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Mietto C.,Critical Care and Pain Medicine | Pinciroli R.,Critical Care and Pain Medicine | Goverman J.,Massachusetts General Hospital | Berra L.,Critical Care and Pain Medicine lberra@partners.org
Respiratory care | Year: 2014

Accumulation of secretions may suddenly occlude an endotracheal tube (ETT), requiring immediate medical attention. The endOclear catheter (Endoclear LLC, Petoskey, Michigan) is a novel device designed to clear mucus and debris from an ETT and restore luminal patency. We present 3 subsequent cases of life-threatening partial ETT occlusions recorded over a period of 6 months at Massachusetts General Hospital. After conventional methods (standard tracheal suctioning and bronchoscopy) failed, the endOclear was used, with successful restoration of the airways in all 3 cases. The respiratory conditions rapidly improved, and all 3 patients tolerated the ETT-cleaning maneuver. These results show that such a device is safe and easy to use during an emergency airway situation for efficient and rapid removal of secretions from obstructed ETTs by respiratory therapists. Copyright © 2014 by Daedalus Enterprises.


PubMed | Critical Care and Pain Medicine., Mahidol University, Massachusetts General Hospital, Critical Care and Pain Medicine and University of California at San Diego
Type: Journal Article | Journal: Respiratory care | Year: 2016

The Centers for Disease Control and Prevention have recently introduced new ventilator-associated pneumonia (VAP) surveillance on the basis of the infection-related ventilator-associated complication (IVAC) definition. We aim to evaluate the accuracy of this new IVAC algorithm for detecting VAP according to the 2008 Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) definition as the reference diagnosis (VAP-NHSN) in high-risk trauma patients.This retrospective single-center study included all trauma subjects who were admitted to the ICU, required mechanical ventilation for >48 h, and received a blood transfusion. The new IVAC surveillance and the criteria for VAP-NHSN diagnosis were applied. The accuracy of the new IVAC surveillance for detecting VAP-NHSN was determined, and the clinical outcomes were compared between groups.The sensitivity, specificity, and positive and negative predictive values of IVAC for VAP-NSHN identification were 28.12%, 91.45, 58.06%, and 75.14%, respectively. Subjects with IVAC, VAP-NHSN, or both had higher morbidity when compared with those without IVAC and VAP-NHSN. Subjects with IVAC only had lower morbidity compared with those with VAP-NHSN only or those with both IVAC and VAP-NHSN. There was no significant difference in clinical outcomes between subjects with VAP-NHSN only and those with both IVAC and VAP-NHSN.IVAC criteria had a low accuracy for identifying VAP-NHSN in subjects with high-risk trauma.


News Article | October 26, 2016
Site: www.eurekalert.org

The latest study from a Massachusetts General Hospital (MGH)/Massachusetts Institute of Technology (MIT) team investigating the mechanisms underlying general anesthesia finds that stimulating a specific group of neurons in mice produces signs of arousal -- including getting on their feet and walking -- even as the animals continue to receive the anesthetic drug isoflurane. In addition to developing ways to actively reverse anesthetic-induced unconsciousness, the findings may someday help improve treatment of conditions such as coma or opioid overdose. "There currently are no ways to actively wake someone from general anesthesia, and understanding the mechanisms that promote arousal could help us develop therapies to treat other low-arousal conditions, such as traumatic brain injury," says Norman Taylor, MD, PhD, of the MGH Department of Anesthesia, Critical Care and Pain Medicine, lead author of the report published online in the Proceedings of the National Academy of Sciences. "Finding one set of neurons that is able to produce such a powerful arousing effect changes the way we think about recovery from anesthesia and possibly coma as well." Taylor is part of a team led by Emery Brown, MD, PhD, of the MGH Department of Anesthesia, Critical Care and Pain Medicine and the MIT Department of Brain and Cognitive Sciences, that has been investigating both how general anesthesia induces unconsciousness and ways of reversing the effects. Several previous studies led by Ken Solt, MD, MGH Department of Anesthesia, the senior author of the current study, found that stimulant drugs such as methylphenidate and amphetamine could restore consciousness to animals continuing to receive general anesthetics. A paper in the August 2014 issue of Anesthesiology found that stimulating the ventral tegmental area (VTA), a brain region that releases the neurotransmitter dopamine, also could arouse anesthetized rats. Since the electrical stimulation used in the 2014 study can activate all adjacent neurons, the current study used optogenetics, a method of activating specific populations of neurons by means of light, to target only dopamine-responsive neurons in the VTA. Every one of six mice engineered to express a light-responsive protein in dopamine neurons showed signs of arousal -- including moving, standing up and walking -- in response to pulses of light delivered to the VTA, even while they continued to receive isoflurane. Use of an agent that blocks signaling by the D1 receptor -- one of five dopamine receptors -- prevented the arousal response to light stimulation, indicated that dopamine signaling was responsible for counteracting anesthetic effects. EEG readings taken during optogenetic stimulation of the VTA showed patterns similar but not identical to those of unanesthetized animals. "We now need to study whether the activation of dopamine neurons can help in coma-like states," says Taylor, who is an instructor in Anesthesia at Harvard Medical School. "One of the effects of dopamine neuron stimulation we observed was increased respiratory rate, which may have implications for treating the sedating effects of medications such as opioids and provide insight into how to save the lives of more overdose patients." In addition to Solt and Brown, the co-authors of the PNAS paper are Christa Van Dort, PhD, Jonathan Kenny, JunZhu Pei, Jennifer Guidera, Ksenia Vlasov, and Justin Lee, of both the MGH Department of Anesthesia, Critical Care and Pain Medicine and the MIT Department of Brain and Cognitive Sciences; and Edward Boyden, PhD, MIT Brain and Cognitive Sciences. Support for the study includes National Institutes of Health grants TR01 GM104948 and T32 GM07592. Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $800 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals, earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2016 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."


PubMed | University of Chicago, University of Southern California, McMaster University, Critical Care and Pain Medicine and 7 more.
Type: Journal Article | Journal: Neurocritical care | Year: 2016

The risk of death from venous thromboembolism (VTE) is high in intensive care unit patients with neurological diagnoses. This is due to an increased risk of venous stasis secondary to paralysis as well as an increased prevalence of underlying pathologies that cause endothelial activation and create an increased risk of embolus formation. In many of these diseases, there is an associated risk from bleeding because of standard VTE prophylaxis. There is a paucity of prospective studies examining different VTE prophylaxis strategies in the neurologically ill. The lack of a solid evidentiary base has posed challenges for the establishment of consistent and evidence-based clinical practice standards. In response to this need for guidance, the Neurocritical Care Society set out to develop and evidence-based guideline using GRADE to safely reduce VTE and its associated complications.


PubMed | Critical Care and Pain Medicine., Mahidol University, Massachusetts General Hospital and University of California at San Diego
Type: Journal Article | Journal: Respiratory care | Year: 2016

Re-intubation is associated with high morbidity and mortality. There is limited information regarding the risk factors that predispose patients admitted to the surgical ICU to re-intubation. We hypothesized that preoperative comorbidities, acquired muscular weakness, and renal dysfunction would be predictors of re-intubation in the surgical ICU population.This was a prospective observational study in 2 surgical ICUs of a large tertiary hospital. All patients who were extubated during their surgical ICU stay were included. Demographic and clinical data were collected before and after extubation. The primary outcome was re-intubation within 72 h. Using multivariate logistic regression analysis, independent risk factors of re-intubation were determined, and a prediction score was developed.Between December 1, 2012, and January 31, 2014, we included 764 consecutive subjects. Of these, 65 subjects (8.5%) required re-intubation. Independent risk factors of re-intubation were blood urea nitrogen level of >8.2 mmol/L (odds ratio [OR] 3.66, 95% CI 1.97-6.80), hemoglobin level of <75 g/L (OR 2.10, 95% CI 1.23-3.61), and muscle strength of 3 (OR 2.03, 95% CI 1.16-3.55). The presence of all 3 risk factors was associated with an estimated probability for re-intubation of 26.8%.In noncardiac surgery, surgical ICU subjects, elevated blood urea nitrogen level, low hemoglobin level, and muscle weakness were identified as independent risk factors for re-intubation. The presence of these risk factors can potentially aid clinicians in making informed decisions regarding optimal airway management in patients considered for an extubation attempt. (ClinicalTrials.gov registration NCT01967056.).


Jones R.,Critical Care and Pain Medicine | Jones R.,Harvard University | Capen D.E.,Critical Care and Pain Medicine
Ultrastructural Pathology | Year: 2014

The present studies focus on monocytic circulating cells (CCs) interacting with the endothelial cells of pulmonary capillaries in acute lung injury. The CCs are further defined into sub-sets based on their structural profiles, i.e. CC1-3. They are shown to move into close apposition to adjacent capillary endothelium and to fuse to endothelial plasmalemmal membranes. Similarly, CCs are seen to fuse to the endothelial cells of regenerating capillaries after injury. Immunogold labeling studies demonstrate that CCs express a mediator promoting endothelial cell migration, proliferation and stability, i.e. VEGF, further supporting the potential of a paracrine interaction between the fusing cells, while the expression of CXCR4 by CCs, and of SDF-1α by adjacent endothelial cells, demonstrates a mechanism for retention of these cells at the capillary surface. Myeloid VEGF-R2 +CD11b+ precursors and PDGF-Rβ+ expressing cells are identified within the CC population. The findings establish that, by fusing to endothelial cells, the monocytic CC population studied has the potential to promote capillary surface stability/integrity through a paracrine mechanism. © 2014 Informa Healthcare USA, Inc.


Mitra J.K.,Critical Care and Pain Medicine | Roy J.,JNM Hospital | Bhattacharyya P.,Critical Care and Pain Medicine | Yunus M.,Critical Care and Pain Medicine | Lyngdoh N.M.,Critical Care and Pain Medicine
Journal of Postgraduate Medicine | Year: 2013

Hypotension during cesarean section under spinal anesthesia remains a frequent scenario in obstetric practice. A number of factors play a role in altering the incidence and severity of hypotension. Counteracting aortocaval compression does not significantly prevent hypotension in most singleton pregnancies. Intravenous crystalloid pre-hydration is not very efficient. Thus, the focus has changed toward co-hydration and use of colloids. Among vasopressors, phenylephrine is now established as a first line drug, although there is limited data in high-risk patients. Though ephedrine crosses the placenta more than phenylephrine and can possibly cause alterations in the fetal physiology, it has not been shown to affect the fetal Apgar or neurobehavioral scores.


Pinciroli R.,Critical Care and Pain Medicine | Mietto C.,Critical Care and Pain Medicine | Berra L.,Critical Care and Pain Medicine
Current Opinion in Infectious Diseases | Year: 2013

PURPOSE OF REVIEW: Ventilator-associated pneumonia (VAP) is a controversial entity in the field of critical care. After years of research and significant efforts from regulatory agencies and hospitals, this complication is still frequently affecting mechanically ventilated patients, making VAP an active battleground for research. As a result, several preventive measures have recently been tested in experimental and clinical trials. Our interest is focused on those innovations related to the endotracheal tube (ETT). RECENT FINDINGS: Four ETT-related VAP causative mechanisms are reviewed, together with different associated potential solutions. Technologies such as the subglottic secretion drainage and the Mucus Slurper have been studied to eliminate subglottic secretion pooling. Novel designs for the cuff and the management of its pressure may avoid leakage. Antimicrobial coatings can prevent endoluminal biofilm formation, whereas using an ETT cleaning device may also be beneficial. Finally, preserving the tracheal ciliary function will keep our best physiologic protection active. SUMMARY: VAP prevention strategies are a continuously evolving field. Being able to identify the most valuable ideas needs a deep understanding of the disease pathophysiology. The role of the ETT is crucial and there is need for our standards of care to improve. This may soon be possible with newer technologies becoming increasingly available to clinicians. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Hanna G.M.,Critical Care and Pain Medicine | Levine W.C.,Critical Care and Pain Medicine
Anesthesiology Clinics | Year: 2011

Drug administration errors are a major cause of morbidity and mortality in hospitalized patients. These errors result in major harm and incur dramatic costs to the delivery of health care. This article highlights this problem, especially as it deals with patients in the perioperative setting. © 2011 Elsevier Inc.


BACKGROUND—: Extracellular hemoglobin and cell-free heme are toxic breakdown products of hemolyzed erythrocytes. Mammals synthesize the scavenger proteins haptoglobin and hemopexin, which bind extracellular hemoglobin and heme respectively. Transfusion of packed red blood cells (PRBCs) is a life-saving therapy for patients with hemorrhagic shock. Because erythrocytes undergo progressive deleterious morphological and biochemical changes during storage, transfusion of PRBCs that have been stored for prolonged intervals (SRBCs; stored for 35-40 days in humans or 14 days in mice) increases plasma levels of cell-free hemoglobin and heme. Therefore, in patients with hemorrhagic shock, perfusion-sensitive organs such as the kidneys are challenged not only by hypoperfusion, but also by the high concentrations of plasma hemoglobin and heme that are associated with the transfusion of SRBCs. METHODS—: To test whether treatment with exogenous human haptoglobin or hemopexin can ameliorate adverse effects of resuscitation with SRBCs after two hours of hemorrhagic shock, mice receiving SRBCs were given a co-infusion of haptoglobin, hemopexin or albumin. RESULTS—: Treatment with haptoglobin or hemopexin but not albumin improved the survival rate and attenuated SRBC-induced inflammation. Treatment with haptoglobin retained free hemoglobin in the plasma and prevented SRBC-induced hemoglobinuria and kidney injury. In mice resuscitated with fresh PRBCs, treatment with haptoglobin, hemopexin, or albumin did not cause harmful effects. CONCLUSIONS—: In mice the adverse effects of transfusion with SRBCs after hemorrhagic shock are ameliorated by treatment with either haptoglobin or hemopexin. Haptoglobin infusion prevents kidney injury associated with high plasma hemoglobin concentrations after resuscitation with SRBCs. Treatment with the naturally occurring human plasma proteins haptoglobin or hemopexin may have beneficial effects in conditions of severe hemolysis following prolonged hypotension. © 2016 by the American College of Cardiology Foundation and the American Heart Association, Inc.

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