Modern Critical Care Research Articles

The role of high-income countries in the establishment and development of modern critical care in low resource settings: A Slovenian model.

Critical care medicine is a young branch of medicine, of which the development was much faster in High Income Countries (HICs) than in Low Resources Settings (LRS). Slovenia, as one of the successor states of former Yugoslavia, passed the process of transition and joined the European Union successfully. On the contrary, Bosnia and Herzegovina (B&H) went through the extremely difficult process of transition (four years of civil war), which left a deep scar to the healthcare system, including critical care medicine. To examine the impact of HICs on the development of critical care in LRS. This review examined the process of growing up the first modern Medical Intensive Care Unit (MICU) in the Republic of Srpska. The five-year process of transferring critical care knowledge from Slovenia to the health care system of Republic of Srpska has contributed to the existence of modern and state of the art MICU with tremendous social effects. The model of using the impact of HICs for improving critical care in LRS can be extrapolated to other similar settings.

The Autumn Ghost. How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care

The Autumn Ghost. How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care

Effect of Hospital Volume on Outcome of Extracorporeal Membrane Oxygenation Support - Nationwide Population-Based Cohort Study in Taiwan.

In modern critical care, extracorporeal membrane oxygenation (ECMO) is crucial in the management of severe respiratory and cardiac failure. Nationwide studies of the relationship between hospital volume and outcomes of ECMO use are unavailable.Methods and Results: Using Taiwan's National Health Insurance Research Database, we identified 11,734 adult patients who received ECMO support in 101 hospitals between January 1, 2001, and December 31, 2017. Outcomes included in-hospital mortality, 1-year mortality, and ECMO-related complications. Cox proportional hazards model, locally estimated scatterplot smoothing, and restricted cubic spline regression were used to analyze the volume-outcome relationship. The overall in-hospital mortality rate was 65.5%, and the 1-year mortality rate was 70.6% in this database. The 101 hospitals were divided into 4 groups based on annual volume. The in-hospital and 1-year mortality rates were significantly lower in the high-volume group (annual volume >40) than in the low-volume group (annual volume <10). For critical care, high-volume hospitals have superior short-term and mid-term outcomes. To make the medical system equitable and reasonable, establishing a rapid and efficient nationwide referral system should be considered.

Tris-Hydroxymethyl Aminomethane in Critically Ill Adults: A Systematic Review.

Tris-hydroxymethyl aminomethane (THAM) is an amino alcohol used clinically to buffer acid loads and raise pH in acidotic conditions. Unlike sodium bicarbonate, which increases plasma sodium levels with use and produces carbon dioxide (CO 2 ) as part of the buffering process, THAM does neither. Although not widely used in modern critical care and unavailable for clinical use in 2016, THAM has been available in the United States since 2020. Clinical experience and existing literature suggest that THAM may have clinical utility in acid-base management in conditions such as liver transplantation where rising sodium levels during perioperative care may be dangerous, and in managing acid-base derangements during care of patients with acute respiratory distress syndrome (ARDS). To clarify the evidence base supporting the clinical use of THAM, we conducted a systematic review to assess the efficacy and safety of THAM as a buffering agent in critically ill adults using Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection. Randomized-, crossover-, retrospective cohort-, parallel-designed clinical trials, case series, and case reports of adult patients who received THAM in the operative or critical care setting were included. Conference abstracts of qualifying study designs were also included. Two independent reviewers extracted the data regarding the study details, demographics, treatment, and outcomes data. A third reviewer adjudicated discrepancies. A total of 21 studies including 3 randomized controlled trials, 5 observational studies, 4 case series, and 9 case reports met inclusion criteria. Eight studies (38%) were abstracts published in conference proceedings. In total, 417 critically ill patients received THAM to treat acidosis in critically ill surgical and nonsurgical patients, during liver transplantation, and in ARDS. In general, THAM corrected acidosis with an efficacy equivalent to sodium bicarbonate and did so with less hypercarbia and hypernatremia. Adverse effects of THAM included hyperkalemia, hypoglycemia, ventilator depression, and tissue damage with extravasation. We conclude that THAM may have potential advantages in some critical care settings, but that clinical evidence is limited, and high-quality evaluations are necessary.

SOCCA: A Growing Community of Intensivists Embracing the Challenges of Modern Critical Care

SOCCA: A Growing Community of Intensivists Embracing the Challenges of Modern Critical Care

Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT.

Continuous kidney replacement therapy (CKRT) is well entrenched as one of the dominant KRT modalities in modern critical care practice. Since its introduction four decades ago, there have been considerable innovations in CKRT machines that have improved precision, safety, and simplicity. CKRT is the preferred KRT modality for critically ill patients with hemodynamic instability. Early physical therapy and rehabilitation can be feasibly and safely provided to patients connected to CKRT, thus obviating concerns about immobility. Although randomized clinical trials have not shown a mortality difference when comparing CKRT and intermittent hemodialysis, CKRT allows precision delivery of solute and fluid removal that can be readily adjusted in the face of dynamic circumstances. Accumulated evidence from observational studies, although susceptible to bias, has shown that CKRT, when compared with intermittent hemodialysis, is associated with better short- and long-term kidney recovery and KRT independence. Critical care medicine encompasses a wide range of sick patients, and no single KRT modality is likely to ideally suit every patient in every context and for every condition. The provision of KRT represents a spectrum of modalities to which patients can flexibly transition in response to their evolving condition. As a vital tool for organ support in the intensive care unit, CKRT enables the personalization of KRT to meet the clinical demands of patients during the most severe phases of their illness.

Development of critical care medicine in post-war Republic of Srpska: Banja Luka region

Critical care medicine as relatively young discipline, started developing in mid1950s in response to epidemy of poliomyelitis. This branch of medicine evolved much faster in high-income countries (HIC) than in low resource settings (LRS) where the Republic of Srpska (Western Balkan) belongs. The experience of setting up a modern critical care program under the LRS constraints as a promising way forward to meet the increased demand for critical care worldwide is described. Main tool was systematic analysis of written documents related to the establishment of the first multidisciplinary MICU and its development to the present day. Successful development is contingent on formal education and continued mentorship from HIC, establishment of a multidisciplinary team, the support from local healthcare authorities, development of a formal subspecialty training, academic faculty development and research. Critical care medicine is a critical public health need in HIC and LRS alike.

Quantifying deep neural network uncertainty for atrial fibrillation detection with limited labels

Atrial fibrillation (AF) is the most common arrhythmia found in the intensive care unit (ICU), and is associated with many adverse outcomes. Effective handling of AF and similar arrhythmias is a vital part of modern critical care, but obtaining knowledge about both disease burden and effective interventions often requires costly clinical trials. A wealth of continuous, high frequency physiological data such as the waveforms derived from electrocardiogram telemetry are promising sources for enriching clinical research. Automated detection using machine learning and in particular deep learning has been explored as a solution for processing these data. However, a lack of labels, increased presence of noise, and inability to assess the quality and trustworthiness of many machine learning model predictions pose challenges to interpretation. In this work, we propose an approach for training deep AF models on limited, noisy data and report uncertainty in their predictions. Using techniques from the fields of weakly supervised learning, we leverage a surrogate model trained on non-ICU data to create imperfect labels for a large ICU telemetry dataset. We combine these weak labels with techniques to estimate model uncertainty without the need for extensive human data annotation. AF detection models trained using this process demonstrated higher classification performance (0.64–0.67 F1 score) and improved calibration (0.05–0.07 expected calibration error).

A prospective clinical study on the mechanisms underlying critical illness myopathy-A time-course approach.

Critical illness myopathy (CIM) is a consequence of modern critical care resulting in general muscle wasting and paralyses of all limb and trunk muscles, resulting in prolonged weaning from the ventilator, intensive care unit (ICU) treatment and rehabilitation. CIM is associated with severe morbidity/mortality and significant negative socioeconomic consequences, which has become increasingly evident during the current COVID-19 pandemic, but underlying mechanisms remain elusive. Ten neuro-ICU patients exposed to long-term controlled mechanical ventilation were followed with repeated muscle biopsies, electrophysiology and plasma collection three times per week for up to 12days. Single muscle fibre contractile recordings were conducted on the first and final biopsy, and a multiomics approach was taken to analyse gene and protein expression in muscle and plasma at all collection time points. (i) A progressive preferential myosin loss, the hallmark of CIM, was observed in all neuro-ICU patients during the observation period (myosin:actin ratio decreased from 2.0 in the first to 0.9 in the final biopsy, P<0.001). The myosin loss was coupled to a general transcriptional downregulation of myofibrillar proteins (P<0.05; absolute fold change >2) and activation of protein degradation pathways (false discovery rate [FDR] <0.1), resulting in significant muscle fibre atrophy and loss in force generation capacity, which declined >65% during the 12day observation period (muscle fibre cross-sectional area [CSA] and maximum single muscle fibre force normalized to CSA [specific force] declined 30% [P<0.007] and 50% [P<0.0001], respectively). (ii) Membrane excitability was not affected as indicated by the maintained compound muscle action potential amplitude upon supramaximal stimulation of upper and lower extremity motor nerves. (iii) Analyses of plasma revealed early activation of inflammatory and proinflammatory pathways (FDR<0.1), as well as a redistribution of zinc ions from plasma. The mechanical ventilation-induced lung injury with release of cytokines/chemokines and the complete mechanical silencing uniquely observed in immobilized ICU patients affecting skeletal muscle gene/protein expression are forwarded as the dominant factors triggering CIM.

100 Years of Critical Care in the Pages of Anesthesia & Analgesia.

The founding of Anesthesia & Analgesia (A&A) in 1922 was roughly contemporaneous with the creation of the first intensive care unit (ICU) in the United States at Johns Hopkins in 1923. Throughout the next 100 years, the pages of A&A have mirrored the development of critical care as its own distinct specialty. Although primarily a journal focused on intraoperative anesthesia, A&A has maintained a small but steady presence in critical care research. This review highlights the history and development of critical care publications in the pages of A&A from early observations on the physiology of critical illness (1922-1949) to the groundbreaking work of Peter Safar and others on cardiopulmonary resuscitation (1950-1970), the growth of modern critical care (1970-2010), and the 2020 to 2022 coronavirus disease 2019 (COVID-19) era.

A prospective clinical study on the mechanisms underlying Critical Illness Myopathy – A time‐course approach

BackgroundCritical illness myopathy (CIM) is a consequence of modern critical care resulting in general muscle wasting and paralyses of all limb and trunk muscles, and prolonged weaning from the ventilator. CIM is associated with severe morbidity/mortality and significant negative socioeconomic consequences which has become increasingly evident during the current COVID‐19 pandemic, but underlying mechanisms remain elusive.MethodsTen neuro‐ICU patients exposed to long‐term controlled mechanical ventilation (CMV) were followed with repeated muscle biopsies 3times/week for up to 12 days. Single muscle fiber contractile recordings were conducted on the first and final biopsy. A multiomics approach was taken to analyze gene and protein expression in muscle and plasma at all six timepoints.Findingsi) A progressive preferential myosin loss, the hallmark of CIM, was observed in all neuro‐ICU patients during the observation period. The myosin loss was coupled to a general transcriptional downregulation of myofibrillar proteins and activation of protein degradation pathways, resulting in significant muscle fiber atrophy and loss in force generation capacity which declined &gt;65% during the 12‐day observation period, ii) membrane excitability was not affected as indicated by the maintained compound muscle action potential amplitude upon supramaximal stimulation of upper and lower extremity motor nerves, and iii), analyses of plasma revealed early activation of inflammatory and proinflammatory pathways, as well as a redistribution of zinc ions from plasma in parallel with the activation of zinc transporters.InterpretationThe mechanical ventilation induced lung injury with release of cytokines/chemokines and the complete mechanical silencing uniquely observed in immobilized ICU patients affecting skeletal muscle gene/protein expression are forwarded as the dominant factors triggering CIM. It is therefore suggested that future intervention strategies should target the lung injury and the mechanical silencing in critical ill ICU patients.

Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations.

Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.

ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness.

The advent of modern critical care medicine has revolutionized care of the critically ill patient in the last 50 years. The Society of Critical Care Medicine (was formed in recognition of the challenges and need for specialized treatment for these fragile patients. As the specialty has grown, it has achieved impressive scientific advances that have reduced mortality and saved lives. With those advances, however, came growing recognition that the burden of critical illness did not end at the doorstep of the hospital. Delirium, once thought to be a mere by-product of critical illness, was found to be an independent predictor of mortality, prolonged mechanical ventilation, and long-lasting cognitive impairment. Similarly, deep sedation and immobility, so often used to keep patients "comfortable" and to facilitate mechanical ventilation and recovery, worsen mortality and lead to the development of ICU-acquired weakness. The realization that these outcomes are inextricably linked to one another and how we manage our patients has helped us recognize the need for culture change. We, as a specialty, now understand that although celebrating the successes of survival, we now also have a duty to focus on those who survive their diseases. Led by initiatives such as the ICU Liberation Campaign of the Society of Critical Care Medicine, the natural progression of the field is now focused on getting patients back to their homes and lives unencumbered by disability and impairment. Much work remains to be done, but the futures of our most critically ill patients will continue to benefit if we leverage and build on the history of our first 50 years.

JAK/STAT inhibition augments soleus muscle function in a rat model of critical illness myopathy via regulation of complement C3/3R.

Critical illness myopathy (CIM) is a frequently observed negative consequence of modern critical care. Chronic Janus kinase (JAK)/signal transducer and activator of transcription activation impairs muscle size and function and is prominent following mechanical ventilation. We identify pSTAT-3 activation in tibialis anterior of CIM patients, before examining the potential benefits of JAK1/2 inhibition in an experimental model of CIM, where muscle mass and function are impaired. CIM activates complement cascade and increased monocyte infiltration in the soleus muscle, which was ameliorated by JAK1/2 inhibition, leading to reduced muscle degeneration and improved muscle force. Here, we demonstrate that JAK1/2 inhibition augments CIM muscle function through regulation of the complement cascade. Critical illness myopathy (CIM) is frequently observed in response to modern critical care with negative consequences for patient quality of life, morbidity, mortality and healthcare costs. Janus kinase (JAK)/signal transducer and activator of transcription (STAT) activation is observed in limb muscles following controlled mechanical ventilation. Chronic JAK/STAT activation promotes loss of muscle mass and function. Thus, we hypothesized that JAK1/2 inhibition would improve muscle outcomes for CIM. Following 12 days of intensive care unit conditions, pSTAT-3 levels increased in tibialis anterior muscle of CIM patients (P=0.0489). The potential of JAK1/2 inhibition was assessed in an experimental model of CIM, where soleus muscle size and force are impaired. JAK1/2 inhibition restores soleus force (P<0.0001). CIM activated muscle complement cascade, which was ameliorated by JAK1/2 inhibition (P<0.05, respectively). Soleus macrophage number corresponded with complement activity, leading to reduced muscle degeneration and augmented muscle function (P<0.05). Thus, JAK/STAT inhibition improves soleus function by modulating the complement cascade and muscle monocyte infiltration. Collectively, we demonstrate that JAK/STAT inhibition augments muscle function in CIM.

Aerosol delivery via invasive ventilation: a narrative review

In comparison with spontaneously breathing non-intubated subjects, intubated, mechanically ventilated patients encounter various challenges, barriers, and opportunities in receiving medical aerosols. Since the introduction of mechanical ventilation as a part of modern critical care medicine during the middle of the last century, aerosolized drug delivery by jet nebulizers has become a common practice. However, early evidence suggested that aerosol generators differed in their efficacies, and the introduction of newer aerosol technology (metered dose inhalers, ultrasonic nebulizer, vibrating mesh nebulizers, and soft moist inhaler) into the ventilator circuit opened up the possibility of optimizing inhaled aerosol delivery during mechanical ventilation that could meet or exceed the delivery of the same aerosols in spontaneously breathing patients. This narrative review will catalogue the primary variables associated with this process and provide evidence to guide optimal aerosol delivery and dosing during mechanical ventilation. While gaps exist in relation to the appropriate aerosol drug dose, discrepancies in practice, and cost-effectiveness of the administered aerosol drugs, we also present areas for future research and practice. Clinical practice should expand to incorporate these techniques to improve the consistency of drug delivery and provide safer and more effective care for patients.

Successfulimplementationof modern critical care in the low-resources country Bosnia and Herzegovina : Single-center experience.

BackgroundCritical care medicine is a relatively young discipline, developed in the mid-1950s in response to the outbreak of poliomyelitis. The mass application of mechanical ventilation and its subsequent technical advancement helped manage large numbers of patients with respiratory failure. This branch of medicine evolved much faster in high-income (HIC) than low- and middle-income countries (LMIC). Seventy years later, mankind’s encounter with coronavirus disease 2019 (COVID-19) represents another major challenge for critical care medicine especially in LMIC countries where over two thirds of the world population live.MethodsSystematic analysis of written documents related to the establishment of the first multidisciplinary medical intensive care unit (MICU) in Bosnia and Herzegovina and its development to the present day.ResultsWe describe the experience of setting up a modern critical care program under LMIC constraints as a promising way forward to meet the increased worldwide demand for critical care. Successful development is contingent on formal education and continued mentorship from HIC, establishment of a multidisciplinary team, the support from local health care authorities, development of a formal subspecialty training, academic faculty development, and research. Novel technologies including tele-education provide additional opportunities for rapid development and dissemination of critical care medicine programs in LMIC.ConclusionCritical care medicine is a critical public health need in HIC and LMIC alike. The challenges associated with the coronavirus pandemic should serve as a wakeup call for rapid development of critical care programs around the world.

Neurogenic vs. Myogenic Origin of Acquired Muscle Paralysis in Intensive Care Unit (ICU) Patients: Evaluation of Different Diagnostic Methods.

Introduction. The acquired muscle paralysis associated with modern critical care can be of neurogenic or myogenic origin, yet the distinction between these origins is hampered by the precision of current diagnostic methods. This has resulted in the pooling of all acquired muscle paralyses, independent of their origin, into the term Intensive Care Unit Acquired Muscle Weakness (ICUAW). This is unfortunate since the acquired neuropathy (critical illness polyneuropathy, CIP) has a slower recovery than the myopathy (critical illness myopathy, CIM); therapies need to target underlying mechanisms and every patient deserves as accurate a diagnosis as possible. This study aims at evaluating different diagnostic methods in the diagnosis of CIP and CIM in critically ill, immobilized and mechanically ventilated intensive care unit (ICU) patients. Methods. ICU patients with acquired quadriplegia in response to critical care were included in the study. A total of 142 patients were examined with routine electrophysiological methods, together with biochemical analyses of myosin:actin (M:A) ratios of muscle biopsies. In addition, comparisons of evoked electromyographic (EMG) responses in direct vs. indirect muscle stimulation and histopathological analyses of muscle biopsies were performed in a subset of the patients. Results. ICU patients with quadriplegia were stratified into five groups based on the hallmark of CIM, i.e., preferential myosin loss (myosin:actin ratio, M:A) and classified as severe (M:A < 0.5; n = 12), moderate (0.5 ≤ M:A < 1; n = 40), mildly moderate (1 ≤ M:A < 1.5; n = 49), mild (1.5 ≤ M:A < 1.7; n = 24) and normal (1.7 ≤ M:A; n = 19). Identical M:A ratios were obtained in the small (4–15 mg) muscle samples, using a disposable semiautomatic microbiopsy needle instrument, and the larger (>80 mg) samples, obtained with a conchotome instrument. Compound muscle action potential (CMAP) duration was increased and amplitude decreased in patients with preferential myosin loss, but deviations from this relationship were observed in numerous patients, resulting in only weak correlations between CMAP properties and M:A. Advanced electrophysiological methods measuring refractoriness and comparing CMAP amplitude after indirect nerve vs. direct muscle stimulation are time consuming and did not increase precision compared with conventional electrophysiological measurements in the diagnosis of CIM. Low CMAP amplitude upon indirect vs. direct stimulation strongly suggest a neurogenic lesion, i.e., CIP, but this was rarely observed among the patients in this study. Histopathological diagnosis of CIM/CIP based on enzyme histochemical mATPase stainings were hampered by poor quantitative precision of myosin loss and the impact of pathological findings unrelated to acute quadriplegia. Conclusion. Conventional electrophysiological methods are valuable in identifying the peripheral origin of quadriplegia in ICU patients, but do not reliably separate between neurogenic vs. myogenic origins of paralysis. The hallmark of CIM, preferential myosin loss, can be reliably evaluated in the small samples obtained with the microbiopsy instrument. The major advantage of this method is that it is less invasive than conventional muscle biopsies, reducing the risk of bleeding in ICU patients, who are frequently receiving anticoagulant treatment, and it can be repeated multiple times during follow up for monitoring purposes.

Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: Guideline-Driven Care Should Be Our Natural Reflex.

Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: Guideline-Driven Care Should Be Our Natural Reflex.

Generalizability of SuperAlarm via Cross-Institutional Performance Evaluation.

Bedside patient monitors are ubiquitous tools in modern critical care units to provide timely patient status. However, current systems suffer from high volume of false alarms leading to alarm fatigue, one of top technical hazards in clinical settings. Many studies are racing to develop improved algorithms towards precision patient monitoring, while little has been done to investigate the aspect of algorithm generalizability across different health institutions. Our group has been developing an evolving framework termed SuperAlarm that extracts multivariate patterns in data streams (monitor alarms, electronic health records and physiologic waveforms) of modern health enterprise to predict patient deterioration and has demonstrated great potential in mitigating alarm fatigue. In this study, we further investigate the generalizability of SuperAlarm by designing a comprehensive approach to achieve performance comparison in predicting in-hospital code blue (CB) events across two health institutions. SuperAlarm model trained with alarm data in one institution is tested on both internal and external test sets. Results show comparable performance with sensitivity up to 80% within one-hour window of events and over 90% in reduction of false alarms in both institutions. Cross-institutional performance agreement can be further improved by predicting a more stringent CB subtype (cardiopulmonary arrest), with internal sensitivity lying within 95% confident interval of external one up to 8-hour before event onset. The cross-institutional performance comparison offers first-hand knowledge on both advantages and challenges in generalizing a prediction algorithm across different institutions, which hold key information to guide the design of model training and deployment strategy.

TAKE MY BREATH AWAY: NEWLY DIAGNOSED MYASTHENIC IN CRISIS; A DIAGNOSTIC DILEMMA

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Neuromuscular disorders should be considered for patients presenting with rapid onset bulbar weakness and shortness of breath. CASE PRESENTATION: A 30 y.o. man with no history of neurologic illness returned from a 4 day Caribbean trip with a 1 day history of dysphagia, voice change and dyspnea. He denied diplopia. He has history of Thyroid cancer post thyroidectomy and radiation, Hep B on Tenofovir. He had tachypnea, ptosis, dysphonia, dysphagia. Initial ABG revealed mild hypoxia with pO2 76 and hypercapnia with pCO2 52. He had proximal muscle weakness, intact reflexes and Negative Inspiratory Force (NIF) of -12cmH2O(normal:>-60cmH2O). He was intubated with differentials: Guillain Barre Syndrome(GBS), acute flaccid paralysis and Myasthenia Gravis(MG). He was given high dose steroids and 5 days plasmapheresis. His workup revealed a negative viral panel,AChRAB,HIV,syphilis,dengue,Zika,lyme. Acetylcholine Receptor Blocking Antibody was present with 43% inhibition. Electromyography revealed absent F waves, which was suggestive of GBS, but there was no cytoalbuminologic dissociation in CSF and Anti-GQ1B and Anti-VGCC were negative.Pyridostigmine was added and there was improvement in strength. His stay was complicated by ventilator-associated pneumonia, was extubated on day18 and discharged on day 22. DISCUSSION: The annual incidence of MG is 1–2/100,000.Myasthenic Crisis (MC) is the initial presentation for 20% of patients with ⅓ of patients surviving. 21% have onset after 60 years and 30% of them develop some degree of bulbar/respiratory weakness.Average age of admission with MC is 59.MG shows a bimodal distribution, with the following male:female ratios:3:7 if 50 years. Variants of GBS may present similarly and should be evaluated for. MG is an autoimmune disorder affecting neuromuscular transmission. It is due to autoantibodies against acetylcholine receptors in the postsynaptic motor end-plate. MC is characterized by worsening weakness resulting in respiratory failure. Most patients have a predisposing factor that triggers MC, generally a respiratory infection. Immunoglobulins, plasma exchange, and steroids are the pillars of therapy. Today with the modern critical care mortality <5%. The decision to intubate this patient was made on bedside measures of respiratory function. Only 19% of patients have crisis starting with bulbar symptoms and 5% with weakness of respiratory muscles. Majority of patients begin with generalized weakness. Our patient is a young male who had rapid onset bulbar weakness. Elective intubation is recommended rather than emergently after respiratory collapse. If the suspicion is high, quick bedside tests like NIF should be done and patients promptly intubated. CONCLUSIONS: When respiratory failure is expected, bedside assessments can document weakness and indicate need for invasive ventilation prior to respiratory embarrassment. Reference #1: Berrouschot J, Baumann I, Kalischewski P, et al. Therapy of myasthenic crisis. Crit Care Med 1997; 25:1228. Reference #2: Alshekhlee A, Miles JD, Katirji B, Preston DC, Kaminski HJ. Incidence and mortality rates of myasthenia gravis and myasthenic crisis in US hospitals. Neurology 2009;72:1548-1554 DISCLOSURES: No relevant relationships by Raghav Chaudhary, source=Web Response No relevant relationships by Latoya Gayle, source=Web Response No relevant relationships by Philip Kanemo, source=Web Response No relevant relationships by Rikki Racela, source=Web Response No relevant relationships by Rani Sittol, source=Web Response