26 results on '"Kapil Rajwani"'
Search Results
2. H3 G34-mutant high-grade gliomas: integrated clinical, imaging and pathological characterisation of a single-centre case series
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José Pedro Lavrador, Zita Reisz, Naomi Sibtain, Kapil Rajwani, Asfand Baig Mirza, Francesco Vergani, Richard Gullan, Ranjeev Bhangoo, Keyoumars Ashkan, Cristina Bleil, Bassel Zebian, Barnaby Clark, Ross Laxton, Andrew King, Istvan Bodi, and Safa Al-Saraj
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Surgery ,Neurology (clinical) - Published
- 2023
3. Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting:A multi-centre prospective cohort study
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Julie Woodfield, Ingrid Hoeritzauer, Aimun A.B. Jamjoom, Josephine Jung, Simon Lammy, Savva Pronin, Cathal J. Hannan, Anna Watts, Laura Hughes, Richard D.C. Moon, Stacey Darwish, Holly Roy, Phillip C. Copley, Michael T.C. Poon, Paul Thorpe, Nisaharan Srikandarajah, Gordan Grahovac, Andreas K. Demetriades, Niall Eames, Philip J. Sell, Patrick F.X. Statham, Mohamed Abdelsadg, Motaz MS Abulaila, Usman Ahmed, Qasim Ajmi, Rafid Al-Mahfoudh, Chadi Ali, Meriem Amarouche, Amin Andalib, Mohit Arora, Mukul Arora, Mariam Awan, Asfand Baig Mirza, Antony Bateman, Iwan Bennett, Imran Bhatti, Peter Bodkin, Lalasa Bommireddy, George Bonanos, Anouk Borg, Alexandros Boukas, James Bourne, Rachael Brennan, Jennifer Brown, Katie Brown, Oliver Burton, Christopher Busby, Neil Chiverton, Simon Clark, Phillip C Copley, Simon Cudlip, Yan Cunningham, Ronan Dardis, Benjamin Davies, Andreas K Demetriades, Saurabh Deore, Chris Derham, Muhammad Dherijha, Gareth Dobson, James Duncan, Andrew Durnford, Alexander ZE Durst, Edward W Dyson, Ellie Edlmann, Andrew Edwards-Bailey, Anne Elserius, Becca Elson, Mohammed Fadelalla, Daniel M Fountain, Adrian Gardner, Arnab Ghosh, James R Gill, Stella A Glasmacher, Robin Gordon, Rebecca Grenfell, Awais Habeebullah, Nikolaos Haliasos, Tim Hammett, Cathal John Hannan, Ciaran Scott Hill, David Holmes, Kismet Hossain-Ibrahim, Muhammad Hussain, Shakir Hussain, Ramez Ibrahim, Aimun AB Jamjoom, Bethan John, Shabin Joshi, Oliver Kennion, Muhammad Khan, Adriana Klejnotowska, Ashwin Kumaria, Roberta LaCava, Alistair Lawrence, Matthew Lea, Andraay HC Leung, Ignatius Liew, Weisang Luo, Oscar MacCormac, James Manfield, Richard Mannion, Joseph Merola, Pranav Mishra, Khalid Abubaker Mohmoud, Richard Moon, Rory Morrison, Odhran Murray, Ali Nader-Sepahi, Colin Nnandi, Anand Pandit, Nitin Patel, Anita Philip, Michael TC Poon, Kuskoor Seethram Manjunath Prasad, Shyam Pujara, Balaji Purushothaman, Kapil Rajwani, Fahid Tariq Rasul, Ahmed-Ramadan Sadek, Moritz Schramm, Gabrielle Scicluna, Philip J Sell, Roozbeh Shafafy, Himanshu Sharma, Asim Sheikh, Vinothan Sivasubramaniam, Agbolahan Sofela, George Spink, Patrick FX Statham, Stuart Stokes, Euan Strachan, Chrishan Thakar, Gopiga Thanabalasundaram, Christian Ulbricht, Alison Whitcher, David White, Kathrin Whitehouse, Martin Wilby, and Ardalan Zolnourian
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Oncology ,Health Policy ,Internal Medicine - Abstract
BackgroundCauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.MethodsThis is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.FindingsIn 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.InterpretationPost-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.FundingDCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.
- Published
- 2022
4. Therapeutic Strategies and Challenges in the Management of Craniospinal Tumors in Pregnancy: A Ten-Year Retrospective Tertiary-Center Study, Systematic Review, and Proposal of Treatment Algorithms
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Prajwal Ghimire, Graeme Pang, Jerry Philip, Sally Hazem, Kapil Rajwani, Jose Pedro Lavrador, Gordan Grahovac, Cristina Bleil, Nicholas Thomas, Richard Gullan, Francesco Vergani, Ranjeev Bhangoo, and Keyoumars Ashkan
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Surgery ,Neurology (clinical) - Abstract
This study aims to review therapeutic strategies in the management of craniospinal tumors in pregnant patients and the factors that may influence the management along with their influence on maternal and fetal outcomes.A retrospective single-center cohort study was performed at a tertiary neurosurgical referral center. Pregnant patients referred to the neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumor were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed of the available literature as per PRISMA guidelines.Twenty-five patients were identified, with a mean age of 31 years. Of these patients, 88% (n = 22) had cranial lesions and 12% (n = 3) had spinal lesions. Most of the patients had World Health Organization grade I/II tumors. Of the patients, 44% underwent surgery when pregnant, whereas in 40%, this was deferred until after the due date. Of patients, 16% did not require surgical intervention and were followed up with serial imaging in the MDM. The left lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review and retrospective data led to proposal of treatment algorithms addressing the therapeutic strategy for management of craniospinal tumors during pregnancy. Factors that may influence maternal and fetal outcomes during management of these tumors were identified, including aggressiveness of the tumor and stage of pregnancy.Craniospinal tumors presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Factors influencing maternal and fetal outcomes are to be considered during management and patient counseling.
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- 2022
5. Implementation of Simulation Training During the COVID-19 Pandemic
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Di Pan and Kapil Rajwani
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Coronavirus disease 2019 (COVID-19) ,Epidemiology ,Critically ill ,business.industry ,media_common.quotation_subject ,Medicine (miscellaneous) ,030204 cardiovascular system & hematology ,Public relations ,Hospital experience ,Education ,Simulation training ,03 medical and health sciences ,0302 clinical medicine ,Resource (project management) ,Modeling and Simulation ,Political science ,Pandemic ,Health care ,Institution ,030212 general & internal medicine ,business ,media_common - Abstract
SUMMARY STATEMENT Simulation played a critical role in our institution's response to the COVID-19 pandemic in New York City. With the rapid influx of critically ill patients, resource limitations, and presented safety concerns, simulation became a vital tool that provided solutions to the many challenges we faced. In this article, we describe how simulation training was deployed at our institution throughout the course of the pandemic, which included the period of our medical surge. Simulation helped refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers in unfamiliar roles. We also discuss the obstacles we encountered with implementing simulations during the pandemic, the measures we took to adapt to our limitations, and the simulation strategies and end products that were derived from these adaptations.
- Published
- 2021
6. Percutaneous and Open Tracheostomy in Patients with COVID-19
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Victoria Cooley, Edward Scheneck, Shanna S. Hill, Carol Li, Sallie Long, Andrew B. Tassler, Kapil Rajwani, Noah Z. Feit, Sei Chung, Jonathan Villena-Vargas, Brendon M. Stiles, Apoorva T. Ramaswamy, and Alexander Chern
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Mechanical ventilation ,medicine.medical_specialty ,Percutaneous ,business.industry ,medicine.medical_treatment ,Sedation ,Perioperative ,Intensive care unit ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Respiratory failure ,Interquartile range ,law ,030220 oncology & carcinogenesis ,Emergency medicine ,Medicine ,Intubation ,030211 gastroenterology & hepatology ,Surgery ,medicine.symptom ,business - Abstract
Objective The aim of this study was to report the safety, efficacy, and early results of tracheostomy in patients with COVID-19 and determine whether differences exist between percutaneous and open methods. Summary background data Prolonged respiratory failure is common in symptomatic patients with COVID-19, the disease process caused by infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Tracheostomy, although posing potential risk to the operative team and other healthcare workers, may be beneficial for safe weaning of sedation and ventilator support. However, short- and long-term outcomes remain largely unknown. Methods A prospectively collected database of patients with COVID-19 undergoing tracheostomy at a major medical center in New York City between April 4 and April 30, 2020 was reviewed. The primary endpoint was need for continued mechanical ventilation. Secondary outcomes included complication rates, sedation weaning, and need for intensive care unit (ICU) level of care. Patient characteristics, perioperative conditions, and outcomes between percutaneous and open groups were analyzed. Results During the study period, 67 consecutive patients underwent tracheostomy, including 48 males and 19 females with a median age of 66 years [interquartile range (IQR) 52-72]. Two surgeons alternated techniques, with 35 tracheostomies performed percutaneously and 32 via an open approach. The median time from intubation to tracheostomy was 23 days (IQR 20-26). At a median follow-up of 26 days, 52 patients (78%) no longer required mechanical ventilation and 58 patients (87%) were off continuous sedation. Five patients (7.5%) died of systemic causes. There were 11 total complications (16%) in 10 patients, most of which involved minor bleeding. There were no significant differences in outcomes between percutaneous and open methods. Conclusions Tracheostomy under apneic conditions by either percutaneous or open technique can be safely performed in patients with respiratory failure due to COVID-19. Tracheostomy facilitated weaning from continuous intravenous sedation and mechanical ventilation. Continued follow-up of these patients to ascertain long-term outcome data is ongoing.
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- 2020
7. Telesimulation for COVID-19 Ventilator Management Training With Social-Distancing Restrictions During the Coronavirus Pandemic
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Kevin Ching, Joy D. Howell, Kapil Rajwani, Neel Naik, and Robert A Finkelstein
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2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,Social distance ,05 social sciences ,Graduate medical education ,050301 education ,General Social Sciences ,Management training ,medicine.disease_cause ,Computer Science Applications ,Nursing ,Political science ,0502 economics and business ,Pandemic ,medicine ,0503 education ,Shut down ,050203 business & management ,Coronavirus - Abstract
Background. In early 2020, the novel coronavirus pandemic forced communities around the globe to shut down and isolate. Routine graduate medical education activities have also been suspended as resident and fellow physicians-in-training have been re-deployed to support critical patient care services. Innovation. We developed a two-part hybrid telesimulation model to teach COVID-19 ventilator management strategies while physically separating a group of learners and an instructor from one another. Learners consisted of non-ICU health care providers with limited experience in ventilator management being redeployed to manage ICU level COVID-19 infected patients. In the first week, the video tutorial has been viewed over 500 times and we have facilitated 14 telesimulation sessions, including 48 participants comprised of hospitalists, emergency medicine physicians and physician assistants, pediatric residents, nurses, and a nurse educator. Conclusion. We believe that the combination of a video tutorial followed by an interactive telesimulation was successful in providing timely education during a coronavirus pandemic. Furthermore, it reinforced the value and flexibility in which simulation education could continue conveniently for learners despite significant restrictions in place during the coronavirus pandemic. Research is needed to assess the efficacy of this hybrid intervention in preparing healthcare workers and to determine if the knowledge is successfully transferred to the clinical setting.
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- 2020
8. Respiratory Mechanics and Gas Exchange in COVID-19–associated Respiratory Failure
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Kapil Rajwani, Justin J Choi, Lisa K. Torres, David A. Berlin, Parag Goyal, Katherine Hoffman, Natalia S. Ivascu, Edward J. Schenck, Fernando J. Martinez, and Christopher W. Tam
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Pulmonary and Respiratory Medicine ,Male ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Pneumonia, Viral ,Respiratory physiology ,Betacoronavirus ,Pandemic ,Medicine ,Humans ,Letters ,Pandemics ,Aged ,biology ,business.industry ,Pulmonary Gas Exchange ,SARS-CoV-2 ,COVID-19 ,Middle Aged ,biology.organism_classification ,medicine.disease ,Virology ,Respiration, Artificial ,Pneumonia ,Respiratory failure ,Respiratory Mechanics ,Female ,business ,Coronavirus Infections ,Respiratory Insufficiency - Published
- 2020
9. Therapeutic strategies and challenges in the management of craniospinal tumours in pregnancy: a 10-year retrospective tertiary centre study, systematic review, and proposal of treatment algorithms
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Prajwal Ghimire, Graeme Pang, Jerry Philip, Sally Hazem, Kapil Rajwani, Jose Pedro Lavrador, Gordon Grahovac, Cristina Bleil, Nicholas Thomas, Richard Gullan, Francesco Vergani, Ranjeev Bhangoo, and Keyoumars Ashkan
- Abstract
Objectives: The study aims to evaluate therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that influence the management along with their influence on maternal & foetal outcomes. Materials and Methods:A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral centre. Pregnant patients referred to neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumour were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed on the available literature in PubMed as per PRISMA guidelines. Results:Thirty-three patients were identified with a mean age of 31 years. 91%(n=30) had cranial lesions and 9%(n=3) had spinal lesions. Most of the patients had WHO Grade I/II tumours. 33.3% underwent surgery when pregnant whilst in 24.2% this was deferred until after the due date. 27.2% patients did not require surgical intervention and were followed up with serial imaging in the MDM. Left Lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review identified 26 eligible articles. Treatment algorithms are proposed addressing the therapeutic strategy for management of cranio-spinal tumours during pregnancy and the challenges for maternal and foetal outcomes were tabulated. Conclusions:Craniospinal tumours presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Maternal and foetal outcomes are to be considered during patient counselling.
- Published
- 2021
10. Impact of Tubular Retractor-Assisted Transsulcal Minimal Invasive Parafascicular Approach for Deep-Seated Lesions in Cortical Vascularization
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Pablo de la Fuente, Kapil Rajwani, Sally Ann Price, Francesco Vergani, Keyoumars Ashkan, Richard Gullan, Ranjeev Bhangoo, and Jose Pedro Lavrador
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS Assess the impact of tubular retractor-assisted transsulcal minimal invasive parafascicular approaches(tsMIPS) in the cortical vascularization using indocianin green angiography(ICGA) during removal of deep-seated cerebral tumours. METHOD Single-centre prospective cohort study of patients with deep-seated lesions – distance to nearest sulcus > 10mm - where ICGA was performed. Zeiss FLOW800 Software was used to analyse the following variables - delay time, speed, time to peak and rise time - before and after insertion of the tubular retractor (NICO BrainPath). RESULTS 13 patients were enrolled. 60 regions-of-interest were analysed. The most common pathology was high grade glioma (69%). The average depth of tumours was 34,2mm (23– 45mm) and the time-under-retraction 166mins (45-280 mins). The most common vascular pattern before-after tubular retractor was: increase on the delay time, time to peak and rising time (present in 8 patients) and a decrease on the speed (present in 7 patients). Two patients had a mayor neurological deficit after the surgery. Both had the same flow pattern with an increase on the speed and decrease on the time to peak and rise time, the delay was indifference. CONCLUSION This is the first study assessing the impact of tubular retractor-assisted tsMIPS in cortical vascularization during deep-seated lesion resection. The most common cortical vascular pattern is: an increase on the delay time, time to peak and rising time and a decrease on the speed. The two patients who presented vascular injury shared the same pattern (increase on the speed, decrease on the time to peak and rise time, with indifference delay).
- Published
- 2022
11. Exploring the Role of Specialist Physiotherapy in Awake Craniotomy Surgery for the Neuro-Oncology Patient
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Amy Jones, Sally Price, Jose Pedro Lavrador, Richard Gullan, Francesco Vergani, Ranjeev Bhangoo, Kapil Rajwani, Keyoumars Ashkan, and Ana Mirallave-pescador@nhs.net
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS To describe the methods used to assess and monitor motor function during awake craniotomy surgery for tumour resection. METHOD A service review was carried out over 10 months. Patients with highly motor eloquent lesions – invasion of primary motor cortex or fronto-parietal connections involved in motor cognition – were included. Clinical notes were reviewed and summarised using descriptive analysis. Dexterity and grip strength were measured using 9-hole peg test and handheld dynameter pre/intra and post-operatively. Patient occupation/interests were reported to guide bespoke assessments to trial intra-operatively. RESULTS From April 2021 to January 2022, 13 patients (mean age 39.7 years, 4 female:10 male, 9 low grade:5 high grade gliomas) were included. Mean score 9-hole peg test 22.2sec pre-operatively, 30.6sec post-operatively; handheld dynameter 26.7kg pre-operatively, 18.4kg post-operatively. At discharge 5 of 7 impaired patients demonstrated motor improvement. For motor coordination, motor tasks used frequently included repetitive finger tapping, open/closed hand. Bespoke tasks included texting/writing, playing instruments, and computer games. Movement was closely monitored and verbal feedback given to the neurosurgeons throughout. With video analysis movement comparisons were made. CONCLUSION The role of physiotherapy in awake surgery is evolving to provide movement analysis for complex motor tasks such as upper limb sequencing and dexterity. A combination of standard and bespoke assessments have been trialled and their feasibility within surgery tested. A post-operative deterioration of motor function (power and cognition) is expected after surgery for highly eloquent motor gliomas. However, intraoperative motor assessment for motor cognition allows function preservation and potentiates its recovery.
- Published
- 2022
12. Surgery on a Primary Cranial Vault Lymphoma
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Pablo de la Fuente, Kapil Rajwani, Iñigo Sistiaga, and Jose Pedro Lavrador
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS Unique cranial involvement in Lymphomas is extraordinary and when it occurs, it is usually accompanied by systemic involvement. The role of the surgery in these cases is still unclear. METHOD Case report of a 72-year-old female with a primary cranial vault lymphoma with primary surgical management at time of recurrence. RESULTS 72-year-old female, with a background of treated breast cancer and ischemic heart, presented with a right parieto-occipital lytic bone lesion with a soft tissue mass with a diagnosis of Non-Hodgkin’s Lymphoma Type B, compatible with follicular lymphoma, with no other symptoms Systemic involvement was ruled out in PET CT bone marrow biopsy. First-line chemotherapy was precluded due to the cardiotoxicity, and she was started on Rituximab-Bendamustine and radiotherapy. PET-CT one year later shows local progression with lytic destruction. The MRI showed an imprint on the brain and a lesion in intimate contact with the superior longitudinal sinus. As an apparently localized lesion and the patient could not receive the optimal chemotherapy treatment, a craniectomy was proposed. Fifteen months after surgery the patient is free of disease on PET CT. CONCLUSION Primary cranial lymphoma is an unusual entity which precludes clear algorithms. The primary treatment is the chemotherapy, nonetheless, If the patient cannot receive the optimal treatment due to his background or in the presence of recurrent disease with limited treatment options, surgery should be considered if technically plausible and adequate to patient’s performance status.
- Published
- 2022
13. Percutaneous and Open Tracheostomy in Patients With <scp>COVID</scp> ‐19: The Weill Cornell Experience in New York City
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Shanna S. Hill, Victoria Cooley, Alexander Chern, Andrew Tassler, Sallie Long, Edward J. Schenck, Brendon M. Stiles, Kapil Rajwani, and Noah Z. Feit
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Male ,medicine.medical_specialty ,Time Factors ,Percutaneous ,medicine.medical_treatment ,Sedation ,Conscious Sedation ,outcomes ,03 medical and health sciences ,Tracheostomy ,percutaneous and open tracheostomy ,0302 clinical medicine ,COVID‐19 ,Cause of Death ,Original Reports ,medicine ,Clinical endpoint ,Humans ,Intubation ,Weaning ,Prospective Studies ,030212 general & internal medicine ,030223 otorhinolaryngology ,Aged ,Mechanical ventilation ,SARS-CoV-2 ,business.industry ,Mortality rate ,COVID-19 ,Middle Aged ,Respiration, Artificial ,Surgery ,Treatment Outcome ,Otorhinolaryngology ,Airway Extubation ,Female ,New York City ,medicine.symptom ,business ,Complication ,Ventilator Weaning - Abstract
OBJECTIVE Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN Review of prospectively collected data. METHODS Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2849-E2856, 2021.
- Published
- 2021
14. Percutaneous and Open Tracheostomy in Patients with COVID-19: Comparison and Outcomes of an Institutional Series in New York City
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Sallie M, Long, Alexander, Chern, Noah Z, Feit, Sei, Chung, Apoorva T, Ramaswamy, Carol, Li, Victoria, Cooley, Shanna, Hill, Kapil, Rajwani, Jonathan, Villena-Vargas, Edward, Schenck, Brendon, Stiles, and Andrew B, Tassler
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Adult ,Aged, 80 and over ,Male ,Critical Care ,COVID-19 ,Middle Aged ,Respiration, Artificial ,Cohort Studies ,Survival Rate ,Postoperative Complications ,Tracheostomy ,Humans ,Female ,New York City ,Aged - Abstract
The aim of this study was to report the safety, efficacy, and early results of tracheostomy in patients with COVID-19 and determine whether differences exist between percutaneous and open methods.Prolonged respiratory failure is common in symptomatic patients with COVID-19, the disease process caused by infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Tracheostomy, although posing potential risk to the operative team and other healthcare workers, may be beneficial for safe weaning of sedation and ventilator support. However, short- and long-term outcomes remain largely unknown.A prospectively collected database of patients with COVID-19 undergoing tracheostomy at a major medical center in New York City between April 4 and April 30, 2020 was reviewed. The primary endpoint was need for continued mechanical ventilation. Secondary outcomes included complication rates, sedation weaning, and need for intensive care unit (ICU) level of care. Patient characteristics, perioperative conditions, and outcomes between percutaneous and open groups were analyzed.During the study period, 67 consecutive patients underwent tracheostomy, including 48 males and 19 females with a median age of 66 years [interquartile range (IQR) 52-72]. Two surgeons alternated techniques, with 35 tracheostomies performed percutaneously and 32 via an open approach. The median time from intubation to tracheostomy was 23 days (IQR 20-26). At a median follow-up of 26 days, 52 patients (78%) no longer required mechanical ventilation and 58 patients (87%) were off continuous sedation. Five patients (7.5%) died of systemic causes. There were 11 total complications (16%) in 10 patients, most of which involved minor bleeding. There were no significant differences in outcomes between percutaneous and open methods.Tracheostomy under apneic conditions by either percutaneous or open technique can be safely performed in patients with respiratory failure due to COVID-19. Tracheostomy facilitated weaning from continuous intravenous sedation and mechanical ventilation. Continued follow-up of these patients to ascertain long-term outcome data is ongoing.
- Published
- 2020
15. Noninvasive Ventilation for High-Risk Endotracheal Intubation
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Igor Barjaktarevic, Jimmy Johannes, Omar Awan, Kapil Rajwani, and David A. Berlin
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business.industry ,medicine.medical_treatment ,Hemodynamics ,Oxygenation ,Hypoxemia ,Respiratory failure ,Anesthesia ,Positive airway pressure ,medicine ,Breathing ,Intubation ,Noninvasive ventilation ,medicine.symptom ,business - Abstract
For patients with severe hypoxemic respiratory failure, significant hemodynamic instability, and/or abnormal upper airway anatomy, endotracheal intubation may be high risk for complications such as worse hypoxemia, hemodynamic collapse, and failed intubation. Noninvasive ventilation to support endotracheal intubation has emerged as a tool to transition high-risk patients in acute respiratory failure to invasive ventilation in place of bag-valve-mask ventilation and apneic oxygenation. Data supporting its use for the entire intubation process continue to be limited to case series. Nevertheless, the use of noninvasive ventilation to support the intubation process may help minimize perturbations in oxygenation and hemodynamics and potentially increase the chance for successful endotracheal intubation in high-risk patients.
- Published
- 2020
16. Critical Care Management of Gastrointestinal Bleeding and Ascites in Liver Failure
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Robert S. Brown, Kapil Rajwani, and Brett E. Fortune
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Liver Cirrhosis ,Pulmonary and Respiratory Medicine ,Gastrointestinal bleeding ,medicine.medical_specialty ,Cirrhosis ,Critical Care ,medicine.medical_treatment ,Peritonitis ,Liver transplantation ,Critical Care and Intensive Care Medicine ,03 medical and health sciences ,0302 clinical medicine ,Spontaneous bacterial peritonitis ,Hypertension, Portal ,Ascites ,medicine ,Ascitic Fluid ,Humans ,Intensive care medicine ,business.industry ,Mortality rate ,030208 emergency & critical care medicine ,medicine.disease ,Review article ,030211 gastroenterology & hepatology ,Portasystemic Shunt, Transjugular Intrahepatic ,medicine.symptom ,Gastrointestinal Hemorrhage ,business ,Transjugular intrahepatic portosystemic shunt ,Liver Failure - Abstract
Gastrointestinal (GI) bleeding and ascites are two significant clinical events that frequently present in critically ill patients with chronic liver failure or decompensated cirrhosis. GI bleeding in patients with cirrhosis, particularly portal hypertensive-associated bleeding, carries a high short-term mortality (15–25%) and requires early initiation of a vasoactive agent and antibiotics as well as timely endoscopic management. Conservative transfusion strategies and adequate airway protection are also imperative to assist in bleeding control. The presence of ascites among hospitalized cirrhotics requires early analysis of ascitic fluid to diagnose spontaneous bacterial peritonitis and initiate appropriate antibiotics and albumin to reduce patients' high associated mortality rates of greater than 25%. Appropriate utilization of portal decompression using transjugular intrahepatic portosystemic shunt placement for selected patients with failure to control bleeding or ascites and early consideration for liver transplantation referral is critical to improve patient survival. This review will aim to elucidate the current strategies for the management of critically ill patients with chronic liver failure presenting with GI bleeding or ascites.
- Published
- 2018
17. A Brain-Based Instruction Simulation Approach to Improve Code Team Response in an Internal Medicine Unit
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Joanna Lee, Kevin Ching, Kapil Rajwani, Elizabeth Mauer, Stephanie L. Miller, Kirana Gudi, Linda M. Gerber, and Timothy C. Clapper
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Teamwork ,business.industry ,Computer science ,media_common.quotation_subject ,education ,05 social sciences ,050301 education ,General Social Sciences ,Computer Science Applications ,Unit (housing) ,Course (navigation) ,03 medical and health sciences ,0302 clinical medicine ,Code (cryptography) ,030212 general & internal medicine ,Software engineering ,business ,0503 education ,Lesson plan ,media_common - Abstract
Background and Objectives. The code team course is a 3-hour, interactive course that follows a 4-phase brain-based lesson plan for simulation. Interprofessional teams receive instruction and practice in evidence-based teamwork, communication, and individual skills. Methods. This quantitative research included a pre-test and post-test design in an urban Department of Medicine. Sixteen groups (n=109) participated in the course over a period of eight weeks. Classroom metrics included pre- and post-course High-Quality cardiopulmonary resuscitation (CPR) and code team didactic knowledge assessed by Wilcoxon rank-sum tests. In addition, four in-situ mock code simulations were conducted to provide the researchers with baseline and post-intervention data. Code team performance assessment scores were tallied and compared between baseline and post-intervention by Fisher’s Exact Test. Results. The classroom metrics produced significant results. High-Quality CPR scores were higher post-training than pre-training (median score 4 vs. 3, respectively; p=0.006). Didactic knowledge test scores were also significantly higher (median score 90 vs. 70, respectively; p Conclusion. The results of this pilot study suggest that code team training using the 4-phase BBL plan for simulation is associated with improvements in interprofessional team knowledge and performance during cardiac emergencies. It is equally important that the training is conducted over a short period in order to ensure that all team members are properly prepared.
- Published
- 2018
18. Bronchoscopic Delivery of Aminocaproic Acid as a Treatment for Pulmonary Bleeding: A Case Series
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Liz G. Ramos, Clara Oromendia, Lourdes M. Sanso, Russell P. Simon, and Kapil Rajwani
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Pulmonary and Respiratory Medicine ,Male ,medicine.medical_specialty ,Hemoptysis ,Deep vein ,Hemorrhage ,Article ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,Bronchoscopy ,medicine ,Humans ,Pharmacology (medical) ,030212 general & internal medicine ,Adverse effect ,Stroke ,Lung ,Aged ,Retrospective Studies ,medicine.diagnostic_test ,business.industry ,Biochemistry (medical) ,Middle Aged ,medicine.disease ,Thrombosis ,Antifibrinolytic Agents ,Surgery ,medicine.anatomical_structure ,Treatment Outcome ,030228 respiratory system ,Tranexamic Acid ,Hemostasis ,Aminocaproic Acid ,Female ,Aminocaproic acid ,business ,Tranexamic acid ,medicine.drug - Abstract
Objective Bronchoscopy is an essential therapeutic modality in the treatment of pulmonary bleeding. Although numerous endoscopic treatments exist, topical e-aminocaproic acid has not been described in the literature. This study documents the use of this novel treatment for pulmonary bleeding and compares it to available evidence for tranexamic acid , a similar anti-fibrinolytic agent. Design Case-series study. Setting ICU and general inpatient floors of a tertiary medical center. Patients Forty-six patients receiving endobronchial e-aminocaproic acid for the treatment or prevention of pulmonary bleeding. Measurements and main results Of the 46 patients included in the study, 41.6% and 13% presented with non-massive and massive hemoptysis , respectively. In patients with active pulmonary bleeding, endobronchial application of e-aminocaproic acid and accompanying therapies resulted in cessation of bleeding in 94.7% of cases. A total of six patients received e-aminocaproic acid monotherapy ; in three patients with active bleeding, 100% achieved hemostasis after treatment. Of the 36 patients successfully treated for active pulmonary bleeding, 27.8% had recurrent bleeding within 30 days. Thirty-day adverse events were as follows: death (10 patients), deep vein thrombosis (2 patients), renal failure (2 patients), and stroke (2 patients). Conclusions Endobronchial administration of e-aminocaproic acid during bronchoscopy may be a safe and efficacious option in the treatment and prevention of pulmonary bleeding. Further studies are necessary to better define e-aminocaproic acid's safety profile, optimal routes of administration , and comparative effectiveness to tranexamic acid.
- Published
- 2019
19. HIGH FIDELITY SIMULATION TRAINING: DOES IT IMPROVE INTERNAL MEDICINE RESIDENT PHYSICIAN CONFIDENCE, KNOWLEDGE, AND SKILL PERFORMANCE REGARDING TRACHEOSTOMY?
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Paul J. Christos, Kelly Crane, Timothy C. Clapper, and Kapil Rajwani
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Quality management ,Coronavirus disease 2019 (COVID-19) ,business.industry ,media_common.quotation_subject ,Fidelity ,Resident physician ,Critical Care and Intensive Care Medicine ,Checklist ,High Fidelity Simulation Training ,Intervention (counseling) ,Internal medicine ,High fidelity simulation ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,media_common - Abstract
TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Internal Medicine (IM) resident physicians lack confidence and knowledge on how to manage basic and emergent clinical situations involving tracheostomy. High fidelity simulation is an effective training medium to address such deficiencies but is under-researched and under-utilized. This prospective, quantitative pilot educational and quality improvement study sought to answer if high fidelity simulation training on tracheostomy improves IM resident knowledge, confidence, and team skill performance. METHODS: Over 4 months (January - April 2021), 31 post-graduate year (PGY) 2 and PGY3 IM residents at a large academic hospital participated in this study. Participants were scored on baseline skill performance as a team in a high fidelity simulation of desaturation in a tracheostomy patient using a validated checklist. Thereafter, participants underwent a 3 hour educational intervention comprised of lecture, skills stations, and several simulations of emergent tracheostomy clinical situations. Final team performance on the same simulation initially used to assess baseline performance was scored. Pre and post intervention confidence and knowledge were assessed and compared to PGY2 and PGY3 IM residents who did not take the course. RESULTS: 20 PGY2 IM residents underwent the course. Confidence (P
- Published
- 2021
20. Improving the competence and confidence of pulmonary and critical care medicine fellows in performing a cricothyrotomy
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Kapil Rajwani, Elizabeth Mauer, and Timothy C. Clapper
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medicine.medical_specialty ,Medicine (General) ,business.industry ,4. Education ,medicine.medical_treatment ,Survey result ,Education (General) ,You Should Try This! ,3. Good health ,R5-920 ,Medicine ,General Materials Science ,Cricothyrotomy ,L7-991 ,business ,Intensive care medicine ,Competence (human resources) ,Lesson plan - Abstract
Clinical opportunities to practice or perform a cricothyrotomy are limited. We developed an evidence-based cricothyrotomy course following the 4-phase lesson plan for simulation that provides pulmonary and critical care medicine fellows with demonstrations, practice, and feedback to increase their confidence and competence.Survey results demonstrated an improvement in perceived confidence (p
- Published
- 2019
21. Ultrasound in the diagnosis and management of pneumonia
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Kapil Rajwani and Edward J. Schenck
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Microbiology (medical) ,medicine.medical_specialty ,Pathology ,business.industry ,Point-of-Care Systems ,Radiography ,Point of care ultrasound ,Ultrasound ,030208 emergency & critical care medicine ,Pneumonia ,Disease ,medicine.disease ,Clinical correlation ,Lung ultrasound ,03 medical and health sciences ,0302 clinical medicine ,Infectious Diseases ,medicine ,Humans ,030212 general & internal medicine ,Radiology ,business ,Ultrasonography ,Point of care - Abstract
Purpose of review Point of care ultrasound continues to become more prevalent in the diagnosis and management of many disease states. In this review, we focus on the use of bedside lung ultrasound (LUS) in the diagnosis of pneumonia. We describe the sonographic findings associated with pneumonia and the recent literature exploring its use in different settings and patient populations. Recent findings The limited sensitivity of chest radiography in the diagnosis of pneumonia has been well described. Ultrasound is an attractive option because of its low cost, lack of ionizing radiation, portability, and repeatability. An alveolar or focal interstitial pattern has been described as the usual sonographic findings in pneumonia. Multiple studies have compared LUS with chest radiography in pneumonia, and have shown that LUS is at least equivalent, and in many instances superior, to chest radiography. Summary Point of care LUS is an invaluable tool in the diagnosis of multiple pulmonary conditions, including pneumonia. Its use in real time with clinical correlation makes it an ideal tool for rapid diagnosis, especially in situations with unstable patients or in low-resource settings.
- Published
- 2016
22. THE USE OF A STEP STOOL DURING CHEST COMPRESSIONS: DOES IT MAKE A DIFFERENCE, AND DO CLINICIANS CHOOSE TO USE IT?
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Nina Rusiewski, Kapil Rajwani, Imaani Easthausen, Melissa Moulton, Samantha Smith, Kelly M Griffin, Elyse LaFond, and Timothy C. Clapper
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Medicine ,Medical physics ,Cardiology and Cardiovascular Medicine ,Critical Care and Intensive Care Medicine ,business - Published
- 2020
23. Cardiopulmonary Emergencies
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Lisa K. Torres, James Horowitz, Kapil Rajwani, and David A. Berlin
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Emergencies of the cardiovascular and respiratory systems are common causes of death and disability. Virtually all illnesses can culminate in disorders of these two systems. This chapter will review some of the most common causes of cardiovascular and respiratory failure that occur in hospitalized patients. It will review the systematic primary and secondary survey approach to rapidly identify life-threatening organ failure and provide a framework for initial resuscitation.
- Published
- 2018
24. Pulmonary effects of aging
- Author
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Kapil Rajwani, Daniel Tran, and David A. Berlin
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medicine.medical_specialty ,Aging ,Population ,Respiratory physiology ,Pulmonary function testing ,03 medical and health sciences ,0302 clinical medicine ,Immunity ,Forced Expiratory Volume ,Medicine ,Humans ,030212 general & internal medicine ,education ,Intensive care medicine ,Lung ,education.field_of_study ,business.industry ,Pulmonary Gas Exchange ,Public health ,Stressor ,Anesthesiology and Pain Medicine ,030228 respiratory system ,Anesthetic ,business ,Airway ,medicine.drug - Abstract
Purpose of review As the population ages, the increase in chronic illnesses among patients with decreasing lung function will pose a major public health challenge. Determining which elderly patients are fit for surgery is an increasingly important skill. Anesthetic care of elderly patients requires an understanding of the effects that chronic diseases have on normal age-related changes in physiology and function. Postoperative respiratory complications are significantly increased in patients over 65 years of age, especially those with preexisting diseases. Recent findings Advanced age is associated with changes in the immunity of the pulmonary system. Dysregulation of pro-inflammatory mediators and antimicrobial defense systems contribute to a reduction in pulmonary function and its response to infections. Aging is also associated with a disruption of the function of alveolar macrophages, neutrophils, and natural killer cells. Summary Aging can increase the risk of postoperative complications because of a loss of physiologic reserve and airway defenses. These limitations may only become apparent after the stressors of surgery and anesthesia.
- Published
- 2017
25. Gibson's theory of affordances and situational awareness occurring in urban departments of pediatrics, medicine, and emergency medicine
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Kapil Rajwani, Joanna Lee, Kevin Ching, Neel Naik, Jeffrey Phillips, and Timothy C. Clapper
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medicine.medical_specialty ,Urban Population ,Situation awareness ,media_common.quotation_subject ,education ,Efficiency, Organizational ,Pediatrics ,Education ,03 medical and health sciences ,Patient safety ,0302 clinical medicine ,medicine ,030212 general & internal medicine ,Affordance ,Qualitative Research ,media_common ,Teamwork ,030503 health policy & services ,Debriefing ,Theoretical sampling ,General Medicine ,Models, Theoretical ,Feeling ,Health Facility Environment ,Emergency medicine ,Emergency Medicine ,0305 other medical science ,Psychology ,Delivery of Health Care ,Qualitative research - Abstract
Background: The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) program provides a situation-monitoring tool that allows health-care professionals to perform an environmental scan. This process includes scanning the status of the patient, team members, and the environment, to ensure that patient care is progressing toward the goal. It is assumed that health-care professionals will act in a certain way by providing feedback and support based on the scan. However, there is limited research supporting the impact of the clinical environment on behavior among health-care professionals. Methods: This qualitative research used in situ simulation and a theoretical sampling of six day and overnight shift clinical teams (n = 34) from three departments in an urban hospital in New York City: pediatric medicine, emergency medicine, and internal medicine. Notebook entries by the participants at three intervals during the case and a debriefing following the cases captured participant views, observations, and concerns about the immediate clinical environment. Results: In all six cases, and with every shift, there were documented examples of someone in the environment who saw something but did not speak up, possibly making a difference in regard to patient safety and the outcomes in the case. Some of the noted reasons include not wanting to be wrong, not wanting to hurt someone's feelings, or not being sure. Discussion: Our research explored the environmental scan that health-care team members conducted in three unique department settings, including how they perceived affordances, and the reasons why individuals may not speak up when another team member is not performing properly. Each person possesses a unique awareness and deficit of available affordances because of his/her position in the environment. Patient safety is somewhat reliant on the views and observations of each team member. Educators should use these outcomes to justify teamwork and communication training that includes targeted emphasis on providing candid feedback, situation monitoring, and mutual support.
- Published
- 2018
26. Albumin Protects Against Gut-Induced Lung Injury In Vitro and In Vivo
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Qi Lu, George W. Machiedo, Edwin A. Deitch, Tamara L. Berezina, Da-Zhong Xu, Carl J. Hauser, Kapil Rajwani, Sergey B. Zaets, and Adena J. Osband
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Lung Diseases ,Male ,Pathology ,medicine.medical_specialty ,Lung injury ,In Vitro Techniques ,Shock, Hemorrhagic ,Sensitivity and Specificity ,Andrology ,Rats, Sprague-Dawley ,Random Allocation ,Injury Severity Score ,In vivo ,Reference Values ,Albumins ,medicine ,Animals ,Mesentery ,Probability ,Analysis of Variance ,medicine.diagnostic_test ,business.industry ,Albumin ,Endothelial Cells ,Lung Injury ,Rats ,Endothelial stem cell ,Red blood cell ,Disease Models, Animal ,Bronchoalveolar lavage ,medicine.anatomical_structure ,Linear Models ,Surgery ,Human umbilical vein endothelial cell ,Original Article ,Lymph ,business - Abstract
OBJECTIVE Since albumin has the ability to detoxify, we assessed whether low-dose albumin could protect against trauma/hemorrhagic shock (T/HS)-induced endothelial cell, lung, gut, and red blood cell (RBC) injury in vivo and endothelial cell injury in vitro. SUMMARY BACKGROUND DATA T/HS cause ischemic insult to the gut, resulting in the release of biologically active factors into the mesenteric lymph, which then cause injury to multiple distant organs. METHODS In vitro experiments tested the ability of albumin to reduce the cytotoxicity of mesenteric lymph from male rats subjected to T/HS (laparotomy + MAP 30 mm Hg for 90 minutes) for human umbilical vein endothelial cell (HUVEC). In subsequent in vivo experiments, the ability of albumin given as part of the resuscitation regimen to protect against T/HS-induced injury was tested by comparing the magnitude of injury in T/HS rats receiving human albumin (shed blood + 0.12, 0.24, or 0.36 g/kg) or lactated Ringer's solution (shed blood + 2 x volume of shed blood as LR) with that observed in rats subjected to trauma/sham shock. Rats were killed after a 3-hour recovery period and had lung permeability evaluated by bronchoalveolar lavage and myeloperoxidase assays, intestinal microvillous injury by histology, and RBC deformability using ektacytometry. RESULTS Both bovine and human albumin prevented T/HS lymph-induced HUVEC cytotoxicity in vitro, even when added 30 minutes after the lymph (viability 15 +/- 4% to 88 +/- 3%, P < 0.01). In vivo RBC deformability was better preserved by blood plus albumin than blood plus lactated Ringer's solution (P < 0.01). Likewise, albumin administration reduced T/HS-induced lung permeability and neutrophil sequestration in a dose-dependent fashion, with 0.36 g/kg of albumin effecting total lung protection (P < 0.01). In contrast, albumin treatment did not prevent T/HS-induced gut injury. CONCLUSIONS Low-dose albumin protects against gut lymph-induced lung, HUVEC, and RBC injury by neutralizing T/HS lymph toxicity.
- Published
- 2004
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