Faculty Bibliography

Desmopressin, a synthetic vasopressin analog, is used to treat central diabetes insipidus, hemostatic disorders such as von Willebrand's disease, and nocturnal enuresis. We present the case of a 69-year-old man who developed severe hyponatremia during treatment with intranasal desmopressin at 10 µg twice daily for chronic polyuria and nocturia thought to be due to central diabetes insipidus. After 5 months of therapy, the patient noticed progressive fatigue, anorexia, dizziness, weakness, light-headedness, decreased concentration, and new-onset falls. At 6 months of therapy, the patient was brought to the emergency department for altered mental status and was found to be severely hyponatremic with a serum sodium level of 96 mmol/L, down from a value of 134 mmol/L at the initiation of therapy. The intranasal desmopressin was discontinued and the patient was admitted to the intensive care unit where the hyponatremia was slowly corrected over the next week to 132 mmol/L, never increasing by more than 8 mmol/L a day, with careful fluid management. This included infusion of over 11 L of 5% dextrose to account for a high urine output, which peaked at 7.4 L in 1 day. However, while the recommended rate for sodium correction was followed, the patient's magnetic resonance imaging of the brain obtained after discharge displayed evidence of central pontine myelinolysis. Despite this finding, the patient eventually returned to his baseline mental status with no permanent neurologic deficits.

PURPOSE OF REVIEW: Early identification and appropriate management of sepsis improves outcomes. Despite convincing data showing the benefits of early recognition and treatment of sepsis and septic shock, implementation of such evidence-based therapy is suboptimal. This review describes methods that have been shown to improve bedside application of the evidence-based guidelines. RECENT FINDINGS: The Surviving Sepsis Campaign (SSC) has developed guidelines for the management of severe sepsis and septic shock. The initial SSC guidelines were published in 2004; as evidence continued to evolve, the guidelines were updated, with the most recent iteration published in 2016. Guidelines by themselves can take years to change clinical practice. To affect more rapid change, the SSC guidelines are filtered into bundles to impact behavior change in a simple and uniform way. SUMMARY: Implementation of the SSC bundles revolves around practice improvement measures. Hospitals that have successfully implemented these bundles have consistently shown improved outcomes and reductions in healthcare spending. Finally, the Centers for Medicare and Medicaid Services has approved SSC bundle compliance as a core measure, and hospitals in the United States are mandated to collect and report their data regularly to Centers for Medicare and Medicaid Services.

PURPOSE: Our overall goal is to create a sustainable ultrasound(US) intervention in resource-limited settings in Dhaka, Bangladesh. Our baseline needs-assessment of the intensive care unit (ICU) of Dhaka Medical College Hospital (DMCH) found that reliable imaging is not available, including ultrasound. The lack of adequate imaging was found to be a deterrent to the proper care of patients. The growing use of point-of-care ultrasound in the ICU as a tool for rapid diagnosis and management led to the creation of the Bangladesh Ultrasound Initiative. This project is designed to bring a successful point-of-care ultrasound training program to physicians in the ICU and emergency room of DMCH. METHODS: Participants were recruited via posters and emails. Training workshops spanned the course of two days. All sessions included individuals that represented all levels of physician training. The following topics were covered: technical aspects, basic echocardiography, pleural ultrasound, DVT and IVC assessment, US-guided CVL placement, US-guided thoracentesis and FAST exam. Training sessions were divided into three parts: lecture-based learning (2 hours), image interpretation with normal and pathological images shown to participants(1.5 hours), and hands-on practical use with the aid of volunteers(2.5 hours). A pre-test and post-test with the same questions was distributed before and after each workshop respectively. Statistical analysis was completed with the use of a chi-square test and paired t-test. RESULTS: Fifty individuals were included in the final analysis. The pre-test/post-test had a total of 37 questions, 25 of which were knowledge-based. Knowledge-based questions were grouped into the topics covered as listed in the methods section. There was a statistically significant (p<0.05) difference between pre- and post-test scores; the mean pre-test score was 3 (SD=3) and the mean post-test score was 12 (SD=3). A 5-point Likert scale was used to ask questions regarding level of confidence. The mean confidence level on the pre-test was 1 (very unconfident) in every category to 5 (very confident) in the post-test(p<0.05). A subgroup analysis showed no difference in mean pre-test and post-test scores of participants who had attended an ultrasound course at any point prior to our intervention compared to those who had never attended a previous ultrasound course. CONCLUSIONS: The results of this study show that a simple workshop in point-of-care ultrasound, using lectures and hands-on practice, can improve knowledge and confidence with statistical significance. This study also shows that the pre- and post-test scores are similar despite some participants having had training in ultrasound prior to the current intervention

PURPOSE: The PROSEVA (Proning Severe ARDS patients) trial demonstrated that prone positioning in patients with severe ARDS improves mortality. Patients in this seminal trial, however, were manually proned in a regular ICU bed. Despite this, many hospitals extrapolate the findings of the PROSEVA trial to a kinetic bed (Rotoprone) in the absence of significant evidence supporting its use. We performed a retrospective study to evaluate the hemodynamic and gas exchange alterations in patients with severe ARDS before and after prone position with the Rotoprone bed. METHODS: We completed a retrospective chart review of 9 patients with severe ARDS who underwent prone positioning with the Rotoprone bed in our tertiary care adult ICU. Baseline demographic data, physiologic data (including oxygenation index and dead space fraction) and hemodynamic data (including vasopressor requirement, mean arterial pressure, central venous pressure and urine output) were collected 4 hours before and after prone positioning. For patients in shock, vasopressor dosing was used as an index for degree of hypotension. Complications associated with prone positioning were also collected. A paired 2-tailed t-test was used for statistical analysis RESULTS: There was a trend towards improvement in oxygenation index (supine:23.6 vs. prone: 16.5, p= 0.13) though no significant difference in dead space fraction (supine: 0.33 vs. prone 0.31, p=0.28). There was no change in MAP and vasopressor dosing before and after the initial phase of proning. There were no complications during proning with the use of the Rotoprone bed. CONCLUSIONS: Our retrospective data demonstrates promising trends in improving gas exchange in patients with severe ARDS proned with the Rotoprone bed. While both indices of gas exchange improved, they did not reach statistical significance, possibly due to the small sample size. No complications or hemodynamic changes associated with proning were noted in our cohort. Larger studies to further define changes in hemodynamics and gas exchange in this population are warranted