Acute Clinical Deterioration Research Articles

Acute paraparesis and sensory loss following intravenous corticosteroid administration in a case of longitudinally extensive transverse myelitis caused by spinal dural arteriovenous fistula: case report and review of literature.

The underlying causes of longitudinally extensive transverse myelitis (LETM) are broad and include inflammatory processes, compression and spinal dural arteriovenous fistula (SDAVF). Presenting symptoms of SDAVF are nonspecific and often go misdiagnosed. Acute clinical deterioration from SDAVF has been described following exertion or valsalva. However, deterioration has been recently recognized following steroid administration and may contribute to increased morbidity. We describe a 63-year-old woman with a 2-year history of intermittent lower extremity numbness and back pain, lumbar stenosis, who presented with subacute worsening of symptoms following a course of oral steroids for an upper respiratory infection. Initial whole-spine imaging was concerning for LETM and lumbar puncture was concerning for an inflammatory process. The patient was treated with intravenous (IV) methylprednisolone, after which she developed acute onset bilateral lower extremity paraparesis with a sensory level. Angiogram confirmed the diagnosis of SDAVF and the patient was treated surgically. Post-operative course was complicated and subsequent clinical improvement has been slow with incomplete recovery to date. This case illustrates the nonspecific presentation of SDAVF and the difficulty of differentiating it from other causes of LETM. It demonstrates acute clinical deterioration of SDAVF following steroid administration, a recently recognized clinical entity. The most likely mechanism is hydrostatic steroid effect coupled with iatrogenic fluid co-administration causing increased venous congestion. Previous cases have demonstrated this effect to be transient and resolves after discontinuation of steroids. This case highlights a recent association of increased morbidity following steroid administration despite definitive treatment.

Perioperative management of the patient with diabetes requiring emergency surgery

Perioperative management of the patient with diabetes requiring emergency surgery

Current practices related to family presence during acute deterioration in adult emergency department patients.

To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department. Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration. Descriptive exploratory study using nonparticipatory observation. Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis. Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take. Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration. This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research.

Identify, Triage, and Treat (ITT) – A Programmatic Approach to the Assessment and Treatment of Patients with Clinical Changes to Limit Readmission

Increasing pressure by payers to limit readmissions across the continuum of care requires all providers in post-acute care and long term care (PA/LTC) to be aware of opportunities to treat patients who develop acute clinical deterioration safely and successfully without transfer. Readmission from (PA/LTC) account for 23.5% of the Medicare readmissions with infection diagnoses representing up to 30% of (PA/LTC). Early recognition and treatment of infections can decrease morbidity and mortality and limit transfers to higher level of care. Other conditions can mimic infection and maybe inappropriately treated with antibiotics, jeopardizing antibiotic stewardship, increasing resistant organism dissemination, delaying proper treatment and increasing cost and adverse effects. Therefore, an effective design should have a positive impact on readmissions.

PP81. A CASE OF EXTRACRANIAL GLIOBLASTOMA WITH METASTASIS IN PLEURA & LIVER

AbstractBACKGROUND: Extraneural and extracranial metastases of Glioblastoma (GB) are rarely reported in literature and accounted to be around 0.2% all GB patients CASE PRESENTATION: We are presenting a 66 year old Caucasian male who presented with acute confusion, dizziness and dysphagia in May 2014 at which time the imaging revealed a 5cm * 4cm mass lesion with surrounding oedema in the left temporal lobe. Had maximum surgical debulking followed by concurrent chemo-radiotherapy 60Gy in 30 fractions over 6 weeks with daily oral Temozolomide 75mg/m2 although could not manage to continue with Temozolamide during last few days of treatment on account of the acute kidney injury. Showed significant response to the concurrent chemo-radiation following which proceeded to adjuvant Temozolomide chemotherapy and patient declined treatment after completion of 3 cycles for no apparent significant reason apart from generalized pruritus of skin and constipation which resolved with symptomatic management. Thereafter he was followed up in the clinic with repeat MRI scans the first of which in 4 months showed stable disease but the follow up MRI scan in 8 months showed debatable early disease progression which was confirmed 2 months later to be definite early disease progression at the primary site, extending to the adjacent corpus callosum. Whilst being suggested to re-challenge with Temozolomide, a month later presented with shortness of breath due to malignant pleural effusion and coincidentally noted liver metastasis. Pleural effusion was drained and was re-commenced on adjuvant Temozolomide but re-admitted with recurrent pleural effusion and died following acute clinical deterioration. His overall survival was 20 months, progression free survival was 17 months and ended up with metastatic disease at 18 months and died of the complications of metastatic disease 2 months later before he could start chemotherapy. CONCLUSION: Although rare in incidence, extra-neural metastasis from primary glioblastoma can be very aggressive and life threatening. Since the incidence seems to increase with time, maintaining a central registry and involvement in clinical trials would help to formulate ideal management protocol. KEYWORDS: Glioblastoma, Extra-neural metastasis, Extracranial metastasis, Case report

Contrast-Enhanced Computed Tomography in Intensive Care Unit Patients With Acute Clinical Deterioration: Impact of Hyperattenuating Adrenal Glands

PurposeThe study sought to assess the frequency and prognostic value of hyperattenuating adrenal glands on contrast-enhanced computed tomography (CT) scans of surgical intensive care unit (ICU) patients with acute clinical deterioration. MethodsEighty-eight consecutive ICU patients (63.2 ± 14.5 years of age) were included in this retrospective analysis. All patients underwent biphasic contrast-enhanced CT due to an acute clinical deterioration. Hyperattenuation of the adrenal glands was assessed subjectively and objectively. Subjective presence or absence of hyperattenuating adrenal glands was assessed by 2 blinded radiologists (J.B. and R.S.L.) in consensus. Hounsfield units (HU) were measured in the adrenal glands and in the inferior vena cava. Objective hyperattenuation was defined as HU (adrenal glands) > HU (inferior vena cava) with a 15-HU threshold. Death within 14 days following CT was set as endpoint and acquired from electronic patient data. ResultsThirty-eight patients (43.2%, Group Asubj) exhibited hyperattenuation of the adrenal glands, whereas 50 patients (56.8%, Group Bsubj) did not. Concerning the objective analysis, 31 patients (35.2%, Group Aobj) exhibited hyperdense adrenal glands, whereas 53 patients (64.8%, Group Bobj) did not. Overall 27 of 88 patients (30.6%) died within 14 days following the CT examination. Lethal outcome was significantly more frequent among patients in Group Asubj and Aobj (19 of 38 patients [50.0%] and 15 of 31 patients [48.4%]) as compared with patients in Group Bsubj (8 of 50 patients [16.0%]) and Group Bobj (12 of 57 patients [21.1%]; P < .05). Subjective and objective analysis correlated significantly (P < .05). ConclusionsHyperattenuation of adrenal glands on contrast-enhanced CT of ICU patients with acute clinical deterioration is associated with a high mortality and might serve as a prognostic marker for patients' outcome.

Abstract 13937: Electrocardiography-Derived Respiratory Rate Detects Clinical Deterioration in Acute Care Patients With Cardiovascular Disease

Introduction: Clinical deterioration resulting in ICU transfer occurs in 4 to 5 of every 100 acute care admissions. Early Warning Scores (EWS) identify high risk patients, but rely on intermittent assessments. Continuous ECG not only provides heart rate (HR) and rhythm, but can also estimate respiratory rate (RR). Hypothesis: Continuous ECG data improves the predictive validity of EWS prior to acute deterioration leading to ICU transfer or unanticipated death. Methods: Among floor patients admitted with continuous ECG, we identified those with deterioration resulting in ICU transfer or unanticipated death. We analyzed 60 patient-years of ECG data and applied previously validated methodologies for detection of atrial fibrillation (AF) and estimation of RR. We evaluated the predictive validity of common EWS and compared them to models that incorporate ECG data. We excluded observations after DNR/DNI orders or transitions to comfort care. We calculated the fold change in mortality, and the predictive validity (C-statistic). Results: From 8,033 consecutive admissions, we identified 544 instances of clinical deterioration in 508 admissions. Admissions with events had a 50-fold increase in mortality (19.8% vs 0.4%) despite unexpected deaths accounting for only 6% of all events. We analyzed the 274 deteriorations that had ECG data in the 24-hours leading up to events. EWS had C-statistics ranging from 0.63 to 0.70. A model using only ECG-derived measurements had a C-statistic of 0.67 and the strongest predictors included RR, HR, and AF. Addition of the ECG-only model to the best EWS improved its C-statistic to 0.72. Conclusions: Continuous ECG data improves the ability of intermittent EWS to identify the highest risk patients up to 24-hours in advance of acute clinical deterioration.

Family presence during management of acute deterioration: Clinician attitudes, beliefs and perceptions of current practices

The nature of acute clinical deterioration has changed over the last three decades with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite this change, research related to family presence continues to focus on care during resuscitation rather than during acute deterioration. To explore healthcare clinician attitudes, beliefs and perceptions of current practices surrounding family presence during episodes of acute deterioration in adult Emergency Department patients. Clinicians (n=156) from a single study site in Melbourne, Australia completed a 17-item survey. Participants disagreed that family members would interrupt (59.0%) or interfere (61.5%) with patient care if present during episodes of patient deterioration. Most (77.6%) participants stated that they included family during episodes of patient deterioration. Females, nurses and Australians/New Zealanders had a more positive attitude towards including family during episodes of patient deterioration when compared to males, doctors and clinicians of other ethnicities. Nurses with post-graduate qualifications and those with more years of experience had a more positive attitude towards including family during episodes of patient deterioration than nurses without post-graduation qualification and with less years of experience. Clinicians had predominantly positive attitudes towards including family during episodes of patient deterioration and perceived it to be a common day-to-day practice. Gender, profession, country of birth, education level and years of experience all impacted on clinician attitudes, beliefs and perceptions of family presence during acute deterioration.

Epidemiology and Healthcare Burden of Acute-on-Chronic Liver Failure.

Chronic liver disease and cirrhosis, a common end result of viral hepatitis, alcohol abuse, and the emerging epidemic of nonalcoholic fatty liver disease are a significant source of morbidity and premature mortality globally. Acute clinical deterioration of chronic liver disease exemplifies the pinnacle of healthcare burden due to the intensive medical needs and high mortality risk. Although a uniformly accepted definition for epidemiological studies is lacking, acute-on-chronic liver failure (ACLF) is increasingly recognized as an important source of disease burden. At least in the United States, hospitalizations for ACLF have increased several fold in the last decade and have a high fatality rate. Acute-on-chronic liver failure incurs extremely high costs, exceeding the yearly costs of inpatient management of other common medical conditions. Although further epidemiological data are needed to better understand the true impact and future trends of ACLF, these data point to the urgency in the clinical investigation for ACLF and the deployment of healthcare resources for timely and effective interventions in affected patients.

PO02 – Clinical profile of children admitted to a paediatric intensive care unit due to acute clinical deterioration

PO02 – Clinical profile of children admitted to a paediatric intensive care unit due to acute clinical deterioration

Living Donor Liver Transplantation in a Hepatitis B Patient with Acute on Chronic Liver Failure Accompanying Hepatocellular Carcinoma

Acute clinical deterioration in patients with chronic liver disease is called acute on chronic liver failure (ACLF). Principles of management of ACLF consist of early identifying etiology of liver disease, rapid intervention of precipitating event and discreet intensive cares. Despite medical intensive cares, if liver failure progresses, liver transplantation could be the other option. Also, liver transplantation is the only treatment that offers a chance of cure for hepatocellular carcinoma (HCC) and the underlying liver cirrhosis simultaneously. Emergent living donor liver transplantation (LDLT) can be performed for patients with acute liver failure and improves survival rate, especially in circumstances which liver graft is often not available because of deceased donors are not affordable. Here, we describe a chronic hepatitis B patient who developed ACLF accompanying early HCC. Because he did not improved with medical care, he received emergent LDLT. After LDLT, he showed great improvement without critical complications. (Ewha Med J 2016;39(3):76-80) Received July 29, 2015 Accepted May 18, 2016

Real-Time, In Vivo Monitoring, and Quantitative Assessment of Intra-Arterial Vasospasm Therapy.

Our study aimed to evaluate whether the effect of an intra-arterial vasospasm therapy can be assessed quantitatively by in vivo blood flow analysis using the postprocessing algorithm parametric color coding (PCC). We evaluated 17 patients presenting with acute clinical deterioration due to vasospasm following subarachnoidal hemorrhage treated with intra-arterial nimodipine application. Pre- and post-interventional DSA series were post-processed by PCC. The relative time to maximum opacification (rTmax) was calculated in 14 arterially and venously located points of interest. From that data, the pre- and post-interventional cerebral circulation time (CirT) was calculated. Additionally, the arterial vessel diameters were measured. Pre- and post-interventional values were compared and tested for significance, respectively. Flow analysis revealed in all arterial vessel segments a non-statistically significant prolongation of rTmax after treatment. The mean CirT was 5.62s (±1.19s) pre-interventionally and 5.16s (±0.81s) post-interventionally, and the difference turned out as statistically significant (p=0.039). A significantly increased diameter was measurable in all arterial segments post-interventionally. PCC is a fast applicable imaging technique that allows via real-time and in vivo blood flow analysis a quantitative assessment of the effect of intra-arterial vasospasm therapy. Our results seem to validate in vivo that an intra-arterial nimodipine application induces not only vasodilatation of the larger vessels, but also improves the microcirculatory flow, leading to a shortened cerebral CirT that reaches normal range post-interventionally. Procedural monitoring via PCC offers the option to compare quantitatively different therapy regimes, which allows optimization of existing approaches and implementation of individualized treatment strategies.

Recanalization of chronic neurovascular arterial occlusion with acute clinical deterioration: Endovascular treatment and clinical outcome

Recanalization of chronic neurovascular arterial occlusion with acute clinical deterioration: Endovascular treatment and clinical outcome

Recurrent Direct Current Cardioversion Induced Takotsubo Cardiomyopathy

&lt;p&gt;Stress cardiomyopathy (SCM), also called broken heart syndrome and Takotsubo cardiomyopathy is an increasingly reported syndrome generally characterized by transient systolic dysfunction of the apical and or mid segments of the left ventricle that mimics myocardial infarction, in the absence of obstructive coronary artery disease. Typically patients present within a few hours of exposure to physical or emotional stress. However, the mechanism by which these stressors result in myocardial dysfunction is unclear. Proposed factors include catecholamine excess and coronary vasospasm&lt;sup&gt;1&lt;/sup&gt;. We present the case of a 61-year-old female who experienced acute pulmonary edema secondary to stress cardiomyopathy, on two occasions immediately after undergoing elective direct current cardioversion (DCCV) for atrial fibrillation (Afib). After an urgent hospitalization for management of acute left ventricular failure, she made a complete clinical and echocardiographic recovery. The incidence, clinical implications and prognosis of DCCV induced SCM is unknown. Given DCCV for Afib is a common outpatient procedure and DCCV induced SCM can lead to acute clinical deterioration it is important that physicians are vigilant about this newly recognized electrical cardioversion complication.&lt;/p&gt;

Tracking failure to rescue in the future hospital

We describe the development of a scoring tool, based around the main ‘failure to rescue’ modes [1, 2], that can be used to identify and track the quality of care given to patients with acute clinical deterioration on the ward. Between February and May 2014, the notes of all patients admitted

Acute-on-Chronic Liver Failure: Can We Agree on a Definition?

Acute-on-chronic liver failure (ACLF) has recently received more recognition. It is a condition characterized by acute clinical deterioration in patients with chronic liver disease and is often associated with a precipitant event. It is a form of decompensated cirrhosis characterized by the presence of extrahepatic organ failure and high short-term mortality. Several definitions have been recently proposed for ACLF; however, larger prospective studies are still needed to refine our understanding of this new entity. This article explores the most recently proposed definitions, classification, and prognostic models of ACLF.

Acute inflammatory reactions to hemostatic materials mimicking post-operative intracranial abscess

Oxidized cellulose can cause acute neurologic worsening in the immediate post-operative period. MRI often shows restricted diffusion around the surgical cavity on the first post-operative MRI. When acute clinical deterioration occurs with the typical MRI findings, the material must be removed surgically.

Benchmarking the Use of a Rapid Response Team by Surgical Services at a Tertiary Care Hospital

Rapid response teams (RRT) are used to prevent adverse events in patients with acute clinical deterioration, and to save costs of unnecessary transfer in patients with lower-acuity problems. However, determining the optimal use of RRT services is challenging. One method of benchmarking performance is to determine whether a department's event rate is commensurate with its volume and acuity. Using admissions between 2009 and 2011 to 18 distinct surgical services at a tertiary care center, we developed logistic regression models to predict RRT activation, accounting for days at-risk for RRT and patient acuity, using claims modifiers for risk of mortality (ROM) and severity of illness (SOI). The model was used to compute observed-to-expected (O/E) RRT use by service. Of 45,651 admissions, 728 (1.6%, or 3.2 per 1,000 inpatient days) resulted in 1 or more RRT activations. Use varied widely across services (0.4% to 6.2% of admissions; 1.39 to 8.73 per 1,000 inpatient days, unadjusted). In the multivariable model, the greatest contributors to the likelihood of RRT were days at risk, SOI, and ROM. The O/E RRT use ranged from 0.32 to 2.82 across services, with 8 services having an observed value that was significantly higher or lower than predicted by the model. We developed a tool for identifying outlying use of an important institutional medical resource. The O/E computation provides a starting point for further investigation into the reasons for variability among services, and a benchmark for quality and process improvement efforts in patient safety.

A case of pneumonia and sepsis in cirrhosis as paradigm of the problems in the management of bacterial infections in cirrhosis and of the limitations of current knowledge

Bacterial infections are a major problem in the management of liver cirrhosis. They represent the first precipitating cause of death since patients with cirrhosis carry an increased risk of sepsis, sepsis-induced organ failure and death. Although the clinical presentation is often misleading, the presence of bacterial infection should always be actively searched and ruled out with certainty whenever a cirrhotic patient is admitted to the hospital with an acute clinical deterioration. Major changes in the epidemiology of bacterial infections have also occurred in the last decade making the choice of empirical antibiotic therapy a challenge. We report a paradigmatic case of a 54-year old man with hepatitis C-related cirrhosis admitted to the hospital for worsening of his ascites and onset of hepatic encephalopathy, an excellent example for the difficulties of management of sepsis in cirrhosis and the limits of current knowledge.

Prospective memory and chronic heart failure

BackgroundPatients with chronic heart failure (CHF) experience a number of debilitating symptoms, which impact on activities of daily living and result in poor quality of life. Prospective memory, which is defined as memory to carry out future intentions, has not been investigated in this group. However, emerging evidence suggests CHF patients have difficulties with cognitive processes related to prospective memory. Self-care, which partly relies on prospective memory, is essential in symptom management and preventing acute clinical deterioration. This study aims to measure prospective memory in CHF patients, and examine the relationship between prospective memory and CHF self-care.Methods/DesignA comprehensive neuropsychological assessment will be conducted to assess a range of cognitive functions and psychopathology. The primary focus will be an assessment of prospective memory using a well-established behavioral measure; Virtual Week. Thirty CHF patients attending a nurse-led management program will be recruited from three hospital sites in Melbourne, Australia and their self-care behaviors will be assessed using the Self-care Chronic Heart Failure Index (SCHFI), a validated self-report tool. An additional 30 healthy controls, matched on age, gender, and IQ will be recruited from the general community.DiscussionThis is a group comparison study that will provide an evaluation of the prospective memory abilities of CHF patients. The findings of this research will provide insight into whether prospective memory may be hindering patients’ ability to perform adequate self-care.