Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation.

Context: Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings.

Objectives: We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients.

Methods: Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania.

Peripherally Infused Norepinephrine to Avoid Central Venous Catheter Placement in a Medical Intensive Care Unit: A Pilot Study.

Background: Reducing central venous catheter (CVC) utilization can reduce complications in the intensive care unit (ICU). While norepinephrine (NE) is traditionally administered via a CVC, lower concentrations may be safely administered via peripheral intravenous (PIV) lines.

Objective: We aimed to describe the implementation of a pilot protocol utilizing PIVs to administer a low-dose and lower-concentration NE, review the number of CVCs avoided, and evaluate any adverse events.

Comparison of three cisatracurium dosing strategies in acute respiratory distress syndrome: A focus on drug utilization and improvement in oxygenation.

Purpose: Three continuous dosing strategies of cisatracurium (CIS) for acute respiratory distress syndrome (ARDS) have been described in the literature. After implementation of a ventilator synchrony protocol (VSP), we sought to determine which continuous CIS dosing strategy utilized the least amount of drug without compromising efficacy.

Methods: We retrospectively reviewed patients with ARDS receiving continuous CIS from January 1, 2013 to December 31, 2018.

A Quality Improvement Evaluation of a Primary As-Needed Light Sedation Protocol in Mechanically Ventilated Adults.

Objectives: First, to implement successfully a light-sedation protocol, favoring initial as-needed (prioritizing as-needed) boluses over continuous infusion sedation, and second, to evaluate if this protocol was associated with differences in patient-level sedative requirements, clinical outcomes, and unit-level longitudinal changes in pharmacy charges for sedative medications.

Design: Retrospective review comparing patients who received the prioritizing as-needed sedation protocol to similar patients eligible for the prioritizing as-needed protocol but treated initially with continuous infusion sedation.

Setting: Thirty-two bed medical ICUs in a large academic medical center.

Treatment with allogeneic mesenchymal stromal cells for moderate to severe acute respiratory distress syndrome (START study): a randomised phase 2a safety trial.

Background: Treatment with bone-marrow-derived mesenchymal stromal cells (MSCs) has shown benefits in preclinical models of acute respiratory distress syndrome (ARDS). Safety has not been established for administration of MSCs in critically ill patients with ARDS. We did a phase 2a trial to assess safety after administration of MSCs to patients with moderate to severe ARDS.

Measuring associations between the microbiota and repeated measures of continuous clinical variables using a lasso-penalized generalized linear mixed model.

Background: Human microbiome studies in clinical settings generally focus on distinguishing the microbiota in health from that in disease at a specific point in time. However, microbiome samples may be associated with disease severity or continuous clinical health indicators that are often assessed at multiple time points. While the temporal data from clinical and microbiome samples may be informative, analysis of this type of data can be problematic for standard statistical methods.

Home discharge following critical illness: A qualitative analysis of family caregiver experience.

Background: Few studies have longitudinally explored the experience and needs of family caregivers of ICU survivors after patients' home discharge.

Methods: Qualitative content analysis of interviews drawn from a parent study that followed family caregivers of adults ICU survivors for 4 months post-ICU discharge.

Results: Family caregivers (n = 20, all white, 80% woman) viewed home discharge as positive progress, but reported having insufficient time to transition from family visitor to the active caregiver role.

Clinical Outcomes and Mortality Impact of Hyperbaric Oxygen Therapy in Patients With Carbon Monoxide Poisoning.

Objectives: Carbon monoxide poisoning affects 50,000 per year in the United States alone. Mortality is approximately 3%, and up to 40% of survivors suffer from permanent neurocognitive and affective deficits. Hyperbaric oxygen therapy has shown benefit on reducing the long-term neurologic sequelae of carbon monoxide poisoning but has not demonstrated improved survival.

Association Between Train-of-Four Values and Gas Exchange Indices in Moderate to Severe Acute Respiratory Distress Syndrome.

Background: Acute respiratory distress syndrome (ARDS) is associated with a mortality rate of approximately 40%. Neuromuscular blockade is associated with an improvement in oxygenation and a reduction in mortality in ARDS.

Objective: The goal of this evaluation was to determine if the depth of paralysis, determined by train-of-four (TOF) monitoring, correlates with gas exchange in moderate to severe ARDS.

Referral to Palliative Care Infrequent in Patients with Idiopathic Pulmonary Fibrosis Admitted to an Intensive Care Unit.

Background: Palliative care has been recommended as a means to assist patients with idiopathic pulmonary fibrosis (IPF) in managing symptom burden and advanced care planning. Timing of referral is important because although most patients display a gradually progressive course, a minority experience acute deterioration, an outcome associated with high mortality.

Aim: To describe characteristics of IPF patients referred to a specialty lung disease center over a 10-year period who experienced acute deterioration and subsequent intensive care unit (ICU) admission, including frequency and timing of referral to palliative care.

Sleep in family caregivers of ICU survivors for two months post-ICU discharge.

Objective: To describe changes in sleep quality in family caregivers of ICU survivors from the patients' ICU admission until two months post-ICU discharge.

Design: Descriptive repeated measure design.

Setting: Academic hospital medical ICU.

Full Spectrum of LPS Activation in Alveolar Macrophages of Healthy Volunteers by Whole Transcriptomic Profiling.

Despite recent advances in understanding macrophage activation, little is known regarding how human alveolar macrophages in health calibrate its transcriptional response to canonical TLR4 activation. In this study, we examined the full spectrum of LPS activation and determined whether the transcriptomic profile of human alveolar macrophages is distinguished by a TIR-domain-containing adapter-inducing interferon-β (TRIF)-dominant type I interferon signature. Bronchoalveolar lavage macrophages were obtained from healthy volunteers, stimulated in the presence or absence of ultrapure LPS in vitro, and whole transcriptomic profiling was performed by RNA sequencing (RNA-Seq).

Psychological and Physical Health in Family Caregivers of Intensive Care Unit Survivors: Current Knowledge and Future Research Strategies.

Purpose: This article provides an overview of current knowledge on the impact of caregiving on the psychological and physical health of family caregivers of intensive care unit (ICU) survivors and suggestions for future research.

Methods: Review of selected papers published in English between January 2000 and October 2015 reporting psychological and physical health outcomes in family caregivers of ICU survivors.

Results: In family caregivers of ICU survivors followed up to five years after patients' discharge from an ICU, psychological symptoms, manifested as depression, anxiety and post-traumatic stress disorder, were highly prevalent.

Depressive symptoms and anxiety in intensive care unit (ICU) survivors after ICU discharge.

Background: The association between intensive care unit (ICU) survivors' psychological sequelae, individual care needs, and discharge disposition has not been evaluated.

Objective: To describe depressive symptoms and anxiety in ICU survivors and explore these symptoms based on individual care needs and discharge disposition for 4 months post-ICU discharge.

Methods: We analyzed data from 39 ICU survivors who self-reported measures of depressive symptoms (Center for Epidemiologic Studies-Depression 10 items [CESD-10]) and anxiety (Shortened Profile of Mood States-Anxiety subscale [POMS-A]).

Autoantibody-Targeted Treatments for Acute Exacerbations of Idiopathic Pulmonary Fibrosis.

Background: Severe acute exacerbations (AE) of idiopathic pulmonary fibrosis (IPF) are medically untreatable and often fatal within days. Recent evidence suggests autoantibodies may be involved in IPF progression. Autoantibody-mediated lung diseases are typically refractory to glucocorticoids and nonspecific medications, but frequently respond to focused autoantibody reduction treatments.

Fatigue in family caregivers of adult intensive care unit survivors.

Context: Family caregivers are a vital resource in the recovery of intensive care unit (ICU) survivors. Of concern, the stress associated with this role can negatively affect caregiver health. Fatigue, an important health indicator, has been identified as a predictor of various illnesses, greater use of health services, and early mortality.

Plasma B lymphocyte stimulator and B cell differentiation in idiopathic pulmonary fibrosis patients.

We hypothesized B cells are involved in the pathogenesis of idiopathic pulmonary fibrosis (IPF), a progressive, restrictive lung disease that is refractory to glucocorticoids and other nonspecific therapies, and almost invariably lethal. Accordingly, we sought to identify clinically associated B cell-related abnormalities in these patients. Phenotypes of circulating B cells were characterized by flow cytometry.

Self-reported physical symptoms in intensive care unit (ICU) survivors: pilot exploration over four months post-ICU discharge.

Context: Survivors of critical illness must overcome persistent physical and psychological challenges. Few studies have longitudinally examined self-reported physical symptoms in intensive care unit (ICU) survivors.

Objectives: To describe prevalence and severity of self-reported symptoms in 28 adult medical ICU survivors during the first four months post-ICU discharge and their associations with family caregiver responses.

Health risk behaviors in family caregivers during patients' stay in intensive care units: a pilot analysis.

Background: Studies of family caregivers of the critically ill have mainly focused on the psychological impact of the patients' stay in the intensive care unit and related stress. Despite known associations between stress and physical health, limited attention has been paid to the need to promote and maintain physical health in these caregivers.

Objective: To explore how family caregivers' health risk behaviors are associated with patients' preexisting care needs and the caregivers' depressive symptoms and burden.

Patients with idiopathic pulmonary fibrosis with antibodies to heat shock protein 70 have poor prognoses.

Rationale: Diverse autoantibodies are present in most patients with idiopathic pulmonary fibrosis (IPF). We hypothesized that specific autoantibodies may associate with IPF manifestations.

Objectives: To identify clinically relevant, antigen-specific immune responses in patients with IPF.

Current venues of care and related costs for the chronically critically ill.

The chronically critically ill (CCI) patient population is characterized by a prolonged need for high cost medical interventions, a high 1-year mortality rate, and a very high demand for post acute care services. The best characterized CCI patient population is patients on prolonged mechanical ventilation (PMV). This review will focus on the current knowledge of costs and care venues for the care of this patient population.

Patterns of depressive symptoms in caregivers of mechanically ventilated critically ill adults from intensive care unit admission to 2 months postintensive care unit discharge: a pilot study.

Objective: To examine trajectories of depressive symptoms in caregivers of critically ill adults from intensive care unit admission to 2 months postintensive care unit discharge and explore patient and caregiver characteristics associated with differing trajectories.

Design: Longitudinal descriptive study.

Setting: Medical intensive care unit in a tertiary university hospital.

Acute respiratory distress syndrome: A clinical review.

The acute respiratory distress syndrome (ARDS) is a complex disorder of heterogeneous etiologies characterized by a consistent, recognizable pattern of lung injury. Extensive epidemiologic studies and clinical intervention trials have been conducted to address the high mortality of this disorder and have provided significant insight into the complexity of studying new therapies for this condition. The existing clinical investigations in ARDS will be highlighted in this review.

Doppler-defined pulmonary hypertension in medical intensive care unit patients: Retrospective investigation of risk factors and impact on mortality.

Pulmonary hypertension (PH) is poorly characterized in the critically ill. No prior studies describe the burden of or outcomes associated with PH in a general medical intensive care unit population. We hypothesize that PH is an important comorbidity prevalent in the modern medical intensive care unit.