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South Burlington, VT, United States

Nguyen B.,Pulmonary Critical Care Medicine | Bernstein D.B.,University of Vermont | Bates J.H.T.,University of Vermont
Journal of Critical Care | Year: 2014

Purpose: The current ventilatory care goal for acute respiratory distress syndrome (ARDS) and the only evidence-based approach for managing ARDS is to ventilate with a tidal volume (VT) of 6 mL/kg predicted body weight (PBW). However, it is not uncommon for some caregivers to feel inclined to deviate from this strategy for one reason or another. To accommodate this inclination in a rationalized manner, we previously developed an algorithm that allows for VT to depart from 6 mL/kg PBW based on physiological criteria. The goal of the present study was to test the feasibility of this algorithm in a small retrospective study. Materials and Methods: Current values of peak airway pressure, positive end-expiratory pressure (PEEP), and arterial oxygen saturation are used in a fuzzy logic algorithm to decide how much VT should differ from 6 mL/kg PBW and how much PEEP should change from its current setting. We retrospectively tested the predictions of the algorithm against 26 cases of decision making in 17 patients with ARDS. Results: Differences between algorithm and physician VT decisions were within 2.5 mL/kg PBW, except in 1 of 26 cases, and differences between PEEP decisions were within 2.5 cm H2O, except in 3 of 26 cases. The algorithm was consistently more conservative than physicians in changing VT but was slightly less conservative when changing PEEP. Conclusions: Within the limits imposed by a small retrospective study, we conclude that our fuzzy logic algorithm makes sensible decisions while at the same time keeping practice close to the current ventilatory care goal. © 2014 Elsevier Inc. Source

Lemay A.C.,Pulmonary Critical Care Medicine | Anzueto A.,University of Texas Health Science Center at San Antonio | Restrepo M.I.,University of Texas Health Science Center at San Antonio | Mortensen E.M.,University of Texas Health Science Center at San Antonio
American Journal of the Medical Sciences | Year: 2014

BACKGROUND:: Mortality rates after severe sepsis are extremely high, and the main focus of most research is short-term mortality, which may not be associated with long-term outcomes. The purpose of this study was to examine long-term mortality after a severe sepsis and identify factors associated with this mortality. METHODS:: The authors performed a population-based study using Veterans' Affairs administrative data of patients aged 65 years and older. The outcome of interest was mortality > 90 days following hospitalization. Our primary analyses were Cox proportional hazard models to examine specific risk factors for long-term mortality. RESULTS:: There were 2,727 patients that met the inclusion criteria. Overall mortality was 55%, and 1- and 2-year mortality rates were 31% and 43%, respectively. Factors significantly associated with long-term mortality included congestive heart failure, peripheral vascular disease, dementia, diabetes with complications and use of mechanical ventilation. Smoking cessation and cardiac medications were associated with decreased long-term mortality rates. CONCLUSIONS:: The authors identified several factors, including receipt of mechanical ventilation, which were significantly associated with increased long-term mortality for survivors of severe sepsis. This information will help clinicians discuss prognosis with patients and their families. Source

Palmer S.M.,Duke University | Limaye A.P.,University of Washington | Banks M.,Duke University | Gallup D.,Duke University | And 14 more authors.
Annals of Internal Medicine | Year: 2010

Background: Cytomegalovirus (CMV) is the most prevalent opportunistic infection after lung transplantation. Current strategies do not prevent CMV in most at-risk patients. Objective: To determine whether extending prophylaxis with oral valganciclovir from the standard 3 months to 12 months after lung transplantation is efficacious. Design: Randomized, clinical trial. Patients were randomly assigned by a central automated system to treatment or placebo. Patients and investigators were blinded to treatment status. (ClinicalTrials.gov registration number: NCT00227370) Setting: Multicenter trial involving 11 U.S. lung transplant centers. Patients: 136 lung transplant recipients who completed 3 months of valganciclovir prophylaxis. Intervention: 9 additional months of oral valganciclovir (n = 70) or placebo (n = 66). Measurements: The primary end point was freedom from CMV disease (syndrome or tissue-invasive) on an intention-to-treat basis 300 days after randomization. Secondary end points were CMV disease severity, CMV infection, acute rejection, opportunistic infections, ganciclovir resistance, and safety. Results: CMV disease occurred in 32% of the short-course group versus 4% of the extended-course group (P < 0.001). Significant reductions were observed with CMV infection (64% vs. 10%; P < 0.001) and disease severity (110 000 vs. 3200 copies/mL, P = 0.009) with extended treatment. Rates of acute rejection, opportunistic infections, adverse events, CMV UL97 ganciclovir-resistance mutations, and laboratory abnormalities were similar between groups. During the 6 months after study completion, a low incidence of CMV disease was observed in both groups. Limitation: Longer-term effects of extended prophylaxis were not assessed. Conclusion: In adult lung transplant recipients who have received 3 months of valganciclovir, extending prophylaxis by an additional 9 months significantly reduces CMV infection, disease, and disease severity without increased ganciclovir resistance or toxicity. A beneficial effect with regard to prevention of CMV disease seems to extend at least through 18 months after transplantation. © 2010 American College of Physicians. Source

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