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OBJECTIVE: Permissive hypercapnia (PH) may result from mechanical ventilation (MV) strategies that intentionally reduce minute ventilation. Sedative doses required to tolerate PH have not been well characterized. With increased attention to lung-protective ventilation, characterization of sedative requirements with PH and determination of sedative dose changes with PH are needed. DESIGN: Retrospective analysis. SETTING: Tertiary care university hospital. PATIENTS: We evaluated 124 patients randomized in a previous study to either propofol or midazolam. PH was employed in ten of 60 patients receiving propofol and 13 of 64 patients receiving midazolam. INTERVENTIONS: We analyzed dosing of propofol and midazolam in patients undergoing PH through a retrospective analysis of an existing database on MV patients. Total sedative (propofol and midazolam) dose was recorded for the first three days of MV. Linear regression analysis (dependent variable: sedative dose) was used to analyze the following independent variables: PH, age, gender, daily sedative interruption, type of respiratory failure, presence of hepatic and/or renal failure, Acute Physiology and Chronic Health Evaluation II score, morphine dose, and Ramsay sedation score. MEASUREMENTS AND MAIN RESULTS: Propofol dose was higher in PH patients (42.5 +/- 16.2 vs. 27.0 +/- 15.3; p = .02); Midazolam dose did not differ between PH and non-PH patients (0.05 [0.04, 0.14] vs. 0.05 [0.03, 0.07]; p = .17). By univariate linear regression analysis, propofol dose was significantly dependent on PH, age, type of respiratory failure, morphine dose, and Ramsay score, with PH (regression coefficient, 11.7; 95% confidence interval, 1.2-22.7; p = .03) and age (regression coefficient, -0.3; 95% confidence interval -0.5 to -0.08; p = .005) remaining significant by multivariate linear regression. By univariate linear regression analysis, midazolam dose was dependent on age, morphine dose, and Ramsay score, but not PH; only morphine dose (regression coefficient, 0.44; 95% confidence interval, 0.22-0.67 for a 0.1-unit increase in morphine dose; p < .001) was significant by multivariate linear regression. CONCLUSIONS: We conclude that higher doses of propofol but not midazolam are required to sedate patients managed with PH. [ABSTRACT FROM AUTHOR]

Critically ill patients often receive sedatives, which may delay liberation from mechanical ventilation and intensive care unit discharge. Daily interruption of sedatives alleviates these problems, but the impact of this practice on long-term psychological outcomes is unknown. We compared psychological outcomes of intensive care unit patients undergoing daily sedative interruption (intervention) with those without this protocol (control). Assessments using (1) the Revised Impact of Event Scale (evaluates signs of posttraumatic stress disorder [PTSD]), (2) the Medical Outcomes Study 36 item short-form health survey, (3) the State-Trait Anxiety Inventory, (4) the Beck Depression Inventory-2, (5) and the Psychosocial Adjustment to Illness score (overall quality of adjustment to current or residual effects of illness) were done by blinded observers. The intervention group had a better total Impact of Events score (11.2 vs. 27.3, p=0.02), a trend toward a lower incidence of PTSD (0% vs. 32%, p=0.06), and a trend toward a better total Psychosocial Adjustment to Illness score (46.8 vs. 54.3, p=0.08). We conclude that daily sedative interruption does not result in adverse psychological outcomes, reduces symptoms of PTSD, and may be associated with reductions in posttraumatic stress disorder. [ABSTRACT FROM AUTHOR]

Background and Objectives: Generalized convulsive seizures (GCSs) are the main risk factor of sudden unexpected death in epilepsy (SUDEP), which is likely due to peri-ictal cardiorespiratory dysfunction. The incidence of GCS-induced cardiac arrhythmias, their relationship to seizure severity markers, and their role in SUDEP physiopathology are unknown. The aim of this study was to analyze the incidence of seizure-induced cardiac arrhythmias, their association with electroclinical features and seizure severity biomarkers, as well as their specific occurrences in SUDEP cases., Methods: This is an observational, prospective, multicenter study of patients with epilepsy aged 18 years and older with recorded GCS during inpatient video-EEG monitoring for epilepsy evaluation. Exclusion criteria were status epilepticus and an obscured video recording. We analyzed semiologic and cardiorespiratory features through video-EEG (VEEG), electrocardiogram, thoracoabdominal bands, and pulse oximetry. We investigated the presence of bradycardia, asystole, supraventricular tachyarrhythmias (SVTs), premature atrial beats, premature ventricular beats, nonsustained ventricular tachycardia (NSVT), atrial fibrillation (Afib), ventricular fibrillation (VF), atrioventricular block (AVB), exaggerated sinus arrhythmia (ESA), and exaggerated sinus arrhythmia with bradycardia (ESAWB). A board-certified cardiac electrophysiologist diagnosed and classified the arrhythmia types. Bradycardia, asystole, SVT, NSVT, Afib, VF, AVB, and ESAWB were classified as arrhythmias of interest because these were of SUDEP pathophysiology value. The main outcome was the occurrence of seizure-induced arrhythmias of interest during inpatient VEEG monitoring. Moreover, yearly follow-up was conducted to identify SUDEP cases. Binary logistic generalized estimating equations were used to determine clinical-demographic and peri-ictal variables that were predictive of the presence of seizure-induced arrhythmias of interest. The z -score test for 2 population proportions was used to test whether the proportion of seizures and patients with postconvulsive ESAWB or bradycardia differed between SUDEP cases and survivors., Results: This study includes data from 249 patients (mean age 37.2 ± 23.5 years, 55% female) who had 455 seizures. The most common arrhythmia was ESA, with an incidence of 137 of 382 seizures (35.9%) (106/224 patients [47.3%]). There were 50 of 352 seizure-induced arrhythmias of interest (14.2%) in 41 of 204 patients (20.1%). ESAWB was the commonest in 22 of 394 seizures (5.6%) (18/225 patients [8%]), followed by SVT in 18 of 397 seizures (4.5%) (17/228 patients [7.5%]). During follow-up (48.36 ± 31.34 months), 8 SUDEPs occurred. Seizure-induced bradycardia (3.8% vs 12.5%, z = -16.66, p < 0.01) and ESAWB (6.6% vs 25%; z = -3.03, p < 0.01) were over-represented in patients who later died of SUDEP. There was no association between arrhythmias of interest and seizure severity biomarkers ( p > 0.05)., Discussion: Markers of seizure severity are not related to seizure-induced arrhythmias of interest, suggesting that other factors such as occult cardiac abnormalities may be relevant for their occurrence. Seizure-induced ESAWB and bradycardia were more frequent in SUDEP cases, although this observation was based on a very limited number of SUDEP patients. Further case-control studies are needed to evaluate the yield of arrhythmias of interest along with respiratory changes as potential SUDEP biomarkers.

Spirometry provides clues to solving this puzzle of dyspnoea and wheeze in a young nonsmoker-the loops never lie! http://ow.ly/YC9zI A 10 s recording of expiratory sounds from this case can be found at: http://ow.ly/UVVu300moD1.

The diagnosis of pulmonary embolism (PE) remains challenging despite the evolution of well-validated clinical algorithms over the past few decades, largely because of nonspecific clinical features altering clinician suspicion. D-dimer is a simple noninvasive test that is an essential part of the diagnostic algorithm but is often deemed to be of little value in patients who are elderly or have other comorbidities. We describe a case of an elderly man who presented with clinical features and initial imaging consistent with pneumonia and a positive D-dimer test. Adherence to the suggested diagnostic algorithm and obtaining chest imaging, however, prevented what could have been a catastrophic missed diagnosis of PE. We review existing evidence on the importance of suspecting PE in the presence of alternative diagnosis and explore the literature on the association between the magnitude of D-dimer and the diagnosis of PE.

Background: A 66-year-old white man with a history of cryptogenic cirrhosis complicated by hepatocellular carcinoma, ascites and hepatic encephalopathy presented with a productive cough and pleuritic chest pain on his right side. He underwent transarterial chemoembolization for hepatocellular carcinoma 6 months before presentation. The patient had a history of coronary artery disease, type 2 diabetes mellitus and hypertension., Investigations: Medical history and physical examination, laboratory investigations, diagnostic thoracentesis, bacterial culture and Gram staining studies, abdominal MRI with magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, infused chest CT and examination of the thorax during open thoracotomy., Diagnosis: Biliopleural fistula with connections between the right pleural space and a branch of the right intrahepatic biliary tree., Management: Antibiotics, placement and removal of a chest tube, endoscopic retrograde cholangiopancreatography to guide biliary sphincterotomy with placement and removal of a hepatic-duct stent, open thoracotomy with decortication, percutaneous transhepatic cholangiography and placement of a catheter.

Background: Central venous pressure (CVP) provides important information for the management of critically ill patients. The external jugular vein (EJV) is easier to visualize than the internal jugular vein and may give a reliable estimate of CVP., Methods: To determine the usefulness of the EJV examination in detecting abnormal CVP values, we performed a prospective blinded evaluation comparing it with CVP measured using an indwelling catheter in critically ill patients with central venous catheters. Blinded EJV examinations were performed by clinicians with 3 experience levels (attending physicians, residents and fellows, and interns and fourth-year medical students) to estimate CVP (categorized as low [/=10 cm of water]). The usefulness of the EJV examination in discriminating low vs high CVP was measured using receiver operating characteristic curve analysis., Results: One hundred eighteen observations were recorded among 35 patients. The range of CVP values was 2 to 20 cm of water. The EJV was easier to visualize than the internal jugular vein (mean visual analog scale score, 8 vs 5; P<.001). The reliability for determining low and high CVP was excellent, with areas under the curve of 0.95 (95% confidence interval [CI], 0.88-1.00) and 0.97 (95% CI, 0.92-1.00), respectively, for attending physicians and 0.86 (95% CI, 0.78-0.95) and 0.90 (95% CI, 0.84-0.96), respectively, for all examiners., Conclusion: The EJV examination correlates well with catheter-measured CVP and is a reliable means of identifying low and high CVP values.

Context: Invasive procedures are often performed emergently in the intensive care unit (ICU), and patients or their proxies may not be available to provide informed consent. Little is known about the effectiveness of intensivists in obtaining informed consent., Objectives: To describe the nature of informed consent in the ICU and to determine if simple interventions could enhance the process., Design, Setting, and Patients: Prospective study of 2 cohorts of consecutively admitted patients (N = 270) in a 16-bed ICU at a university hospital. All patients admitted to the ICU during the baseline period from November 1, 2001, to December 31, 2001, and during the intervention period from March 1, 2002, to April 30, 2002, were included., Intervention: A hospital-approved universal consent form for 8 commonly performed procedures (arterial catheter, central venous catheter, pulmonary artery catheter, or peripherally inserted central catheter placement; lumbar puncture; thoracentesis; paracentesis; and intubation/mechanical ventilation) was administered to patients or proxies. Handouts describing each procedure were available in the ICU waiting area. Physicians and nurses were introduced to the universal consent form during orientation to the ICU., Main Outcome Measures: Incidence of informed consent for invasive procedures at baseline and after intervention; whether the patient or proxy provided informed consent; and understanding by the consenter of the procedure as determined by the responses on a questionnaire., Results: Fifty-three percent of procedures (155/292) were performed after consent had been obtained during the baseline period compared with 90% (308/340) during the intervention period (absolute difference, 37.4%; P<.001). During baseline, the majority (71.6%; 111/155) of consents were provided by proxies. This was also the case during the intervention period in which 65.6% (202/308) of consents were provided by proxies (absolute difference, 6.0%; P =.23). Comprehension by consenters of indications for and risks of the procedures was high and not different between the 2 periods (P =.75)., Conclusions: Invasive procedures are frequent in the ICU and consent for them is often obtained by proxy. Providing a universal consent form to patients, proxies, and health care clinicians significantly increased the frequency with which consent was obtained without compromising comprehension of the process by the consenter.

Study Objectives: To describe the outcome of patients with status asthmaticus (SA) treated in a medical ICU with positive pressure ventilation (PPV), and to identify those factors associated with increased length of hospital stay., Design: Retrospective chart review., Setting: University-based hospital in Chicago, IL., Patients: All patients admitted with SA and treated with PPV over a 5-year period., Results: The first ICU admission for each of 78 patients was analyzed. Fifty-six patients underwent endotracheal intubation (ETI) during the hospitalization, while 22 patients were treated with noninvasive PPV alone. Three patients died. The median hospital length of stay was 5.5 days. Cox regression analysis revealed the following factors to be independently associated with increased length of hospital stay: female gender (p < 0.01), ETI (p < 0.01), the administration of neuromuscular blockers for > 24 h (p < 0.01), inhaled corticosteroid use prior to ICU admission (p = 0.01), and increasing APACHE (acute physiology and chronic health evaluation) II score (p < 0.01)., Conclusions: This study suggests that while the mortality associated with SA treated with contemporary methods of PPV is low, certain factors, including female gender, ETI, and the prolonged use of neuromuscular blockade, are associated with an increased length of hospital stay. The development of respiratory failure despite preadmission use of inhaled corticosteroids is also associated with prolonged hospitalization.

Changes in task-related mood and physiology associated with 31 days of smoking abstinence were assessed in smokers, 34 of whom were randomly assigned to a quit group and 22 to a continuing-to-smoke control group. A large financial incentive for smoking abstinence resulted in very low participant attrition. Individuals were tested during prequit baselines and at 3, 10, 17, and 31 days of abstinence. Abstinence was associated with decreases in heart rate and serum cortisol, a slowing of electroencephalogram (EEG) activity, and task-dependent and trait-depression-dependent hemispheric EEG asymmetries. Differences between the quit group and the smoking group showed no tendency to resolve across the 31 days of abstinence. Trait depression and neuroticism correlated with increases in left-relative-to-right frontal EEG slow-wave (low alpha) activity at both 3 and 31 days of abstinence. In contrast, prequit nicotine intake and Fagerström Tolerance scores correlated with alpha asymmetry and with greater EEG slowing only at Day 3. Thus, the effects of smoking abstinence appear to last for at least several months.