Purpose: Inferior vena cava (IVC) diameter and variation are commonly measured in the supine position to estimate intravascular volume status of critically ill patients.Many scientific societies describe the measurement of IVC diameter in the supine position. However, critically ill patients are rarely placed supine due to concerns for aspiration risk, worsened respiratory mechanics, increases in intracranial pressure, and the time it takes to change patient position. We assessed the influence of headof-bed (HOB) elevation on IVC measurements. Methods:We conducted a prospective observational study of critically ill patients undergoing critical care ultrasound. With HOB at 0 , IVC maximum (IVCmax0 ) and minimum (IVCmin0 ) diameters were measured. Measurements were then repeated with HOB elevated to 30 and 45 . Collapsibility index (CI), defined as (IVCmax − IVCmin)/IVCmax, was calculated for each HOB elevation. Mean differences were then compared.
PURPOSE:The objective in management of patients experiencing cardiac arrest is to identify reversible causes. The introduction of Point-of-Care Ultrasound (POCUS) into critical care has opened avenues not previously available in the management of these patients. We aimed to observe the effects of introduction of POCUS in management of patients experiencing in-hospital cardiac arrest (IHCA). IHCA has been reported to have a survival rate of 6.6% to hospital discharge. While multiple protocols exist for intra-arrest echocardiography, a recent meta-analysis of 15 studies examining POCUS in cardiac arrest consisted entirely of prehospital and/or Emergency Department settings. This is the first study examining the impact of POCUS on IHCA. METHODS:We collected a convenience sample of 19 patients with IHCA between July 2016 and February 2017 who had a POCUS performed as part of their management due to critical care fellow availability. In our tertiary-care urban community teaching hospital, we have ultrasound-trained critical care fellows and faculty. In general, we would perform POCUS in cases where a second fellow would be available to perform and interpret the exam since the primary fellow would be involved with other aspects of patient care during cardiac arrest.RESULTS: Out of 75 total IHCA at our institution during the study period, 24 occurred during times when 2 fellows would normally be present and were announced overhead. 15 of our studies occurred during this time period (4 occurred outside of this time period), yielding 63% of potential IHCA patients underwent POCUS. Average age of patients was 67.7 years and 52.6% of them were male. 47.4% of arrests occurred in the medical ICU and PEA was the initial rhythm in 73.7% of patients. Average time of CPR was 16.1 minutes (Range 4-37) and 73.7% of patients achieved ROSC. All patients had goal-directed echocardiography including, at minimum, a subcostal view. 5.3% of patients (1/19) received tPA due to severe RV dysfunction. One patient had a small IVC diameter and therefore received IV Fluids. All patients who were checked for lung sliding had lung sliding present and therefore pneumothorax was ruled out as a cause of cardiac arrest. No pericardial effusions were noted and therefore cardiac tamponade was ruled out as a cause of cardiac arrest. LV function was found to be normal or hyperdynamic in 6 patients, all of whom achieved ROSC. CONCLUSIONS: POCUS is feasible and useful in management of patients experiencing in-hospital cardiac arrest.CLINICAL IMPLICATIONS: POCUS should play a larger role for IHCA in hospitals which have that capability. Future studies should focus on larger patient population and potential use of POCUS in assessing efficacy of compressions by examining realtime surrogate markers of stroke volume.
PURPOSE: Pneumocystis jiroveci pneumonia (PJP) is a serious infection that occurs in immunocompromised patients and is associated with high morbidity and mortality. According to the CDC, in the U.S., the mortality rate ranges from 5 to 40% in patients receiving treatment and up to 100% in those without therapy. High flow nasal oxygen (HFNO) has been demonstrated to decrease mortality compared to oxygen via face mask and non-invasive ventilation in patients with pneumonia and possibly in immunocompromised patients with acute respiratory failure. There is a paucity of literature describing the use of HFNO in patients with PJP. The objective of this study was to evaluate the outcomes of patients with PJP who received HFNO. METHODS:We retrospectively reviewed consecutive patients with PJP and acute respiratory distress syndrome treated with HFNO from 10/2015-02/2017. We reviewed the clinical, physiological, radiological characteristics, treatment and outcome of patients with PJP. Severity of acute respiratory distress syndrome was defined by the SpO 2 :FiO 2 ratio: 214-357 for mild and 89-213 for moderate acute respiratory distress syndrome. The diagnosis of PJP was established via bronchoscopy (n=2) or by high clinical suspicion for PJP (n=3) determined by Infectious Disease and Pulmonary specialists.RESULTS: Five patients were treated for PJP with HFNO. Mean age was 60.8 and 80% were women. The etiology of their immunocompromised states included: AIDS, and non-HIV patients with lymphoma, and rheumatoid arthritis, with severe lymphopenia, on immunosuppressive therapy. None of the patients were on PJP prophylaxis prior to diagnosis. All patients had bilateral pulmonary infiltrates. Four patients had mild acute respiratory distress syndrome and one patient had moderate acute respiratory distress syndrome characterized by a median SpO 2 :FiO 2 ratio of 289. All of the patients were treated with trimethoprim-sulfamethoxazole along with a prednisone taper for a total of 21 days. The average length of use of HFNO was 8 days. One patient required intubation prior to HFNO, and was extubated to HFNO. None of the patients required intubation after HFNO. The median CD4 count for patients with HIV was 73.5. Median serum LDH was 1006. One patient developed a pneumothorax. In-hospital mortality was 20%, this patient was transferred to inpatient hospice for her underlying disease. Average hospital length of stay was 20 days (range12-34 days).CONCLUSIONS: PJP remains one of the most common life-threatening opportunistic infections in immunosuppressed patients. We have demonstrated the possible utility of HFNO in patients with mild acute respiratory distress syndrome with PJP. Four out of five patients tolerated HFNO and were discharged without any complications. Larger prospective studies are necessary to evaluate the safety and efficacy HFNO for mild to severe PJP.CLINICAL IMPLICATIONS: A trial of HFNO may be a reasonable alternative to oxygen via face mask or non-invasive ventilation in immunocompromised patients with PJP and acu...
Idiopathic Pulmonary Fibrosis (IPF) is an Interstitial Lung Disease (ILD) with significant morbidity and mortality. Guidelines recommend frequent monitoring for disease progression, co-morbidities, and early referral to pulmonary rehabilitation and palliative care 1 . Previous studies have shown improved survival in patients with ILD cared for in dedicated ILD clinics in tertiary care centers 2 . In May 2019, a dedicated weekly ILD clinic was established at the Hunter Holmes McGuire Veterans Affairs Medical Center. We performed a retrospective chart review to assess whether the ILD clinic improved adherence to guideline-based metrics in veterans with IPF. METHODS:A list of all patients on antifibrotic therapy, reflecting most individuals with IPF at our medical center, was obtained from the pharmacy. We then performed a chart-based retrospective review comparing the frequency of guideline-recommended monitoring and discussions performed for patients seen in ILD clinic compared to the general pulmonary clinic. The ILD clinic consisted of a dedicated Pulmonologist and Respiratory Therapist. Each new patient seen in the clinic completed an extensive medical, exposure and family history. A 6-minute walk test (6MWT) and bedside spirometry was attempted every patient visit. Charts from May 1, 2019 to March 31, 2020 were reviewed, reflecting the period from when ILD clinic was initiated until usual clinic operations were halted due to the COVID-19 pandemic.RESULTS: A total of 20 IPF patients were identified; 7 were followed in the ILD clinic while the remaining 13 were seen in general pulmonary clinic. Individuals followed in the ILD clinic had closer monitoring of end points used to monitor for disease progression, such as spirometry and 6MWT, with both occurring every 6 months in 85.7% of patients. In the general pulmonary clinic, 46% had PFTs every 6 months while none had 6MWT every 6 months. Of the IPF patients seen in the ILD clinic, 100% underwent screening for sleep apnea, gastroesophageal reflux disease and hypoxia, while 46.2%, 84.6% and 76.9% respectively were screened in general pulmonary clinic. ILD clinic patients also had discussions regarding pulmonary rehab and goals of care, 100% and 42.9% of the time compared to 23% and 38.5% in those seen in general pulmonary clinic.CONCLUSIONS: ILD clinics, regardless of their association with a tertiary care center, can lead to improved monitoring of disease progression and co-morbidities in patients with IPF. Such dedicated care can also lead to more referrals to pulmonary rehab and palliative care. The key limitations to this study are the sample size and the retrospective design. In addition, we may not have captured patients with IPF who were not considered to be candidates for anti-fibrotic therapy.CLINICAL IMPLICATIONS: With minimal associated cost, dedicated ILD clinics, even those located in small healthcare systems, can improve care provided to patient's with IPF.1) Idiopathic pulmonary fibrosis: diagnosis and treatment. International Consensus Statement. A...
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