PubMed Health⌕ Search

Biomedical subjects

Jesse B Hall

Publications and source records attributed to Jesse B Hall.

At least 19 recordsLinked to original sources
PubMed2007

Daily sedative interruption in mechanically ventilated patients at risk for coronary artery disease.

OBJECTIVES: To determine the prevalence of myocardial ischemia in mechanically ventilated patients with coronary risk factors and compare periods of sedative interruption vs. sedative infusion. DESIGN: Prospective, blinded observational study. SETTING: Medical intensive care unit of tertiary care medical center. PATIENTS: Intubated, mechanically ventilated patients with established coronary artery disease risk factors. INTERVENTIONS: Continuous three-lead Holter monitors with ST-segment analysis by a blinded cardiologist were used to detect myocardial ischemia. Ischemia was defined as ST-segment elevation or depression of >0.1 mV from baseline. MEASUREMENTS AND MAIN RESULTS: Comparisons between periods of awakening from sedation vs. sedative infusion were made. Vital signs, catecholamine levels, and time with ischemia detected by Holter monitor during the two periods were compared. Heart rate, mean arterial pressure, rate-pressure product, respiratory rate, and catecholamine levels were all significantly higher during sedative interruption. Eighteen of 74 patients (24%) demonstrated ischemic changes. Patients with myocardial ischemia had a longer intensive care unit length of stay (17.4+/-17.5 vs. 9.6+/-6.7 days, p=.04). Despite changes in vital signs and catecholamine levels during sedative interruption, fraction of ischemic time did not differ between the time awake vs. time sedated [median [interquartile range] of 0% [0, 0] compared with 0% [0, 0] while they were sedated [p=.17]). The finding of similar fractions of ischemic time between awake and sedated states persisted with analysis of the subgroup of 18 patients with ischemia. CONCLUSIONS: Myocardial ischemia is common in critically ill mechanically ventilated patients with coronary artery disease risk factors. Daily sedative interruption is not associated with an increased occurrence of myocardial ischemia in these patients.

Aged↗
PubMed2006

Usefulness of the external jugular vein examination in detecting abnormal central venous pressure in critically ill patients.

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 [</=5 cm of water] or high [>/=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.

Aged↗
PubMed2006

The relationship between sedative infusion requirements and permissive hypercapnia in critically ill, mechanically ventilated patients.

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.

Adult↗
PubMed2006

Sedation in the mechanically ventilated patient.

OBJECTIVE: To discuss the approach to sedation of the mechanically ventilated patient. DATA SYNTHESIS: Mechanically ventilated patients in the intensive care unit frequently require sedation and analgesia for anxiety and pain experienced during the time they are intubated. Multiple drugs are available for this purpose. Strategies that optimize comfort while minimizing the predilection for sedative and analgesic drug accumulation with prolongation of effect have been shown to improve outcomes. In particular, such strategies may decrease mechanical ventilation duration, intensive care unit length of stay, and complications associated with critical illness. CONCLUSIONS: Sedation and analgesia are important in the management of patients who require mechanical ventilation. An evidence-based approach to administering sedatives and analgesics is necessary to optimize short- and long-term outcomes in mechanically ventilated patients.

Analgesics, Opioid↗
PubMed2006

Brain dysfunction in critically ill patients--the intensive care unit and beyond.

Critical care physicians often find themselves prognosticating for their patients, attempting to predict patient survival as well as disability. In the case of neurologic injury, this can be especially difficult. A frequent cause of coma in the intensive care unit is resuscitation following cardiac arrest, for which mortality and severe neurologic disability remain high. Recent studies of the clinical examination, of serum markers such as neuron-specific enolase, and of somatosensory evoked potentials allow accurate and specific prediction of which comatose patients are likely to suffer a poor outcome. Using these tools, practitioners can confidently educate the family for the majority of patients who will die or remain comatose at 1 month. Delirium is a less dramatic form of neurologic injury but, when sought, is strikingly prevalent. In addition, delirium in the intensive care unit is associated with increased mortality and poorer functional recovery, prompting investigation into preventative and therapeutic strategies to counter delirium. Finally, neurologic damage may persist long after the patient's recovery from critical illness, as is the case for cognitive dysfunction detected months and years after critical illness. Psychiatric impairment including depression or post-traumatic stress disorder may also arise. Mechanisms contributing to each of these entities are reviewed.

Biomarkers↗
PubMed2005

Critical care organization.

The organizational structure of critical care services likely affects the quality of patient care, and ultimately, patient outcomes. Based on the available data, the ideal intensive care unit would be a closed-unit staffed by dedicated intensivists. Whether or not around-the-clock intensivist staffing is necessary, however, is debatable. Because financial realities preclude all units from being ideal, alternative strategies for organization must be explored.

Critical Care↗
PubMed2004

Risk factors for ventilator-associated pneumonia: from epidemiology to patient management.

Risk factors for the development of ventilator-associated pneumonia (VAP), as identified in epidemiological studies, have provided a basis for testable interventions in randomized trials. We describe how these results have influenced patient treatment. Single interventions in patients undergoing intubation have focused on either reducing aspiration of oropharyngeal secretions, modulation of colonization (in either the oropharynx, the stomach, or the whole digestive tract), use of systemic antimicrobial prophylaxis, or ventilator circuit changes. More recently, multiple simultaneously implemented interventions have been used. In general, routine measures to decrease oropharyngeal aspiration and antibiotic-containing prevention strategies appear to be the most effective, and the latter were associated with improved rates of patient survival in recent trials. These benefits must be balanced against the widespread fear of emergence of antibiotic resistance. In hospital settings with low baseline levels of antibiotic resistance, however, the benefits to patient outcome may outweigh this fear of resistance. In settings with high levels of antibiotic resistance, combined approaches of non-antibiotic using strategies and education programs might be most beneficial.

Anti-Bacterial Agents↗
PubMed2004

Delirium and sedation.

Critically ill patients nearing the end of life frequently present with needs for aggressive sedation and analgesia. Optimizing patient comfort while permitting effective communication are challenging goals in this patient population. This article discusses delirium and sedation as it applies to dying patients, and provides recommendations for effective management strategies to optimize the experience of such patients at the end of life.

Algorithms↗
PubMed2004

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients.

OBJECTIVE: In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known. DESIGN: Blinded, retrospective chart review. SETTING: University-based hospital in Chicago, IL. PATIENTS: One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy. Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention. The incidence of complications was evaluated for each patient's hospital course. One hundred twenty-six of 128 charts were available for review. Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04). CONCLUSIONS: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

Adult↗
PubMed2004

Acute asthma in adults: a review.

All patients with asthma are at risk of having exacerbations. Hospitalizations and emergency department (ED) visits account for a large proportion of the health-care cost burden of asthma, and avoidance or proper management of acute asthma (AA) episodes represent an area with the potential for large reductions in health-care costs. The severity of exacerbations may range from mild to life threatening, and mortality is most often associated with failure to appreciate the severity of the exacerbation, resulting in inadequate emergency treatment and delay in referring to hospital. This review describes the epidemiology, costs, pathophysiology, mortality, and management of adult AA in the ED and in the ICU.

Acute Disease↗
PubMed2003

The long-term psychological effects of daily sedative interruption on critically ill patients.

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.

Adult↗
PubMed2002

Effectiveness of medical resident education in mechanical ventilation.

Specific methods of mechanical ventilation management reduce mortality and lower health care costs. However, in the face of a predicted deficit of intensivists, it is unclear whether residency programs are training internists to provide effective care for patients who require mechanical ventilation. To evaluate these educational outcomes, we administered a validated 19-item case-based test and survey to resident physicians at 31 diverse U.S. internal medicine residency programs nationwide. Of 347 senior residents, 259 (75%) responded. The mean test score was 74% correct (SD, 14%; range, 37 to 100%). Important items representing evidence-based standards of critical care answered incorrectly were as follows: use of appropriate tidal volume in the acute respiratory distress syndrome (48% incorrect), identifying a patient ready for a weaning trial (38% incorrect), and recognizing indication for noninvasive ventilation (27% incorrect). Most accurately identified pneumothorax (86% correct) and increased intrathoracic positive end-expiratory pressure (93% correct). Better scores were associated with "closed" versus "open" intensive care unit organization (76 versus 71% correct, p = 0.001), resident perception of greater versus lesser ventilator knowledge (79 versus 71% correct, p = 0.001), and graduation from a U.S. versus international medical school (75 versus 69% correct, p = 0.033). Although overall training satisfaction correlated strongly with program use of learning objectives (r = 0.89, p < 0.0001), only 46% reported being satisfied with their mechanical ventilation training. We conclude that senior residents may not be gaining essential evidence-based knowledge needed to provide effective care for patients who require mechanical ventilation. Residency programs should emphasize evidence-based learning objectives to guide mechanical ventilation instruction.

Educational Measurement↗
PubMed2002

The utility of albuterol nebulized with heliox during acute asthma exacerbations.

Heliox improves lung deposition of inhaled particles when compared with air or oxygen inhalation. We studied the spirometric effects of albuterol nebulized with heliox during emergency room visits for asthma exacerbations. Forty-five patients were randomized to receive albuterol nebulized with oxygen (control) versus heliox (n = 22 control and 23 heliox subjects). At baseline, demographics, outpatient asthma medications, vital signs, oxygen saturation, and forced expiratory volume in one second were not different between the two groups. Three consecutive albuterol treatments were given to each group. The heliox group had a significantly higher heart rate after albuterol nebulization compared with the control group. Following albuterol Treatment 1, the median change in forced expiratory volume in one second was 14.6% in the control group and 32.4% in the heliox group (p = 0.007). After Treatment 2, the results were 22.7% versus 51.5%, respectively (p = 0.007). After Treatment 3, the results were 26.6% versus 65.1%, respectively (p = 0.016). We conclude that during acute asthma exacerbations, albuterol nebulized with heliox leads to a more significant improvement in spirometry when compared with albuterol nebulized with oxygen. This is likely due to the low-density gas improving albuterol deposition in the distal airways.

Administration, Inhalation↗
PubMed2002

Skin necrosis after extravasation of low-dose vasopressin administered for septic shock.

OBJECTIVE: To describe a case of severe skin necrosis resulting from peripheral intravenous administration of low-dose vasopressin in a patient with catecholamine-resistant septic shock. DESIGN: Case report. SETTING: Medical intensive care unit at the University of Chicago, Chicago, IL. PATIENT: A 46-yr-old female with ventilator-dependent, proliferative-phase acute respiratory distress syndrome complicated by Pseudomonas aeruginosa bacteremia and sepsis. MEASUREMENTS AND MAIN RESULTS: A patient recovering from acute respiratory distress syndrome developed septic shock from Pseudomonas aeruginosa bacteremia while in the medical intensive care unit. Vasopressin (0.04 units/min) was administered through a peripheral venous catheter for hypotension unresponsive to exogenous catecholamines. The patient subsequently developed severe ischemic necrosis of the skin and soft tissue surrounding the catheter site. The vasopressin was stopped, and the skin lesion progressed to bullae formation with extensive superficial erosion. CONCLUSIONS: Peripheral administration of low-dose vasopressin for septic shock should be discouraged because of the risk of ischemic skin complications.

Dose-Response Relationship, Drug↗