent with Tularemia leading to multiorgan failure.The admission chest x ray was unremarkable and his respiratory status was stable until 2 weeks into the admission when the symptoms of pneumonia developed. He developed progressive respiratory failure unresponsive to multiple antibiotics. Bronchoscopy the day of transfer revealed extensive mucosal necrosis and sloughing of the trachea and main bronchus, consistent with necrotizing tracheobronchitis. The patient was started on IV antimicrobials, including vancomycin, tobramycin, piperacillin/ tazobactam and LAMB. On day 4, the Aspergillus index was elevated and the bronch sample grew a mold consistent with aspergillus. A diagnosis of pseudomembranous tracheobronchitis and invasive pulmonary aspergillosis was made, voriconazole was added and the LAMB was discontinued. On day 9, a repeat bronch was performed that showed mild improvement of the airways but still prominent ulcerations.The patient continued to be febrile with leukocytosis and markedly elevated beta glucan and Aspergillus index levels, micafungin and inhaled LAMB were added to his antifungal regimen. The LAMB for inhalation was prepared at a concentration of 2.5 mg/mL with a dose of 30 mg every 12 hours nebulized over 30 minutes.The duration of treatment for the triple antifungal therapy was 1 month, with the voriconazole being continued thereafter. Extensive workup of the patient failed to reveal any underlying condition that would explain predisposition for such extensive disease.The patient’s condition gradually improved, complicated by ventilator associated pneumonia with Pseudomonas,which was successfully treated. After 2 months of hospital stay he was discharged decannulated to a rehab facility.

Erin Nagle, Robert Pretzlaff, Jeremiah Duby, Aaron Roberts, Manasa Murthy, William Dager, University of California Davis Medical Center


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PULMONARY INFARCTION: AN UNUSUAL COMPLICATION OF PHENTERMINE/PHENDIMETRAZINE FOR WEIGHT LOSS

ONE YEAR OUTCOME FOLLOWING RESCUE ECMO IN AN INFANT GIRL WITH MALIGNANT PERTUSSIS

Ayodeji Adegunsoye, Rowsonara Akhter, Michael Rachshtut, Eric Green, Mercy Catholic Medical Center, Drexel University

Case Reports: Introduction: Rarely, infants with pertussis develop “malignant” pertussis, characterized by fulminant respiratory failure, refractory pulmonary hypertension, variable leukocytosis, and high mortality. Case fatality rate for pertussis requiring ECMO approaches 70%, but recent case reports have shown improved survival with leukopheresis and exchange transfusion. Case Report: A previously healthy 7 week old girl was admitted to the PICU after four days of worsening respiratory symptoms. She rapidly developed hypoxemic respiratory failure, refractory pulmonary hypertension and right sided heart failure requiring cannulation onto VA-ECMO. Of note, Bordetella pertussis PCR was positive and peak WBC count was 63K/mcL. During her ECMO run she developed renal failure requiring CVVH. Bronchoscopies revealed severe mucous plugging and friable, swollen airways. She had gradual improvement in her right ventricular function, and successfully came off ECMO on day 10. Her heart function continued to improve, her pulmonary hypertension resolved on sildenafil, and her renal function improved. She required 15 more days of invasive mechanical ventilation, delivered mostly via NAVA. Her initial PICU stay was 36 days. Her 87 day hospital course included another 9 day PICU stay for respiratory distress. A paralyzed right vocal cord and dysphagia required placement of a G-J tube. She has since had 6 readmissions (and 5 PICU stays) for respiratory distress. Two documented infections (RSV and Moraxella catarrhalis) have required intubation. Six months after initial admission, a lung biopsy revealed no significant parenchymal scarring or inflammation, but uniform simplification and distention of the alveolar spaces, mild smooth muscle hypertrophy and mild medial thickening of small pulmonary arteries. Now at 13 months of age, she has no pulmonary hypertension, but continues to have systemic hypertension, chronic lung disease (1/4 L O2 requirement), and mild developmental delay. Discussion: Infants who successfully survive “malignant” pertussis after ECMO can experience significant long term morbidity. As survival improves, further evaluation of long term outcomes is warranted.

Case Reports: Appetite suppressants (anorexigens) are increasingly being prescribed as “combination pharmacotherapy.” We report a rare case of extensive pulmonary infarction following combined use of phentermine and phendimetrazine for weight loss. A 31-yr-old woman presented with progressive dyspnea and chest pain. 3 months earlier, she had initiated oral phentermine 30 mg & phendimetrazine 35 mg daily for management of obesity. She had no recent pregnancies, family history of thrombosis or hypercoaguability risk factors. She took no other medications or oral contraceptives. Physical examination was notable for respiratory rate of 20/min, pulse oximetry of 98% on room air with reduced breath sounds. Chest x-ray revealed increased prominence of the right ventricular outflow tract and Hampton’s hump. Serum chemistries, liver injury tests, pregnancy test, coagulation studies and drug screen were normal. ECG depicted sinus tachycardia and chest CT showed bilateral lower lobe multifocal pulmonary emboli, extensive pulmonary infarcts and pleural effusion. Extremity duplex ultrasound revealed no deep venous thrombus. Lupus anticoagulant levels, Factor V Leiden activity, prothrombin gene activity, protein C and S, beta-2 glycoprotein, antinuclear antibody and anti-cardiolipin antibody screens were within normal limits. Despite commencing heparin infusion, she developed a large complex pleural effusion with near total lung collapse. She improved with tube thoracostomies and resumed anticoagulation post-extubation. 8 weeks after discharge, her symptoms had completely resolved and she had gained 10 pounds. The global prevalence of obesity has dramatically risen and though anorexigens are commonly used, most have been withdrawn due to the high frequency of adverse effects. Pulmonary hypertension associated with flenfluramine-like amphetamines, has been linked with embolism and eventually fatal pulmonary infarction. It is notable that this occurred in a healthy woman with no thromboembolic risk factors, after only eight weeks of use. Pulmonary infarction, in addition to pulmonary hypertension, should be considered in the evaluation of a patient using anorexigens who presents with dyspnea.

Shilpa Shah, Carrie Morgan, Ken Tegtmeyer, Cincinnati Children’s Hospital

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LABORATORY CONFIRMATION OF TREATMENT EFFECTIVENESS FOR NMDA RECEPTOR ENCEPHALITIS IN ABSENCE OF CLINICAL FINDINGS

BILATERAL VOCAL CORD DYSFUNCTION AFTER INTERSCALENE NERVE BLOCK IN THE SETTING OF RHEUMATOID ARTHRITIS

Lauren Py, Florida Hospital, Anne Tebo, ARUP Institute for Clinical and Experimental Pathology, Aaron Godshall, Florida Hospital for Children

Samira Shojaee, Matthew Koff, Dartmouth Hitchcock Medical Center

Case Reports: A 7-year healthy boy presented to the ED with acute onset of left hand shaking, lip-smacking, and chewing noises. Father observed excessive motor activity during sleep. Upon awakening, he asked the child what was wrong and the child stated his “fingers hurt.” He complained of headache 3 days prior to admission and generalized head pain before going to sleep. He was admitted and diagnosed with partial onset seizures with minimal response to anti-seizure medications,. He was treated with valproic acid and clonazepam. Three days after discharge, he returned to the neurology clinic with periods of unresponsiveness, incontinence and inability to ambulate or speak. Evaluation of his CSF by a cell-based indirect immunofluorescence assay for the presence of N-methy-D aspartate receptor (NMDAR) antibodies confirmed the diagnosis of NMDAR encephalitis with an initial antibody titer of 1:160. Steroid and IVIg therapy failed to reduce symptoms, which continued to worsen despite ongoing treatment with clonazapam and trihexyphenidyl. He was intubated 2 weeks into his hospitalization secondary to respiratory failure requiring pharmacologic paralysis as a consequence of his dystonia. Treatment with Rituximab was initiated with weekly CSF samples drawn to monitor the levels of NMDAR antibodies as part of an ongoing investigational effort. Despite progressive decline in his antibody levels, daily holidays from paralytic drips revealed no change in his symptoms, until NMDAR antibody titers fell to 1:10. He has since begun weaning on sedation and mechanical ventilation. DISCUSSION: NMDA receptor encephalitis is a rare, debilitating disease that requires a high index of suspicion for diagnosis, but specific testing is available. Typically associated with paraneoplastic syndromes, this disease has been described in absence of neoplasm; a condition that often yields a more challenging treatment course. We present a means of monitoring treatment effectiveness through serial measurements of antibody titers in the CSF. This report demonstrates that improvement in laboratory sampling may precede improvements in clinical symptoms and serve as a guide for treatment effectiveness.


Case Reports: Cricoarythenoid joint arthritis as a result of rheumatoid arthritis (RA) is a known condition that rarely results in bilateral vocal cord paralysis. We describe the first case of iatrogenic regional anesthetic vocal cord (VC) paralysis in the setting of contra-lateral cricoarythenoid joint (CJ) ankylosis and immobility. A 70 year old male, with rheumatoid arthritis, was admitted for pain control, after a left total shoulder arthroplasty. Due to his pain, a left sided interscalene (IS) nerve block was done, which resulted in immediate pain control but was also followed by stridor. Racemic epinephrine and 10 mg of IV dexamethasone was administered for presumptive acute edema. Patient’s oxygen saturation was 97% on 3 L of O2. However the patient had severe air hunger and stridor with a respiratory rate of 28. Heliox (70/30 mixture) was initiated resulting in major symptomatic relief. Otolaryngology performed a flexible laryngoscopy and revealed bilateral VC in midline position with twitching of the left VC, immobile right VC and minimal glottis gap. No edema or traumatic injury to the VC was seen. Patient was thought to have bilateral VC dysfunction, with a right VC immobility due to fixation of the CJ and an iatrogenic left cord paralysis from the left sided IS block. Patient was transferred to the ICU, on Heliox. Repeat laryngoscopy at 12 hours showed immobile right VC, but more activity of the left VC with sniffing. Patient’s left VC showed slow functional return over 72 hours and Heliox was discontinued. In outpatient follow up the patient’s VC function had returned to baseline. Bilateral VC paralysis from cricoarythenoid joint arthritis in the setting of RA can on rare occasions lead to significant stridor and can require tracheostomy. Unilateral involvement of the CJ may not pose such deleterious events, but must be recognized through complete ENT evaluation, especially before anesthesia or nerve block. To our knowledge there is no reported case of unilateral CJ arthritis and immobility complicated by iatrogenic contra lateral VC paralysis. Acute management with Heliox can help alleviate symptoms and improve air flow until the VC function return.

860 SUCCESSFUL THROMBOLYTIC TREATMENT OF SEVERE POST-OPERATIVE MECHANICAL MITRAL VALVE STENOSIS FROM THROMBUS IN A 7 MONTH-OLD Eva Cheung, Linda Aponte-Patel, Emile Bacha, Rakesh Singh, Anita Sen, New York Presbyterian Hospital/Columbia University Medical Center Case Reports: Mitral valve (MV) replacement with mechanical prosthesis is recommended in pediatric patients with congenital or acquired MV disease not amenable to surgical repair alone. Mechanical valve thrombosis is a rare but potentially lethal complication and its development while on enoxaparin anticoagulation therapy has only been described in rare pediatric case reports. We present a case of a 7 month-old with a prosthetic MV on enoxaparin who was successfully treated with tissue plasminogen activator (tPA) for severe post-operative MV stenosis from thrombus. Case report: A 7 month-old male with Trisomy 21, complete atrioventricular canal (CAVC) defect, pulmonary hypertension and a Prothrombin 20210G⬎A variant underwent CAVC repair at 4 months-old. At 6 months-old, he underwent MV replacement with a 16 mm Carbomedics mechanical valve for severe mitral regurgitation. For postoperative anticoagulation, the patient received intravenous unfractionated heparin for 3 days and then was transitioned to enoxaparin, with therapeutic levels achieved. On POD 9, he experienced severe hypoxia associated with hypotension and poor perfusion. A chest radiograph demonstrated bilateral pleural effusions and worsening pulmonary edema. An echocardiogram revealed a 1.2 ⫻ 0.8cm thrombus on the anterior MV leaflet resulting in severe MV stenosis with a mean gradient of 24 mmHg. Due to his high reoperative risk, thrombolytic therapy with tPA was started with an intravenous bolus of 0.3 mg/kg over 30 minutes followed by 0.3 mg/kg/hr. Serial echocardiograms showed marked improvement of the mitral stenosis by 6 hours (mean gradient 8 mmHg) and complete resolution within 18 hours. There were no major bleeding complications and tPA was discontinued after 48 hours. The patient was eventually discharged to a rehabilitation facility on coumadin. Discussion: Post-operative anticoagulation with enoxaparin should be used with caution in patients at high risk for thromboembolic events from mechanical valve replacement. Thrombolytic therapy can be a life-saving treatment of mechanical MV thrombosis when surgical reoperation is not possible.

861 DEADLY CONSEQUENCES OF SICKLE CELL TRAIT Matthew Lester, University of Texas Health Science Center, Kristin Vrotsos, The University of Texas Health Science Center at Houston, Bela Patel, UTHSC Houston Medical School Case Reports: Introduction: Sickle cell trait is generally considered a benign condition. However, multiple cases of acute exertional rhabdomyolysis associated with acute kidney injury and disseminated intravascular coagulation (DIC) have been reported in individuals who undergo excessive physical activity or use dietary supplements.Case Presentation: A 23 year-old African American man with no medical history was admitted after he collapsed during a run. He was an Army recruit taking dietary supplements. He was intubated by EMS for agonal breathing. Initial temperature was 104°F. He was hydrated on transport to the hospital.Vitals were temperature 100°F, BP 130/80, HR 110, and SpO2 100%. Physical examination was remarkable only for tachycardia.Labs revealed leukocytosis with bandemia, severely elevated lactate and CK, and elevated creatinine. Initial hemoglobin, platelets, coags, and LFTs were normal. Drug screen was negative. ECG showed sinus tachycardia. Chest x-ray was normal.The patient was aggressively hydrated, but his renal function worsened requiring renal replacement therapy. He developed severe DIC with acute liver failure and spontaneous hemorrhage.Despite massive transfusions, he continued to bleed. On day four, he developed neurologic deficits. CT of the head revealed left frontal intracranial hemorrhage with midline shift and cerebral edema.Neurosurgical evaluation concluded that no intervention was indicated given his poor prognosis. His family decided to withdrawal life support. After his death, he was diagnosed with sickle cell trait that was possibly missed during childhood screening. Discussions: Although sickle cell trait is generally considered a benign condition, acute exertional rhabdomyolysis associated with acute kidney injury and DIC has been reported in athletes, military personnel, and others undergoing excessive physical activity or taking dietary supplements. Our patient was unaware he had sickle cell trait assuming a negative childhood screening.Conclusion: Individuals undergoing excessive physical activity, such as military personnel and athletes, should be screened for sickle cell trait if identified as an at-risk population.

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IMPELLA AND ECMO FOR CARDIOVASCULAR SUPPORT IN FULMINANT VIRAL MYOCARDITIS IN THE INTENSIVE CARE UNIT (CASE REPORT)

ACUTE RIGHT HEART FAILURE PRECIPITATED BY THYROID STORM : AN UNUSUAL MANIFESTATION

Sachin Narain, Gian Paparcuri, Thomas Fuhrman, Richard Silverman, William Peruzzi, University of Miami Leonard M. Miller School of Medicine Case Reports: Description: A previously healthy 31-year-old male was sent to our hospital with severe heart failure. Biopsy showed viral myocarditis with ejection fraction of 10% on echo. He progressed to multi-organ failure requiring intubation and maximal doses of multiple pressors. Hemodynamic support was provided with an Impella 2.5 as a bridge to a peripherally inserted veno-arterial extracorporeal membrane oxygenation (ECMO) system. On full mechanical cardiovascular (CV) support, the patient’s hemodynamic status improved after two days and pressors were tapered off. ECMO and Impella were then explanted and three days later he was extubated and continued on to a full recovery. Discussion: Myocarditis accounts for 10% of acute-onset heart failure. Chances of recovery increase with early recognition and aggressive treatment. There are no specific therapies for fulminant myocarditis but first-line treatment is supportive care and mechanical support, if needed.1 A common mode of support in patients with severe heart failure is ECMO. In severe systolic dysfunction, left ventricular (LV) decompression (venting) is required to reduce myocardial wall stress, decrease myocardial oxygen requirements, and enhance the chances of recovery. Venting historically has been achieved with a left atrial cannula, or percutaneously with an atrial septostomy. The Impella is a much less invasive option as it is placed under fluoroscopic guidance and simply sits across the aortic valve. When compared to other devices, the Impella is associated with lower requirements for blood products and has fewer thromboembolic complications.2 There is an isolated pediatric case where an Impella 5.0 was used as a bridge to full recovery in fulminant viral myocarditis.3 However, to our knowledge, this is the only case reported of the contemporary use of Impella and ECMO as a bridge to full recovery in an adult with myocarditis. And it is the first time an Impella served to vent the LV of a patient on ECMO. References: 1. Gupta S. Nat Clin Pract Cardiovasc Med 2008;5:693–706.2. Lamarche Y. J Thorac Cardiovasc Surg 2011 Jul;142(1):60 – 653. Andrade J. J Heart Lung Transplant 2010;29:96 –97.

Ashish Arora, Meera Sareen, Geetika Sachdeva, William McGee, Tufts University/Baystate Medical Center, Springfield, MA Case Reports: A 39 year old female presented with palpitations, shortness of breath and swelling of lower extremities for one week. The heart rate was 160 bpm; rhythm irregular; BP 132/34 mm hg. Physical examination revealed diffusely enlarged thyroid gland, bibasilar crackles and lower extremity edema. Abnormal laboratory values showed FT4 5.33 ng/dl; FT3 10.4 pg/ml; TSH ⬍0.02 mIU/ml; AST 201 units/L, ALT 189 units/L; Bilirubin 2.5 mg/dl; alkaline phosphatase 169 units/L; INR 3.8. Initial course was complicated by respiratory failure and hypotension. Trans thoracic echo showed a dilated right ventricle with severely reduced systolic function, paradoxical septal motion, severe tricuspid regurgitation consistent with right heart failure. Left ventricular ejection fraction was normal. PAS was 33 mm hg; PAD 14 mm hg; PCWP 10 mm of Hg, PVR 127 dyns/cm 5; RCWI 0.50 Kg/m2; RVSWI 4.24 gm/m2 . CT angiography of the chest ruled out pulmonary embolism. She was treated with beta blockers, iodine and hydrocortisone. Thionamides were not given secondary to liver dysfunction. Subsequent trans esophageal echo on day five showed right ventricle was mildly dilated, systolic function only mildly reduced, moderate tricuspid regurgitation. Thyroid function tests were normal on the sixth day.Thyroid storm is a rare, potentially fatal condition, if untreated. Typical cardiac findings include tachychardia, atrial fibrillation and left heart failure. There are a very few case reports of isolated right heart failure and most have coincident pulmonary hypertension. In our patient, acute right heart failure was reversed in a few days with treatment of thyrotoxicosis. This rapid reversal of right heart failure with treatment of thyrotoxicosis has not been previously described.


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ACUTE SUPERIOR VENA CAVA SYNDROME FOLLOWING POSTERIOR MEDIASTINAL HEMORRHAGE SUSTAINED AFTER FALLING

THE EFFECTS OF HYPERTRIGLYCERIDEMIA ON PLASMA FREE HEMOGLOBIN LEVELS AND ECMO SUPPORT

Vincent Duron, M. George DeBusk, Portia Thurman, Shea Gregg, Rhode Island Hospital, Daithi Heffernan, Brown University Rhode Island Hospital, Andrew Stephen, Michael Connolly, Kevin Dushay, David Harrington, Rhode Island Hospital, Charles Adams, Brown University Case Reports: An 82 year-old female on warfarin for atrial fibrillation presents with constant, non-radiating, mid-sternal chest pain following a syncopal fall from standing. Shortly after presentation, the patient was intubated for hypoxia. Further primary evaluation revealed equal breath sounds and no external signs of bleeding. Initial heart rate was 120 with a blood pressure of 107/62. Secondary exam findings included mild facial swelling and jugular venous distension. A chest radiograph showed a widened mediastinum. Chest CT-angiogram showed a large posterior mediastinal hematoma with areas of intravenous contrast extravasation. Pertinent lab data included: hemoglobin: 16 g/dl; INR: 4.5; troponin: 0.25 ng/ml and lactic acid: 2.9 meq/L.Despite receiving multiple units of fresh frozen plasma for anticoagulation reversal, the patient became hypotensive. The patient’s face and arms had become more swollen and cyanotic-lower limbs were without signs of ischemia. Carotid, radial and femoral pulses were palpable. An emergent bronchoscopy was performed for refractory hypoxia that showed active tracheobronchial collapse during exhalation. The patient went to the operating room for emergent right thoracotomy with a presumptive diagnosis of acute superior vena cava (SVC) syndrome from active mediastinal hemorrhage. Upon entry, the bulging mediastinum was incised behind the SVC and a large amount of clotted blood was evacuated. The patient’s vitals improved immediately and inotropic support was decreased. Hemostasis was achieved following packing of the mediastinum and administration of recombinant factor VIIa. Post-operatively, the patient’s hospital course was uneventful and she was discharged to a rehabilitation center on post-operative day 10.Acute SVC syndrome is a rare clinical entity. Previous reports have been associated with mediastinal hematomas resulting from life threatening ruptured thoracic aneurysms or leaking aortic dissections. When a mediastinal hematoma is due to venous bleeding, most patients can be treated with conservative management. Our patient, however, demonstrates the possible morbidity anticoagulation adds to a typically non-operative scenario.

Julia Ruiz, University of Texas HSC At San Antonio, Veronica Armijo-Garcia, The University of Texas-Health Science Center At San Antonio Case Reports: Exposure of patients to significant hemolysis can lead to serious clinical sequelae such as renal tubular damage, decreased systemic vascular resistance, increased pulmonary vascular resistance, alterations in coagulation profile, platelet dysfunction and mortality. Plasma free hemoglobin (pFHgb) is utilized by most Extracorporeal Membrane Support (ECMO) centers to determine the degree of hemolysis while on ECMO. Normal pFHgb levels at our institution are 0 –90 mg/dL. We present a case of a child on ECMO who developed severe elevations of pFHgb that were of questionable validity. Analysis suggested hypertriglyceridemia to be a potential cause for these false elevations.EC is a 3 year old, previously healthy female, who developed rapidly progressive, multidrug resistant pneumococcal pneumonia and required veno-arterial ECMO support due to poor oxygenation and persistent airleak syndrome. The patient’s pFHgb was ⬍30 mg/dl after ECMO initiation. At ECMO hour 60, she developed tachycardia, poor perfusion, and lower SVO2s which responded to milrinone, improved sedation and increased ECMO flow. At ECMO hour 100, the circuit was changed due to increased pFHgb, need for increased ECMO flow to maintain SVO2, and platelet consumption. Despite the circuit change, pFHgb increased to a peak of 430 mg/dL. Because of persistently elevated pFHgb in the face of other normal hemolytic indices, causes for falsely elevated pFHgb were explored. Turbidity has been known to interfere with spectophotometric assays, like that used to measure pFHgb. A lipid profile was obtained given the propensity of fats to effect plasma turbidity. Our patient’s triglyceride level was found to be 430 mg/dL. On analysis, pFHgb and triglyceride levels were found to have a strong correlation (R ⫽ 0.926).In conclusion, hypertriglyceridemia may lead to false increases in pFHgb, which may complicate a patient’s clinical picture and influence management decisions. Therefore, it should not be the sole value used to assess hemolysis in patients on ECMO. Further investigations into the association between hypertriglyceridemia and pFHbg levels are being developed including a validated pFHgb assay.

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SPONTANEOUS MASSIVE PNEUMOCEPHALUS AND MENINGOENCEPHALITIS AS A PRESENTATION OF POLYMICROBIAL ANAEROBIC SEPSIS

REVERSING DABIGATRAN WITH FEIBA IN A PATIENT WITH A TRANSSEPTAL PERFORATION DURING CARDIAC ABLATION.

Keerthana Keshava, Manar Al Asad, Geisinger Medical Center, Omar Rahman, Geisinger Health System

William Dager, University of California Davis Medical Center, Aaron Roberts, U C Davis Medical Center

Case Reports: Introduction: Spontaneous pneumocephalus is a rarity although there have been a few reported cases secondary to upper respiratory tract infections and middle ear pathology. Most cases follow brain or spinal cord instrumentation/injury. Here we present a case of a patient with pneumocephalus as a presentation of polymicrobial anaerobic sepsis without any such history. Case report- 67 years old male with remote history of duodenal adenocarcinoma treated surgically, had worked in a septic tank a week prior to presentation and since then developed symptoms of upper respiratory tract infection. He was found unconscious with a GCS of 3. CT Head revealed significant intracranial air predominantly in the subarachnoid spaces with associated edema in the brainstem and bilateral cerebellar hemispheres. Lumbar puncture was not performed due to impending brain herniation. Broad spectrum antibiotics including anaerobic coverage was initiated for septic shock with multiorgan failure secondary to meningoencephalitis. Despite resuscitative efforts and aggressive hemodynamic support, the patient rapidly deteriorated and died within 24 hours of admission. Blood cultures obtained during hospital stay and autopsy grew Clostridium Perfringens and Escherichia Coli. Discussion: Spontaneous massive pneumocephalus causing brain herniation as a presentation of polymicrobial anaerobic sepsis has not been reported in current literature. Although gram negative meningitis has been associated with occasional cases of pneumocephalus, the organisms seen here are uncommon causes of meningoencephalitis in adults especially in the absence of invasive procedures or head trauma. E Coli’s outer membrane protein A, a molecule with extracellular loops has been shown to contribute to its transmigration across the blood brain barrier via the human brain microvascular endothelial cells. We hypothesised that his primary source of organism acquisition was upper respiratory given his history. The other source for these organisms is the gastrointestinal tract. However, the patient had no related symptoms and no tumor was found on gross autopsy. This case illustrates both a unique presentation and pathology.

Case Reports: Purpose: To describe the use of FEIBA (Factor Eight Inhibitor Bypassing Activity) to rapidly reverse the anticoagulation effects of the oral direct thrombin inhibitor, dabigatran, in the presence of a life-threatening bleeding event.Case: A 67 y/o man with persistent atrial fibrillation and rapid ventricular rate who was started on dabigatran, receiving his last dose 7 hours prior to cardiac ablation. During the procedure, a transeptal perforation with hypotension occurred after giving 5000 Units IV heparin. Pericardiocentesis was completed and 4.5 L blood lost. Protamine 100 mg and subsequently FEIBA 3159 Units (26 Units/kg actual body weight over 15 minutes) were given after consultation with the Inpatient Anticoagulation Service. He also received 6 L crystalloid, 2 L colloid, 6 units packed red blood cells and 2 units fresh frozen plasma. Roughly 1 minute after initiating the FEIBA infusion slowing of the bleeding was visually observed, with a notable effect within 5 minutes into the infusion. Bleeding from the site stopped before the 15 minute FEIBA infusion was complete. The thrombin time remained over 80 seconds. The patient was discharged 4 days later after removal of the pericardial drain and diuresis. Conclusions: The activated prothrombin complex concentrate FEIBA may be one option to create hemostasis in the presence of dabigatran. The optimal dose requires additional research, but may respond to a low dose of 25 units/kg. The need for additional doses is unclear, and may depend on the situation and time of the last dabigatran dose. The thrombin time may not be an accurate predictor of hemostasis in this setting.


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RHABDOMYOLYSIS CAUSED BY PERIPHERAL T-CELL LYMPHOMA IN SKELETAL MUSCLE

CLOSTRIDIUM PERFRINGRENS-INDUCED CEPHALUS AND MASSIVE HEMOLYSIS

Koichi Sasaki, Rinku General Medical Center, Masaya Yamato, Rinku General Medical Centor, Keiko Yasuda, Rinku General Medical Center, Hiromi Rakugi, Yoshitaka Isaka, Osaka University Graduate School of Medicine

Emily Evans, Jessica Thomas, Janna Landsperger, Arthur Wheeler, Vanderbilt University Medical Center

Case Reports: We report a rare case of rhabdomyolysis caused by peripheral T-cell lymphoma in skeletal muscle. A 62-year-old man with a medical history of diabetes, hypertension and cerebral infarction was admitted to another hospital with complaints of general fatigue and sudden muscle weakness. Examination revealed fever and acute renal failure (ARF) with anuria that remained unimproved despite hydration. He was emergently transferred to our medical center for further evaluation and treatment. On arrival, physical examination confirmed the presence of swelling and tenderness in the right hip and left femoral region. Laboratory abnormalities were identified including markedly elevated creatinine kinase levels, peaking at 62,640 IU/L, and a serum creatinine (Cr) level of 5.0 mg/dL. Computed tomography (CT) revealed tumorous swelling of the right psoas major and obturator internus muscles. Magnetic resonance imaging (MRI) confirmed hematoma in those muscles. ARF caused by rhabdomyolysis was therefore diagnosed and treatment was initiated with hydration and continuous hemodiafiltration, resulting in significant improvements in physical strength and renal function (Cr, 1.79 mg/dL). However, the cause of rhabdomyolysis was still unclear. Recurrent fever and hemophagocytic syndrome were noted. Serum ferritin level elevated dramatically to 104,707.0 ng/mL and Cr level again elevated to 4.09 mg/dL. Biopsies were performed of the bone marrow and inguinal lymph nodes. The diagnosis was peripheral T-cell lymphoma. A 67Ga scan image showed accumulation of isotope in regions presumed to be the sacrum. Finally, rhabdomyolysis caused by peripheral T-cell lymphoma was diagnosed. Methylprednisolone pulse therapy resulted in marked improvement of his general condition and renal function (Cr, 1.48 mg/dL). Computed tomography (CT) revealed clear reductions in tumorous swelling of the right psoas major and obturator internus muscles. Except when the cause is readily apparent, such as in cases of injury, drug reaction or thrombophlebitis, the potential for rhabdomyolysis to represent a sign of lymphoma should be considered.

PNEUMO-

Case Reports: A 50-year-old diabetic woman with dialysis dependent chronic renal failure, peripheral vascular disease, and remote splenctomy was admitted for subdural hematoma following a fall. She was recently discharged after a protracted hospitalization for fem-pop bypass complicated by enterocutaneous fistula formation. Upon ICU admission she was alert, oriented, and complaining of severe headache. With the exception of surgical changes, and a facial contusion, exam was unremarkable with T 36.3C and WBC 7.3. Within 4 hours she developed agitated delirium and hypoglycemia. Correction of hypoglycemia did not correct her mental status and repeat head CT showed pneumocephalus with increasing edema and a stable subdural hematoma without skull fracture. Additional labs were drawn and blood samples were translucent. Decline in mental status and hypotension led to a fatal PEA arrest within 5 hours of mental status changes despite ACLS, transfusions, and antibiotics. At autopsy, the cause of death was established as Clostridium perfringens sepsis, confirmed by blood culture and evidence of widespread systemic and central nervous system infection with gas producing, gram-positive bacilli. C. perfringens is an anaerobic, ubiquitous bacterium that may be found in the GI and GU tracts of humans. Infection produces a wide spectrum of disease from asymptomatic bacteremia to death, based upon bacterial production of a number of different exotoxins. Alpha exotoxin has multiple well-documented effects, including RBC membrane disruption leading to hemolysis. In rare circumstances, C. perfringens sepsis may result in a massive hemolysis, an ominous finding associated with mortality rates ⬎80%. Pneumocephalus caused by bacterial gas production without prior dural penetration is extremely rare, and C. perfringens is a previously unreported etiology. Regardless of cause, pneumocephalus typically presents with headache and changes in cognition. In this case, we suspect the mechanism was seeding of the subdural space with blood containing the organism, which resulted in a rapidly developing pneumocephalus.

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RESCUE MANAGEMENT IN SEVERE HYPOXEMIC RESPIRATORY FAILURE BY THE HIGH FREQUENCY PERCUSSIVE VENTILATION (VOLUMETRIC DIFFUSIVE RESPIRATORVDR)IN THE SICU

SUCCESSFUL PATIENT MANAGEMENT OF MASSIVE HEMOPTYSIS ON VENO-ARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATOR (V-A ECMO)

Felix Khusid, Bashar Fahoum, Emma Fisher, Anthony Tortolani, New-York Methodist Hospital Case Reports: Severe Hypoxemic Respiratory Failure is defined as PaO2/FIO2 ratio of 100 mm Hg or less. The VDR delivers pneumatically powered, pressurelimited, time-triggered, time-cycled, flow interrupted ventilation, which generates a series of high-frequency sub-tidal intrapulmonary volumes in a stepwise pattern in combination with low-frequency convective cycles.The diffusive and convective effects create biphasic oscillations, generating auto-cephalad flow of gas and removal of intrapulmonary secretions; displacement of trapped gas and recruitment of the lung is achieved through improved intrapulmonary diffusion. HFPV is a fusion form of HFV and CMV resulting in two levels of High Frequency Ventilation.HFPV controls the sliding venturi with pressure variations at three levels, responding to the resistance and compliance of the patient. Severe hypoxemic respiratory failure patients that failed traditional mechanical ventilation and were managed on a VDR.1. A 69-year male underwent an emergency Laparotomy for small bowel obsruction.2. A 38-year-old male in septic shock3. A 59-year-old male in septic shock following gastric bypass.All three patients had P/F ratio ⬎60 and conventional mechanical ventilation failed to maintain O2 Saturation ⬍80 despite off PEEP ⬎18, Fi02–1.0 and total sedation and muscle paralysis. All three patients were placed on the VDR, dramatic improvement in oxygenation and ventilation was noted. Two patients were discharged after a prolonged hospital stay; the third is being weaned off mechanical ventilation.HFPV modality is a rescue measure in patients with severe refractory hypoxemia that fail Conventional mechanical ventilation. The greatest strength of an HFPV is an ability to ventilate and oxygenate patients with lower mean airway pressure while limiting strain on the lung by limiting inspiratory tidal stretch. Larger prospective studies are required to further elucidate the predictors of outcome benefit.

Meredith Harrison, Scott Cowan, Thomas Jefferson University Hospital, Hitoshi Hirose, Thomas Jefferson University, Linda Bogar, Nathaniel Evans, Thomas Jefferson University Hospital, Nicholas Cavarocchi, Thomas Jefferson University Case Reports: A 49 year old female with non-ischemic cardiomyopathy secondary to Adriamycin presented with decompensated biventricular heart failure symptoms and liver dysfunction. An echocardiogram demonstrated an ejection fraction of 10% with severe mitral regurgitation. Despite multiple inotropes, there was no hemodynamic improvements and end-organ function worsened. V-A ECMO was instituted as a bridge to decision for end organ recovery.48 hrs after initiation of VA ECMO, the patient developed massive hemoptysis following Swan Ganz manipulation. Bedside bronchoscopy demonstrated hemorrhage from the right upper and lower airways. The heparin infusion was stopped and epinephrine and cold saline were lavaged through the endotracheal tube. This was unsuccessful in controlling the bleeding and a right-sided bronchial blocker was placed, however the bleeding continued. A clamp was placed on the endotracheal tube, the balloon was maximally inflated, and the patient was disconnected from the ventilator while ECMO support continued. An urgent pulmonary arteriogram demonstrated no extravasation. The endotracheal tube was unclamped 36 hrs after the patient’s original episode of hemoptysis; repeat bronchoscopy was performed which demonstrated no bleeding. Chest xrays and ABGs were consistent with ARDS. The patient was placed on an ARDS ventilation protocol and maintained on full ECMO support. Seven days after the event, the patient’s CXR, ABG’s, compliance and oxygen requirements improved. On post ECMO day 20, the patient underwent ECMO wean; a HeartMate II LVAD was placed successfully.Successful management of massive hemoptysis on ECMO has not been described. Full cardiorespiratory support provided by ECMO without heparinization with concomitant clamping of the endotracheal tube and cessation of mechanical ventilation resulted in control of hemoptysis following pulmonary artery injury. Resultant ARDS from hemorrhagic aspiration resolved with full ECMO support. Endotracheal tube clamping during VA ECMO support is a novel therapeutic approach that proved successful in the resolution of massive hemoptysis and subsequent ARDS.


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CASE REPORT OF SPONTANEOUS SPLENIC RUPTURE IN TWO PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES AND BACTEREMIA

ACUTE RAISED INTRACRANIAL PRESSURE IN A GIRL WITH CHRONIC SUBDURAL HEMATOMA AND ARACHNOID CYST

Moumen Asbahi, Ravi Tripathi, Erik Abel, Yazhini Ravi, Chittoor Sai-Sudhakar, Deven Kothari, The Ohio State University Medical Center

Shivanand Medar, The Children’s Hospital At Montefiore, Gina Cassel, Children’s Hospital at Montefiore, Arundhati Biswas, Montefiore Medical Center, Philip Overby, Linda Siegel, Children’S Hospital At Montefiore

Case Reports: Over 200,000 American adults have advanced heart failure refractory to medical therapy. A treatment option is mechanical support, including left ventricular assist devices (LVAD). LVADs enable improved outcomes with acceptable morbidity but significant long-term sequelae, such as infection, thromboembolism, hemorrhage & primary device failure. We report two patients with driveline infections that developed splenic rupture. Case 1: A 56-year-old male with non-ischemic dilated cardiomyopathy & remote LVAD placement presented with sepsis. He underwent driveline debridement & was treated for Methicillin-Sensitive Staphylococcus aureus (MSSA) bacteremia. On hospital day 23, the patient developed severe anemia & peritonitis with no reported abdominal trauma. An emergent exploratory laparotomy revealed splenic rupture requiring splenectomy. Pathologic examination reported foci of subscapular hemorrhagic infarcts with focal necrosis, evidence of recurring infarcts, but no evidence of vascular malformation. After extensive ICU care, the patient was discharged on antibiotic therapy. Case 2: A 55-year-old female with remote LVAD placement due to end stage heart failure & with active treatment for MSSA bacteremia presented for debridement of recurrent driveline infections. On hospital day 35, the patient became hemodynamically unstable & acutely anemic. An emergent exploratory laparotomy revealed splenic rupture requiring splenectomy. Pathologic examination reported extensive splenic necrosis, hemorrhage, acute inflammation & bacterial colonies. After a complicated postoperative course, the patient had resolution of her septic shock. Conclusion: While rare and previously unreported to our knowledge, intensivists should consider splenic rupture in LVAD patients with peritonitis. Possibile etiologies include thromboembolic phenomena due to a hypercoaguable state secondary to an underlying infectious process versus failure of anticoagulation.

Case Reports: A previously healthy 8-year old girl presented to the Emergency Department (ED) of the referring hospital with a 5 day history of frontal headache and non-bilious vomiting. After Toradol and IV rehydration in the ED she was noted to be unresponsive and had tonic limb posturing. A stat head CT scan showed a 6cm space occupying left frontoparietal hyperdensity with midline shift, most consistent with a subdural hematoma. Thinning of the overlying calvarium was also present. The child was intubated and transferred to our hospital for further neurosurgical evaluation. Four hours after admission to our Pediatric critical care unit (PCCU), she had signs of increasing intracranial pressure (ICP). She was taken to the OR for craniotomy and evacuation of the hematoma. At surgery, the subdural collection consisted of liquefied chronic blood. Notably, there was a membrane underlying the clot. Postoperative recovery was uneventful. The unusual finding of a membrane underlying the subdural collection prompted us to investigate further and it was found that she had previously been diagnosed with a left frontal arachnoid cyst. This was diagnosed on MRI as part of her evaluation for a seizure at 18 months of age. Conservative management and follow-up was advised, as she did not have any signs of raised ICP. She was lost to follow-up until she presented to us with chronic subdural hematoma. Discussion: AC are a frequent finding on intracranial imaging in children. The natural history of AC is typically uneventful. A large consecutive series of children undergoing MR imaging found the prevalence rate of AC to be 2.6%. (1) Approximately 9% increase in size (2). The association of chronic subdural hematoma and arachnoid cyst is very rare but has been described in the literature. (2) In cases of isolated subdural hematoma in a pediatric patient without obvious trauma, an underlying arachnoid cyst should be considered. A simple SDH may be drained by a burr hole, but an associated AC requires open craniotomy for evacuation of the hematoma and resection of the membrane. Outcomes are excellent with definitive therapy(3).

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FATAL VIBRIO VULNIFICUS SEPSIS INITIALLY PRESENTING AS FOOT PAIN

METFORMIN TOXICITY PRESENTING WITH SEVERE METABOLIC ACIDOSIS, BLINDNESS AND RENAL FAILURE MIMICKING METHANOL POISONING.

Marcia Brackbill, Shenandoah University, Jeffery Spray, T. Glen Bouder, Winchester Medical Center Case Reports: Vibrio vulnificus is gram-negative bacillus ubiquitous to warm seawater and filter feeding animals. It can cause necrotizing fasciitis and septic shock, but the rarity with which this organism causes illness makes Vibrio septicemia a challenging diagnostic finding. A 66-year-old man presented to the ED complaining of new onset generalized malaise and bilateral foot pain with swelling. He recently returned from vacation 3 days prior to this admission in his usual state of health. The patient has a history of alcohol related liver disease. Physical exam revealed bilateral trace, pitting edema in the feet with streaking erythema that was painful and warm to the touch. The patient was afebrile and tachypneic with leukocytosis. The admitting physician made an initial diagnosis of acute bacterial cellulitis and antibiotics were initiated. The patient was admitted to the ICU for further management. Despite antibiotic therapy, the patient’s condition continued to worsen and septic shock developed. Vasopressors were initiated, the patient was intubated and antibiotic therapy was broadened. The patient’s lower legs became mottled and bullous lesions began to develop on the feet and lower legs. The consulting intensivist, upon further questioning the family, learned the patient had eaten raw oysters on vacation, thus Vibrio sepsis became a concern. Antibiotic therapy was expanded to include doxycycline. Despite aggressive ICU management, the patient’s condition continued to decline. Multiple organ failure ensued with progressive hemorrhagic bullous lesions and necrotizing fasciitis rapidly spreading over the lower extremities. Blood cultures confirmed Vibrio vulnificus. The patient’s family was informed of the low likelihood of recovery and he was made comfort care. He passed away 5 days after admission. This case illustrates how necrotizing fasciitis due to Vibrio may masquerade initially as cellulitis. Additionally, there is a potentially poor prognosis associated with Vibrio even if recognized early. Although Vibrio infection is rare, it is a potential cause of sepsis in patients with liver disease and exposure to raw shellfish should be investigated.


Naveen Rawat, New York Medical College At Westchester Medical Center, Jacobo Hincapie, Nelky Ramirez, Metropolitan hospital center Introduction: Case Reports: A 60 y/o male presented with a one day history of increasing lethargy, visual loss, vomiting and diarrhea after having street food. His past medical history was significant for Diabetes Mellitus type 2, Hypertension,osteoarthritis.Review of systems was unremarkable. His medication included Metformin,Vicodin (hydrocodone/acetaminophen).He denied smoking or illicit drugs but drank alcohol occasionally with the last drink 3 days prior to admission.The patient was normotensive, tachycardic, and tachypneic with oxygen saturation of 99% on room air. He was drowsy with smell of alcohol in breath. Rest of the physical exam including the fundoscopic eye exam was normal.The laboratory tests revealed Anion Gap 30,serum osmolal Gap 60,lactate24 mmol/ l,HCO3- 6 mmol/l BUN 63 mg/dl Cr 9.1 mg/dl.There were mild ketones with a normal blood glucose.The ethanol, ethylene glycol,acetaminophen,salicylate level were normal and the methanol level was sent to an outside lab. Arterial blood gas revealed pH 6.8,PaCO2 18.8,PaO2 74.The patient was intubated started on bicarbonate drip and fomepizole as per poison cell recommendations and arrangements for hemodialysis were made. Due to the presence of lactic acidosis and history of use of metformin a predialysis metformin level was sent Fomepizole was stopped as the methanol level was normal. Patient received 14 hours of hemodialysis in 2 days with normalization of the pH. The blurred vision and diarrhea also resolved and he was successfully extubated on day 4 of intubation. The predialysis metformin level was elevated 46 mcg/ml (therapeutic range 1–2 mcg/ml).The post dialysis metformin levels were 9.0, 8.9, 1.5 mcg/ml after first, second and third dialysis respectively.The patient was discharged home with baseline renal function. Conclusion: Metformin toxicity presents as lactic acidosis but here it presents with visual loss mimicking methanol poisoning but the visual loss was reversible with treatment of the toxicity.We hypothesise that dehydration with diarrhea precipitated acute renal failure which further precipitated metformin toxicity. The cause of vision loss could not be found but was presumed to be due to severe acidosis.

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CHRYSEOMONAS LUTEOLA BACTEREMIA IN A PATIENT ON CHRONIC TREPROSTINIL THERAPY

PROLONGED REFRACTORY HYPOTENSION SECONDARY TO AMLODIPINE OVERDOSE – A THERAPEUTIC CHALLENGE

Andy Wen, Bryan Mitton, Mattel Children’s Hospital at UCLA, Robert Kelly, David Geffen School of Medicine at UCLA Case Reports: Objective: The objective of this abstract is to discuss the association between treprostinil use and gram-negative organism infections.? Design: Case report from a university-affiliated, tertiary care pediatric intensive care unit.Patient: 14-year-old male with World Health Organization Group I idiopathic pulmonary arterial hypertension (PAH) on continuous treprostinil therapy for two years presented with fatigue and fever of 102°F. Admission laboratory studies were notable for white blood cell count of 62,000/␮l and central line blood culture growing Chryseomonas luteola. Results: The patient responded well to a 14-day course of ceftriaxone and all subsequent blood cultures were negative.Conclusion: There is an association between treprostinil therapy and gramnegative sepsis. Chryseomonas luteola is a rare pathogen encountered primarily in patients with indwelling hardware. This case documents the risk of gram-negative sepsis to patients on treprostinil, and is the only case report of Chryseomonas luteola bacteremia in a pulmonary hypertension patient receiving continuous intravenous treprostinil. We speculate that use of alternate diluent solutions such as Sterile Diluent for Flolan (SDF) may decrease this risk.The efficacy of prostanoid therapy in the setting of PAH is well-supported by clinical trials. Treprostinil is a modified prostacyclin analog administered by continuous infusion through a central venous catheter. Five years after its market introduction, a Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report observed that treprostinil use is associated with higher incidence of gram-negative bacterial bloodstream infections (one per 2.5 patient-years of use) compared with epoprostenol. Hypotheses to explain the association with infection include the packaging of treprostinil in multi-dose, multi-use vials, possible immune-modulating effects related to the cell-surface prostacyclin (PGI2) receptor or the peroxisome proliferator-activated receptor, and the previous use of a diluent with neutral pH (sterile saline). Treprostinil is now available in the alkaline SDF, which may confer greater anti-microbial activity.

Shrinivas Kambali, Kenneth Nugent, Raed Alalawi, Texas Tech University Health Science Center Case Reports: Calcium channel blocker (CCB) overdose is one of the leading causes of overdose death among cardiovascular medications. The therapeutic challenge arises from long half-life of these medications. We present a patient with highest reported dose of amlodipine ingestion in combination pill.Our patient is 25 yo female who was brought to ER by EMS 2 hours after ingestion of 90 pills of tribenzor (Olmesartan40/amlodipine10/HCTZ 12.5)(Total amlodipine-900 mg). She was awake and alert BP 100/50,HR 113,RR 18.She became hypotensive and obtunded.She was intubated for airway protection, gastric lavage was done and activated charcoal was given. She was resuscitated with 4L 0.9%NS, calcium chloride, glucagon, insulin and glucose infusions. Her hypotension worsened necessitating use of norepinephrine 200 mcg/min, phenylephrine 200 mcg/min, dopamine 50 mcg/kg/min, and vasopressin 0.06units/min concurrently.She developed ARDS and required high frequency oscillator ventilation. On day 3 her oxygenation and hemodynamics improved.Calcium IV was given to maintain calcium⬎11. She continued to improve and was weaned off vasopressors and mechanical ventilation. She fully recovered and was discharged home.Amlodipine is dihydropyridine CCB with potent vasodilator with little negative chronotropic effect. It has large volume of distribution with peak action in 6 –12 hrs and half-life of 30 –50 hrs.Few cases of extremely high dose ingestion were reported. Patients may be normotensive but rapidly progress to shock depending on ingested dose. High doses are associated with shock, bradycardia, pulmonary edema, renal failure and heart failure. Primary goal is to maintain adequate circulation. Therapy includes IV fluids, glucagon, vasopressors, calcium infusion and atropine. High dose insulin was reported to have positive chronotropic effects. Our patient’s ingestion of a combination pill led to a prolonged refractory hypotension, requiring higher than usual vasopressor doses with multiple agents. Based on our patient and the review of literature we conclude that patients with near fatal CCB ingestion usually have a good outcome with appropriate use of high dose vasopressors, glucagon and insulin.

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DABIGATRAN EFFECT ON INR IN AN ELDERLY PATIENT WITH ACUTE KIDNEY INJURY

RESUSCITATION VIA FEMORAL VEIN IS INADEQUATE IN ABDOMINAL COMPARTMENT SYNDROME

Billie Bartel, Avera McKennan Hospital

Meera Sareen, Tufts University/Baystate Medical Center, Springfield, MA, William McGee, Baystate Medical Center, Bogdan Tiru, Tuft’s University, Ashish Arora, Baystate Medical Center

Case Reports: Dabigatran is a direct thrombin inhibitor approved to reduce the risk of stroke and embolism in patients with non-valvular atrial fibrillation. Dabigatran is renally excreted, requiring dose adjustment in renal disease to avoid adverse effects from drug accumulation. Dabigatran requires no laboratory monitoring; INR is insensitive to dabigatran and may or may not be elevated at therapeutic doses. Current literature indicates dabigatran can increase INR as high as 2 to 3. We report a case of more significant INR elevation in the setting of drug accumulation due to acute kidney injury.An 80 year old female, ht 62 in, wt 83 kg, was admitted to the intensive care unit after presentation to the emergency room with severe hip pain after a fall the evening prior. Upon admission, the patient was lethargic, requiring repeated verbal stimulation to complete review of systems. Past medical history includes atrial fibrillation, congestive heart failure, and chronic kidney disease (baseline serum creatinine 1.3). The patient had been maintained on dabigatran 150 mg twice daily for 2 months after previous difficulty with INR control on warfarin.Labs at admission include serum creatinine 10.5 with anuria, potassium 7.7, PTT 100, PT 117, INR 13.1, bilirubin 0.5, hemoglobin 7.5, and platelets 168. CT of the head showed acute subarachnoid and subdural hemorrhages. Hip and pelvis X-rays were negative. Dialysis was initiated urgently for hyperkalemia. The patient received vitamin K 10 mg IV, 4 units of FFP, and 3 units of PRBCs. Repeat INR was 2.7 after FFP finished infusing and dialysis completed; eight hours later after 4 additional units of FFP INR was 1.9, PT 22, PTT 60.Dabigatran’s effect on INR may be more pronounced in the setting of renal dysfunction due to drug accumulation. Hemodialysis can be used to remove dabigatran, clearing approximately 60 percent in 2 to 3 hours. This intervention may be particularly important in patients with drug accumulation due to acute kidney injury. INR monitoring and reversal interventions in patients with acute bleeding while on dabigatran may be warranted.

Case Reports: A 27 year old male was admitted for acute pancreatitis. He developed worsening abdominal distention and required intubation and transfer to the ICU for hemodynamic instability. Crystalloid boluses and norepinephrine were infused via a femoral catheter during resuscitation.Pulse Contour Analysis was used to obtain hemodynamic variables: Cardiac Index (CI), Stroke Volume Index (SVI), Stroke Volume Variability (SVV). Fluid responsiveness was constantly assessed utilising SVV and change in both CI & SVI with Passive Leg Raising (PLR). Pt received a total of 16L crystalloid over 12 hours and Norepinephrine was weaned off. Urine Output was maintained at 100cc/hr during this period.Subsequently patient became oliguric (10cc/hr) despite 16 liters crystalloids and a MAP ⬎60 mmHg. SVV was 18 and SVI was 21 (normal 35–50) suggesting hypovolemia . However there was no change in SVV or CI/SVI with PLR or fluid challenge via the femoral catheter.Abdominal compartment syndrome (ACS) was diagnosed with an elevated Bladder Pressure of 21 mmHg and inferior veno-caval pressure of 25 mmHg. Surgery was consulted for decompression as the oliguria and acute kidney injury were attributed to ACS. A right Internal Jugular catheter was placed and a rapid infusion of 1 liter 5% human albumin and 1.5L crystalloid led to a dramatic increase in SVI (21 to 42) and CI (3.2 to 6.2) along with decrease in SVV (34 to 12) and heart rate (140 to 120). Urine output picked up to 75cc/hr. This intervention proved that the patient was still volume responsive as indicated by SVV despite PLR test and fluid challenge through femoral vein indicating otherwise.ACS is associated with IVC compression and decreased venous return from thelower half of the body. In ACS, PLR may not predict fluid responsiveness. It does indicate that the patient will not respond to fluid challenge through any venous access that drains into the IVC as shown in our patient. In such patients, SVV still remains a good indicator for fluid responsiveness. This was confirmed by good response to fluid challenge through IJ vein.


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TREATMENT OF SEVERE UNCONJUGATED HYPERBILIRUBINEMIA IN A NEONATE ON EXTRACORPOREAL LIFE SUPPORT USING CELL SAVER FOR MODIFIED DOUBLE VOLUME EXCHANGE TRANSFUSION

HYPERLACTICACIDEMIA, HEPATOMEGALY & RESPIRATORY FAILURE: AN UNUSUAL PRESENTATION OF LYMPHOMA

Laura Czulada, Katherine Clement, University of North Carolina At Chapel Hill Case Reports: A term neonate developed respiratory distress syndrome requiring intubation at 2 days of age. Despite receiving surfactant and initiating high frequency ventilation, inhaled nitric oxide, high doses of vasoactive medications, and sedation with neuromuscular blockade, she required venovenous extracorporeal life support (ECLS). After cannulation, there was dusky discoloration of the abdomen and the lower extremities. Initial chest radiograph showed the cannula at the level of the diaphragm, with concern of occlusion of the inferior vena cava. The cannula was then repositioned into the right atrium. The baby rapidly developed an unconjugated hyperbilirubinemia with initiation of ECLS, with a peak total of 27.6 mg/dL, peak unconjugated component of 23.7 mg/dL in less than 48 hours presumably from hemolysis. Phototherapy was initiated on the baby and the circuit, and cannula position was adjusted to decrease hemolysis. Weight restrictions prevented apheresis at our institution. On day 2 of ECLS, the circuit was changed as a means of partial exchange transfusion. Total bilirubin level transiently decreased to 14 mg/dl, but rose to 21 mg/dl. We then performed a modified double volume exchange transfusion on ECLS day 3 by connecting a cell saver machine to the ECLS circuit where 1360 mls of blood were washed and returned over 1 hour. She also received platelets, plasma, and cryoprecipitate. The procedure was well tolerated. After this intervention, bilirubin fell to 13.2 mg/dl. She was successfully weaned from ECLS after 7 days. Indirect bilirubin fraction continued to fall to minimal levels. Six weeks after ECLS course, bilirubin had normalized. She was discharged home at 2 months of age feeding well with normal neurologic status. Kernicterus is one of the 28 “never events” identified by the National Quality Forum; therefore, neonatal hyperbilirubinemia of any cause should be treated aggressively. Traditional double volume exchange transfusion for this patient on ECLS required replacement of 1.3 liters of blood, and done in the standard way would have taken many hours. Using a cell saver machine can safely assist with exchange transfusion in patients on ECLS.

Sally Webb, Medical University of South Carolina, Joel Cochran, Medical Univ. of South Carolina, Frederick Tecklenburg, Medical University of South Carolina Case Reports: Introduction: Type B lactic acidosis associated with hematologic malignancies is a rare condition usually described in adults. We describe a pediatric case of anaplastic large cell lymphoma (ALCL) masquerading as respiratory failure, massive hepatomegaly and profound lactic acidosis. Case Report: A 10 year old boy was admitted with 2 weeks of abdominal pain without hepatomegaly and new onset of cough, fever and tachypnea. Initial CBC, LFTs, uric acid, anion gap, and renal function were normal. CXR revealed bilateral infiltrates. Bacterial cultures and viral serology were negative. On day#6 he was transferred to the PICU and intubated due to respiratory failure and was noted then to have massive, firm hepatomegaly without adenopathy. A BAL was negative. His WBC was 63K mm3 with a normal peripheral smear. Ferritin and LDH were mildly elevated. Although he was well perfused and had normal BP and CVP after intubation, his initial lactic acid (LA) was 6.1 mMol/L and quickly rose in 24 hours to 18 mMol/L despite NaHCO3 administration. CRRT was ineffective in lowering LA below 11 mMol/L over the next 24 hours. CT scans revealed no masses or adenopathy. Multiple bacterial, fungal, viral and parasitic tests were negative. On day #9, a bone marrow aspirate revealed a diagnosis of ALCL. With chemotherapy, the patient’s LA fell from a peak of 17 to 3.5 mMol/L in 36 hours. At the time of this abstract he remains critically ill in the PICU. Discussion: Lactic acidosis in an ICU is usually associated with impaired tissue oxygenation (Type A). In rare cases, lactic acidosis is unrelated to systemic hypoperfusion and can be associated with some medications, toxins, or malignancy. In the latter case, supranormal LA levels result from high rates of cancer cell glycolysis and will only fall if tumor burden decreases. A high index of suspicion for lymphoma or other hematologic malignancies is necessary when patients have unrelenting lactic acidosis and organ dysfunction without shock.

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SUCCESSFUL USE OF DUAL-MODE INDEPENDENT LUNG VENTILATION AFTER SURGICAL REPAIR OF GASTROBRONCHIAL FISTULA

ASYSTOLE AS A COMPLICATION OF CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY (CIDP)

Bhavin Mehta, Sunil Kamat, Sanjay Chawla, Stephen Pastores, Prasad Adusumilli, Neil Halpern, Memorial Sloan-Kettering Cancer Center

Case Reports: Introduction: Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is a disorder of peripheral nerves and nerve roots. CIDP usually presents as a symmetric or asymmetric polyneuropathy with a progressive or relapsing-remitting clinical course for more than 8 weeks. Asystole is a very rare complication of CIDP. Case Presentation: We report a 74 year old African American male with previous diagnosis of Acute Inflammatory Demyelinating Polyneuropathy (AIDP), who was treated with Intravenous Immunoglobulins (IV IG) 2 months prior to presentation. He presented to the Emergency Department with worsening weakness, tachypnea, and hypotension. The patient was intubated for acute hypoxemic respiratory failure and was treated for pneumonia. He continued to have bilateral upper and lower extremity weakness and continued to fail ventilator weaning parameters. A repeat EMG and CSF confirmed the diagnosis of CIDP. He had multiple episodes of asystole lasting 6 –10 seconds that resolved spontaneously. EKG tracings were reviewed and showed no dysrhythmias prior to the episodes. 12 lead EKG and Troponins showed no evidence of cardiac ischemia. Electrolytes and thyroid function were all within normal range. Echocardiogram showed normal ejection fraction and no wall motion abnormalities. He was not on any atrioventricular blocking agents. The patient was treated with IV IG with no recurrence of asystole. He was discharged in stable condition, but was readmitted 8 weeks after his discharge with relapsing CIDP and more unexplained episodes of transient asystole. Discussion: CIDP usually presents as a symmetric or asymmetric polyneuropathy with a progressive or relapsing-remitting clinical course for more than 8 weeks. CIDP is a temporal continuum of AIDP. Although very few cases of autonomic dysfunction were reported in association with AIDP, none were reported with CIDP. It is thought that the episodes of asystole occurred secondary to autonomic nerve dysfunction from CIPD.

Case Reports: Asymmetric lung injury presents a unique ventilation challenge especially with severe hypoxemia. There are few reports of dual-mode independent lung ventilation (DM-ILV) with only a minority combining HFO and conventional ventilation (CV). We describe a patient who developed ARDS after surgery for a gastro-bronchial fistula (GBF) who was successfully ventilated with DM-ILV using HFO and pressure assist-control (PA/C). A 68-year old man underwent an Ivor-Lewis esophagectomy for cancer that was complicated on POD 13 by a GBF in the posterior wall of the right main stem bronchus. The fistula was repaired with an intercostal muscle flap and reversal of the gastroesophageal anastomosis. At surgery, he was ventilated with a dual lumen tube (DLT) and right lung deflation. At the end, a single lumen tube (SLT) was placed and he developed severe hypoxemia upon reinflation of the right lung. CXR showed bilateral infiltrates with P/F of 50. The DLT was replaced and he was changed to asynchronous ILV with PA/C. The right was set with Pi of 10 cm H2O, PEEP 3 and FiO2 1.0 while the left was set with Pi of 28 cm H2O, PEEP 10 and FiO2 1.0. Upon ICU admission he remained in ARDS (P/F 61). To address the oxygenation failure, minimize pressure to the right bronchus to allow healing of the repaired fistula and avoid air leak, prevent VILI and increase recruitment of the damaged lung, he was switched to HFO to the right lung (frequency 7 Hz and mean airway pressure (MAP) 10 cm H2O which was gradually increased to 20) and PA/C to the left lung (Pi 28 cm H20, PEEP 10 and FiO2 1.0). Ventilation was facilitated with paralytics and sedatives. He also received steroids, antibiotics, and enteral nutrition. Bronchoscopies confirmed viability of the flap and maintained closure of the fistula. By day 8, the hypoxemia had gradually improved with P/F 238 and the DLT was changed to a SLT for conventional ventilation with PA/C. Tracheostomy was performed on ICU day 16. At 30 days since ICU admission, he remains ventilated due to CIPN/M. DM-ILV combining HFO and PA/C is feasible and may be successfully used in managing ARDS in post-esophagectomy patients with GBF.


Ahmed Sulieman Daoud, Jeffrey Jennings, Henry Ford Hospital

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SUBCUTANEOUS EMPHYSEMA, PNEUMOMEDIASTINUM AND BILATERAL PNEUMOTHORACES COMPLICATING MILIARY TUBERCULOSIS

SODIUM POLYSTYRENE SULFONATE (KAYEXALATE) ASSOCIATED BOWEL PERFORATION

Brian Van Den Berg, Lynell Newmarch, Jaime Betancourt, Gregory Bierer, Nader Kamangar, Olive View-UCLA Medical Center Case Reports: Miliary tuberculosis is rarely implicated as a cause of pneumomediastinum. This is a case of miliary tuberculosis complicated by subcutaneous emphysema, pneumomediastinum and bilateral pneumothoraces. A 62-year-old male was admitted to our intensive care unit (ICU) with septic shock and respiratory failure. He was recently hospitalized for unintentional weight loss and left scrotal pain; had undergone a left orchiectomy, with pathology demonstrating caseating granulomas which stained positive for acid fast bacilli (AFB). He was diagnosed with miliary tuberculosis, primarily involving the genitourinary system; was started on therapy RIPE, and was discharged home. Physical exam was notable for diffuse crepitus of the anterior chest wall, and Hammond’s crunch on auscultation of the heart. Chest imaging, including computerized tomography (CT), showed extensive pneumomediastinum and bilateral pneumothoraces; it was also notable for numerous centrilobular nodules. In addition to the management of sepsis, he received antituberculosis chemotherapy. Sputum AFB’s returned negative; however, urine AFB was positive. In spite of an aggressive trial of critical care, the patient’s hospitalization was complicated by multi-organ system failure. He was ultimately transitioned to comfort care and expired. Pneumomediastinum and pneumothorax as a consequence of miliary tuberculosis are exceedingly rare. The exact pathogenesis for pneumomediastinum in miliary tuberculosis is unknown; however, air trapping secondary to mucous plugging from endobronchial spread of tuberculosis represents one possible mechanism. Other suggested mechanisms include the rupture of miliary nodules, leading to interstitial emphysema, and the rupture of subpleural miliary nodules, leading to pneumothoraces. This case highlights the wide spectrum of pulmonary damage that can be seen in disseminated tuberculosis, including some exceedingly rare complications, namely subcutaneous emphysema, pneumomediastinum and bilateral pneumothoraces. To our knowledge, this is the first reported case of miliary tuberculosis presenting with concurrent subcutaneous emphysema, pneumomediastinum, and bilateral pneumothoraces.

Wennie Huang, David Volles, Winston Ally, University of Virginia Health System Case Reports: Introduction: Hyperkalemia is often treated with sodium polystyrene sulfonate (SPS). We present a case of ischemic bowel necrosis and perforation in a post renal transplant patient after receiving SPS. Presentation: A 57 year old male presented for a kidney transplant. On post-operative day (POD) 1 his serum potassium rose to 6.7 mmol/L and the patient was given a total of four 40 g doses of SPS over 5 hours. The potassium continued to rise initially but eventually decreased to 4.6 after 32 hours. The patient’s hospital course progressed as expected and he was transferred out of the ICU. On POD 6, he began to exhibit signs and symptoms of bowel obstruction and sepsis. He was taken to the OR and found to have an ischemic perforated bowel requiring a partial colectomy. The post colectomy hospital course was complicated by a prolonged ICU stay with severe sepsis. The patient recovered from his septic shock and was discharged home. The pathology report from the operative samples demonstrated crystals characteristic of SPS toxicity and concluded that the patient’s bowel perforation was likely caused by SPS. Discussion: SPS is a cation-exchange resin that binds to potassium in the intestine and can be administered orally as a suspension or rectally as an enema. In vivo, approximately 1 mEq of potassium ions are removed with each 1 gram of SPS given. Common side effects of SPS include nausea, vomiting, and diarrhea. SPS can bind intraluminal calcium and can cause constipation and fecal impaction and is therefore mixed with sorbitol. There have been case reports of colonic necrosis secondary to the use of SPSsorbitol suspension and enemas. Postoperatively patients may have a delay in return of normal bowl function and this delay can lead to accumulation and lead to SPS toxicity. Conclusion: SPS is often thought of as a benign medication without significant risk compared to hemodialysis. In patients with impaired bowel motility SPS should be avoided or used with caution. In our institution we developed a learning module to educate health care providers on the risks associated with SPS in these patients with impaired bowel motility.

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888

DE-ESCALATION OF THERAPY FOLLOWING CARDIAC SURGERY USING HEMODYNAMIC ASSESSMENT WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHIC (HTEE)

FOREIGN BODY IN THE AIRWAY-PATIENT SAFETY CONCERN

Amy Reed, Hospital of the University of Pennsylvania, Harold Hastings, ImaCor, Inc., Jiri Horak, Hospital of the University of Pennsylvania Case Reports: Following cardiac surgery, many patients rely on pharmacological or mechanical support for hemodynamic stability. These therapeutic modalities can have significant complications and titration can be difficult, as hemodynamic parameters of pressure, volume and flow may not follow normal physiological relationships, particularly in the immediate postoperative period. TEE can overcome some of these issues by directly visualizing cardiac size and function. Monitoring the cardiac response to therapeutic manipulations and correlating it with traditional hemodynamic parameters may provide a more complete and accurate assessment of patients’ hemodynamics. We describe here TEE-guided hemodynamic assessment (hTEE) with a miniaturized probe (ImaCor ClariTEE probe, Garden City, NY) to de-escalate therapy in two patients in whom postoperative resuscitation strategies could have been deleterious. The first patient was a 73 yo male who presented for a redo-TAAA repair. The patient had baseline moderate LVH with an EF of 55%. Postoperatively, the patient was admitted to the ICU with a spinal drain on combination high dose inotropes to maintain spinal perfusion, tachycardic with a high CVP. Using hTEE, we were able to rapidly augment his preload, weaning inotropic support, thereby decreasing his heart rate, increasing filling time and forward flow. Importantly all of these manipulations were minimally reflected in the CVP, given his requirement for higher filling pressures in a setting of LVH. The second patient was a 21 yo male with ICM (EF 15%) admitted following LVAD removal. The patient presented to the ICU with an right femoral IABP on high levels of inotropic support. Subsequently, pulses became diminished in his leg distal to the IABP, and there was a concern for limb ischemia, both secondary to the IABP and the vasoconstricive properties of high dose epinephrine. Direct visualization of cardiac function allowed us to rapidly wean mechanical as well as pharmacological support. These two patients demonstrate how direct cardiac visualization over time with hemodynamic assessment guided by TEE can allow for confident and rapid de-escalation of therapy in the ICU.

Nikhil Madan, Christopher Gilbert, Scott Cowan, Thomas Jefferson University Hospital, Rohit Kumar, Thomas Jefferson Univeristy Hospital, Anand Kommuri, Jefferson Pulmonary Associates Case Reports: Introduction: Securing the endotracheal tube (ETT) tube has come a long way from using adhesive tapes to modern ETT holders which clearly show improvement in the rates of self extubations. We report a case of aspiration of a part of the ETT holder as a cause of respiratory failure. Case Report: A 44 year old man admitted with neurological deficits and multiple infarcts from small vessel vasulitis. His hospital course was complicated by respiratory failure from hospital acquired pneumonia requiring mechanical ventilation and eventually a tracheostomy and a percutaneous gastric feeding tube. Patient was transferred to a ventilator weaning facility. Two weeks later he developed shortness of breath, fevers and hypoxia requiring mechanical ventilation and was transferred to another hospital .He was found to have left lower lobe collapse consolidation and a infiltrates on the right upper and middle lobe. He was started on antibiotics for a hospital acquired pneumonia. There he underwent a bronchoscopy which revealed an impacted foreign body in the left lower lobe of the lung. Patient was then transferred back to us for removal of the foreign body. He was taken to the operating room and underwent a flexible bronchoscopy. In the medial basilar segment of the left lower lobe, a plastic foreign body was seen. Using a Fogarty balloon, it was then milked back into the main left bronchus. At that point, a snare was used to encircle and eventually remove it. The plastic piece was then identified as a part of the ETT holder. Patient then had a prolonged but uneventful recovery and was discharged back to the long term facility. Discussion: ETT holders have shown significant improvement in the rates of self extubation. They are now recommended and being widely used through out the world. We report a case where a part of the ETT holder which broke, impacted in the lung and caused pneumonia with respiratory failure. This is a patient safety issue and adequate care needs to be taken when using the ETT holders to prevent such complications.This also emphasizes that if you do see dense collpase consolidation in the right clinical setting, do suspect foreign body aspiration.


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890

PNEUMOCEPHALUS FOLLOWING TRANSPHENOIDAL PITUTARY RESECTION: 26 YEARS LATER

PSEUDOMEMBRANOUS ASPERGILLUS TRACHOEBRONCHITIS AS A CAUSE OF UNDIFFERENTIATED ICU FEVER IN AN IMMUNOCOMPETENT PATIENT

Carol Carrillo, Richard Marshall, Arash Afshinnik, Ochsner Health System, Manish Singh, Tulane University, Vivek Sabhwal, Ochsner Health System Case Reports: Symptomatic pneumocephalus is a rare, but well described complication of transphenoidal surgery. Post-operative placement of nasal tubes or positive pressure ventilation further increases the risk of developing pneumocephalus. The rate of pneumocephalus immediately post-operative is 1–3%, but development of pneumocephalus years after surgery is not well reported. Our case is a 74 year old woman with a history of a transphenoidal surgery, twenty-six years ago, who developed significant pneumocephalus after NG tube placement followed by positive pressure mask ventilation. Our patient was admitted to the neurocritical care service, after being found unresponsive at home and her initial workup revealed a large left MCA stroke. Over the following week, her mental status improved and she was transferred to a regular nursing floor. Upon readmission to the neurocritical care service, nasal gastric (NG) tube placement was attempted; and, per nursing reports, significant difficulty and bleeding was encountered during NG tube placement. That same night, the patient’s mental status significantly declined, requiring positive pressure mask ventilation and intubation. CT scan of the head obtained the following morning demonstrated extensive pneumocephalus and hemorrhage in the pituitary region. Our belief is the hemorrhage on CT scan was secondary to trauma sustained during NG tube placement, which then permitted pneumocephalus formation during positive pressure mask ventilation. The patient was treated with 100% FiO2 for twentyfour hours and repeat head CT demonstrated complete resolution of the pneumocephalus. While symptomatic pneumocephalus is commonly reported as a rare complication immediately after transphenoidal surgery, we report an unusual case of pneumocephalus after NG tube placement twenty-six years following transphenoidal surgery. Very little data exists on the long-term risk of developing pneumocephalus or which procedures to avoid many years after surgery. Our case demonstrates even years after transphenoidal surgery, it may not safe to perform blind nasal procedures such as NG tube placement because of the real risk of developing pneumocephalus.

Romel Del Rosario, Subhan Ahmad, Satish Bagdure, Faisal Khasawneh, Texas Tech University Case Reports: Aspergillus tracheobronchitis is a form of invasive pulmonary aspergillosis that is localized to the tracheobronchial tree. It is characterized by ulcerations and pseudomembrane formation. Diagnosis can be delayed given its non-specific signs and symptoms. This infection has been rarely reported in immunocompetent patients. We report a case of pseudomembranous Aspergillus tracheobronchitis (PATB) as a cause of undifferentiated ICU fever in an immunocompetent patient.A 56 year-old male with no significant past medical history admitted to the ICU with severe sepsis secondary to bowel ischemia. The patient underwent exploratory laparotomy with segmental small bowel resection and right hemicolectomy. Post-operatively, the patient was delirious with poor inspiratory efforts and could not be liberated from mechanical ventilation. On the 7th post-operative day, he started to have new fevers. New cultures were sent and the antibiotic coverage was broadened. Chest X-ray showed basal atelectasis but no definite consolidation. The fever continued leading to changing the central venous catheter and ordering computed tomography of the sinuses, abdomen and pelvis and starting empiric antifungal therapy. The patient’s abdominal CT showed continued left lower lobe atelectasis despite of the early initiation of aggressive chest physiotherapy and bronchodilation. Bronchoscopy was done to rule out mucus plugging. During the procedure, multiple white plaques and superficial ulcers were identified in the distal part of the trachea and proximal main bronchi. Biopsies of the lesions showed fungal hyphae embedded within acute inflammatory exudates and necrotic debris. The hyphae were septate and acutely branching at 45 degrees. The findings were consistent with PATB. The patient was started on voriconazole with resolution of fever and successful liberation from mechanical ventilation.PATB is a rare cause of undifferentiated fever in critically ill immunocompetent patients. Making this diagnosis remains challenging but once made it can be treated successfully.

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892

CLINICAL BRAIN DEATH IN A PATIENT WITH SEVERE BRAIN INJURY WITHOUT CEREBRAL ANGIOGRAPHIC CRITERIA

UTILIZATION OF AN HFPV IN A POST CARDIAC ARREST PATIENT

Maria del Rosario Munoz Ramirez, I T E S M Monterrey Campus, Maria Jose Sebastian Ruiz, UMAE No 25, IMSS, Raymundo Cervantes Tello, IMSS, UMAE No 25, Alicia Cataneo Cerna, IMSS, UMAE No.25, Maria Teresa Macias Garcia, IMSS, UMAE No. 25 Case Reports: Brain death is defined as the irreversible cessation of all functions of the entire brain including the brain stem, and is based in a clinical assessment. In several countries a confirmatory tests are required by law. A selective four vessels angiography is the standard of confirmatory tests and may show lack of contrast opacification of the internal carotid arteries beyond the carotid siphon, and filling of the vertebral arteries but no beyond, their intracranial penetration. Case: A 35-year old woman was transferred from an outside hospital 24 hours after suffering a head gunshot wound with brain parenchyma protruding through a left parietal skull defect. On admission GSC 3, in the next 48 hours she developed brain death. Apnea testing documented an increase of PaCO2 above 60 mm Hg. She was considered a medico-legal case and candidat for organ donation. The confirmatory test was made by cerebral angiography which reported patency of the bilateral carotid arteries displaying filling of the middle cerebral artery and through the anterior cerebral artery, passage of contrast media to the contralateral carotid system. Patency of the basilar artery was observed with passage of contrast media through the posterior communicanting artery to the contralateral carotid artery. However, no cerebral parenchymogram in capillary and venous phase was observed. The organ donation process could not carry out because of legal statements of the Mexican Health Law. Conclusions: Arterial blood flow does not exclude brain death, and cerebral blood flow occurs in those conditions where the intracranial pressure is less than intravascular pressure as in decompressive craniectomy or like in this case by skull defects. The absence of the cerebral deep venous dranaige or parenchymogram may be consistent with brain death and the medical staff should be aware of this findings to avoid losing time for brain death declaration in case of organ transplant.


Felix Khusid, Emma Fisher, Liziamma George, Ahmed Abdelwahed, Vishal Patel, Elias Alhanoun, Hary Suseelan, Suhail Raoof, New-York Methodist Hospital Case Reports: High Frequency Percussive Ventilation (HFPV) is a special mode of ventilation that is delivered by the Volumetric Diffusive Respirator (VDR-4). VDR-4 delivers a flow-regulated, time-triggered, time-cycled, pressure-limited breath with the injected sub-tidal volumes in the range of 100 –900 cycles/ minute,while simultaneously stacking them in a coordinated time-cycled fashion to deliver convective breaths at up to 30 cycles/minute. Lung recruitment is achieved by the creation of an oscillatory FRC as well as subtidal volume stacking that may be a less injurious pattern while minimizing stress and strain exerted on the lung. Injected sub-tidal volumes are utilized to create an expiratory oscillatory CPAP with a lower flowrate than during the inspiratory phase of the breath. Oscillatory CPAP warrants peripheral airway patency with hypothetically decreased cardiovascular compromise. A 34-year-old African American woman has a history of CVA since the age of 20 while pregnant. She had seizures with vomiting blood while in the CT scan and suddenly went into cardiac arrest. Post cardiac arrest patient was extremely hypoxemic, O2 Saturation of 66% on the respirator with the following settings:CMV-20, Vt-580, FiO2–1.0, PEEP⫹12 cmH20. Patient was removed from a ventilator and manual ventilation with the PEEP of 15 cmH20 was initiated, unfortunately O2 Saturation never increased above 71%. As a rescue measure patient was placed on the VDR with the following settings: Convective Rate-16, Percussive Rate-600, Oscillatory CPAP⫹10cmH20, Fi02–1.0.Oxygen Saturation immediately increased to 100% and severe cyanosis was no longer observed. An ABG revealed the following: PH-7.36, PaCO2–30, Pa02–174 ,HCO3–17, 02Sat-100%. Within 5 days on mechanical ventilation the patient was weaned and extubated. In this case the VDR was successfully utilized to improve oxygenation, after all standard means of oxygenation were exhausted. High velocity impulses of gas create a simultaneous expiratory airway counter flow that create a sustained cephalad flow of sufficient velocity to continually mobilize intrapulmonary secretions/blood.

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BEYOND MUDPILES, AN UNUSUAL CAUSE OF HIGH ANION GAP METABOLIC ACIDOSIS: 5-OXOPROLINE

ETOMIDATE INFUSION FOR ADRENAL SUPPRESSION PRIOR TO BILATERAL ADRENALECTOMY FOR AN ECTOPIC ACTH-PRODUCING TUMOR

Jonathan Smith, University of Texas Health Science center at Hosuton, Pratik Doshi, University of Texas Health Science Center At Houston Case Reports: High anion gap metabolic acidosis is frequently encountered in clinical practice. In most scenarios, the etiology of the acidosis is discernible after a careful patient history and performing routine laboratory evaluation. Well known causes of a high anion gap acidosis are described by the commonly used acronym MUDPILES. A less commonly reported cause of a high anion gap metabolic acidosis is 5-oxoprolinemia. This condition can be inherited or acquired, in acquired cases, acetaminophen use is the most commonly reported cause. To date however, only a few case reports document this association. We present a case report of a patient who presented with a high anion gap acidosis secondary to 5-Oxoproline.Case: A 36 year old woman with a past medical history of pancreatitis, alcohol abuse, and chronic hip pain presented with one week of abdominal pain, nausea, and vomiting. Her home medications consisted only of hydrocodone/acetaminophen which she had been taking daily. Her review of systems revealed only chronic diarrhea of 3 months duration. Her physical exam was only significant for tachypnea with a respiratory rate of 32 breaths per minute and mild epigastric tenderness. Initial laboratory evaluation from the emergency department was significant for a serum bicarbonate of less than 5 mEq/l, an anion gap of 26 and a lactic acid level of 5 mmol/L. Electrolytes drawn after arrival to the intensive care unit revealed a serum bicarbonate of 8 mEq/L, an anion gap of 19 and an arterial blood gas showed a pH of 7.28, pCO2 of 18 mmHg, which was consistent with a primary anion gap metabolic acidosis, with appropriate respiratory compensation and a non anion-gap metabolic acidosis. Her repeat lactic acid level was 2.3 mmol/L, and her osmolar gap was within normal limits. Acetaminophen and salicylate levels were not elevated, ethanol was undetectable in the plasma, and there were no serum ketones present. With a history of chronic acetaminophen use and no evidence of other more common etiologies to explain her high anion gap acidosis, a qualitative urine organic acid assay was sent to test for elevated levels of 5-oxoproline, which confirmed the diagnosis.

895

Leah Holschbach, Ceanne Simmelink, David Herrmann, Kim Hoang, Froedtert Hospital, Tracy Wang, James Findling, The Medical College of Wisconsin, William Peppard, Froedtert Hospital Case Reports: Background: Since etomidate reliably inhibits adrenal steroidogenesis, its use as a continuous infusion for maintenance of sedation is now obsolete. However, its cortisol lowering effects may be desirable in unique situations. Case: A 73 year-old, 152 kg female presented with worsening electrolyte abnormalities, edema, and cushingoid features. The diagnosis of adrenocorticotropic hormone (ACTH)-dependent Cushing’s syndrome was made and the patient was transferred to our academic medical center for further care. Upon presentation, the patient’s serum cortisol level was extremely elevated at 101.9 ug/dL. Pre-operative hypercortisolemia has been associated with increased morbidity and mortality. Therefore, an etomidate infusion was initiated to reduce the serum cortisol before proceeding with bilateral adrenalectomy. A 5 mg intravenous bolus (0.033 mg/kg) of etomidate was given followed by a continuous infusion of 2.5 mg/hr (0.016 mg/kg/hr). Cortisol levels were measured every 6 hours. The etomidate infusion was titrated over the next 84 hours to a peak of 5 mg/hr (0.033 mg/kg/hr), resulting in a cortisol level of 15.1 ug/dL. Goal cortisol level (10 –15 ug/dL) was achieved at 94 hours; however, the patient’s hematocrit and hemoglobin were too low to proceed to the operating room at that time. Thereafter the goal cortisol level was maintained with an etomidate infusion of 4.5 mg/hr (0.03 mg/kg/hr). Following 165 hours of etomidate infusion the patient’s cortisol level was 16.4 ug/dL and bilateral adrenalectomy was performed. Throughout treatment the patient’s cortisol levels were inversely related to the dose of etomidate infusion. The patient did not require intubation and no side effects or sedation related to etomidate were noted. Conclusion: A titrated etomidate infusion can safely and effectively lower serum cortisol level prior to a bilateral adrenalectomy for an ectopic ACTH-producing tumor. The maximum infusion of 0.033 mg/kg/hr was lower when compared to other reports of etomidate infusion for Cushing’s syndrome (0.06 mg/kg/hr to 0.3 mg/kg/hr).

896

INVASIVE ASPERGILLOSIS IN A PATIENT WITH IDIOPATHIC THROMBOCYTOPENIC PURPURA

LEMIERRE’S SYNDROME: THREATNING DISEASE

Vamsi Emani, Hardeep Rai, Western Reserve Care System/NEOUCOM

Iram Nawaz, Coney Island Hospital, Padmanabhan Krishnan, Coney Island Hoapital

Case Reports: Invasive Pulmonary Aspergillosis is a rapidly progressive, often fatal infection of severely immuno-compromised hosts. We report an unusual case of Idiopathic Thrombocytopenic Purpura (ITP) patient developing invasive aspergillosis after a short course of corticosteroids and Immunoglobulin (IVIg) therapy. A 69 year old man with a past medical history for ITP, CAD, DM type 2 and splenectomy presented to our hospital with progressively worsening dyspnea, fatigue, and productive cough with whitish sputum for 10 days. During a recent hospitalization, he received IVIg and dexamethasone for epistaxis and persistent thrombocytopenia. On presentation, his vitals were: BP 120/75 mmHg, T 99.7F, HR 80 bpm and SpO2 97% on 4L O2. He was alert and awake and his skin was ecchymotic. Heart sounds were normal and lungs had bibasilar crackles. Abdomen was non-tender with no organomegaly. A CBC showed WBC 20000/uL, 17% bands, 80% PMN and 0% eosinophils. Chest radiograph showed a new nodular infiltrate in the right lower lobe. After obtaining cultures, he was started on IV Vancomycin, Cefepime and Ciprofloxacin. A CT scan of chest revealed multiple nodules ranging in size from 10 mm to 50 mm, with “halo sign,” in both lung fields. A bronchoscopy was done and BAL samples were sent for cytology and microbiology analysis. Serum aspergillus antigen tested positive and BAL cultures grew Aspergillus fumigatus. All antibiotics were stopped and IV Voriconazole was started. Patient showed dramatic clinical improvement and was discharged home on oral Voriconazole. A repeat serum aspergillus antigen tested negative 2 months after initiation of treatment and a follow-up CT scan of chest at 3 months showed remarkable improvement in nodular size. Invasive Aspergillosis is typically a disease of highly immune-compromised persons and is a leading cause of infection-related death in these patients. The mechanism of infection in our patient after a short course of steroids can be explained by compromised phagocytosis of macrophages and neutrophils. Early detection and prompt treatment of these patients is needed to prevent life threatening cerebral dissemination.

A

MISDIAGNOSED,

LIFE

Case Reports: Introduction: Lemierre’s disease is a rare oropharyngeal infection caused predominantly by Fusobacterium necrophorum. Infection of deep pharyngeal tissue allows organisms to drain into the lateral pharyngeal space containing carotid artery and internal jugular vein, resulting in septic thrombophlebitis of the internal jugular vein. Case Report: A 20 years old female presented with sore throat and fever. She was hypotensive, tachycardiac, tachypneic and had pharyngeal erythema on exam. She was admitted to the MICU and was screened for HIV, EBV, CMV, HSV GC/Chlamydia and Influenza. Blood cultures grew Fusobacterium Necrophorum. Patient remained febrile despite use of broad spectrum antibiotics for 1 week when she complained of left sided neck pain. Also noted was erythema and tenderness along the border of sternocleidomastoid. CT scan revealed thrombus in left IJ vein extending from its origin at base of skull to the origin of left Subclavian vein. In view of extent of thrombus and persistent fever, she was given anticoagulation therapy for 2 weeks. Discussion: Lemierre’s syndrome, also known as Jugular vein suppurative thrombophlebitis and postanginal sepsis is predominantly seen in healthy, young adults. The causative organisms are usually members of normal oropharyngeal flora, Fusobacterium necrophorum being most common. Septic emboli to the lung are common but can also involve other sites, causing septic arthritis, and/or osteomyelitis. CT scan of the neck is a useful diagnostic tool which may reveal filling defects. Treatment should be focused on prompt use of IV antibiotics, and consideration of surgical intervention and/or anticoagulation. Empiric therapy should include a beta-lactamase resistant beta-lactam antibiotic. Surgical intervention is generally reserved for patients who do not responded to antibiotics. There is not enough data to support the role of anticoagulation for Lemierre’s syndrome, some authors favor anticoagulation only if there is evidence for extension of thrombus. Conclusion: Lemierre’s syndrome remains a rare but life threatening problem. Early recognition and prompt action is the key against this sporadic and fatal illness.


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898

RECURRENT ASYSTOLIC EPISODES ASSOCIATED WITH ENDOTRACHEAL SUCTIONING: ROLE OF NEBULIZED ATROPINE SULFATE

CURIOUSLY RARE CASE OF HYPONATREMIA WITH CONTINUOUS VASOPRESSIN INFUSION FOR SHOCK

Paul Shea, Jean Conner, Rupal Bhakta, Michael Spaeder, Children’s National Medical Center Case Reports: The practice of endotracheal (ETT) suctioning is common in the PICU in intubated patients requiring mechanical ventilation. The bradycardia witnessed in patients undergoing ETT suctioning has been hypothesized to result from a vagal reflex initiated by stimulation of the airway mucosa by the suction catheter passing beyond the tip of the ETT. We present the case of a patient with multiple episodes of bradycardia progressing to asystole associated with ETT suctioning and explore the use of nebulized atropine sulfate as a pretreatment to prevent these episodes. AM is a 17-year-old previously healthy male who presented to our institution with methicillin-sensitive staphylococcus aureus sepsis, osteomyelitis/myositis and respiratory failure. On the 4th hospital day, while undergoing ETT suctioning AM experienced a 10 second episode of asystole noted by an absence of cardiac activity on cardiorespiratory monitoring associated with lack of arterial blood pressure wave form resolving without intervention. Approximately 12 hours later, the patient had a second asystolic episode associated with ETT suctioning lasting 20 seconds. Laboratory investigation and consultation with Cardiology yielded no obvious etiology of the episodes. Despite the use of bolus sedative medications, neuromuscular blockade and 2% lidocaine via ETT, AM experienced an additional 6 episodes of asystole. We initiated treatment with 2 mg atropine sulfate in nebulized solution via ETT 30 minutes prior to ETT suction. AM experienced no symptoms of tachycardia, blood pressure changes, arrhythmias or systemic evidence of atropine toxicity during the administration of nebulized atropine. Over the next 7 days, AM remained intubated and received 2 mg of nebulized atropine sulfate 30 minutes prior to ETT suctioning with the addition of the 2% lidocaine. The patient had no further episodes of asystole. As observed in this case study nebulized atropine was effective in decreasing bradycardia associated with ETT suctioning. Maintenance therapy with nebulized atropine may be a safe and effective alternative to intravenous atropine or glycopyrrolate for controlling bradycardia associated with ETT suctioning.

Shilpa Shah, Cincinnati Children’s Hospital, Rajit Basu, Cincinatti Childrens’s Hospital Case Reports: Introduction: Though the typical dose of continuous vasopressin infusion for vasodilatory shock in children is 20 – 60x higher than that used for the treatment of diabetes insipidus, the incidence of vasopressin induced hyponatremia in this setting is very low: reported incidence in adults and children is 0 –1%. We report an example and explore potential mechanisms for such rare occurrence. Case Report: A previously healthy 16 month old male was admitted to the PICU for pneumonia and septic shock. Laboratory findings included metabolic acidosis and bandemia. After initial fluid resuscitation (60 ml/kg of isotonic fluids), intubation, and administration of antibiotics, vasoactive infusions were initiated. When epinephrine infusion reached 0.4 mcg/kg/min, vasopressin was added and titrated to 0.06U/kg/hr (0.001U/kg/min). Over the next 16 hours, oliguria improved, but urine output remained between 1–2 ml/kg/hr. A subsequent serum sodium was 125 mmol/L (initial sodium 139 mmol/L). Vasopressin infusion was discontinued producing an immediate diuresis (urine output approached 10 ml/kg/hr). The serum sodium rose to a max of 158 mmol/L. With appropriate fluid and electrolyte management, urine output and sodium level normalized. After full recovery, the patient was discharged from the ICU. Discussion: The physiologic response to exogenous vasopressin is altered from baseline in the shock state. Effects seen in patients with shock include hypersensitivity to the cardiovascular effects of vasopressin, increase in urine output, and, unlike that observed in our case, absence of hyponatremia. Proposed and/or demonstrated mechanisms for the discrepant effects in shock include low vasopressin levels (though inconsistently demonstrated) and altered receptor sensitivity and function. The former may occur via depletion of central stores or impairment of secretion by nitric oxide, while the latter may occur through impaired baroreceptor and osmoreceptor responses. Further exploration into the physiology of vasopressin in the shock state is warranted.

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POST-OPERATIVE HYPOXIA-IS IT PULMONARY EMBOLISM OR ABDOMINAL SEPSIS?-DIAGNOSIS MATTERS

MANAGEMENT OF A CRITICAL AIRWAY SECONDARY TO A MASSIVE MEDIASTINAL MASS

Satyanarayana Reddy Mukkera, Mount Sinai Hospital, John Oropello, Mount Sinai School of Medicine, Aditya Uppalapati, Zafar Akram Jamkhana, Mount Sinai Hospital, Anthony Manasia, Mount Sinai Medical Center, Adel BassilyMarcus, Mount Sinai School of Medicine- Mt. Sinai Hospital

Mihaela Damian, Lucile Packard Children’s Hospital, Alisa Van Cleave, Stanford University, Veena Goel, Lucile Packard Children’s Hospital, Saraswati Kache, Center For Excellence In Pulmonary Biology, Madelyn Kahana, Stanford -Lucile Packard Children’s Hospital

Case Reports: Introduction: Severe abdominal sepsis can have many metamorphic presentations. We present a case of acute abdominal sepsis mimicking the clinical picture of massive pulmonary embolism (PE). Case Report: A 49-yearold male with cirrhosis secondary to hemochromatosis was admitted to the ICU, status post liver transplantation. During recovery, on day 6, he acutely became tachycardiac (sinus tachycardia), hypotensive (72/34) and hypoxic (PaO2 of 47 on 100% FiO2) requiring aggressive fluid resuscitation and vasopressors. On exam bilateral air entry was good. Lung ultrasound demonstrated bilateral lung sliding and a-lines, ruling out pneumothorax and massive atelectasis. Chest x-ray was normal. A stat TEE demonstrated no thrombus in the pulmonary trunk and proximal pulmonary arteries. Right ventricle was normal in size and the left ventricle was hyperdynamic with near complete collapse of the cavity in systole. No left ventricular outflow tract obstruction or pericardial effusion was seen. An emergent exploratory laparotomy demonstrated purulent fluid collections in the right upper quadrant, which were drained and lavaged. Post operatively the requirement for pressors ceased and the oxygenation improved to 96% on 40% Fio2. Discussion: This case suggests that patients with post operative abdominal surgery presenting with hypoxemia, hypotension, and tachycardia should be strongly considered to have intraabdominal sepsis. In the postoperative state, due to decreased mobility, PE is very high on the differential diagnosis, but may be less common than sepsis in general surgery patients. Acute abdominal sepsis can often mimic PE with acute hypoxia, tachycardia and hypotension. Sepsis causes cellular hypoxia and severe vasodilatation due to inflammatory mediators such as nitric oxide leading to refractory shock. Failure to recognize or preemptively anticoagulating these patients can result in further morbidity and mortality. A rapid bedside TEE can rule out massive PE eliminating the need for thrombolytics and also avoiding the transport of unstable patients to CT angiogram.

Case Reports: A 2 year-old presented with a 1 week history of fever increased work of breathing and decreased level of activity. CXR and CT revealed a large mediastinal mass with right-sided tracheal deviation. On admission he was very pale, fatigued and tripoding. 8 liters per minute of oxygen by HFNC was initiated. Laboratory data were unremarkable. A bone marrow biopsy and a tru-cut biopsy of the mass were performed with local anesthesia only. Steroids and emergent radiation treatment were initiated and did not improve the patient’s clinical status even after 48 hours. Our ECMO team was on standby for all procedures. Initial biopsy results showed a small blue-cell tumor and the bone marrow results were non-contributory. On day 4 his work of breathing and his perfusion worsened. The decision to perform surgical debulking was made. Induction of anesthesia was significant for hypotension responsive to fluid bolus and epinephrine infusion. On intubation the airway was shifted to the right. The axis of the larynx was torqued and canted so that the vocal cords were in an angle of 45 degrees and the laryngeal inlet was rotated upward. After opening of the sternum a large mass filling the left thoracic cavity and the middle mediastinum causing severe tracheal deviation was visualized. Due to the large mass and lack of viable left-sided pulmonary tissue a left pneumonectomy was performed. Post-operatively the left side of the chest cavity was filled with normal saline and a chest tube to water seal was in place for 2 days. Mechanical ventilation was achieved on a volume mode with low tidal volume and pressure limiting the PIP to 18 in order to minimize the trauma to both the left bronchial stump and the right lung. Although the patient was tachpenic he was successfully extubated on post-op day 4. Pathology confirmed the diagnosis of PPB-type 3. He was reintubated for airway protection during an MRI and his airway anatomy was normal. He had no bone or brain metastasis. To our knowledge this is the first patient with a massive PPB type 3 who successfully underwent urgent surgical tumor removal without any prior chemotherapy.


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PNEUMATOSIS INTESTINALIS FOLLOWING LACTULOSE USE

OLANZAPINE-INDUCED PROLONGED HYPOTHERMIA IN PATIENT WITH RENAL FAILURE

Ravi Agarwala, University of Rochester Medical Center

Sanket Patel, Ankit Kansagra, North Shore Medical Center, Susan Wilcox, Massachusetts General Hospital

Case Reports: Lactulose is a commonly used laxative in the ICU. We report an unusual complication of its use. A 43 year-old woman was admitted for hepatic failure due to an acetaminophen overdose. She was intubated for aspiration due to altered mentation. The patient was started on lactulose and rifamixin for hepatic encephalopathy (HE). Ten days later, her hepatic function had recovered and she began to wean from the ventilator. She then abruptly decompensated with fever, tachypnea and hypotension. Because of abdominal distention and diarrhea, computed tomography of the abdomen was performed. This revealed diffuse bowel dilatation and pneumatosis within the small and large bowel wall. There was air in the portal vein, but all vessels were patent and no peumomediastium was noted. At laparotomy, the bowel was distended and gas was palpable in wall, but no perforation, peritoneal contamination or ischemia was noted. Stool was negative for C difficile. Pneumatosis intestinalis (PI) is defined as the presence of gas within the bowel wall. It is associated with a variety of conditions characterized by mucosal injury and increased intraluminal pressure. While often benign, it is occasionally life threatening. There are several reported cases of PI associated with lactulose use. Lactulose is a non-absorbable disaccharide used as an osmotic laxative and to promote ammonia excretion in HE. Fermentation of lactulose by gut bacteria can lead to gas production. ICU patients may be at particular risk for PI as they may be unable to report discomfort from distention. Constipation in the ICU is associated with poorer outcomes, thus regular stooling is important. When compared, both lactulose and polyethylene glycol (PEG) are effective for constipation in the ICU, but colonic pseudo-obstruction is more common with lactulose. Given the risk of pseudo-obstruction and subsequent PI, we suggest that PEG may be the better laxative in the ICU. Patients receiving lactulose for HE should be monitored closely for abdominal distention and the dose should be carefully titrated.

903 NITROPRUSSIDE INDUCED HYPOXIA Christine Waller, University of Iowa Hospital and Clinics, Sundar Krishnan, University of Iowa Hospitals and Clinics Case Reports: In this case report, we present our experience with two patients who developed hypoxia after intravenous sodium nitroprusside (SNP) therapy was started, followed by resolution of hypoxia within minutes of stopping the medication. Both patients presented with acute ascending aortic dissection and hemopericardium, underwent ascending aortic repair under deep hypothermic cardiac arrest and were admitted to the intensive care unit (ICU) postoperatively. For patient one, a 67 year old male, SNP therapy was started on postoperative day 1 for control of systemic blood pressure titrating to 1.0 mcg/kg/min. This resulted in decreasing SpO2 from 99% to 80%, with increasing Fi02 requirements from 45% to 80%. Correction of the hypoxia was noted within minutes after cessation of SNP. For patient two, a 46 year old male, SNP infusion was titrated up to 0.4 mcg/kg/min. because of hypertension soon after arrival to the ICU. Over the next 30 minutes, the SpO2 was noticed to decrease from 97% to 55%, with increased Fi02 requirement from 40% to 80%. Correction of SpO2 was again noted within minutes of SNP cessation. Blood pressure was controlled successfully in both patients with hydralazine and labetalol. Hypoxia induced by SNP therapy is a well-described phenomenon (1–3); however there is little mention of this phenomenon in recent literature. Postoperative patients develop microatelectasis from intraoperative positioning, anesthesia and muscle relaxants. The atelectasis induces reflex hypoxic pulmonary vasoconstriction (HPV). SNP therapy increases intrapulmonary shunt due to inhibition of HPV. Patients with COPD have blunted HPV reflexes, resulting in an absence of SNP-induced shunting (1). In patients undergoing induced hypotension for major spinal surgery, SNP caused a 122% increase in intrapulmonary shunt, compared to an 11% increase when labetalol was used (2). This case report emphasizes the need to understand the pathophysiology and alternative options for managing hypertension in postoperative patients. References: 1. Casthely PA et al. Anesth Analg 1982;61: 231–5. 2. Goldberg ME et al. Anesth Analg. 1990;70:537– 42. 3. Dennehy KC et al. CJA 1999; 46(1): 56 – 60.

Case Reports: Hypothermia is an infrequent but well-known adverse effect of antipsychotic medications. We present the second case of prolonged hypothermia from olanzapine in a patient with renal failure published in the English literature. An 80-year old man with a history of diabetes, stage III chronic kidney disease and bipolar disease presented with altered mental status and difficulty breathing. His significant vital signs were rectal temperature of 88.20F and heart rate of 33 beats per minute. He was alert but disoriented and in mild respiratory distress. The remainder of his exam was within normal limits. His medications included aspirin, insulin, amlodipine and olanzapine. Significant laboratory data were potassium of 5.5 meq/L and creatinine 1.5 mg/dl, with a creatinine clearance of 43 ml/min. His TSH, random cortisol level and lactate were normal. Toxicology screens were negative. Head CT showed no acute intracranial process. He was admitted to the ICU and was initially treated for sepsis of unknown source with broad spectrum antibiotics. Hypothermia was managed with a forced-air warming system. Further investigations to evaluate for hypothermia included spinal fluid analysis and MRI, both unremarkable. His antibiotics were discontinued after 6 days when no source of infection was found and culture data were without growth. His hypothermia resolved on day 9, with a normalized temperature of 970 F. After other causes of hypothermia were excluded, olanzapine was concluded to be the culprit. Olanzapine is a predominant 5-HT2 receptor antagonist primarily used for treatment of schizophrenia and bipolar disorder. Hypothermia is caused by an imbalance between dopaminergic and 5-HT2 receptor activation. Our patient had prolonged hypothermia for 9 days after his last dose of olanzapine, which could be explained by olanzapine’s long half life of 32–38 hours, large volume of distribution of 1,000 liters and 57% renal excretion. We emphasize the importance of awareness of prolonged hypothermia in patients taking antipsychotics with renal failure, careful observation in monitored setting and prompt management of hypothermia before severe complications arise

904 UNUSUAL PRESENTATION OF CLOSTRIDIUM BOTULINUM INFECTION Jennifer Severing, Univesity Hospital East- OSUMC, Randy Mills, The Ohio State Medical Center, Meredith Deutscher, The Ohio State University Medical Center Case Reports: A healthy, 29- year-old man presented to an outside hospital reporting several days of low-grade fevers, nasal congestion and headaches, which then progressed to dizziness, nausea, continued headaches and blurred vision. He developed dysphagia, dysarthria, and respiratory failure and was tentatively diagnosed with Guillian-Barre syndrome. He required mechanical ventilation and was transferred for further management to our institution. On transfer, vital signs and laboratory values were within normal limits and had 100% O2 saturation on assist control mechanical ventilation with a rate of 15, FiO2 35, tidal volume 550 ml and PEEP 5 mmHg. Musculoskeletal examination revealed 2/5 muscle strength in upper and lower extremities with no loss of sensation. Neurologic workup showed findings more consistent with myasthenic syndrome, but subsequent EMG showed smaller amplitude evoked muscle action potentials upon repetitive nerve stimulation with incremental response, consistent with neuromuscular junction disorder, concerning for botulism poisoning. Directed interview with patient and family revealed consumption of commercially processed potato soup from a bulging plastic container four days prior to admission. Stool samples sent to CDC for testing revealed the presence of botulism toxin A. Heptavalent botulinum antitoxin obtained from CDC and metronidazole were administered approximately 8 days after exposure to contaminated food product. The patient underwent tracheotomy and percutaneous endoscopic gastrostomy and then transferred to a rehabilitation facility after 57 days of hospital admission. This case illustrates an atypical presentation of foodborne botulism, and highlights factors that complicate what is already a complicated diagnosis. This is a common scenario critical care practitioners face, where patients transfer with presumed diagnosis and limited information.


905 A RARE CAUSE OF MALIGNANT HYPERTENSION Pratik Doshi, Artur Grigoriyan, University of Texas Health Science Center At Houston Case Reports: Introduction: Malignant hypertension is recognized as a medical emergency. The etiology of the malignant hypertension requires a broad differential and an extensive diagnostic algorithm. Metanephric Adenoma is a rare tumor histologically similar to Wilm’s tumor, with the major difference being the benign course for this tumor. We present a case report of a young patient who presented with malignant hypertension secondary to Metanephric adenoma.Case: 19 year old caucasian male who was admitted to our ICU with hypertensive emergency. He was well and had no medical problems until 2 weeks prior to presentation at which time he developed nausea, vomiting, fever and diarrhea. This was initially thought to be a viral illness, however his symptoms progressed to include blurry vision, unsteady gait and alteration of consciousness, at which time he presented to the hospital. He was found to be lethargic with an elevated blood pressure of 255/177. His laboratory evaluation revealed thrombocytopenia, with a microangipathic anemia with schistocytes, acute renal failure with a creatinine of 3.2 and anuria. Patient was initiated on nicardipine and intubated for airway protection and admitted to the ICU. MRI of the brain revealed multiple infarcts secondary to uncontrolled hypertension. His toxicology screen was unremarkable. Further evaluation for the etiology of the malignant hypertension included evaluation for pheochromocytoma and renal ultrasound to rule out renal artery stenosis, both of which were normal, however the ultrasound of the kidney did reveal a renal mass, which was confirmed with an MRI, and had no features of vascular involvement. Further exhaustive diagnostic evaluation did not reveal an etiology of the malignant hypertension, at which time a biopsy of the renal mass was performed. The biopsy was consistent with metanephric adenoma. To our knowledge, this is the first case report of metanephric adenoma presenting with malignant hypertension. Metanephric adenoma is a benign variant of Wilm’s tumor which is generally found as an incidental findings and when there are clinical findigns, they generally are milder symptoms of abominal pain and hematuria.

906 USE OF RECOMBINANT FACTOR VIIA DURING INITIAL PRESENTATION OF ACUTE IMMUNE THROMBOCYTOPENIC PURPURA IN A PEDIATRIC PATIENT Reut Gurion, Rainbow Babies & Children’s Hospital, Anita Siu, Ernest Mario School of Pharmacy at Rutgers, the State University of NJ, Aaron Weiss, University of Medicine and Dentistry of New Jersey, Margaret Masterson, University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School Case Reports: Background: Severe bleeding is a rare complication seen in acute immune thrombocytopenic purpura (ITP). This case report contributes to the limited pediatric literature available on the use of recombinant factor VIIa (rFVIIa) during an initial presentation of ITP with hemorrhagic complications. Case Report: A 12 year old Caucasian female presented with hematuria, petechiae and ecchymosis. Severe thrombocytopenia (platelets of 1 x 109/L), hematuria and a positive antinuclear antibody were seen. All other initial laboratory tests were normal. The hospital course was significant for refractory thrombocytopenia, hematuria, and the development of anemia. The patient received anti-D immune globulin (75 mcg/kg), followed later by IVIG (2 g/kg/dose). On fourth day of hospitalization she developed sudden onset of temporal headache and was transferred to the pediatric intensive care unit. She further received methylprednisolone pulse dosing (250 mg IV every six hours) and a second course of IVIG. Despite these measures no recovery was seen. As a result, rFVIIa (30 mcg/kg/ dose) was administered and the hematuria improved within an hour. Discussion: Recombinant factor VIIa can stop active bleeding quickly but the effect is brief with an approximate half life of 1.3 hours in children. Data regarding the use of rFVIIa in children with ITP is limited. Previous reports describe the use of rFVIIa in eight children with acute, chronic and refractory ITP. A recent study reporting on the safety of the off-label use of rVIIa collected from 35 randomized clinical trials showed a higher risk of arterial, but not venous, thromboembolic events most notably among the elderly. A clinical trial evaluating the off label use of rFVIIa in the pediatric population revealed that thrombotic events occurred in 4.3% of children (with highest incidence in the neonatal population). Conclusion: For children presenting with acute ITP and severe bleeding refractory to standard therapy, rFVIIa offers a rapid and safe alternative. Limited data in this population exists supporting the routine use of rFVIIa in this setting; therefore, further investigation is needed.

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CASE REPORT: UNDIAGNOSED HYPOTHYROIDISM PRESENTING AS MYXEDEMA COMA POST-OPERATIVELY

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) FOR MANAGEMENT OF CRITICAL TRACHEAL OBSTRUCTION

Betty Medeiros-Beattie, Antonio Aponte-Feliciano, Steven Heard, University of Massachusetts Memorial Medical Center Case Reports: A 56 year-old Albanian female was scheduled for an elective rotator cuff repair. She had a past medical history of diabetes mellitus type 2, carpal tunnel syndrome, hypertension, and dyslipidemia. Home medications included metformin, lisinopril, and simvastatin. Physical exam and preoperative evaluation were noted to be unremarkable. Preoperatively, an interscalene nerve block for post-operative pain control was performed. Induction agents were propofol 130 mg, and fentanyl 100 mcg. Muscle relaxation was obtained with rocuronium 50 mg without subsequent redosing. After endotracheal intubation, anesthesia was maintained with Sevoflurane 1.8 end tidal % and an FiO2 of 0.61. She was placed in the beach chair position and the remainder of the two-hour surgery was unremarkable. At the completion of the case the patient was breathing spontaneously and following commands. She was extubated and transferred to the post anesthesia care unit. Over the next few hours she was noted to be obtunded which did not improve after an appropriate period of time in which the anesthesia would have been expected to dissipate. Neurologic exam showed no focal signs and lung sounds were clear. Her tongue was noted to be enlarged, but no other positive findings were observed. Post-operative laboratory studies included a glucose level of 170 mg/dL and hemoglobin of 9 g/dL. She was treated with neostigmine 5 mg and glycopyrrolate 1 mg for possible residual paralysis, with no apparent clinical change. An arterial blood gas was performed demonstrating mild hypercapnia with a pH of 7.31 and PaCO2 58 mmHg, therefore placed on BiPAP. A head CT was obtained but showed no acute abnormality. Thyroid function tests were performed and the results indicated that she had Hashimoto’s thyroiditis: TSH was 122 uIU/mL (normal range 0.28 –3.89), free T4 was 0.27 ng/dL (0.58 –1.64), and thyroid peroxidase antibody ⬎1000 IU/mL (⬍35). She was started on levothyroxine therapy and after 24 – 48 hours she gradually emerged from her myxedema coma state with eventual return to her baseline. After one month of treatment her TSH levels decreased to the normal value of 2.2 uIU/mL.


Pankaj Mehta, State University of New York Upstate Medical University, Shahzad Jokhio, David Wormuth, Gregory Fink, SUNY Upstate Medical University, Robert Lenox, State University of New York Case Reports: A critical large airway narrowing challenges traditional techniques for perioperative airway management. Case: We present the case of a 46-year-old woman who presented with dyspnea for 4 weeks. Her symptoms were worse when supine with desaturation to 60’s. CT revealed a large right mediastinal mass with significant tracheal compression down to a tiny sliver of air 2 mm in diameter. We planned a tracheal stent placement however the airway was extremely tenuous for any form of anesthesia. She was placed on ECMO to secure the airway. ECMO was initiated in a near standing position and neurologically intact. The patient was then laid supine and a 16 mmx4cm polyflex tracheal stent was passed under fluoroscopic guidance. The stent was however just a few millimeters higher than optimal but attempts to reposition it with the ET tube were not successful due to the significant airway narrowing. ECMO was weaned and patient admitted to ICU and chemo-radiation initiated. Bronchoscopy with transbronchial biopsy confirmed the diagnosis of non-small cell lung cancer. Weaning attempts however failed. She was taken back to the operating room and the right and left lobe major bronchi were dilated and a Dynamic Y-stent inserted. The patient had a significant improvement in the airway diameters and was successfully weaned from mechanical ventilation. Discussion: Excellent clinical outcomes have been reported in pediatric literature for using ECMO as a bridge to definitive tracheal reconstruction, in neonates born with severe tracheal anomalies. Data in the adult world is however lacking. This case highlights the successful use of ECMO in management of critical airway narrowing which would have precluded a tracheal stent placement if done under routine anesthesia. Airway stenting can provide efficient palliation of symptoms in patients with malignant airway-obstructions. There are two main categories of airway stents-‘silicone stents’ and ‘self-expanding metal stents’. Involvement of the lower trachea/carina and proximal mainstem bronchi usually requires the use of a Y-shaped stent, which proved very effective for weaning and symptom relief in our patient.

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SEVERE ANGIOEDEMA AS COMPLICATION OF ATYPICAL HEMOLYTIC UREMIC SYNDROME DUE TO C3 MUTATION

A RARE PRESENTATION OF INVASIVE CANDIDIASIS: AUTOPSY-PROVEN CANDIDA PNEUMONIA IN A 23 YEAR OLD MALE

Mihaela Damian, Lucile Packard Children’s Hospital, Saraswati Kache, Center For Excellence In Pulmonary Biology Case Reports: A 2 years old female with atypical Hemolytic Uremic Syndrome due to C3 mutation was admitted to the pediatric ward for an acute flare. Previous flares were responsive to FFP infusions. She was initiated on daily FFP transfusions and diuretics. On day 7 due to pulmonary edema, increasing work of breathing and oxygen requirements. She was transferred to the PICU. She was intubated for hypoxic respiratory failure. During direct laryngoscopy the epiglottis was noted to be inflamed red and edematous. 3 hours after intubation the patient began to develop tongue swelling. No leak was elicited around her endotracheal tube suggesting entire upper airway edema. Due to the critical airway deep sedation and muscle paralysis were maintained. Steroids were initiated for concerns of an allergic reaction. An anaphylactic reaction was ruled out as the trypase level was within normal levels. For the following 3 days despite intensive treatment with steroids and low dose epinephrine infusion the patient had progressive upper airway edema and tongue swelling as it tripled in size. The patient’s atypical HUS was poorly controlled during this time despite daily FFP infusions as was demonstrated by decreasing C3 levels and a rising creatinine. Due to concerns of angioedema and pulmonary edema caused by hyper-activation of the complement system plasmapheresis was initiated. Within 5 days of plasmapheresis her angioedema began to improve. She was successfully extubated after 10 days. Treatment with monoclonal antibody anti C5-Ecluzimab was initiated. Since this event she has been on regular Ecluzimab infusions without any additional HUS flares to date. To our knowledge this is the first report of a severe acute angioedema secondary to atypical HUS due to C3 mutationin in which the airway edema could not be controlled with standard of care treatment as she required plasmapheresis to control it and to treat her HUS flare.This can theoretically result in increased levels of complement fragments such as C5a and C3a which can lead to increased vascular permeability or mast cell degranulation. Pulmonary edema and angioedema can result in a non-allergic reaction.

David Green, Paul Cook, Mark Mazer, East Carolina University Case Reports: A 23 year old male, with type 1 DM and Sickle Cell trait, was admitted to the ICU for management of worsening pneumonia, having failed a 10 day course of azithromycin, piperacilin/tazobactam and vancomycin. Vital signs on admission were: BP-110/70,HR-130,RR-28,T-101.5F and O2 saturations of 95% on a 100% NRB. A chest CT revealed dense consolidation of the right lower lobe. The WBC count was 28.6, with 10 –20% bands and BAL cultures grew only 4⫹ yeast. His ICU course was marked by ARDS, septic shock and AKI requiring use of mechanical ventilation, multiple vasopressors, hydrocortisone and CVVH. He remained febrile despite therapy with linezolid, doripenem and tobramycin. After developing profound hemodynamic instability refractory to vasopressor support, he expired on his 6th ICU day. 6 sets of blood cultures remained negative for fungal growth, however 1 urine culture returned positive for Candida albicans. An autopsy revealed scattered, non-encapsulated budding yeast on GMS stains of lung parenchyma, consistent with Candida species. No other organisms were seen and postmortem lung tissue cultures grew only Candida albicans. Discussion: We describe a case of autopsy-proven pulmonary candidiasis in a non-neutropenic, critically ill 23 year old male. Candida pneumonia, an extremely rare form of invasive candidiasis, requires histopathologic evidence of tissue invasion for definitive diagnosis. It occurs either through hematogenous seeding of the lungs or from aspiration of gastric contents. A large retrospective review of autopsy records over 20 years at a large cancer center, reported an incidence of autopsy-proven Candida pneumonia of only 0.4%, with a mortality rate of 84%. The poor diagnostic yield of BAL cultures in identifying Candida pneumonia was highlighted by a recent prospective autopsy series performed over 2 years, which noted a 57% incidence of Candida in respiratory secretions, without a single case of autopsy-proven Candida pneumonia. Our case history underscores the need for better clinical prediction rules and microbiologic criteria to help guide clinicians toward arriving at a rapid diagnosis of this devastating form of invasive candidiasis.

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PERIOPERATIVE VERY LATE CORONARY STENT THROMBOSIS AFTER 69 MONTHS CAUSING ST-ELEVATION MYOCARDIAL INFARCTION AND CARDIOGENIC SHOCK

SEVERE SEPSIS WITH CLOSTRIDIUM TERTIUM BACTEREMIA IN AN IMMUNOCOMPETENT HOST

Markos Kashiouris, Anil Paturi, James Onigkeit, Mayo Clinic Case Reports: Coronary stent thrombosis is defined as acute (within the first 24 hours), subacute (up to 30 days), late (up to a year) and very late stent thrombosis (more than a year after stent deployment). Recently, there have been new concerns about very late stent thrombosis in drug-eluting stents (DES). We present a case of a 70 year-old man who had a lethal very late stent thrombosis 48 hours after discontinuation of aspirin. Presentation: A 70 year-old man with a past medical history for coronary artery disease status post placement of paclitaxel drug-eluting stents in the proximal left anterior descending (LAD) and mid right coronary artery (RCA) in June 2005 was admitted for an elective C1-T1 laminectomy for cervical radiculopathy. After stent placement, he received dual antiplatelet therapy with clopidogrel 75 mg daily and aspirin 325 mg daily for one year and continued on aspirin 81 mg daily thereafter. He was evaluated preoperatively and aspirin was discontinued five days prior to surgery. The intraoperative course was unremarkable. Forty-eight hours after surgery he had an ST elevation myocardial infarction (STEMI). Coronary angiogram showed acute in stent thrombosis of both the LAD and RCA stents. He rapidly developed cardiogenic shock requiring emergent placement of a percutaneous left ventricular assist device. Unfortunately, despite further resuscitative efforts the patient died in the cardiac catheterization laboratory. Discussion: Late stent thrombosis with DES has been reported to occur up to 70 months after stent placement. Our patient had a STEMI secondary to simultaneous stent thrombosis in both stents 69 months post placement and five days after discontinuation of aspirin. Discontinuation of antiplatelet medications has been strongly associated with DES thrombosis. Conclusion: Very late in stent thrombosis is a serious complication which can occur after discontinuation of antiplatelet therapy. Clinicians who manage patients in the perioperative period should be aware of this delayed and potentially lethal complication when making decisions on discontinuation of antiplatelet therapy, even several years after DES implantation.

Naveed Hasan, Nikhil Madan, Thomas Jefferson University Hospital, Rohit Kumar, Thomas Jefferson University, Bharat Awsare, TJUH Case Reports: Introduction: Clostridium tertium (C. tertium) bacteremia is a life threatening infection usually associated with immunosuppression and gastrointestinal pathology. We describe a case of C. tertium bacteremia in an immunocompetent host with acute cholangitis. Presentation: A 45-year-old woman with history of hepatic hemangiomatosis was admitted with abdominal pain, fever, and chills. She had multiple episodes of acalculous cholangitis from intrahepatic ductal obstruction secondary to hemangiomas requiring multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures and stent placements. She deteriorated rapidly requiring mechanical ventilation and vasopressors. Abdominal ultrasound showed common bile duct dilatation. ERCP and balloon extraction revealed purulent bile. She was started on vancomycin and piperacillin/ tazobactam on day 1 and switched to daptomycin, meropenem, and tobramycin on day 2. Initial blood cultures isolated Enterococcus faecium, Klebsiella pneumoniae, Pseudomonas aeruginosa, and C. tertium. The latter grew in an anaerobic bottle and was susceptible to imipenem and metronidazole, intermediate to penicillin, and resistant to clindamycin. C. tertium alone continued to be isolated until day 5 with persistent fever and leukocytosis. Intravenous metronidazole was then added. Blood cultures subsequently sterilized, but the patient expired from complications of severe sepsis. Discussion: C. tertium is an aerotolerant gramvariable rod. Its identification and treatment are frequently delayed. The traditional risk factors for C. tertium bacteremia have been neutropenia, intestinal mucosal injury and prior beta-lactam use. To the best of our knowledge, our patient is only the second immunocompetent patient with C. tertium bacteremia. Vancomycin, metronidazole, imipenem, and fluoroquinolones have been reported to have activity against it. We conclude that C. tertium bacteremia should be suspected even in immunocompetent patients with intestinal mucosal injury.


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PHYSIOLOGIC MEASUREMENTS INCLUDING ABSOLUTE CEREBRAL TISSUE OXYGEN SATURATION DURING CARDIAC ARREST

UNUSUAL PATHOGEN IN A PATIENT WITH FULMINANT LIVER FAILURE CAUSING SEPTIC SHOCK

Henrik Wagner, Skane University Hospital, Lund, Bjarne Madsen Hardig, Jolife AB, David Zughaft, Malin Rundgren, Jan Harnek, Matthias Gotberg, Lars Algotsson, G. Olivecrona, Skane University Hospital, Lund Case Reports: This abstract describes two cases with cardiac arrest due to myocardial infarction (STEMI). The first patient alerted ambulance due to chest pain. On EMS arrival she collapsed, ALS started and ECG showed shock resistant VF, during transportation with on-going (35 min) mechanical chest compressions (MCC) (LUCASTM2). On arrival to hospital, ECG had converted to PEA that was paced to ROSC. The coronary angiogram, during pacing, revealed an occluded LAD that was stented. She then suffered a ventricular storm that converted to ROSC following MCC (10 min) and defibrillation. During transvenous pacing, Average absolute cerebral tissue oxygen saturation (ASctO2) was 61 (60 – 61) %. During MCC in the cath lab (LUCASTM1) we noted low physiologic values, systolic ABP: 50 (42– 60) mmHg, ETCO2: 12.8 (9.0 –21.8) mmHg and the MCC device was readjusted which increased physiologic values; systolic ABP: 94 (81–99) mmHg, ETCO2: 18.0 (12.0 –21.0) mmHg and ASctO2: 44 (42– 46) % seen. Despite therapeutic hypothermia she developed multiple organ failure and died after 40 hours. The second patient was admitted for PCI due to STEMI and cardiogenic shock. Despite pacing he developed PEA. The coronary angiogram showed an occluded left main stem (LM). During MCCs (LUCAS™2) LM/ LAD was stented but with “no flow.” Through the intervention the systolic ABP was: 45 (11–54) mmHg, CPP: 2 (-9 –10) but AsctO2 values indicating similar values to the first case: 46 (45– 47) %. The MCC device was however not readjusted, and he never obtained ROSC. Another interesting finding was the slow decline in ASctO2 from 45 to 33% (11 min) after stop of resuscitation efforts. Conclusion: These cases indicate the importance of performing CCs on the correct pressure point, which seem to vary between patients. Cerebral oximetry seems to be able to reflect circulation during various circulation support therapies. Interestingly, ASctO2 during MCCs was higher compared to earlier studies on manual CC1–2. How this correlates to neurologic intact survival needs further exploration. References 1. Martens PR et al. Resuscitation Vol. 81 (11) 1590 – 1591 2. Ramakers F et al. Euro J Anaesthesiol, 2010, (suppl 47): 3AP6 –11

Elias Alhanoun, New York Methodist Hospital, Shadi Khir, Aleppo University School of Medicine, VISHAL PATEL, Felix Khusid, Liziamma George, New York Methodist Hospital Case Reports: Introduction: Hafnia Alvei is a gram-negative anaerobe belongs to the Enterobacteriaceae family rarely causing human infections. We are reporting a case of H. alvei septic shock in a patient with liver failure. Case report: 31 y/o female with history of alcohol abuse who presented to our hospital with acute liver failure. Trans-jugular liver biopsy was consistent with acute alcoholic hepatitis. During her hospital stay, she developed high temperatures and hospital acquired pneumonia necessitating mechanical ventilatory support. Her bronchoalveolar lavage grew H. alvei and MSSA. H. alvei was also cultured from the urine cultures. Blood cultures were negative. Her condition worsened further into septic shock requiring vasopressors. Patient was started on doripenem and nafcillin with improvement in her fevers and chest radiograph findings. Discussion: H. alvei is a gram-negative, facultative anaerobic bacillus in the family Enterobacteriaceae that may occur as a gastrointestinal commensal. It is rarely considered to be pathogenic, however, it may be responsible for serious infections in immunocompromised patients. H. alvei has been associated with a wide array of clinical infections. It has been reported as a cause of meningitis, diarrhea, necrotizing entercolitis, pneumonia, urinary tract infection, endophtalmitis and soft tissue infection. In most of these cases it was reported as a coisolate with other organisms. Intubated patients who are immunosuppressed as a result of cardiac surgery or trauma seem to harbor H. alvei in their respiratory tracts more often than do patients who have previously undergone abdominal surgery. The organism is resistant to usual antibiotics. Most active antimicrobials against H. alvei were netilmicin, ciprofloxacin and imipenem. However, it occasionally has been found resistant to first and second generations cephalosporins, also sometimes it was found to be resistant to semisynthetic beta lactames. Conclusion: Hafnia alvei is a commensal of the human GI tract and not normally pathogenic, but may cause disease in immunocompromised patients. It is often resistant to multiple antibiotics including the Aminopenicillins.

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916

AN UNUSUAL CASE OF METHEMOGLOBINEMIA IN A HEALTHY YOUNG MAN

A FATAL CASE OF ACUTE LIVER FAILURE RELATED TO THE USE OF IRBESARTAN

Jasleen Pannu, Sriranjini Ramaswamy, Western Reserve Care System, Sushrut Dharmadhikari, Jackson Memorial Hospital/University of Miami, Hardeep Rai, Western reseve care system, Lawrence Goldstein, Western Reserve Care System

Mariya Geube, Shiva Birdi, Cleveland Clinic Foundation

Case Reports: Methemoglobinemia is a very rare cause of hypoxia and cyanosis. It refers to an altered state of hemoglobin in which the ferrous ions of heme moiety are oxidized to ferric state decreasing it’s ability to bind oxygen. It can be congenital, secondary to cytochrome b5 reductase deficiency or acquired. We report an unusual case of acquired methemoglobinemia in a previously healthy young man.A 42 year old caucasian male presented to our hospital with complaints of chest discomfort, dyspnea and palpitations for 1 hour. He had his lawn sprayed with a urea based liquid weedicide one day prior to presentation and complained of fatigue since then. He was a nonsmoker with no pertinent past medical or family history. Patient appeared pale and dusky, but was alert and oriented. His blood pressure was 129/73 mmHg, pulse 147 bpm, respiratory rate 18/min and SpO2 89% on room air. On exam, his pupils were normal size, round and reactive. Heart sounds were normal. Lungs were clear to auscultation. A 12-lead ECG revealed sinus tachycardia. A comprehensive metabolic panel and cardiac enzymes were unremarkable. While obtaining a CAT scan of chest, he became profoundly cyanotic and confused. He was intubated and mechanically ventilated, but his SpO2 persisted at 91–92%. Initial arterial blood gas samples were dark-brown with pH of 7.18, pCO2 of 45, pO2 of 71 and saturation of 100% on AC mode. Co-oximetry showed: metHb 59.9%, totalHb 14.7 gm/dl, carboxyHb 0% and deoxyHb of 3.9%. Methylene blue was administered intravenously resulting in resolution of cyanosis and hypoxia. A repeat ABG showed: pH 7.35, pCO2 33, pO2 125 of 33, SaO2 of 98% and methemoglobin level of 1.7%. Cytochrome b5 reductase levels were normal. Patient improved clinically and was subsequently extubated.Methemoglobinemia should be an important differential in the work up of unexplained, persistent hypoxia and cyanosis. Saturation gap and poor response to mechanical ventilation are major clues to the diagnosis. We postulate our patient’s exposure to the weedicide composed of 17% nitrogen, 2% phosphate and 3% potassium as being the trigger for methemoglobinemia.


Case Reports: Although Angiotensin Receptor Blockers (ARBs) have gained popularity in the treatment of hypertension because of their efficacy and safety profile, there are at least 5 case reports of acute liver injury in the literature related to the use of Irbesartan. Our patient is a 73 year old female who presented with hives, lip swelling and abdominal pain, and was noticed to have abnormal liver function tests three weeks after she was started on Irbesartan. She had the same complaints 9 months prior when she was started on another medication from the same class, but symptoms resolved with discontinuation of the drug. An extensive work up was performed to rule out any known cause of acute liver failure. In the Surgical Intensive Care Unit, patient deteriorated rapidly with a clinical picture of acute liver failure, high lactate levels, encephalopathy, profound circulatory shock, acute kidney failure, hypothermia, hypoglycemia and acute myocardial infarction. She was deemed not to be a liver transplant candidate because of her severe illness and advanced age and she expired 3 days after being admitted. Drug Induced Liver Injury (DILI) has a variable clinical presentation that may range from mild disease with complete recovery to severe irreversible acute liver failure with fatal outcome. The two major components in the assessment of DILI are careful exclusion of all known causes of liver injury and temporal relationship between the drug administration and the development of acute liver injury. In our case, factors that strongly suggested DILI were timeliness of the drug institution and the symptoms occurrence, and the positive re-challenge test with a medication from the same class. The only therapeutic solution for the most severe cases remains liver transplantation. If it is not feasible, integrated multi-disciplinary approach with supportive care should be utilized in order to achieve the best possible clinical outcome.

917 METFORMIN ASSOCIATED LACTIC ACIDOSIS Susan M. Hellervik, Arthur P. Wheeler, Anna Burgner, Vanderbilt University Medical Center Case Reports: A 56 yo female with type 2 diabetes mellitus receiving metformin, presented with flank pain, dyspnea, tachycardia and acidosis (pH ⬍6.8, pCO2 12 mmHg, paO2 127 and HCO3 ⬍3 mmol/L). Lactate 25 meq/L, creatinine 10 mg/dL(1 week prior 0.9 mg/dl), WBC 27.3 thou/uL, osmolar gap 30, and anion gap 42. Glucose 223/mg/dL. (salicylates, ketones, ethylene glycol and methanol levels undetectable). In the ED she suffered PEA arrest, and was resuscitated but remained hypotensive. Septic shock was suspected with initial acute renal failure thought to be secondary to pyelonephritis. Treatment with isotonic saline, high dose vasopressors, antibiotics, ⬎10 amps of NaHCO3, hyperventilation, and high flow hemodialysis followed by CRRT using NaHCO3 containing replacement fluid was initiated. Within 8 hours of beginning CRRT pH rose to 7.32, AG ⫽ 22 and vasopressor weaning began. Metformin level returned 47 mcg/ml (therapeutic ⬍2 mcg/ml). Complete recovery of neurological and cardiovascular function occurred in 4 days but renal injury persisted. Metformin associated lactic acidosis (MALA), easily confused with septic shock, should be considered in the differential of metabolic acidosis of patients taking metformin. MALA is a rare (3/100,000 patient years of use) but often (⬃50%) fatal complication from intentional overdose or therapeutic misadventure when hepatic, or especially when renal function becomes impaired. Volume depletion, NSAID use and contrast exposure are common antecedents. Toxicity is related to blockage of hepatic gluconeogenesis and glycogenolysis, increasing pyruvate and alanine concentrations, supporting lactate formation . Impaired mitochondrial respiration and oxidative phosphorylation lead to lactate production. Despite elevated metformin levels, hypoglycemia is rare due to the decrease in gluconeogenesis and because metformin does not augment insulin production. Key points are suspecting the diagnosis, deliberate hyperventilation to compensate for metabolic acidosis until correction with bicarbonate and prompt dialysis, which also removes metformin.

918 SUCCESSFUL APPLICATION OF MECHANICAL CPT WITH A UNIQUE DEVICE IN A VENTILATED INFANT WITH INTRACTABLE CONSOLIDATION Michael Hewitt, St. Joseph’s Hospitals, Robert DeShields, St. Joseph’s Children’s Hospital, Theresa Griffith, Amy Dittmer, St. Joseph’s Hospital Case Reports: Introduction: The MetaNeb® System from Hill-Rom Corp. is a unique FDA approved device that provides a combination of CPEP, aerosol and vibratory therapy via a single circuit in both ventilated and non-ventilated patients of all age groups. We present a case where the vibratory component of the device was utilized effectively in a patient with an intractable RUL consolidation that failed to respond to traditional therapies. Case Summary: The patient is a 4 month old, 2.8kg male who presented to our emergency department with a sudden onset of respiratory distress. Patient was intubated and admitted to the PICU. Initial CXR revealed bilateral parenchymal opacities. Further workup in the PICU suggested a vascular ring physiology which was confirmed. Corrective surgery was performed. The patient developed a significant RUL consolidation that failed to respond to repeated manual CPT. The decision was made to initiate vibratory therapy via the MetaNeb® System. Therapy was delivered via spring loaded T-piece to limit the number of times that the integrity of the circuit would be compromised. CXR on the day the therapy was initiated continued to reveal a significant RUL consolidation. Over the next 24 hours, the patient received 5 inline treatments with the MetaNeb® System. Subsequent CXR revealed a resolved RUL process. Discussion: Existing literature of the use of CPT in patients with consolidation, atelectasis or secretion issues does not suggest effectiveness of CPT, the majority of that literature is based on manual approaches. Anecdotal experience suggests that mechanically delivered CPT is effective in lung expansion and mobilization of secretions. Cases such as this suggest that this approach may be more effective than the traditional, manually administered CPT therapies. Formalized studies would be appropriate in this area.

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DISSEMINATED ASPERGILLUS INFECTION IN ADDITION TO BACTERIAL SEPSIS IN A SEVERELY IMMUNOCOMPROMISED PATIENT: NEED FOR A HIGH INDEX OF SUSPICION

A POSITIVE GALACTOMANNAN TEST IN BRONCHOALVEOLAR LAVAGE FLUID IS NOT ALWAYS INDICATIVE OF ASPERGILLOSIS: A CASE OF CROSS-REACTIVITY IN ACUTE DISSEMINATED HISTOPLAMOSIS IN A TRANSPLANT PATIENT

Krishna Aparanji, Peter Dicpinigaitis, Albert Einstein Hospital Case Reports: Introduction: Immunocompromised patients presenting with the clinical picture of severe sepsis pose a challenge in management. Aspergillus is a common fungal pathogen in immunocompromised hosts especially with hematological malignancies; manifestations vary from mild illness to invasive pneumonia and fulminant disseminated disease and may elude diagnosis by routine investigations. Case Presentation: A 54-year-old man with low-grade NonHodgkins lymphoma, diabetes, CHF, and hepatitis C was admitted for Pneumonia. He recently had plasmapheresis and rituximab therapy for worsening membranoproliferative glomerulonephritis causing deline in renal function requiring hemodialysis. His hospital course was complicated by a perforated duodenal ulcer requiring surgical repair and septic shock. Despite aggressive ICU management with broad spectum antibiotics, the patient succumbed to refractory septic shock and multisystem organ failure. Although numerous cultures of blood, sputum, urine, peritoneal, and cerebrospinal fluid failed to demonstrate fungal infection, autopsy revealed disseminated, invasive aspergillus infection with necrotic abscesses in various organs. Discussion: Some studies have shown higher incidence of invasive aspergillosis in lymphoproliferative disorders pretreated with rituximab during post transplant neutropenic phase. Sometimes, despite identification of a causative organism, additional, undiagnosed infections prevent a positive clinical response. Our patient had received rituximab and was on steroids, hence immunosuppressed. He was neither a transplant organ recipient nor had any post transplant chemotherapy. He was neutropenic upon admission only for one day, Thereafter; he remained non-neutropenic throughout his hospitalization giving no reason to suspect aspergillosis or to begin anti fungal therapy empirically. Conclusions: The present case illustrates that disseminated, invasive Aspergillus infection may exist despite negative cultures from numerous sources. Irrespective of granulocyte count one must consider the possibility of invasive aspergillosis in febrile patients with lymphomas especially when rituximab has been administered.

Edgardo Flores Anticona, Moises Huaman, Ramon del Busto, Emanuel Rivers, Henry Ford Hospital Case Reports: Testing for fungal antigens in bronchoalveolar lavage (BAL) fluid has become routine practice in solid organ transplant patients with severe febrile respiratory illness. Although detection of BAL galactomannan is frequently used to support the diagnosis of invasive aspergillosis (IA), cross-reactivity with other fungal infections has been suggested. This is a case of a 46 year-old male with type 1 diabetes status post pancreas and kidney transplantation 6 years prior, presenting with a febrile episode of unknown etiology. His outpatient regimen included stable doses of mycophenolate, tacrolimus and dexamethasone. Physical exam was normal except for mild tachycardia. CBC showed pancytopenia with normal neutrophil count and profound lymphopenia. Initial chest X ray, renal and liver function were normal. Blood and urine cultures were negative, as well as serology for HIV-1, Hepatitis B & C and cryptococcus. EBV and CMV PCR were undetectable. Five days after admission, the patient rapidly developed hypoxemia and diffuse bilateral interstitial lung infiltrates. The patient required mechanical ventilation and inotropic support in the ICU despite empiric IV vancomycin, cefepime, metronidazole, azithromycin, trimethoprim/sulfamethoxazol and anidulafungin. Initially, bacterial, AFB and viral cultures from BAL fluid were negative as well as Legionella and Pneumocystis antigens. Galactomannan in serum (4.1 Index) and BAL (6.9 Index) were positive, voriconazole was initiated but with partial response. BAL and blood fungal cultures later were positive for Histoplasma capsulatum. Aspergillus was not isolated on any cultures. IV liposomal amphotericin was started with excellent response, later transitioned to oral itraconazole with full recovery. In retrospect, the patient was exposed to parakeets over the last year. This case illustrates the histoplasmosis-associated cross-reactivity of BAL and serum galactomannan antigen in a patient with acute disseminated histoplasmosis. The clinical caveat is that a false positive BAL galactomannan test can occur in this setting. One should consider histoplasmosis if there is not an adequate response to therapy for aspergillosis.


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ARIPIPRAZOLE-INDUCED QTC INTERVAL PROLONGATION AND TORSADES DE POINTES: A CASE REPORT

BACLOFEN PUMP FAILURE LEADING TO SEVERE AND PROLONGED WITHDRAWAL

Sarah Nelson, University of Pittsburgh Medical Center

Nikhil Madan, Christopher Gilbert, Thomas Jefferson University Hospital, Bharat Awsare, Thomas Jefferson Univeristy Hospital, Michael Baram, Thomas Jefferson University Hospital, Anand Kommuri, Jefferson Pulmonary Associates

Case Reports: Aripiprazole is a novel atypical antipsychotic agent indicated for schizophrenia, bipolar I disorder, major depressive disorder, and aggression associated with autism. In clinical practice, aripiprazole has also been used in the treatment of ICU delirium. Unlike other atypical antipsychotics, aripiprazole may cause a decrease in the QTc interval. This makes it an attractive option in ICU patients that often have multiple risk factors for QTc interval prolongation. QTc interval prolongation is associated with the development torsades de pointes (TdP), an often fatal arrhythmia. We report the case of a 42 y/o Caucasian male with schizophrenia and delirium who developed TdP following initiation of low dose aripiprazole. The patient was admitted to the ICU following two days of fever, diarrhea, and altered mental status. His course was complicated by the development of septic shock, acute renal failure, adrenal insufficiency, and acute respiratory distress syndrome. Following the resolution of his acute illness he was started on his home medication, quetiapine 400 mg orally at bedtime. Quetiapine was discontinued after one dose due to a QTc interval increase from 528 msec to 644 msec. Twenty three days later, with a baseline QTc interval of 414 msec, aripiprazole 2.5 mg orally once daily was initiated for treatment of schizophrenia and ICU delirium. Following five days of aripiprazole, the patient suffered a cardiac arrest due to TdP as identified by an electrocardiogram. The patient received CPR for 30 seconds, one shock of 200 J, and 4 grams of magnesium sulfate given IV push. The patient returned to normal sinus rhythm and was intubated. No other risk factors for QTc interval prolongation were present, including concomitant medications or electrolyte abnormalities. Additionally, a cardiac catheterization completed the following day did not reveal significant disease, ruling out other causes of TdP. This case demonstrates that despite its association with QTc interval shortening, aripiprazole still has the propensity to cause TdP.

Case Reports: Baclofen withdrawal is a serious and potentially life threatening condition. It can vary from mild symptoms of sleepiness, diaphoresis and fatigue to severe symptoms of high fevers, seizures rhabdomyolysis, altered mental status and multiorgan failure. We report a case of severe prolonged withdrawal from recurrent baclofen pump failure in a patient with Stiff- person syndrome (SPS). Case: 53 year old lady with a history of SPS was electively admitted for 5 days of intravenous immune globulin (IVIG) therapy for her SPS. At baseline she has spasms and rigidity for which she is on a continuous infusion of baclofen via a pump. Her exam was significant for an increase in tone and a decrease in power in upper and lower extremities. On day 4 she had worsening mental status, witnessed seizure and fever to 104. She was transferred to the intensive care, intubated for airway protection and started on antibiotics after sending cultures. Over the next couple of days she continued to have fevers to 106 F despite broad spectrum antibiotics and cultures being negative. Her creatine kinase was elevated to 45,000 IU/L. There was no reason to suspect neuroleptic malignant syndrome or serotonin syndromes. She had a history of failure of the baclofen pump in the past with mild withdrawal. A nuclear medicine scan to evaluate the baclofen pump showed lack of dye spread and blockage of the catheter and pump. She was started on benzodiazepines and oral doses of baclofen and underwent a revision surgery. Her post operative recovery was uneventful but prolonged requiring high doses of intravenous baclofen. Discussion: Baclofen is an analog of the inhibitory neurotransmitter, gamma amino butyric acid (GABA). It causes slow neuronal hyperpolarization and reduces the output of excitatory neurotransmitters.Abrupt withdrawal cause severe spasticity and central nervous system hyperexcitability in part because chronic intrathecal infusion downregulates GABA B-receptor sensitivity. Pump failure needs to be identified early in the course to avoid catastrophic outcomes. If baclofen withdrawal due to pump failure is suspected, oral baclofen and benzodiazepine therapy should be initiated.

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RUPTURED SEPTIC SPLENITIS IN CRITICALLY ILL BURN PATIENT

SYSTEMIC SEPTIC EMBOLIZATION THROUGH A RESIDUAL RIGHT-TO-LEFT SHUNT: AN ATYPICAL LEMIERRE’S SYNDROME

Jong Lee, University of Texas Medical Branch, David Herndon, Shriners Hospital for Children Galveston Case Reports: Ruptured septic splenitis is a rare entity. It has not been reported in burn patients in the literature. We report a patient with burn injury who developed septic shock who was found to have ruptured septic splenitis on autopsy. The medical record of the patient was reviewed to obtain information of his hospitalization and outcome. This was a 77 year old man who sustained 32% flame burn to his face, bilateral arms, chest, abdomen, and back while burning trash. He underwent two excision and grafting operations. He developed multidrug resistant Acinetobacter baumanni wound infection and pneumonia. His hospital course was complicated by sepsis with multi-organ failure. His condition had been deteriorating due to his pneumonia, wound infection and sepsis. He developed septic shock requiring intermittent vasopressor support. On hospital day #23, he became hemodynamically unstable and did not respond to vasopressors. His hemoglobin went from 9.8 to 9.2. He had no signs of obvious bleeding. His physical examination was limited by being unresponsive and in septic shock. Family had been already discussing DNR status due to his age, grave condition and poor prognosis. Due to his deterioration, he was made DNR, and shortly thereafter he expired. The autopsy showed 3.2 liters of blood and clot in the peritoneal cavity and disrupted splenic capsule and parenchyma.Ruptured septic splenitis is rare has not been reported in burn patients. We had a critically ill patient with burn injury who developed ruptured septic splenitis. Clinicians should be cognizant of ruptured septic splenitis in critically ill burn patients.


Gina Cassel, Jacqueline Weingarten-Arams, Shivanand Medar, Children’s Hospital at Montefiore Case Reports: A 13-year old female was admitted to the pediatric critical care unit with hypotension and right upper quadrant abdominal pain. Her history included 5 days of pharyngeal and neck pain associated with fever. One day prior to admission she was treated for dehydration in the ED and streptococcal pharyngitis was ruled out. Her past medical history was significant for tricuspid atresia palliated by a fenestrated Fontan at 2 years of age. On admission, she had direct hyperbilirubinemia and abdominal ultrasound showed gallbladder wall thickening and hepatomegaly, with normal vascular patency. An echocardiogram revealed hyperdynamic cardiac function, laminar flow through the Fontan and no evidence of thrombus. She was treated with vancomycin, ceftriaxone, and clindamycin, and supported with dopamine and norepinephrine. Her abdominal pain improved and over the next 48 hours vasopressors were weaned off. A blood culture obtained at admission grew Bacteroides gracilis. She developed left hip pain with point tenderness of the left sacroiliac joint. Her antibiotics were narrowed to ampicillin/sulbactam and clindamycin for suspicion of an atypical Lemierre’s syndrome. Classically, Lemierre’s syndrome is characterized by suppurative thrombophelbitis of the jugular vein with embolization. Although imaging of the neck failed to demonstrate superficial or deep vein thrombosis, her complaint of pharyngitis, followed by neck pain, anaerobic septicemia, and hip tenderness were suggestive of septic metastases. A CT scan of the chest revealed bilateral nodular opacities with cavitation consistent with septic emboli, and MRI of the pelvis/hip showed evidence of sacroilitis and focal osteomyelitis of the left iliac bone. She improved clinically and was discharged with enteral clindamycin and low-dose aspirin for anticoagulation. Although pulmonary septic emboli occur frequently in Lemierre’s syndrome, this case is unique. It is interesting to highlight that our patient presented with right sided neck pain and was later diagnosed with left iliac osteomyelitis. It was the fenestrated Fontan and presence of a residual right-to-left shunt that allowed systemic septic embolization to occur.

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926

INHALATION PNEUMONITIS IN A NOT SO “SMARTIES” ADOLESCENT

A CASE OF AZATHIOPRINE HYPERSENSITIVITY SYNDROME, ACUTE RESPIRATORY DISTRESS SYNDROME, AND SHOCK

Nina Verdino, University of North Carolina At Chapel Hill, Keith Kocis, Division of Pediatric Cardiology The University of North Carolina Case Reports: A 13 year old healthy male presents with a one week history of cough.On presentation at an urgent care the patient was found to be hypoxic with oxygen saturations of 86% with absence of wheezing and non labored breathing.The patient was transferred to our pediatric emergency department with continued hypoxia (SaO2 ⫽ 92%) despite 3L nasal cannula. Physical exam was notable for RR 23, minimal wheezing in left lower lung base and decreased air movement bilaterally. Initial chest radiograph revealed diffuse haziness to the lung fields predominantly in the left upper lobe with bronchial wall thickening.The patient’s hypoxemia persisted despite continuous Albuterol nebulizer treatments and he was admitted to the pediatric inpatient unit with a presumptive diagnosis of atypical pneumonia with reactive airway disease.Initial treatment included supplemental oxygen,Ceftriaxone, Azythromycin and oral steroids.The patient’s condition deteriorated necessitating transfer to the PICU.Physical exam at time of transfer was significant for oxygen saturations of 85– 88% despite face mask oxygen therapy with limited air movement noted bilaterally,absence of wheeze, appropriate metal status and no increased work of breathing. Upon transfer to PICU, patient was placed on a 100% non-rebreather face mask to maintain oxygen saturations greater than 90%.Repeat chest radiograph revealed bronchial wall thickening, moderate left perihilar opacity with no evidence of a pleural effusions. The patient then disclosed “huffing” crushed “Smarties” (Ce De Candy, Inc., Union,NJ) candies one week prior to admission, which consist of Dextrose,Citric Acid,Calcium Sterate,Artificial Flavors and Colors.Oral steroids were continued and supplemental oxygen therapy was weaned over the following 2 days. Subsequent chest radiograph showed improved bronchial wall thickening. The patient was discharged home on hospital day 3.In conclusion this shows an episode of “huffing” a candy containing a known tusinogenic ingredient such as citric acid resulting in hypoxia and clinical picture consistent with likely acute lung injury secondary to inhalation pneumonitis.

Jason Frost, Brown University/The Miriam Hospital, Gerardo Carino, Miriam Hospital, Jeffrey Mazer, Rhode Island Hospital At Brown University Case Reports: Systemic hypersensitivity is a rare but documented side effect of azathioprine. Uncommonly it can present with features of a systemic infection with end organ dysfunction. We report a case of azathioprine hypersensitivity syndrome leading to acute respiratory distress syndrome and subsequent multiorgan system failure. The patient is an 88-year-old gentleman presenting to the emergency department with tremors, mild puritis and decreased urine output in the setting of whole body rash developing over six days. Three days prior to this episode, he was started on azathioprine by his pulmonologist, due to corticosteroid intolerance for newly diagnosed interstitial lung disease. On admission, he was afebrile, hemodynamically stable and had an oxygen saturation of 96 percent on room air. His exam at that time was notable for only a diffuse maculopapular rash covering the majority of his body, most prominent on his upper and lower extremities, sparing his head. Laboratory studies revealed a leukocytosis of 12.5 x10exp and lactic acid of 2.8 mEq/L. A chest radiograph showed his underlying ILD. All cultures prior to antibiotics were eventually negative. He was started on broad-spectrum antibiotics in the ED. Over the first 24 hours of ICU admission, he rapidly deteriorated. He was started on pressors, his lactate continued to rise and was intubated for hypoxic respiratory failure. Follow up chest radiograph now showed diffuse bilateral alveolar infiltrates without effusions. BNP, Ekg and echo were unchanged from prior consistent with a diagnosis of Acute Respiratory Distress Syndrome. A bronchoscopy with alveolar lavage was negative (including AFB, Fungus, PCP, viral and Legionella). He initially improved, but subsequently declined requiring three pressor agents and developed severe refractory acidosis, at which time his family decided to withdraw care. Azathioprine’s side effect of hypersensitivity syndrome, although rare, is well documented. Side effects of hypotension and shock are uncommon but reported while cases of ARDS are undocumented. This case documents an unusual presentation of hypersensitivity syndrome and its potentially fatal implications.

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EFFECT OF DIRECT HEMOPERFUSION WITH CYTOKINE ABSORBING COLUMN IN A SEVERE ARDS PATIENT WITH MULTIPLE ORGAN FAILURE

MAGGOT DEBRIDEMENT AN ALTERNATIVE TO SURGICAL DEBRIDEMENT A CASE REPORT OF A BURN PATIENT

Takumi Taniguchi, Masaki Okajima, Kanazawa University Hospital

Case Reports: Although survival rates from burns have improved due to better wound care, early excision and grafting, and overall increased knowledge of burn management, elderly patients still are at an increased risk of death from burn injuries from multiple factors. We present the case of an 80 year old female admitted to the burn unit secondary to a full thickness flame burn, which she sustained 7 days prior to hospital admission, on 7% of her total body surface area (TBSA). On admission the patient was confused, had acute kidney injury and had ischemic cardiac changes. The patient was taken emergently for cardiac catheterization where drug eluting coronary stents were placed. The patient post-operatively remained in critical condition and was initiated on dual antiplatelet therapy. The patient was deemed a prohibitively high risk for surgical intervention by the cardiology consultants. The alternative option of biodebridement with sterile maggots was discussed with the patient and her family. Consent was obtained and the patient underwent the first biodebridement on hospital day 17. During the initial application 5–10 maggots were placed per square centimeter and the dressing left intact for 68 hours. Initial debridement was marginal and a significant amount of eschar and burned tissue remained. Prior to the second application the burn eschar was scored to allow for improved debridement and emulsification of the necrotic tissue. Approximately 20 –25 maggots were applied per square centimeter for the second application and left undisturbed for 72 hours. After the second biodebridement the burned necrotic tissue was completely debrided, the underlying tissue was beefy ready, bled easily and was not infected. Biodebridement proved to be an effective agent for debridement of burned tissue. Although, surgical debridement is the standard care for deep or full thickness burn injuries; in a select patient population biodebridement may be an alternative therapy that is well tolerated and less invasive.

Case Reports: Acute respiratory distress syndrome (ARDS) is an inflammatory condition of the lungs that is associated with high mortality. ARDS pathogenesis is thought to result from massive activation of proinflammatory response, including release of inflammatory mediators such as cytokines. A 69-yr-old woman with severe ARDS transferred to our ICU. She had acute renal failure, DIC and hypercalcemia in addition to ARDS. Immediately after entered ICU, she intubated and mechanically ventilated. However, her pulmonary condition did not improve by the conventional therapy. Then, she received the direct hemoperfusion with cytokine absorbing column for three days and continuous hemodiafiltration for five days. After this treatment, her pulmonary condition was getting better, and she could extubate two days after the treatment. The plasma concentrations of TNF-alpha and IL-6 significantly decreased after the treatment. She was discharged to our ICU seven days after the treatment. The direct hemoperfusion with cytokine absorbing column may be beneficial treatment in ARDS patients.

Jane Faris, Leah Bair, Michael White, Detroit Receiving Hospital


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AN ATYPICAL BUG IN AN UNUSUAL LOCATION: MYCOBACTERIUM CHELONAE PRESENTING AS A SUBDURAL ABSCESS IN AN IMMUNOCOMPROMISED PATIENT

DOBUTAMINE-INDUCED STRESS CARDIOMYOPATHY DURING TREATMENT FOR CEREBRAL VASOSPASM FOLLOWING SUBARACHNOID HEMORRHAGE

Mark Warner, University of Texas Houston Medical School, Pratik Doshi, University of Texas, Rosa Estrada-y-Martin, University of Texas-Houston Medical School

Muhammad Kamran Athar, Hospital of the University of Pennsylvania, Joshua Levine, Hospital of the Univ. of Pennsylvania

Case Reports: We report the case of a 66 year old woman with Rheumatoid Arthritis that was taking etanercept and prednisone for many years, who presented with acute confusion and low back pain and a protracted history of leg weakness and difficulty with ambulation. She had suffered a T12 compression fracture 7 years earlier and had a spine stabilization with implantation of an interbody device. On presentation, she was febrile (103.5 F), somnolent and had marked lower extremity weakness. Laboratories were significant for a leukocytosis of 10,100 wbc/cm without band forms, ESR 64 mm/hr and a C-reactive protein of 181.00 mg/L. A lumbar puncture was performed at L2 and yielded frank pus with a glucose of 12 mg/dL. Cultures of the spinal fluid were negative. Computed tomography and magnetic resonance imaging (MRI) of the brain were negative. MRI of the spine showed an epidural abscess with enhancement of the thecal sac and nerve roots. A lumbar laminectomy failed to evacuate the abcess, which was shown to persist on a second MRI. The patient failed to improve despite broadspectrum antibiotics and was taken for an additional surgery. Intraoperatively, the abscess was found to be inside the dural sac rather than in the epidural space and was communicating with the previously implanted hardware. After evacuation of the abscess, the patient improved; cultures yielded Mycobacteria chelonae. Patients with Rheumatologic diseases are commonly given immunomodulatory agents, which render them more susceptible to mycobacterial infections. The suspicion of mycobacterial infection increased when the patient did not respond to antibiotic coverage for the usual bacteria that infect indwelling hardware. Mycobacterial tuberculosis commonly infects immunosuppressed, non-HIV infected patients. Less commonly, Mycobacterium chelonae has been reported in instances with delayed infections of orthopedic hardware in immunosuppressed (non-HIV) patients such as ours, and should therefore be considered in such a clinical scenario.

Case Reports: Neurogenic stunned myocardium (NSM) is a reversible cardiomyopathy that may occur in patients with cerebral injury. We report a case of reversible cardiomyopathy in a patient with aneurysmal subarachnoid hemorrhage (aSAH) caused by infusions of dobutamine and norepinephrine.A 71-yearold woman with a known left MCA aneurysm presented with thunderclap headache. Head CT revealed a left temporal hematoma and blood in left sylvian fissure. She underwent aneurysm clipping 2 days later. Pre-operative transthoracicechocardiogram (TTE) showed normal LV function. Induced hypertension was initiated on post-op day 1 with norepinephrine and dobutamine for left MCA vasospasm. Over the next 48 hrs she became hypoxemic, requiring intubation. EKG showed diffuse T-wave inversions. Peak troponin was 0.28. Repeat TTE showed left ventricular ejection fraction of 10% and akinesis of all segments except basal. Vasoactive medications were changed to milrinone, vasopressin and phenylephrine. Hemodynamics improved and pressors and inotropes were weaned off over 72 hrs. A follow-up TTE showed EF of 40%.The pathophysiology of NSM is poorly understood. Proposed mechanisms include coronary vasospasm and direct myocyte injury due to excessive catecholamine release from nerve terminals in the heart. In aSAH patients, NSM typically occurs at the time of aneurysm rupture. In this case, however, cardiomyopathy developed later and was temporally related to administration of catecholamines, with recovery of cardiac function after the drugs were withheld.While association of NSM with acute brain injury is well recognized, the observation that it may also occur as an iatrogenic complication of vasoactive medications is frequently under appreciated. Cases of NSM have been described in association with triple-H therapy in SAH. Development of a similar cardiomyopathy in patients with pheochoromocytoma suggests that its pathogenesis may involve not only direct release of catecholamines from nerve terminals, but also high circulating levels of catecholamines. A combination of milrinone,vasopressin and/or neosynephrine may be preferred to avoid excessive stimulation of myocardial beta-receptors.

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DELAYED AWAKENING FROM THERAPEUTIC HYPOTHERMIA AFTER VENTRICULAR FIBRILLATION ARREST

RESOLUTION OF PERSISTENT PULSELESS ELECTRICAL ACTIVITY (PEA) WITH THROMBOLYTIC THERAPY IN A PATIENT WITH MASSIVE PULMONARY EMBOLISM

Osman Farooq, Orlando Regional Healthcare, Jeffrey Sadowsky, Orlando Regional Medical Center, Rakesh Gupta, OrlandoHealth Case Reports: 41 year old male with history of HTN had a 5 minute witnessed seizure. On EMS arrival, he was unresponsive with agonal breathing. EKG showed V-fibrillation. Pt. underwent ACLS for 10 minutes before return of spontaneous circulation. On arrival to hospital, he was in status epilepticus with generalized tonic clonic activity not responding to Cerebyx, Ativan or Propofol drip. Pt. given loading dose then placed on Pentobarbital drip (1 mg/kg/hr) for burst suppression pattern on continuous EEG. Pt. underwent therapeutic hypothermia and reached goal cooling temperature of 33C in 4 hours. He remained hypothermic for 24 hours and was re-warmed over 12 hours. Once patient was re-warmed, all sedative (including Pentobarb), analgesic and paralytic agents were stopped. He was placed on Dilantin and Keppra for seizure control His hospital course was complicated by mild renal (creatinine 2) dysfunction. On exam, pt had a GCS of 3 with poorly reactive pupils. A weak corneal and gag reflex was present. Pt showed no neurological improvement for 5 days. Family updated daily on overall grave prognosis. Day 5, pt started to twitch his right upper extremity to painful stimuli. Day 7, pt opened eyes to deep sternal rub. With mild improvement, family decided to proceed with tracheostomy and PEG tube placement. Due to holiday weekend, procedures were delayed several days. Day 8, pt was blinking eyes spontaneously and squeezing hands on command. Day 9, showed marked neurological improvement with pt moving his arms and legs. He was extubated the same day. Pt underwent a cardiac catherization showing normal coronary arteries and an EF of 65%. A prophylactic AICD was placed. Pt underwent aggressive physical therapy and subsequently discharged home. At time of discharge pt was walking with minimal assistance with a walker. He had no focal neurological or speech deficits. Conclusion: The traditional 72 hours maybe too short to assess neurological recovery post therapeutic hypothermia. There are no good clinical predictors for a meaningful improvement but one should consider providing full supportive care for at least seven to ten days to assess for neurogical recovery.


Brian Singeltary, Muhammad Afzal, Ryan Pack, Good Samaritan Hospital Case Reports: Background:Twentypercent of the patients presenting with cardiac arrest have pulselesselectrical activity (PEA). Massive pulmonary embolism (PE) is a known cause ofPEA. However, there is a lack of evidence if thrombolytics improve clinical outcomeof these patients. This case illustrates the successful use of thrombolytics inPEA secondary to PE. Case report: A sixty-four year old white female wasbrought to our emergency department (ED) from an outpatient psychiatricfacility after a cardiac arrest. Advanced cardiac life support protocols wereinitiated by EMS during transport to the ED. Upon arrival in the ED, thepatient was found to have PEA and given intravenous epinephrine. Following administration of epinephrine, the patient regained a pulse with stabilizationof blood pressure. However, she continued to suffer intermittent episodes ofPEA necessitating use of continuous epinephrine infusion. A pulmonary embolismwas thought to be the cause of persistent PEA. Basic metabolic panel was significantfor a creatinine of 1.8 mg/dl. Due to persistent PEA and high suspicion ofpulmonary embolism; a CT pulmonary angiogram (CTPA) of the chest was performed despite elevated creatinine. CTPArevealed a large pulmonary embolus in the left pulmonary artery as well as numerousemboli in the right upper and lower pulmonary artery branches. A CT scan ofhead without contrast was performed to rule out any intracranial hemorrhage. Patientreceived tissue plasminogen activator without any complication. PEA resolvedafter thrombolysis and patient steadily improved over next few days without anyresidual kidney injury. Prior to discharge, the patient was ambulating shortdistances independently and requiring minimal oxygen. The patient wasdischarged in stable condition for inpatient rehabilitation. Conclusion: Massive pulmonary embolism is anestablished cause of PEA. Thrombolytics could be life saving in selectedpatients. However, the underlying kidney injury could be an impediment toperform CTPA. This case illustrates an example where early intervention bythrombolysis was life saving.

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ECALLANTIDE TREATMENT FOR ANGIOTENSIN CONVERTING ENZYME INHIBITOR INDUCED ANGIOEDEMA (ACEI-IA): A CASE SERIES AND PHARMACOECONOMIC ASSESSMENT

TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR BICAVAL DUAL LUMEN VV ECMO CANNULATION FOR NECROTIZING PNEUMONIA IN A BURN PATIENT

Cara McDaniel, Michael Baram, Cindy Wordell, John R. Cohn, Thomas Jefferson University Hospital

Case Reports: MRSA pneumonia can be a devastating disease. It accounts for 15%-27% of VAPs and can have a mortality rate approaching 40%. Some strains of SA produce a cytotoxin called Panton-Valentine leukocidin (PVL). This toxin destroys leukocytes and causes tissue necrosis. Respiratory failure is a common complication of MRSA pneumonia. On rare occasions traditional therapies are unsuccessful and further management is required for survival. ECMO can be a life saving therapy. A 43 yo female was admitted with a 75% 2d/3d degree burn on 5/28. Despite her 60% mortality rate, the pt was able to be stabilized and was making marked improvement. On POD 8, the pt developed a necrotizing MRSA pneumonia requiring rapid escalation of respiratory care. Despite inhaled epoprostenol, APRV, oscillatory ventilation and proning, the pt had refractory hypoxemia and a worsening acidosis. Due to the full thickness chest burn, a TTE was unable to be performed to evaluate her cardiac function. A TEE was utilized to evaluate her cardiac status. It was decided that VV ECMO was the appropriate therapy. A bicaval view was performed to assist in the guide wire advancement from the SVC, through the RA and into the IVC. This same view was then utilized to advance the Avalon bicaval dual lumen cannula into its proper location. To ensure adequate oxygenation, the distal tip needs to be in the IVC and the return port located in the RA and directed at the tricuspid valve. A significant risk of cardiac injury can occur if the cannula is advanced blindly while attempting to position the distal tip in the IVC. Cannulation was successful and the pt was placed on ECMO. The pt received Vancomycin and was maintained on VV ECMO for 6 days. She was decannulated and eventually went on to be extubated on hospital day 28. Our pt was discharged home on 8/18. She was ambulatory, fully functioning and did not require any supplimental oxygen or pulmonary care. As the US continues to see an explosion of MRSA infections with the expression of PVL, the risk of necrotizing pneumonia will only worsen. TEE directed cannulation for VV ECMO is safe and effective in managing refractory respiratory failure.

Case Reports: While fatal airway obstruction from ACEI-IA has been described, effective therapy has not been demonstrated. Since ACEI-IA is thought to be primarily bradykinin and kinin-kallikrein system mediated, ecallantide, a kallikrein inhibitor, may offer benefit. However, due to the high cost of therapy, a pharmacoeconomic assessment is essential. We describe three African American patients with ACEI-IA. One presented with progressive lingual and soft palate swelling over 3 days. The second presented with throat and soft palate swelling over several hours. The third presented with oropharyngeal swelling developing over 24 hours and dyspnea. In addition, all had direct visualization showing life-threatening edema. All patients received steroids and antihistamines and two received epinephrine in the Emergency Room prior to admission for observation and airway management. Two patients were admitted directly to the ICU, given ecallantide, and intubation was avoided. The third was admitted to a floor bed, transferred to the ICU, intubated, and then received ecallantide. After receiving ecallantide, all three patients had notable response within hours, prompt improvement and/or resolution in signs and symptoms, and were discharged home ⬍24 hours after receiving ecallantide therapy. ACEI-IA is a recognized complication of treatment, occurring months to years after starting therapy. Incidence has been reported to be 0.1– 0.7% and can be higher in African Americans. This case series suggests ecallantide may be effective in reversing ACEI-IA, even in patients requiring endotracheal intubation. Due to the $8350 cost of ecallantide therapy, judicious use of this agent is imperative to optimize outcomes and remain cost-effective. The daily cost of a floor and ICU bed averages $1400 and $2500, respectively; however the majority of patients with ACEI-IA do not require admission or have prolonged hospitalization. While ecallantide use may not be cost effective in most ACEI-IA patients, if prolonged hospitalization or the need for intubation can be prevented, then ecallantide use may be pharmacoeconomically sound. Better risk assessment tools will be required to optimize treatment.

935 EXTRACORPOREAL MEMBRANE OXYGENATION IN MASSIVE PULMONARY EMBOLISM ASSOCIATED WITH LIFETHREATENING CIRCULATORY COLLAPSE Krishna Aparanji, John Cavagnaro, David D’Alessandro, Wilma Lopez, Montefiore Medical Center Case Reports: Introduction: Massive Pulmonary Embolism is associated with a high risk of mortality. Our case report illustrates the potential role of extracorporeal membrane oxygenation (ECMO) as an adjunct in the treatment of massive pulmonary embolism refractory to conventional treatment. Case Presentation: 38-year old morbidly obese female with comorbidities including seizure disorder, atrial fibrillation and non compliance with medication regimen presented to the emergency room(ER) with one week history of dyspnea, chest pain, and a near syncope. While in the ER, she developed hypoxemic respiratory failure requiring intubation. Her echo findings were significant for severe right ventricular (RV) hypokinesis and dilatation, of new onset. Her EKG showed sinus tachycardia. She sustained multiple episodes of PEA/asystolic cardiac arrest, thus deemed unstable for CT scan or angiogram; tissue plasminogen activator (tpa) was administered for the presumptive diagnosis of pulmonary embolism (PE). Despite clot resolution and hemodynamic support, she continued to show evidence of cardiovascular collapse. Venoarterial ECMO via percutaneous peripheral access was initiated at a rate of 6.6L/min with marked improvement in her hemodynamic profile. Although the patient’s course was complicated by development of liver and renal failure, she was eventually weaned off ECMO on day 2, discharged from the intensive care unit to the general ward where she returned to her baseline neurological status. Discussion: Most studies of ECMO use in massive PE utilize demonstration of complete recovery of RV function as criterion for weaning off support. Despite the fact that intraoperative echo at the time of ECMO discontinuation still showed moderate RV dysfunction, our patient remained stable without hemodynamic support. ECMO duration in our case is shorter than what is usually reported in most case series and it did not compromise outcome. Conclusions: ECMO can be an effective supportive modality in life-threatening circulatory collapse associated with massive PE. Duration of ECMO support could be of short term and not necessarily contingent on demonstration of complete recovery of RV function.

Patrick Cullinan, Mladen Sokolovic, Washington Hospital Center

936 SPONTANEOUS BILATERAL ADRENAL HEMORRHAGE Saurabh Dahiya, Baystate Medical Center Case Reports: S. Dahiya MD, A. Bhagavan MD, M. Carreno MD, W. Ooi MDAdrenal insufficiency is a potentially life threatening condition and early recognition is the key in outcomes. We report a case of 46 year old male with history of hypertension, dyslipidemia and occasional cocaine use who presented with abdominal pain, vomiting for the last few weeks and a episode of nearsyncope on the day of presentation. He reported intermittent fevers and a 8 kilogram weight loss over 1 month. Patient was noted to have tachycardia and left flank tenderness. No rash, petechiae, neck rigidity was found on physical exam.Laboratory data revealed hyponatremia, acute kidney injury, a lactate of 3.7 mmol/l and a negative urine toxicology screen. 6 hours later a CT abdomen showed diffuse bilateral enlargement of adrenal glands. Random cortisol level was obtained and revealed a level 0.6 mcg/dl, suggesting severe adrenal insufficiency. Soon after patient was commenced on Hydrocortisone. The first dose of hydrocortisone was given almost 10 hours later to the presentation to the hospital. Within an hour of administration of steroids patient went into a PEA arrest and coded almost for 30 minutes. An exhaustive infectious workup for possible underlying infection precipitating adrenal crisis was negative. Workup for adrenomegaly which included, PPD, adrenal cortex antibody, HIV, RPR, ANA, anticardiolipin antibody and histoplasma antibody was unrevealing. Patient remained on ventilatory and pressor support for next 3 days. In view of poor neurological recovery, patient was declared brain dead and care was withdrawn after family discussion. Interestingly,autopsy revealed bilateral adrenal hemorrhage as the cause of adrenomegaly. Adrenal hemorrhage is an uncommon cause of adrenal insufficiency. Risk factors for adrenal hemorrhage include anticoagulant use, thromboembolic disease, antiphospholipid syndrome, trauma and sepsis.All were essentially ruled out as an etiology, making a case for spontaneous bilateral adrenal hemorrhage, a rarely reported phenomenon. Nonetheless early recognition and treatment of adrenal insufficiency is the key, which unfortunately did not occur in this case and proved fatal.


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A SEVERE CASE OF METFORMIN-ASSOCIATED LACTIC ACIDOSIS PRECIPITATED BY OBSTIPATION

METABOLIC ALKALOSIS: ONE MORE INDICATION FOR RENAL REPLACEMENT THERAPY IN ACUTE KIDNEY INJURY

Vinay Shah, Marilyn Haupt, Synergy Medical Education Alliance, B. Paidipaty, Saint Mary’s Pulmonary and Critical Care Associates

Mohammed Al Faiyumi, Henry Ford Hospital

Case Reports: Metformin-associated lactic acidosis is a rare condition with an incidence of 5.1 cases per 100,000 patient years and a fatality rate of 50%. Metformin toxicity usually is noted in renal, heart, and liver failure, hypoperfusion and hypoxic states. We are presenting a case where metformin toxicity was precipitated by obstipation. A 37-year-old African-American male with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, chronic constipation, and bipolar disorder presented with increasing abdominal pain, dizziness, vomiting and no bowel movement for 2 weeks. He was found unresponsive after receiving a saline enema at a psychiatric facility and was transferred to our ICU. He was on the following medications: metformin 1000 mg BID, lisinopril, metamucil, colace, valproic acid, paliperidone, simvastatin, and aspirin. On arrival, he was oriented but agitated. Arterial pressure was 85/46 mmHg, pulse 110 bpm, and respiratory rate 20/min. Abdomen was distended and tense with hypoactive bowel sounds. No occult blood was noted in stool. A CT scan showed extensive fecal retention in the rectum and sigmoid. His creatinine was 1.8 mg/dL (was 0.9 mg/dL two weeks ago), anion gap 25, pH 7.01, HCO3 11 mmol/L, PCO2 45 mmHg and lactate was 12 mmol/L. Acetaminophen and salicylate levels were not elevated, glucose was 235 mg/dL, and ketones were not detected. Metformin levels were noted to be 47 mcg/mL (therapeutic: 1–2 mcg/mL). He was intubated and placed on mechanical ventilation, started on vasopressors and a bicarbonate drip. Hemodialysis was initiated. In spite of these efforts, HCO3 decreased to 5 mmol/L, creatinine increased to 2.7 mg/dL, lactate increased to 26 mmol/L, and anion gap increased to 41. Despite continuous monitoring and treatment in the ICU, he expired three days later. Metformin toxicity can occur in a variety of clinical conditions. In this case, metformin toxicity and acidosis was caused by severe obstipation, dehydration and renal failure. We are unaware of reports of this association in the literature. Vigilance for severe constipation or obstipation in patients taking metformin is warranted to prevent life threatening toxicity.

939 SUDDEN UNEXPECTED DEATH IN EPILEPSY (SUDEP) Elvira Umyarova, Mario Cerdan, Raed Alalawi, Kenneth Nugent, TTUHSC Case Reports: SUDEP has been defined as the sudden, unexpected witnessed or unwitnessed, non-traumatic, and non-drowning death of a subject with epilepsy with or without evidence for a seizure in which the autopsy does not reveal a structural or toxicological cause of death. Overall SUDEP causes 7–17% of deaths among all patients with epilepsy. We present a case of SUDEP.A 57 y.o. man with history of a generalized seizure disorder and recent subtherapeutic levels of valproic acid and phenytoin was found by paramedics in asystole with fixed, dilated pupils. Oral intubation, CPR with defibrillation, and epinephrine were administered and patient was flown to the nearest emergency department. General examination revealed a cyanotic and unresponsive patient with absent vital signs and corneal reflexes. Despite all the efforts, the patient remained cyanotic, in asystole and was pronounced dead. His autopsy did not show any intracranial changes. No pathology was identified on gross exam, and microscopic findings did not show any inflammatory infiltrates, hemorrhages, necrosis, or infarcts. Post-mortem blood analysis did not reveal any pathogenic organisms, and vitreous electrolyte analysis showed no evidence of electrolyte abnormalities.Undiagnosed genetic, functional, or anatomic disorders could contribute to the development of SUDEP, but in most cases seizures appear to trigger the cascade of events leading to death. The pathophysiology involves imbalances in the central nervous system leading to acute respiratory failure, cardiac arrhythmias, and/or acute stress cardiomyopathy. Our patient had the typical profile for a patient with SUDEP: having generalized seizure disorder, recent subtherapeutic levels of antiseizure medications and lack of any fatal lesions or electrolyte imbalances on autopsy. By describing this patient we would like to highlight an importance of maximal seizure treatment, which can lead to reduction of SUDEP risk. SUDEP is strongly associated with active epilepsy, particularly in patients with generalized tonic-clonic seizures. Studies in patients with near-SUDEP indicate that risk reduction largely depends on optimization of seizure control.


Case Reports: Objectives: To recognize that renal replacement therapy is a potential intervention for the management of refractory metabolic alkalosis. Case: We report a case of an 85 year-old woman who presented with persistent nausea, vomiting and weight loss of few weeks’ duration. She was found to have volume depletion with orthostatic hypotension, in addition to hypokalemia, acute kidney injury and metabolic alkalosis. Initial work up for vomiting was unrevealing and she continued to have high gastric output from nasogastric tube suctioning. Despite aggressive fluid therapy with normal saline, potassium replacement, proton pump inhibitor and later treatment with acetazolamide, she continued to have metabolic alkalosis in addition to worsening respiratory status with hypopnea, hypercapnea and hypoxemia. She was transferred to the intensive care unit and was started on hemodialysis mainly to manage her persistent alkalosis in the setting of worsening kidney function. This was followed by correction of her metabolic abnormalities, namely, the metabolic alkalosis, and improvement in her respiratory status. Further evaluation after initial improvement showed a duodenal adenocarcinoma with obstruction that required a palliative gastrojejunostomy. Kidney function started to improve after her first hemodialysis session and she did not require any further renal replacement therapy. Discussion: Metabolic alkalosis is a common acid-base disturbance. In chlorideresponsive alkalosis, treatment usually consists of chloride repletion in the form of sodium chloride, potassium chloride or hydrogen chloride depending on the volume status and the associated electrolyte abnormality. In refractory metabolic alkalosis associated with acute kidney injury, renal replacement therapy seems to be an effective intervention especially when other traditional measures fail to correct this abnormality.

940 PNEUMOMEDIASTINUM WITH BILATERAL APICAL EXTRA PLEURAL AIR COLLECTION MIMICKING BILATERAL PNEUMOTHORAX Iram Nawaz, Coney Island Hospital, Padmanabhan Krishnan, Coney Island Hoapital Case Reports: Introduction: Air in mediastinum can dissect in the extra pleural space and resemble a pneumothorax. Failure to differentiate extra pleural from intra pleural air can lead to erroneous diagnosis of pneumothorax. Case Report: A 24 year old man presented with subcutaneous emphysema over chest and neck after self induced vomiting. Barium imaging was unremarkable; chest radiograph showed subcutaneous emphysema and chest CT was reported as bilateral pneumothorax. Bilateral chest tube insertion was advised but patient refused. Chest radiograph and CT were reviewed and pneumomediastinum was diagnosed by the presence of ’continuous diaphragm sign’ and ’V sign of Naclerio’. Also noted was mediastinal air extending in extra pleural space bilaterally, initially mistaken for pneumothorax. Presence of blood vessels and fibrous tissue tethered to the parietal pleura within the air space confirmed extra pleural air collection. Patient was given high concentration of inspired oxygen and pneumomediastinum/extra pleural apical air was gradually resolved. Discussion: Pneumomediastinum occurs from alveolar, airway or esophageal rupture. Air in the mediastinum can extend between the parietal pleura and extra pleural tissue by causing detachment of the parietal pleura. Radiographic findings of extra pleural air include air along cardiac and aortic margins and around blood vessels; referred as “ring around the artery sign.” Extension of air between the heart and diaphragm is another sign of extra pleural air referred as “the continuous diaphragm sign.” Air between parietal pleura and medial portion of left hemidiaphragm/descending aorta forming a V shaped configuration is referred as “V sign of Naclerio.” The CT may exhibit vascular structures in the air space adjacent to the lung. The visceral pleural, seen as smooth white line in pneumothorax, is not seen in this manner. Another feature of extra pleural air unlike in pneumothorax is failure of air to shift when patient changes positions. Conclusion: Knowledge and correct interpretation of radiologic findings is essential to differentiate extra pleural air collection form pneumothorax and avoid unnecessary chest tube insertion.

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PURULENT PERICARDITIS CAUSED BY PSEUDOMONAS AERUGINOSA PRESENTING AS ACUTE CORONARY SYNDROME

A CASE OF EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK AND DIC CURED BY CONTINUOUS LONGDURATION PMX-DHP THERAPY

Anuja Waghela, Dhwanil Vyas, Tatiana Thom, University of Connecticut

Masaya Yamato, Keiko Yasuda, Koichi Sasaki, Rinku General Medical Center, Hiromi Rakugi, Yoshitaka Isaka, Osaka University Graduate School of Medicine

Case Reports: A 41yo male presented to the emergency room (ER) with sudden onset of severe, non-radiating substernal pressure associated with nausea and diaphoresis. He denied any fever, chills, palpitations or shortness of breath. His past medical history was significant for congenital unilateral renal agenesis, spina bifida (with meningomyelocele and secondary neurogenic bladder), hypertension and hyperlipidemia. On physical examination, he appeared to be in moderate distress due to the chest discomfort. He was afebrile, hypotensive (99/51), tachypneic (28) and tachycardic (102). Chest x-ray did not show any acute changes. Infero-lateral ST-segment elevations were noted on EKG and cardiac enzymes were elevated. He underwent emergent cardiac catheterization which did not reveal any coronary artery disease. The patient was transferred to a Step Down Unit, where overnight he had marked shortness of breath with worsening hypotension. A repeat chest x-ray was remarkable for globular appearance of the cardiac silhouette, consistent with pericardial effusion. A bedside Echocardiogram showed a moderate pericardial effusion. Meanwhile, the patient was moved to the Intensive care unit (ICU) where he required vasopressor support with Norepinephrine and due to deteriorating respiratory status, he was eventually intubated. Due to worsening clinical condition and concern for cardiac tamponade, the patient was emergently taken to the operating room for a pericardiocentesis. Several hundred milliliters of cloudy pericardial fluid was removed, with an instantaneous improvement in his hemodynamics. The pericardial fluid cultures grew Pseudomonas aeruginosa, which was also isolated from his urine obtained on admission. His blood cultures, however, remained negative. The patient stayed in the ICU for next 48 hrs for close hemodynamic monitoring during which he received appropriate intravenous antibiotics with significant clinical improvement.

Case Reports: A 59-year-old woman with diabetes was referred to our hospital with complaints of nausea, vomiting, diarrhea and left side abdominal pain. Initial vital signs showed clear consciousness, a temperature of 34.8°C, heart rate of 80 beats per minute and blood pressure of 70/- mmHg. Physical examination confirmed left-sided costovertebral angle tenderness. Laboratory tests revealed a white blood cell (WBC) count of 4,900/mm3, hemoglobin of 12.2 g/dL, platelet count of 33,000/mm3, blood glucose of 227 mg/dL, serum creatinine (Cr) of 3.95 mg/dL and markedly elevated CRP to 47.0 mg/dL. Urine analysis demonstrated numerous WBC and gram negative bacilli identified as Escherichia-coli. Abdominal Computed tomography (CT) revealed swelling, gas formation in the renal parenchyma and perirenal tissue of the left kidney. Emphysematous pyelonephritis was diagnosed. At first, any surgical treatment due to septic shock and DIC could not be performed. Treatment was immediately initiated by intravenous injection of meropenem, volume infusion and vasopressor administration according to EGDT. However, examination revealed persistent hypotension (64/44 mmHg), PaO2/FiO2 ratio less than 70 under mechanical ventilation and acute kidney injury (AKI) with oliguria that remained unimproved. Therefore, PMX-DHP and CHDF were initiated within 12 hours after admission, resulting in significant improvements in blood pressure. However, fall in blood pressure was observed again upon interruption of PMX-DHP after 24 hours and elevation of blood pressure was observed upon continuation of PMX-DHP by using second column, suggesting that continuous long-duration PMX-DHP was effective. At day 8, abdominal CT revealed extensive necrosis and residual gas formation in the left kidney. CRP was newly elevated to 10.0 mg/dL. Continuous long-duration PMX-DHP therapy (144 hours) resulted in significant improvements of PaO2/ FiO2 ratio more than 400 and withdrawal in septic shock and DIC. Left nephrectomy was performed at day 9 with success. Cr was 0.88 mg/dL at discharge. The potential for continuous long-duration PMX-DHP in septic shock with difficulty to eliminate the focus of infection should be considered.

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FULMINANT HEPATITIS SECONDARY TO HERPES SIMPLEX VIRUS INFECTION IN AN IMMUNOCOMPETENT PATIENT

METHEMOGLOBINEMIA DUE TO DAPSONE AND METABOLIC ACIDOSIS IN A CHILD WITH RENAL FAILURE

Pratik Doshi, University of Texas Health Science Center At Houston, Mark Warner, University of Texas Houston Medical School Case Reports: Introduction: Fulminant Hepatitis secondary to herpes simplex infection is a clinical condition that is not common, but clearly defined in pediatric, immunocompromised and pregnant populations. It is rare in immunocompetent patients. Case: 47 year old caucasian male with no significant past medical history who was admited to our intensive care unit with fever, pancytopenia and acute hepatitis. Patient’s symptoms had intially begun 8 days prior with dysuria and inguinal rash, which had progressed to fevers chills, myalgias, vomiting and diarrhea. He had been evaluated twice in those 8 days and prescribed skin ointment, Cipro and Tamiflu with no improvement. Pt’s remaining history was unremarkable other than travel to Australia and Singapore 2 months prior. His physical exam was significant for fever, tachycardia, and heptomegaly with mild RUQ tenderness. Subsequently patient was also found to have a 2x3 cm rash in the inguinal area that appeared erythematous, macerated and was not tender. Patient’s initial laboratory evaluation was significant for elevated transaminases(ALT 2204, AST 4613), elevatd creatinine(1.6) and pancytopenia(WBC 0.6, Hemoglobin 10.4, and platelets 54000). Patient’s coagulation studies were normal. Initial evaluation for infectious etiologies(CMV, EBV, HIV, HAV, HBV, HCV, Parvovirus, malaria, Typhus, histoplasmosis), rheumatologic disease or toxins were all negative. On day 3, patient developed altered mental status and continued to show worsening multi-organ failure. At this time, a lumbar puncture was performed which revealed an elevated opening pressure and bloody CSF. Acyclovir was initiated and patient had his inguinal lesion cultured and had blood sent for HSV PCR. Patient’s muti-organ failure continued to progress requiring mechanical ventilation, renal replacement therapy and vasopressor therapy. Patient developed abdominal compartment syndrome on Day 5 and required bedside laparotomy. Patient’s bleeding could not be controlled secondary to his DIC despite massive transfusions of blood products and factor VII and patient expired. Patient’s inguinal lesion, blood and CSF all returned positive for HSV, postmortem.

Madhuradhar Chegondi, Alfredo Castellanos, Felix Ramirez-Seijas, Balagangadhar Totapally, Miami Children’s Hospital Case Reports: Case: A 4-yr-old Middle-Eastern female with h/o Jeune syndrome, end stage renal disease, s/p renal transplant with chronic rejection on immunosuppressive therapy was admitted with cardiorespiratory failure. Child received mechanical ventilation, peritoneal dialysis, and dapsone. Dapsone was started six months before the admission for Pneumocystic prophylaxis. During the 3rd week of hospital stay she developed diarrhea with metabolic acidosis, cyanosis and low saturation on pulse oximetry (89%). Her methemoglobin (MetHb) level was 21.5%. She was started on daily ascorbic acid (vit C) 500 mg via G-tube. Dapsone was replaced by inhaled pentamidine. Vit C was continued for four days after MetHb levels came down to 0.4%. Methemoglobin levels remained low at 0.3% after Vit C was discontinued. Discussion: Methemoglobin is ferric form of hemoglobin, formed from oxidation of ferrous Hb. Hb normally undergoes autooxidation to form MetHb. The rate of oxidation increases with exposure to exogenous or exogenous oxidants. RBC has multiple reducing systems to maintain normal methemoglobin level, the most important being MetHb reductase. Dapsone metabolite, monoacetyl dapsone is a potent oxidant. It is known to cause methemoglobinemia. In renal failure, impaired excretion of monoacetyl dapsone makes patients more susceptible for methemoglobinemia. Metabolic acidosis decreases the activity of MetHb reductase and can worsen the condition. The child in our case report was on dapsone for several months before the event. However, addition of metabolic acidosis led to significant increase in MetHb. Usually, methemoglobinemia is treated with oral or iv methylene blue. Vit C reduces MetHb levels at a slower rate. As the child was of Middle-Eastern descent and G6PD status was not known we have elected to treat her with Vit C. Cimetidine is also helpful as it reduces the formation of dapsone metabolites by inhibiting the cytochrome P450 system. Conclusions: Dapsone is a known cause of methemoglobinemia; its occurrence is more common in patients with impaired renal clearance and associated other factors like diarrhea and metabolic acidosis further increases the risk.


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INTERESTING CAUSE OF HYPOXIA ON VENO ARTERIAL EXTRA CORPOREAL MEMBRANE OXYGENATION (ECMO)

LINEZOLID-RESISTANT STAPHYLOCOCCUS PNEUMONIA: A CASE REPORT

Nikhil Madan, Thomas Jefferson University Hospital, Nicholas Cavarocchi, Hitoshi Hirose, Thomas Jefferson University, Michael Baram, Christopher Gilbert, Thomas Jefferson University Hospital, Anand Kommuri, Jefferson Pulmonary Associates

Heather Rouse, Ryan Simon, Penn State M.S. Hershey Medical Center

Case Reports: Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a fast growing treatment modality for cardiopulmonary failure with promising results. We report a case of hypoxia in a patient on veno- arterial (VA) ECMO due to methemoglobinemia caused by dapsone. Case Report: This is a 36-year-old man with Acute Myeloid Leukemia (AML) status post haploallogeneic stem cell transplant three months ago was admitted with cough and shortness of breath.His chest X-ray and CT scan showed diffuse right lung infiltrates consistent with pneumonia. He was started on antibiotics and antifungal therapy but deteriorated quickly requiring mechanical ventilation. He continued to worsen and was started on VA ECMO for hypoxic respiratory failure. His oxygen saturations remained persistently low at 80 – 85% despite significant support from the ventilator and ECMO. Initially this was thought be due to poor flow in the circuit which was not the case. Not being able to correct hypoxia on VA ECMO was puzzling. Surprisingly we found that his hypoxia did not correlate well with the arterial oxygen concentration which was at lower level of normal. The blood was noticed to be dark brown in color. We then realized that the patient was on dapsone which is a well recognized cause of methemoglobinemia. A co-oximetry panel was requested for methemoglobin percentage which was 7.5%. Dapsone was immediately discontinued and patient was started on methylene blue.After treatement with methylene blue the hypoxia resolved and methemoglobin level dropped to 1.1% within 4 days. Unfortunately during the following days patients bone marrow biopsy confirmed relapse of his AML and family decided to withdraw medical care. Discussion: This case illustrates an interesting cause of hypoxia while on veno- arterial ECMO. It is almost always possible to oxygenate while on VA ECMO. In this case we demonstrate that the hypoxia was not as a result of ECMO failure but due to methemoglobinemia from Dapsone. We conclude that medication interactions are something that a clinician needs to keep in mind while evaluating patients on ECMO.

AUREUS

Case Reports: Resistance amongst Staphylococcus species has increased over the past 20 years, with methicillin-resistant Staphylococcus aureus (MRSA) incidence on the rise as well as an increase in MRSA minimum inhibitory concentrations (MIC) to vancomycin, termed the “MIC creep.” With this increase in MRSA resistance, other antimicrobials are being utilized for MRSA pneumonia such as the oxazolidinone, linezolid. This is a case of a 22-year old male with cystic fibrosis (CF) and recurrent MRSA pneumonias, requiring sixteen hospitalizations for acute respiratory distress in a one and a half year period. During each admission he was empirically started on broad spectrum antibiotics for coverage of gram-negative organisms, including Pseudomonas species, as well as gram-positive organisms, including MRSA. The patient also had reported allergies to amoxicillin, cephalosporins, and vancomycin, reactions not specified. During each admission tracheal aspirates were sent for culture analysis and antimicrobial sensitivities and each revealed MRSA with varying linezolid MICs (⬍/⫽ 1 mcg/ mL– 4 mcg/mL). On his fifteenth admission, a tracheal aspirate was analyzed and again grew MRSA, this time not susceptible to linezolid (MIC ⬎4 mcg/mL). An E-test was performed on this specimen to determine in-vitro susceptibility to tigecycline, with resultant MIC of 0.25 mcg/mL. The patient was initiated on tigecycline 100 mg times one dose followed by 50 mg IV every 12 hours and was treated for a total of twenty-two days before returning to our institution with an acute CF exacerbation requiring mechanical ventilation despite current antimicrobial therapy. The patient underwent desensitization to ceftaroline and was treated for seven days before being discharged to hospice care. Linezolid resistance remains uncommon, however it is reported in the literature. The most common mechanism of linezolid-resistant MRSA is a point mutation in the domain V of the 23S rRNA, and is not likely to develop cross-resistance between other antistaphylococcal antibiotics. This patient likely became colonized with this linezolid-resistant strain of MRSA as a result of his prolonged course of treatment with linezolid.

947

948

PULMONARY EMBOLECTOMY FOR SHOCK FROM MASSIVE PULMONARY EMBOLISM

ADENOCARCINOMA OF THE LUNG PRESENTING WITH RAPID ATRIAL FIBRILLATION

Anand Kommuri, Elisabeth Carr, Rohit Kumar, Nikhil Madan, Andrea Adams, Thomas Jefferson university Hospital

Barbara Birriel, Pennsylvania State University

Case Reports: Introduction: Pulmonary embolectomy is indicated in shock from massive pulmonary embolism with contraindication to or failed thrombolysis.We report a case of massive pulmonary embolism with right atrial clot in transition treated by emergency pulmonary embolectomy and right atrial clot extraction by cardiopulmonary bypass. Case report: A 84 yr old male presented with 5 day duration of dyspnea, chills, fatigue and pain in right hypochondrium preceded by nausea, vomiting, diarrhea and altered sensorium. He had recently returned from a trip to Florida.In the emergency room, he was found to be dehydrated, hypotensive with low grade fever. He remained hypotensive despite fluid resuscitation (5 litres), antibiotic therapy (pending cultures), was started on pressors and transferred to the intensive care for closer monitoring. His past medical problems were hypertension, diabetes, hypothyroidism, bullous pemphigoid and chronic lymphocytic leukemia. He was an active healthy man, non smoker with no history of drug abuse. His home medications were aspirin, thyroxine, tetracycline and antihypertensive medications.Over the next few hours, he had a major hypotensive episode ,worsening respiratory distress, hypoxia with new pulmonary infiltrates on repeat imaging. An emergency echocardiogram showed severely dilated right ventricle with decreased function and presence of an elongated mobile mass in the right atrium prolapsing into the right ventricle representing a pulmonary embolus in transit.Patient had an emergent pulmonary embolectomy and right atrial clot extraction using cardiopulmonary bypass. He was anticoagulated and had a temporary vena caval filter placed for an acute left femoro- popliteal deep vein thrombosis. His clinical course was complicated by renal failure, aspiration pneumonia, failure to wean from ventilator requiring tracheostomy and was finally discharged to a long term acute care facility. Discussion: In selected highly compromised patients whose critical status does not allow sufficient time for systemic thrombolysis therapy, pulmonary embolectomy may be the most appropriate intervention to achieve a successful outcome.


Case Reports: 57 y.o. male presented with sudden dyspnea and palpitations. He had been in good health and physically active with a 40 pack year history of tobacco use. He was in rapid atrial fibrillation (AF) with a heart rate of 190 bpm. He was admitted to the ICU, heart rate controlled with IV diltiazem and anticoagulated with IV heparin. Once his heart rate was controlled, his symptoms resolved. All laboratory studies, including thyroid function were normal. ECG was normal except for the AF. Echocardiogram showed mild right heart strain, normal systolic function, no atrial enlargement and no intracardiac thrombus. He had mild right leg edema but no calf tenderness and negative Homan’s sign. Venous doppler showed occlusive thrombus in the right popliteal vein. CT scan showed moderate pulmonary embolism (PE) and a 1.5 cm mass in the left lung. Later biopsy confirmed adenocarcinoma of the lung which was treated surgically.AF is most often related to cardiovascular pathologies, hypertension, or thyrotoxicosis. AF occurs in 3% of patients with PE. This patient had no identified risk factors for developing AF. The right leg edema/confirmed deep venous thrombus and right heart strain on echocardiogram were suspicious for PE, leading to the decision for CT scan which established PE as the etiology of the AF. Venous thromboembolism (VTE) is most often related to surgical or nonsurgical trauma, immobility, obesity, inherited or acquired hypercoaguable states. This patient had no identified risk factors for VTE. Identification of the left lung mass on CT scan established hypercoaguable state related to the malignancy as the etiology of VTE.This case demonstrates the need to pursue complete diagnostic evaluation to identify the cause of diagnoses. The patient was asymptomatic related to his lung cancer. He presented only due to the symptoms caused by the AF. The AF was caused by the right heart strain from the PE. The PE/VTE was caused by the hypercoaguable state from the lung adenocarcinoma. Complete evaluation and full diagnosis resulted in successful treatment for the lung adenocarcinoma at an early stage in the disease process.

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950

SOUTHERN TICK ASSOCIATED RASH ILLNESS (STARI) PRESENTING AS MENINGOENCEPHALITIS AND STATUS EPILEPTICUS

SYMPTOMATIC HYPOCALCEMIA DURING URINARY ALKALINIZATION FOR ACUTE ASPIRIN TOXICITY

Jiri Brabec, Ryan Hakimi, Oklahoma University

Jennifer Flint, Children’S Mercy Hospital and Clinics, Bruce Banwart, Children’s Mercy Critical Care

Case Reports: Southern Tick Associated Rash Illness (STARI), also known as Master’s disease, is similar to Lyme disease and is vectored by the lone star tick (Amblyomma americanum). The causative agent has not been isolated. In the current literature, symptoms related to STARI are described as mild, and have not been linked to any neurological, arthritic or chronic symptoms. To our knowledge, this is the first report of a patient with STARI presenting with status epilepticus and meningoencephalitis.A 29-year-old male with no previous significant medical history developed a rash and symptoms of an upper respiratory infection shortly after he was in South Carolina during his army training. Within a week, the rash spread from his torso to all four extremities, and he developed meningeal signs with a fever of 40.1° C. The patient developed clinical status epilepticus and was transferred to our University’s Neurosciences ICU, following an unremarkable CT of the brain. Lumbar puncture and MRI of the brain with gadolinium were consistent with meningoencephalitis. Broad diagnostic workup (cerebrospinal fluid analysis, cultures, serologic studies and skin biopsy) was negative for common causes of meningoencephalitis associated with rash including Rocky Mountain Spotted Fever, Lyme disease, or Ehrlichiosis amongst others. Treatment with broad spectrum intravenous antibiotics including doxycycline led to symptom resolution. The patient was discharged home nine days after the admission without any neurological deficits.We believe this to be first report of STARI presenting initially with rash and mild constitutional symptoms, going untreated, and then progressing to fever, meningoencephalitis and status epilepticus. Treatment with intravenous antibiotics including doxycycline led to rapid resolution of symptoms.STARI is likely underdiagnosed due to its similarity to Lyme disease and to its response to doxycycline. Further studies investigating the incidence, etiology, and clinical course of STARI are warranted.

Case Reports: A 16y/o ingested 165 tablets of 325 mg ASA (1000 mg/kg). He presented to an outside facility 8 hours after ingestion alert with stable vital signs and ASA level 78 mg/dL. Initial lab values showed an arterial blood gas (ABG) pH 7.46, pCO2 26 mmHg, HCO3 18 mmol/L, ionized calcium 1.09 mmol/L, serum calcium 10 mg/dL, albumin 4.5 gm/dL, magnesium 2.1 mg/dL. Urinary alkalinization was initiated with a sodium bicarbonate infusion (NaHCO3) and he arrived to our facility 12 hours after ingestion with Kussmaul respirations and altered mentation. Repeat ASA 116 mg/dL, ionized calcium 0.88 mmol/L and serum calcium 8.8 mg/dL. He became encephalopathic with marked hyperpnea and diaphoresis. He was not intubated due to the risk of impairing his respiratory drive and lowering his pH. Jaw thrust maneuvers were provided to maintain his airway. A dialysis catheter was placed without sedation and dialysis was initiated. He developed bradycardia, hypotension, ST segment depression, and ventricular dysrhythmias. He required 5 liters of fluid, 3.5 gms calcium chloride, 175 mcg (3.4 mcg/kg) intermittent bolus epinephrine and continuous infusions of dopamine (10 mcg/kg/min), epinephrine (0.12 mcg/kg/min), and norepinephrine (0.05 mcg/kg/min). After 3 hours of dialysis, ASA level 49 mg/dL, vital signs stabilized, ionized calcium normalized, vasopressors were weaned off, and neurological status returned to baseline. To our knowledge, this is the first case report of urinary alkalinization leading to low ionized calcium levels with associated hemodynamic instability and dysrhythmias. Altering the serum pH during urinary alkalinization can alter the availability of ionized calcium. Urinary calcium loss may be enhanced by the excretion of the sodium load from a NaHCO3 infusion due to inhibition of calcium reabsorption in the proximal and late distal tubule, contributing to total calcium losses. The degree of insensible losses and volume depletion can be underappreciated in the setting of acute aspirin toxicity. Hypocalcemia in combination with volume depletion and rapid volume shifts seen with initiation of dialysis can lead to significant hemodynamic instability.

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952

STRESS-INDUCED CARDIOMYOPATHY DUE TO SYSTEMIC AIR EMBOLISM-INDUCED CEREBROVASCULAR ACCIDENT

TRAVELER’S DIARRHEA . . . AND THEN SOME!

Lioudmila Karnatovskaia, Mayo Clinic

Case Reports: Despite being the fourth leading cause of community acquired pneumonia, legionellosis continues evade timely diagnosis by exhibiting an array of clinical presentations. CW, a 52 year old AAF with a history of hysterectomy for uterine fibroids presents with 3 days of diarrhea and mild flu-like symptoms. After visiting Oklahoma, she presented to her local NYC ER where the symptoms were addressed as gastroenteritis and was discharged with supportive treatment. Following a day of mild improvement, CW returned to the ER with an increase in fever/chills and new onset SOB and cough with sputum. Physical exam showed bilateral rales and decreased breath sounds consistent with community acquired pneumonia. Further questioning revealed instances of confusion/inattentiveness and mild cough over the past week. CAP work-up was sent and initial treatment was started. A rapid progression to respiratory distress necessitated an ICU transfer with aggressive bipap ventilation and subsequent intubation. CXR and spiral CT showed bilateral basal infiltrates and evident air bronchogram signs respectively. Sputum and blood cultures were negative however L. pneumophila specific sputum culture and urine legionella antigen tested positive. Despite ten days of vigorous organism specific treatment, the patient continued exhibit prominent symptoms of legionellosis. Concomitant bronchiolitis obliterans with obstructive pneumonia was ruled out with a left lingular biopsy. Although delayed, the patient ultimately responded well to continued therapy, recovered, and was discharged. This case illustrates the importance of acquiring, assessing, and pursuing all of a patient’s clinical manifestations. Unfortunately, often times associated clinical symptoms are overshadowed by a pronounced primary complaint. Although lacking predisposing factors, many clues from CW’s history and physical pointed toward legionellosis. Prompt diagnosis and disease directed therapy is imperative to successfully manage legionellosis. This patient’s delayed diagnosis/ treatment was a probable cause for her prolonged clinical response to therapy.

Case Reports: Systemic air embolism is a very rare (⬍0.1%) complication of transthoracic CT scan needle biopsy and can result in serious neurologic and/or cardiac sequelae. This is the first reported case of stress cardiomyopathy following an air embolus induced stroke. A 71 year old female undergoing percutaneous CT scan guided needle lung biopsy started coughing, and became bradycardic; she responded to a dose of epinephrine. Patient developed left hemiplegia. Postprocedure chest CT frames showed intraluminal air in aorta. CT head demonstrated scattered air emboli. ECG showed ST elevations; patient denied chest discomfort. She underwent hyperbaric treatment with marked improvement in neurologic symptoms. Repeat ECG showed T-wave depressions; patient had elevated cardiac biomarkers. TTE was significant for EF of 35% and apical ballooning. ACS protocol was initiated until subsequent coronary angiography showed no evidence of obstructive coronary artery disease. Brain MRI demonstrated hemorrhagic conversion of the ischemic stroke. Subsequent TTE showed EF of 65% without evidence of wall motion abnormalities. Discussion: Three major causes of systemic air embolism have been identified: communication between pulmonary vein and atmosphere; arterial air traversing into a pulmonary vein; and bronchovenous fistula. Standard therapy consists of 100% oxygen followed by hyperbaric treatment in symptomatic cases initiated as early as possible, as delay in treatment adversely affects outcome. Patients need to be placed in a flat supine position unlike in cases of venous air emboli where left lateral decubitus position is preferred. Stress induced cardiomyopathy has been reported in association with IV epinephrine and CNS events, most commonly subarachnoid hemorrhage and ischemic stroke. Initial management is as per ACS protocol. Administration of fibrinolytics can lead to harm; therefore, transfer to a center capable of performing emergency coronary angiography is recommended. Familiarity of clinicians with pathophysiology of systemic air emboli, awareness of potential complications, and knowledge of management recommendations are paramount to successful treatment of such patients.

Umar Kaleem, Ross university, Robert Glennon, Bay Ridge Pulmonary Associates
