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Kollef M.H.,University of Washington | Micek S.T.,Barnes Jewish Hospital
Seminars in Respiratory and Critical Care Medicine | Year: 2010

The care of critically ill patients has become increasingly complex as severity of illness continues to increase, the number of patients requiring intensive care is on the rise, the amount of clinical information available at the bedside is growing, and the quantity of evidence supporting or refuting specific therapies and interventions for this population is escalating. It has become problematic for clinicians to master all of these tasks and to process the quantity of available clinical and scientific information in an effective and safe manner. Additionally, a culture promoting safety and accountability has emerged in the United States and throughout the world in regard to medical care. The expectation is that patients entering hospitals should receive the highest quality of care with minimal to no medical errors occurring. To accomplish this goal, as well as to allow more accurate monitoring of day to day medical practices, several strategies have been developed that have primarily been employed in the intensive care unit (ICU) setting. These strategies include the use of paper-based or electronic protocols for disease (e.g., severe sepsis and septic shock) or process of care (e.g., weaning of mechanical ventilation) management, national guidelines, and targeted clinician education with or without periodic feedback regarding compliance with best medical practices and resultant patient-based outcomes. This review focuses on the use of protocols in the ICU setting and how they can best be utilized to improve patient outcomes. © 2010 by Thieme Medical Publishers, Inc.

Boothpur R.,Barnes Jewish Hospital | Brennan D.C.,University of Washington
Journal of Clinical Virology | Year: 2010

Polyoma viruses are ubiquitous infecting many different mammalian species including humans. There are five known human polyoma viruses. JC virus and BK virus are two polyoma viruses identified nearly three decades ago. Recently WU, KI and Merkel cell polyoma viruses have been isolated from humans. The exact role of these three newly discovered viruses in human disease is not known. Most human polyoma disease is caused by BK and JC viruses which are usually acquired in childhood. Approximately 50-80% of humans have seropositivity to these viruses. Clinically apparent diseases in immunocompetent hosts are extremely rare. These viruses remain latent possibly in the lymphoid organs, neuronal tissue, and kidney and under the circumstances of severe immunosuppression both these viruses reactivate. Neurotropic JC virus reaches the brain and causes progressive multifocal leukoencephalopathy, a demyelinating disease of the central nervous system with a high mortality rate. BK virus is urotheliotropic and its reactivation causes a form of interstitial nephritis, known as BK or polyoma virus associated nephropathy which is associated with high graft loss if not recognized early. There are no known effective antiviral agents for any of the polyoma viruses. © 2009 Elsevier B.V. All rights reserved.

Barnes B.J.,University of Kansas Medical Center | Hollands J.M.,Barnes Jewish Hospital
Critical Care Medicine | Year: 2010

The objective of this review is to characterize the mechanisms, risk factors, and offending pharmacotherapeutic agents that may cause drug-induced arrhythmias in critically ill patients. PubMed, other databases, and citation review were used to identify relevant published literature. The authors independently selected studies based on relevance to the topic. Numerous drugs have the potential to cause drug-induced arrhythmias. Drugs commonly administered to critically ill patients are capable of precipitating arrhythmias and include antiarrhythmics, antianginals, antiemetics, gastrointestinal stimulants, antibacterials, narcotics, antipsychotics, inotropes, digoxin, anesthetic agents, bronchodilators, and drugs that cause electrolyte imbalances and bradyarrhythmias. Drug-induced arrhythmias are insidious but prevalent. Critically ill patients frequently experience drug-induced arrhythmias; however, enhanced appreciation for this adverse event has the potential to improve prevention, treatment, patient safety, and outcomes in this patient population. Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

Drewry A.M.,University of Washington | Fuller B.M.,University of Washington | Skrupky L.P.,Barnes Jewish Hospital | Hotchkiss R.S.,University of Washington
Critical Care Medicine | Year: 2015

Objective: To determine whether hypothermia within 24 hours of sepsis diagnosis is associated with development of persistent lymphopenia, a feature of sepsis-induced immunosuppression. Design: Retrospective cohort study. Setting: A 1,200-bed university-affiliated tertiary care hospital. Patients: Adult patients diagnosed with bacteremia and sepsis within 5 days of hospital admission between January 1, 2010, and July 31, 2012. Interventions: None. Measurements and Main Results: Leukocyte counts were recorded during the first 4 days following sepsis diagnosis. Persistent lymphopenia was defined as an absolute lymphocyte count less than 1.2 cells/μL × 10 3 present on the fourth day after diagnosis. Of the 445 patients with sepsis included, hypothermia developed in 64 patients (14.4%) (defined as a body temperature < 36.0°C) within 24 hours of sepsis diagnosis. Hypothermia was a significant independent predictor of persistent lymphopenia (adjusted odds ratio, 2.70 [95% CI, 1.10, 6.60]; p = 0.03) after accounting for age, disease severity, comorbidities, source of bacteremia, and type of organism. Compared with the nonhypothermic patients, hypothermic patients had higher 28-day (50.0% vs 24.9%, p < 0.001) and 1-year mortality (60.9% vs 47.0%, p = 0.001). Conclusions: Hypothermia is associated with higher mortality and an increased risk of persistent lymphopenia in patients with sepsis, and it may be an early clinical predictor of sepsis-induced immunosuppression. © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Strasberg S.M.,Washington University in St. Louis | Fields R.,Barnes Jewish Hospital
Cancer Journal (United States) | Year: 2012

Adenocarcinoma of the body and tail of the pancreas is an aggressive malignancy, and classically there have been few survivors after surgery. Radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection are new procedures for these tumors. Radical antegrade modular pancreatosplenectomy is designed to establish an operation with oncologic rationales both for the dissection planes used to achieve negative margins and the extent of node dissection. The extent of lymph node dissection is based on the descriptions of N1 lymph node drainage, and dissection planes are based on fascial planes of the retroperitoneum. Radical antegrade modular pancreatosplenectomy is modular, adjusting the posterior plane of dissection based on the position of the tumor on preoperative computed tomograms. It is also performed right to left to increase visibility and control blood supply early. Radical antegrade modular pancreatosplenectomy is not an extended pancreatectomy but brings the rationales of the modern Whipple procedure to left-sided tumors. In long-term results from our center in 47 patients, there was a high negative tangential margin rate of 89% and an actuarial overall 5-year survival rate of 35.5%. The actual 5-year survival in 23 patients was 30.4%. Distal pancreatectomy with celiac axis resection is a procedure for cancers that have involved the celiac axis. It is based on the fact that resection of the celiac axis may be performed without devascularizing the liver, which then receives its blood supply by the pancreaticoduodenal arcade. It is an extended pancreatectomy. Mature long term results are just becoming available. Results with distal pancreatectomy with celiac axis resection are mixed with some series reporting few or no long-term survivors, whereas others report long-term survival at approximately 20%. Copyright © 2012 by Lippincott Williams &Wilkins.

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