Albuterol administration is commonly associated with increases in serum lactate in asthmatics treated for acute exacerbation of asthma. (Fortenberry)

Lewis LM, Ferguson I, House SL, Aubuchon K, Schneider J, Johnson K, Matsuda K. Albuterol administration is commonly associated with increases in serum lactate in asthmatics treated for acute exacerbation of asthma. Chest. 2014 Jan; 145(1): 53–59.

BACKGROUND: Controversy exists surrounding the incidence and cause of hyperlactatemia during asthma exacerbations. We evaluate incidence, potential causes, and adverse events of hyperlactatemia in patients with acute asthma exacerbation.

METHODS: Sub-analysis of placebo subjects from a prospective, randomized trial evaluating an intravenous beta-adrenergic agonist in acute asthma exacerbation (clinicaltrials.gov identifier NCT00683449).Subjects had plasma albuterol, serum lactate and bicarbonate concentrations measured at baseline and 1.25 hours as well as dyspnea score and spirometry measured at baseline and hourly for 3 hours. All subjects had a therapeutic trial consisting of 5-15 mg of nebulized albuterol, 0.5-1 mg of nebulized ipratropium, and at least 50 mg of oral prednisone, or its equivalent prior to initiation of the study. Following randomization, subjects were treated with continued albuterol and intravenous magnesium at the discretion of their treating physician. Subjects were followed to admission or discharge with follow up at 24 hours and 1 week.

Results: 175 subjects were enrolled in the parent trial, 84 in the placebo group. 65 had complete data. Mean albuterol administration prior to baseline was 12.3mg (SD±5.3).Mean baseline lactate was 18.5mg/dL (SD±8.4) vs. 26.5mg/dL (SD±11.8) at 1.25 hours; p>0.001. 45 subjects (69.2%) had hyperlactatemia. Mean baseline bicarbonate was 22.6mEq/L (SD±2.9) vs. 21.9mEq/L (SD±4.0) at 1.25 hours; p=0.11.Plasma albuterol concentration correlated to lactate concentration (β coefficient=0.45; p<0.001), and maintained significant association after adjusting for asthma severity (β=0.41; p=0.001). Hyperlactatemia did not increase the risk of hospitalization/relapse (p=0.26), nor was it associated with lower %FEV1 at 3 hours (p=0.54).

CONCLUSION: Plasma albuterol was significantly correlated with serum lactate concentration, after adjusting for asthma severity. Hyperlactatemia was not associated with poorer pulmonary function as measured by 3-hour %FEV1, or increased hospitalization/relapse at one week.

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Ventilator-associated tracheobronchitis in a mixed medical/surgical pediatric intensive care unit. (Kamat)

Chest. 2013 Jan 3. doi: 10.1378/chest.12-2343. [Epub ahead of print] PMID: 23288075

BACKGROUND Adult studies have demonstrated that ventilator-associated tracheobronchitis (VAT) may be a precursor to ventilator-associated pneumonia. No published data on VAT in pediatric intensive care units (PICU) were found. The purpose of this retrospective, descriptive study is to describe the incidence, characteristics and outcomes of patients at risk for VAT and formalize a process of VAT surveillance in the PICU population.

METHODS All patients meeting criteria for VAT during 2009-2010 were reviewed and data collected on risk of mortality, index of mortality, interventions, demographic data, respiratory cultures and organisms identified.

RESULTS 645 (32.7%) patients admitted met mechanical ventilation criteria with 22 (3.4%) meeting criteria for VAT. VAT patients experienced a significantly longer mean PICU length of stay (27.6 days + 22.043 vs. 6.61 days + 7.27; p= 0.000) and higher mean total ventilator time in hours (519.31 + 457.60 hours vs. 95.60 + 138.83 hours; p = 0.000). There is a significant association between tracheostomy and VAT (p=0.000) and between chronic ventilator dependence and VAT (p=0.002). Gram negative rods accounted for 71%; staphylococcal or streptococcal species were identified as 26% of causative pathogens. Six of 25 (24%) VAT events identified two or more potentially causative pathogens; four of these (67%) were in patients with a tracheostomy.

CONCLUSION VAT occurred less frequently than reported in adult studies and no cases of VAT progressed to VAP in our population. Our results suggest that VAT is a clinically significant HAI in the PICU population.

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Trendelenburg position does not increase cross-Sectional area of the internal jugular vein predictably. (Kamat)

Chest. 2013 Feb 7. doi: 10.1378/chest.11-2462. [Epub ahead of print] PMID: 23392444

BACKGROUND: The Trendelenburg position is used to distend the central veins, improving both success and safety of vascular cannulation. The purpose of this study was to measure the cross-sectional area (CSA) of the internal jugular vein (IJV) in three different positions using surface ultrasound.

METHODS: Fifty one subjects were enrolled. A Sonosite Titan 180 or M-Turbo portable ultrasound machine with a 10.5 mHz broadband linear surface probe was used. We measured the CSA of the IJV (at end-expiration at the level of the cricoid cartilage) in three positions: 15 degrees reverse Trendelenburg, supine, and 15 degrees Trendelenburg.

RESULTS: The mean CSA at 15 degrees reverse Trendelenburg was 0.83 cm2 (Std Dev 0.86), in the supine position it was 1.25 cm2 (Std Dev 0.98) and at minus 15 degrees Trendelenburg it was 1.47 cm2 (Std Dev 1.03). Moving from reverse Trendelenburg to supine, CSA increased 50 percent. In contrast, lowering the head to a Trendelenburg position increased mean CSA only 17 percent. Surprisingly, Trendelenburg positioning reduced CSA in 9 of 51 subjects.

CONCLUSIONS: Trendelenburg positioning augments CSA only modestly, on average, compared with the supine position, and in some patients reduces the CSA. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01099254.

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Integrating advanced practice providers into medical critical care teams. (from CHEST, March 2013 – Wittkamp)

CHEST. 143(3):847-850, March 2013. PMID: 23460162

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Because there is increasing demand for critical care providers in the United States, many medical ICUs for adults have begun to integrate nurse practitioners and physician assistants into their medical teams. Studies suggest that such advanced practice providers (APPs), when appropriately trained in acute care, can be highly effective in helping to deliver high-quality medical critical care and can be important elements of teams with multiple providers, including those with medical house staff. One aspect of building an integrated team is a practice model that features appropriate coding and billing of services by all providers. Therefore, it is important to understand an APP’s scope of practice, when they are qualified for reimbursement, and how they may appropriately coordinate coding and billing with other team providers. In particular, understanding when and how to appropriately code for critical care services (Current Procedural Terminology [CPT] code 99291, critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 min; CPT code 99292, critical care, each additional 30 min) and procedures is vital for creating a sustainable program. Because APPs will likely play a growing role in medical critical care units in the future, more studies are needed to compare different practice models and to determine the best way to deploy this talent in specific ICU settings.

Physician staffing models impact the timing of decisions to limit life support in the ICU. (from CHEST, March 2013 – Wittkamp)

CHEST. 2013;143(3):656-663. doi:10.1378/chest.12-1173.

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BACKGROUND:  A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making.

METHODS:  A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record.

RESULTS:  The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death (P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days (P = .09), time to decision to limit any life support was shortened by 1 day (P = .08), time to death was shortened by 2 days (P = .08), and intubations against patient wishes decreased (from three to none; P = .12).

CONCLUSIONS:  The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.

Decisions to withdraw or withhold life support are routinely made in the ICU when patients, surrogate decision-makers, and the health-care team transition from curative to comfort care.1 The two most important factors influencing such decisions are patient preferences and patient prognosis.2,3 Numerous additional patient-, provider-, and surrogate-related factors impact such decisions and create significant variability in decision-making.4‐6 In an era when up to 20% of all adults die in the ICU and one-third of all health-care dollars in the United States are used in the last year of life, understanding how decisions to limit life support are made and implementing strategies to improve decision-making have been the subjects of continued research.1,7‐10

Additionally, there has been a growing trend and recommendations toward the use of continuous, 24-h, intensivist staffing of ICUs.11 This is typically accomplished by alternating daytime and nighttime intensivist shifts. The impact of adding continuous, attending intensivist coverage in the ICU has been associated with improvement in a number of patient outcomes including decreased hospital length of stay; decreased ICU complication rate; increased staff satisfaction; improvement in a number of evidence-based care processes, such as ventilator bundle compliance; and decreased mortality rates in some care settings.12‐14

In this single-center study, we sought to measure the impact of intensivist staffing models on decisions to limit life support in the ICU. We hypothesized that the continuous (24-h) presence of an attending intensivist would be associated with improved care at the end of life and improved end-of-life decision-making.