Pellerito's Corner - November 2014

Author: Peter Pellerito, President & CEO
Facility: ImaCor Inc. Garden City NY
Summary: Welcome to the Resuscitation Issue, covering patient management scenarios, compelling new research, and online commentary. The focus is timely as the Surviving Sepsis Campaign recently announced that it will immediately review its protocol for Early Goal Directed Therapy (EGDT) following two large significant studies that showed no measurable benefit from EGDT.

Management of severe sepsis and septic shock – past, present, future?

Author: Harold M. Hastings PhD CTO and Co-Founder
Facility: ImaCor Inc. Garden City NY
Summary: Let’s consider the following:

• “Early” sepsis mortality pre-EGDT: 45%, EGDT produced significant reductions (Rivers, 2001)
• “Early” sepsis mortality 2014 standard of care or EGDT: 19-21% (ProCESS, 2014; ARISE – ANZICS, 2014)
• “Late” sepsis mortality (1 year and beyond) is a continuing challenge (Linder et al., 2014; Trzeciak, 2014)

• What have we learned?
• Where do we go? How can we further reduce mortality?

Pellerito's Corner - October 2014

Author: Peter Pellerito, President & CEO
Facility: ImaCor Inc. Garden City NY
Summary: “Current practice suggests that only one-third of patients with Sepsis receive excellent care.” (Cooke CR, Iwashyna TJ. JAMA, 2014). Two significant studies have shown that early goal-directed therapy and invasive hemodynamic targets (CVP and ScvO2) fail to impact Sepsis patient outcomes. If now is not the time to change how we care for our Sepsis patients, when?

hTEE for tamponade management: A win-win-win

Author: Harold M. Hastings PhD CTO and Co-Founder
Facility: ImaCor Inc. Garden City NY
Summary: Background. Your patient becomes unstable. You suspect tamponade. What should you do? TTE? hTEE? Re-explore surgically?

Let's look to the evidence for guidance:
1. Fewer than half of the patients with tamponade physiology may actually have tamponade (43% - Hirose H et al. J Surg Research 2014; 44% - Floerchinger B et al., J Cardiothorac Surg 2013). … need more information about my patient.
2. Re-operation increases morbidity and mortality, (Ranucci et al., Ann Thorac Surg 2008; Kristensen et al., 2012), also cost: approximately $ 25,000 in 2008 dollars, over $ 30,000 today (Speir et al, 2009). … avoid re-operation if possible.
3. However, delays increase the likelihood of adverse events (Karthik S et al. Ann Thorac Surg 2004). … intervene quickly when necessary.
4. TTE is of limited utility (Floerchinger et al. 2013; Grumann A et al. Ann Thorac Cardiovasc Surg. 2012), alternatives include CT (Floerchinger et al. 2013) and TEE (Grumann et al., 2012). … CT requires moving my patient, … can’t wait for CT or TEE.
5. “The diagnosis of pericardial tamponade postcardiotomy is feasible using a disposable hTEE …” (Hirose H et al. J Surgical Research 2014, see also Sarosiek et al. ASAIO J. 2014. … use hTEE.

Literature Review: The Unmet Need for Addressing Cardiac Issues in Intensive Care Research

Author: Harold M. Hastings PhD
Facility: ImaCor Inc. Garden City NY
Summary: van Diepen S, Granger CB, Jacka M, Gilchrist IC, Morrow DA, Katz JN.
Crit Care Med. 2014 Sep 19. [Epub ahead of print]
“Cardiovascular diseases are the number one cause of death worldwide and account for a significant portion of acute and chronic conditions seen among ICU patients (www.who.int/mediacentre/factsheets/fs310/ en/index3.html). Up to 15% of ICU patients have a prior history of cardiovascular disease, and up to 38% of patients have a primary cardiac reason for their ICU admission (Bagshaw SM, et al. Crit Care 2009; 13:R45; Vincent JL, et al. JAMA 2009; 302:2323; Doig GS, et al. JAMA 2013; 309:2130; Lily CM, et al. JAMA 2011; 305:2175).

Pellerito's Corner - September 2014

Author: Peter Pellerito, President & CEO
Facility: ImaCor Inc. Garden City, NY
Summary: 2015 will be a decisive year for hospitals as they strive to conform to the Patient Protection and Affordable Care Act which is focused on value-based initiatives. In 2015, hospitals will be evaluated based on 26 quality measures. Complex, poly-chronic patients require greater care and ICU resources. Improving ICU quality and patient safety is, therefore, crucial to building sustainable clinical programs and surviving the current reimbursement landscape.

Pellerito's Corner - August 2014

Author: Peter Pellerito, President & CEO
Facility: ImaCor Inc. Garden City NY
Summary: Vent-acquired pneumonia, pressure ulcers, reoperations, readmissions before 30 days - there is a jungle of potential complications in today's ICUs. We recognize that you are looking for earlier signs of patient instability and exploring new ways to escalate care for patients who fail to respond to treatment and need increasing levels of support to stabilize. The advanced hemodynamic management approach is designed specifically to address the need for quicker identification and avoidance of complications.

Pellerito's Corner - July 2014

Author: Peter Pellerito, President & CEO
Facility: ImaCor Inc. Garden City NY
Summary: As this is our special edition for Fellows, let me wish a warm welcome to all Fellows, as well as encourage any of our readers to forward this to new physicians at your institutions.

Pellerito's Corner - June 2014

Author: Peter Pellerito, President & CEO
Facility: ImaCor Inc. Garden City, NY
Summary: Our technology, complemented by our immersive hTEE program, continues to grow within SICUs and trauma sites both globally and the US. Targeted, hTEE-guided fluid management has become routine for many of our users. We continue to see these clinicians, along with their service line directors, align the economic value with hTEE’s impact on improving patient care.

Hemodynamic management of burn patients

Author: Harold M. Hastings, PhD Co-Founder and CTO
Facility: ImaCor Inc. Garden City, NY
Summary: I found the recent article (Burns, 2014) by Dr. Marc O. Maybauer (an anesthesiologist on faculty at University of Texas Medical Branch and Phillips-Universität Marburg) and colleagues on “Transesophageal echocardiography in the management of burn patients” one of the most interesting and informative articles I have read in my role as Co-Founder and CTO at ImaCor. Although recent advances in patient management have vastly improved survival rates – especially for patients aged 5 to 50 without inhalation injury (National Burn Repository, www.ameriburn.org) – inhalation injury and burns in elderly patients pose major challenges. Resuscitation in major burn cases requires steering a careful path through sometimes murky waters to provide adequate hemodynamic support without causing volume overload.