OBJECTIVES:This study characterized deviations from an institutional peripheral vasopressor protocol and assessed associated extravasation events. DESIGN:Retrospective observational study of electronic medical records data. SETTING:Ten hospitals in an academic health system from October 2020 to May 2023. PATIENTS:All admitted adult patients who received vasopressor infusions. INTERVENTIONS:Implementation of a peripheral vasopressor protocol in October 2020. MEASUREMENTS AND MAIN RESULTS:Three thousand five hundred eighteen patients were identified as having received peripheral vasopressors from October 2020 to May 2023, with 1258 patients suspected of having a deviation from the protocol. One hundred sixty-two patients were randomly selected for chart review, and 73 patients had confirmed deviation. Sixty-three (86.3%) exceeded the maximum allowed dose, 23 had multiple simultaneously infusing peripheral vasopressors, 13 had a peripheral vasopressor infusing longer than 24 hours, and 13 received peripheral vasopressin. Most deviations (79.4%) occurred due to worsening shock while waiting for central access. Extravasation occurred in 10 patients (13.7%), with three patients requiring phentolamine treatment. Fifty-six patients (76.7%) subsequently required central access for continued vasopressor support. In a secondary analysis of the original source population, 47 of 3518 patients (1.3%) received phentolamine for peripheral vasopressor extravasation, of whom the majority (72.4%) were protocol concordant at the time of extravasation. CONCLUSIONS:Deviations from a peripheral vasopressor protocol primarily involved exceeding the protocol dose limit in the setting of worsening shock while awaiting central access. Clinically significant extravasations were infrequent even among patients with protocol deviations and most treated extravasations occurred in protocol-concordant patients, supporting the overall safety of peripheral vasopressors.

BACKGROUND:Research on ICU experiences from medical students' perspectives and their impact on professional development is limited. Reflective practices like storytelling enhance wellness and cultivate empathy among medical professionals, yet student involvement remains limited. OBJECTIVE:To qualitatively analyze fourth-year medical student reflections from a required critical care clerkship, identify key themes, and suggest curricular improvements. METHODS:Inductive qualitative methods were employed to develop a codebook through thematic analysis with consensus building and inter-rater reliability testing (Cohen's kappa ≥0.65). Frequency and collocation analyses identified patterns and contextual relationships. RESULTS:Fifty-four percent of students participated, yielding 119 coded reflections. Six themes and 15 elements emerged, with top themes being "communicating with patient, family, or care team" (36.1%), "grappling with end-of-life, death, or dying" (26.1%), and "witnessing role modeling" (10.1%). Leading elements included "humanity" (44.5%), "professional development" (35.3%), "teamwork" (33.6%), and "duty" (32.8%). Reflections emphasized complex patient interactions, moral ambiguity, and personal growth over medical knowledge acquisition. CONCLUSION:The Critical Care Sub-Internship is a formative experience in which fourth-year medical students not only learn clinical medicine but also engage in professional identity formation. Qualitative analysis of student reflections identified six dominant themes: navigating social challenges; addressing ethical dilemmas; observing role modeling; communicating with patients, families, and interprofessional teams; grappling with end-of-life care; and coping with emotional distress. Findings support targeted curricular enhancements including structured education in serious illness communication and end-of-life care, and intentional faculty development for positive role modeling.

BACKGROUND:Transferred patients are clinically complex, with high mortality risk and longer length of stay. Although interhospital transfers are common, it is unclear if hospitals with higher rates of transfer-in patients have worse risk-adjusted performance metrics because of their patient case mix. RESEARCH QUESTION:Do hospitals with higher transfer-in prevalence have worse risk-adjusted outcomes, including mortality, length of stay, and hospital charges? STUDY DESIGN AND METHODS:This study used the National Inpatient Sample from 2019 to 2020. The study included all hospitalized adults in generalizable acute care hospitals. Hierarchical regression was used to model hospitals' mean risk-adjusted mortality, length of stay, and hospital charge. Each hospital's transfer-in patient prevalence was correlated to their risk-adjusted outcomes. RESULTS:There were 2,811,367 encounters across 4,261 hospitals. The median age was 67 years (interquartile range, 55-78 years), 52% were female, and 68% were non-Hispanic White. The annual transfer-in prevalence for hospitals ranged from 0% to 47.4%. In the hierarchical model, transfer-in patients had higher odds of in-hospital mortality compared with nontransfer patients (OR, 1.53; 95% CI, 1.47-1.60), but hospitals with higher transfer-in patient prevalence had lower risk of mortality for transfer-in patients (OR, 0.33; 95% CI, 0.23-0.47). In the Spearman correlation, higher hospital transfer-in patient prevalence was associated with a small increase in overall risk-adjusted mortality, longer risk-adjusted mean length of stay, and greater hospital charge (ρ = 0.04, P = .006; ρ = 0.24, P < .001; and ρ = 0.10, P < .001, respectively). INTERPRETATION:Our research shows that hospitals with high transfer-in prevalence have lower risk of mortality for transfer-in patients, but these hospitals have disproportionately longer lengths of stay despite rigorous risk adjustment. Future studies should investigate the feasibility of repatriation to potentially reduce the longer than expected length of stay at tertiary centers.

BACKGROUND:Platelets and fresh frozen plasma (FFP) are frequently administered to critically ill patients. Considering the variability in indications and thresholds guiding these transfusions, a comprehensive review of current evidence was conducted to provide guidance to critical care practitioners. This American College of Chest Physicians guideline examined the literature on platelet transfusions in critically ill patients with thrombocytopenia, with and without active bleeding, as well as data on prophylactic platelet and FFP transfusions for common procedures in the critical care setting. METHODS:A panel of experts developed 7 Population, Intervention, Comparator, and Outcome questions addressing platelet and FFP transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence, and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations. RESULTS:The initial search identified a total of 7,172 studies, and after the initial screening, 100 articles were reviewed. Sixteen studies met inclusion criteria, comprising 1 randomized controlled trial and 15 observational studies. Overall, the certainty of the evidence for all questions was very low. The panel formulated 7 conditional recommendations. CONCLUSIONS:In critically ill patients with thrombocytopenia or coagulopathy, a risk/benefit assessment should be made by providers prior to transfusion of platelets or FFP. Given the known risks of blood product transfusion, and the limited data regarding the benefits from platelet or FFP transfusion, most patients will benefit from avoiding transfusion of these blood products. In patients at high risk of bleeding, or where the bleeding complication may be catastrophic, transfusion should be considered.

Introduction:Significant gastrointestinal (GI) losses are a common cause of hypovolemia and electrolyte disturbances. We describe a case of a gastrocolic fistula leading to severe hypovolemia, profound hypernatremia, and peripheral cyanosis. Case Presentation:A 69-year-old male presented to the emergency department with four weeks of fatigue and diarrhea. Past medical history was notable for paraesophageal hernia with repair seven months prior, complicated by esophageal perforation necessitating esophagectomy and partial gastrectomy with Percutaneous Endoscopic Gastrostomy (PEG) placement. On presentation, he was afebrile, hemodynamically stable, and saturating well on room air. He was awake and alert, but lethargic with slowed mental processing. Peripheral cyanosis was present in the fingers and toes. Skin turgor was poor and mucous membranes were dry. Initial laboratory tests revealed Sodium 189 mEq/L, Chloride 140 mEq/L, blood urea nitrogen 138 mg/dL, creatinine 6.5 mg/dL, and serum osmolarity of 430. Venous blood gas showed pH 7.12, pCO2 27, HCO3 9, and lactic acid 2.3. Computerized Tomography (CT) of the abdomen showed a fistula between the PEG tube and transverse colon. Stool studies were consistent with osmotic diarrhea. The patient was diagnosed with severe hypovolemia due to GI losses from a gastrocolic fistula, resulting in severe hypernatremia and peripheral cyanosis from reduced perfusion. Over the first 24 hours, he received resuscitation with continuous intravenous infusion of dextrose 5% in water, followed by infusion of hypotonic saline to gradually correct hypernatremia and prevent cerebral edema. His cyanosis and mental status resolved with the correction of metabolic abnormalities. Colorectal surgery was consulted to manage the gastrocolic fistula. Discussion:This case illustrates the association between osmotic diarrhea, volume depletion, severe hypernatremia, and peripheral cyanosis. PEG tube feeds often contain high concentrations of solutes, which act as osmotic agents, drawing water into the intestine to maintain osmotic balance. This excess fluid in the bowel can accelerate intestinal transit leading to osmotic diarrhea, resulting in free water loss in excess of electrolyte loss, leading to hypernatremia. When severe, hypernatremia leads to serum hyperosmolarity, thickening blood, slowing circulation, and decreasing oxygen delivery to peripheral tissues. This is further exacerbated by concurrent hypovolemia, which decreases circulating blood volume, also compromising peripheral perfusion. These physiologic changes result in the appearance of peripheral cyanosis. Clinicians should recognize osmotic diarrhea as a cause of fluid loss and monitor closely for signs of circulatory compromise and hypernatremia.

BACKGROUND: Blood products frequently are administered to critically ill patients. Considering recent trials and practice variability, a comprehensive review of current evidence was deemed essential to offer pertinent guidance to critical care practitioners. This American College of Chest Physicians (CHEST) guidelines panel examined the literature on RBC transfusions among critically ill patients overall and specific subgroups, including patients with gastrointestinal bleeding, acute coronary syndrome (ACS), cardiac surgery, isolated troponin elevation, and septic shock, to provide evidence-based recommendations. STUDY DESIGN AND METHODS: A panel of experts developed six Population, Intervention, Comparator, and Outcome questions addressing RBC transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations. RESULTS: The initial search identified a total of 3,082 studies, and after the initial screening, 38 articles were reviewed. Among them, 23 studies met inclusion criteria, comprising 22 randomized controlled trials and one cohort study. Based on the analysis of these studies, the panel formulated two strong and four conditional recommendations. The overall quality of evidence for recommendations ranged from very low to moderate. CONCLUSIONS: In most critically ill patients, a restrictive strategy was preferable to a permissive approach because it does not increase the risk of death or complications, but does decrease RBC use significantly. Data from critically ill subpopulations also supported a restrictive approach, except in patients with ACS, for whom favoring a restrictive approach could increase adverse outcomes. CHEST 2025; 167(2):477-489

Introduction: Medical education research has emphasized graduate medical education with few studies describing clinical experiences of medical students. Fourth year medical students often complete a sub-internship in the intensive care unit (ICU), where they confront a steep learning curve of managing complex patients, engaging in challenging conversations, and exposure to death. Reflective practices like storytelling have proven effective in promoting wellness, preventing burnout, and fostering empathy in medical professionals, though opportunities for students to participate are limited. At our institution, critical incident reflections are integrated in the ICU sub-internship to help students process impactful experiences. In this study we qualitatively analyzed these reflections to identify key themes and emotions, aiming to guide curricular improvements and enhance the students’ experiences. Methods: Students were introduced to the reflection assignment and research project at the start of their clerkship and asked to write about one of the following: 1) an issue or experience that was distressing, 2) a scenario that created an opportunity for quality improvement, 3) an interaction that highlighted a pre-existing health inequity, 4) any other experience that was impactful for them. Deductive qualitative research methods were used to identify major themes and elements (sub-themes) in a sample of narratives. Once saturation was achieved, a code book with definitions of themes and elements was created and used to test code for inter-rater reliability (IRR). Any code with a kappa IRR < 0.65 was revised. The remaining reflections were qualitatively analyzed using the revised coding schema. Results: Of the 236 students who completed the assignment, 120 consented to having their essay included in the analysis, 67 declined, and 49 did not answer. We deduced 6 major themes which included: “navigating social challenges”; “addressing an ethical dilemma”; “witnessing role modeling”; “communicating with a patient, family, care team”; “grappling with end of life care, dying, death”; and “coping with emotions”; and 15 minor elements (Table 1). Themes with the highest IRR (kappa> 0.8) were communicating with patients, grappling with end-of-life-care, and coping with emotions. Elements with the highest IRR agreement were “teamwork” and “bias”. Conclusion: Medical students on critical care sub-internship rotations frequently encounter a patient experience or scenario that will have a lasting impact on their professional trajectory. Qualitative analyses of student reflections could help inform ways to better prepare and support learners during and after their ICU sub-internship.

Rationale: Despite historical concerns for tissue injury from extravasation, studies suggest that peripheral administration of vasopressors is safe. However, peripheral vasopressor use remains variable. Objectives: To characterize the use of peripheral vasopressors over time, identify variability in use, and assess outcomes associated with their use. Methods: We conducted a retrospective cohort study of adult patients admitted to 10 hospitals in Minnesota (October 2020-October 2023) who received any vasopressors. Patients receiving vasopressors initially through a peripheral intravenous catheter were compared with those receiving vasopressors initially through central access. Safety, efficacy, and use patterns across hospitals and providers were studied. Results: A total of 9,493 patients received vasopressors, including 3,734 with peripheral initiation and 5,759 with central initiation. Thirty-one (0.8%) of the 3,734 patients with peripheral vasopressors received phentolamine for extravasation events, with one receiving a surgical consultation for tissue necrosis. Community hospitals had the highest use of peripheral vasopressors (50.7%), and academic medical centers had the lowest use (27.6%). Initiation of vasopressors peripherally was not associated with increased hospital (adjusted odds ratio [aOR], 0.87; 95% confidence interval [CI], 0.78-0.97), 90-day (aOR, 0.92; 95% CI, 0.83-1.02), or 1-year mortality (aOR, 1.0; 95% CI, 0.91-1.11). Significant variation in use of peripheral vasopressors was observed across providers. Conclusions: Peripheral vasopressors were commonly and safely used in our 10-hospital health system, particularly in the community hospitals. Peripheral initiation of vasopressors was not associated with increased mortality at 90 days, but it was associated with decreased hospital length of stay. Variation in peripheral vasopressor use was found across hospitals and providers.

The ventilatory management of morbidly obese patients presents an ongoing challenge in the Intensive Care Unit (ICU) as multiple physiologic changes in the respiratory system complicate weaning efforts and make extubation more difficult, often leading to increased time on the ventilator. We report the case of a young adult male who presented to our ICU on two separate occasions with hypoxemic respiratory failure requiring intubation. Esophageal manometry (EM) guided positive end expiratory pressure (PEEP) titration was utilized during both ICU admissions to improve oxygenation and aid in extubation with spontaneous breathing trials performed on higher-than-normal (PEEP) settings and successful liberation on both occasions.

Background: There is an evolving focus on interprofessional education (IPE) to promote teamwork and collaboration in health professions education. Studies in medical students have shown that exposure to IPE leads to perceived improvements in interprofessional communication, effective work in healthcare teams, and understanding of professional limitations. Most research focuses on IPE in undergraduate medical education; less is known about how this functions in graduate medical education. Objective: To develop and implement a lecture-based intensive care unit (ICU) educational curriculum, incorporating content delivery by interprofessional team members (IPMs), and to use a mixed methods approach to explore learner and IPM perceptions surrounding the benefits and opportunities with this model of education. Methods: A standardized curriculum of core topics in critical care medicine was designed and implemented as a recurring interactive lecture series over the course of a medical ICU rotation at an academic hospital. The lectures were delivered by pulmonary and critical care attendings or fellows and IPMs, including pharmacists, dietitians, advanced practice providers, and physical therapists. Internal medicine residents' perceptions of faculty engagement in teaching, involvement in interprofessional care teams, and educational value of the rotation were analyzed quantitatively before and after intervention. Semistructured focus groups with residents and IPMs were held after implementation to explore the experience, motivations, and effectiveness of IPMs as educators. Themes were identified using a deductive approach, with coding by multiple team members. Results: Before lecture series implementation, 57 residents completed end-of-rotation evaluations. The average score for perceived faculty engagement and interest in teaching was 4.16 out of 5 (standard deviation [SD], 1.05). Forty-five residents completed evaluations after implementation, and the perception of faculty interest in teaching was not statistically different at 4.20 (SD, 0.92; P = 0.98). Qualitative themes emerging from the focus groups included investment, shared goals and motivation for teaching, specialized knowledge and mutual respect, improving patient care, engagement and environment, downsides, and, finally, prioritization. Conclusion: Teaching by IPMs can be integrated into a lecture-based curriculum in an academic ICU. After implementation, residents identified that engagement of IPMs as teachers may lead to improved understanding of roles and responsibilities and mutual respect. IPMs cite sharing of specialized knowledge and return on investment as motivations for teaching.

BACKGROUND: Respiratory therapist (RT)-driven spontaneous breathing trial (SBT) protocols have been shown to improve patient outcomes. RESEARCH QUESTION: Can an RT-driven SBT protocol be implemented and sustained to improve outcomes? STUDY DESIGN AND METHODS: This quality improvement (QI) project aimed to standardize and re-establish RT-driven protocol for screening patients for SBT readiness and administering SBTs to appropriate patients. Endotracheally intubated and mechanically ventilated adult patients admitted to an academic medical center ICU were screened daily by RTs for SBT readiness. Eligible patients received an SBT with extubation decisions made by the physician team. Patient demographics, indications for intubation, SBT eligibility and exclusionary indications, SBT ventilator settings, start times, duration, and outcomes were collected from the electronic health record. QI interventions included staff re-education, documentation tips, creation of process maps, and interdisciplinary open forum discussions. RESULTS: One hundred twenty-eight patients representing 759 safety screen weaning assessment opportunities were included over a baseline sample and three plan-do-study-act (PDSA) cycles. Documentation of SBT eligibility increased from 25% at baseline to 86% in PDSA cycle 3 (P .001). Patients assessed to be eligible for and who received an SBT constituted 42% at baseline, 35% at PDSA cycle 1, 36% at PDSA cycle 2, and 51% at PDSA cycle 3 (P = .092). Use of the protocolized SBT ventilator settings improved significantly from 18% to 83% (P .001). Patients who started an SBT before 9 AM increased from 41% to 67% (P = .097), and the median duration of SBT decreased from 211 to 64 min (P = .008). INTERPRETATION: This study shows that standardization of an RT-driven SBT protocol is feasible despite multiple obstacles, including staffing and communication challenges and poor shared understanding of terminology.

Airway management outside the operating room is associated with increased risks compared with airway management inside the operating room.Moreover, airway management-whether in the intensive care unit, emergency department, interventional radiology suite, or general wards-often requires mastery of not only the anatomically difficult airway but also the physiologically and situationally difficult airway.The 2015 Difficult Airway Society Guidelines encourage the airway team to ''stop and think''.This article provides a practical review of how that evidence applies during emergency airway management outside of the operating room.To counter the challenges of airway management outside the operating room, we offer a mnemonic that combines both technical and non-technical insights summarized using the seven letters of the word PREPARE (P: pre-oxygenate/position; R: reset/resist; E: examine/explicit; P: plan A/B; A: adjust/ attention; R: remain/review; E: exit/explore).We hope it can unite potentially disparate personnel with a structure that allows them to make acute decisions, coordinate action, and communicate unequivocally.

IMPORTANCE:. Provider staffing models for ICUs are generally based on pragmatic necessities and historical norms at individual institutions. A better understanding of the role that provider staffing models play in determining patient outcomes and optimizing use of ICU resources is needed. OBJECTIVES:. To explore the impact of transitioning from a low- to high-intensity intensivist staffing model on patient outcomes and unit composition. DESIGN, SETTING, AND PARTICIPANTS:. This was a prospective observational before-and-after study of adult ICU patients admitted to a single community hospital ICU before (October 2016–May 2017) and after (June 2017–November 2017) the transition to a high-intensity ICU staffing model. MAIN OUTCOMES AND MEASURES:. The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), and unit composition characteristics including type (e.g., medical, surgical) and purpose (ICU-specific intervention vs close monitoring only) of admission. RESULTS:. For the primary outcome, 1,219 subjects were included (779 low-intensity, 440 high-intensity). In multivariable analysis, the transition to a high-intensity staffing model was not associated with a decrease in 30-day (odds ratio [OR], 0.90; 95% CI, 0.61–1.34; p = 0.62) or in-hospital (OR, 0.89; 95% CI, 0.57–1.38; p = 0.60) mortality, nor ICU LOS. However, the proportion of patients admitted to the ICU without an ICU-specific need did decrease under the high-intensity staffing model (27.2% low-intensity to 17.5% high-intensity; p < 0.001). CONCLUSIONS AND RELEVANCE:. Multivariable analysis showed no association between transition to a high-intensity ICU staffing model and mortality or LOS outcomes; however, the proportion of patients admitted without an ICU-specific need decreased under the high-intensity model. Further research is needed to determine whether a high-intensity staffing model may lead to more efficient ICU bed usage.

OBJECTIVES:We sought to identify factors affecting physicians' cognition and clinical behavior when evaluating patients that may need fluid therapy.BACKGROUND:Proponents of dynamic fluid responsiveness testing advocate measuring cardiac output or stroke volume after a maneuver to prove that further fluids will increase cardiac output. However, surveys suggest that fluid therapy in clinical practice is often given without prior responsiveness testing.DESIGN:Thematic analysis of face-to-face structured interviews.SETTING:ICUs and medical-surgical wards in acute care hospitals.SUBJECTS:Intensivists and hospitalist physicians.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:We conducted 43 interviews with experienced physicians in 19 hospitals. Hospitalized patients with hypotension, tachycardia, oliguria, or elevated serum lactate are commonly seen by physicians who weigh the risks and benefits of more fluid therapy. Encounters are often with unfamiliar patients and evaluation and decisions are completed quickly without involving other physicians. Dynamic testing for fluid responsiveness is used much less often than static methods and fluid boluses are often ordered with no testing at all. This approach is rationalized by factors that discourage dynamic testing: unavailability of equipment, time to obtain test results, or lack of expertise in obtaining valid data. Two mental calculations are particularly influential: physicians' estimate of the base rate of fluid responsiveness (determined by physical examination, chart review, and previous responses to fluid boluses) and physicians' perception of patient harm if 500 or 1,000 mL fluid boluses are ordered. When the perception of harm is low, physicians use heuristics that rationalize skipping dynamic testing.LIMITATIONS:Geographic limitation to hospitals in Minnesota, United States.CONCLUSIONS:If dynamic responsiveness testing is to be used more often in routine clinical practice, physicians must be more convinced of the benefits of dynamic testing, that they can obtain valid results quickly and believe that even small fluid boluses harm their patients.

SESSION TITLE: Encounters with Mechanical Ventilation SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Obese, critically ill patients present numerous treatment challenges due to alterations in physiology, among these are difficulties in management and liberation from mechanical ventilation. Esophageal pressure monitoring (PESO) is a tool which may be used to help determine optimal positive end-expiratory pressure (PEEP), thus improving oxygenation and respiratory-system compliance. This may be of particular benefit in obese patients who are at increased risk of atelectasis given decreased functional residual capacity. The utility of PESO to guide PEEP titration for spontaneous breathing trials (SBT) in obese patients is relatively unknown. METHODS: We conducted a retrospective analysis of adult patients with BMI > 45 requiring mechanical ventilation, in whom PESO was used for PEEP titration as part of routine clinical care. Using PESO, PEEP was titrated to a transpulmonary pressure of -2 to 0. This PEEP was considered the optimal PEEP to prevent derecruitment and atelectasis. To evaluate the effects of PESO titrated PEEP for SBT on extubation success, we separated patients into two groups. The low PEEP group underwent SBT on PEEP 0-9 cm H2O. The high PEEP group underwent SBT using PEEP >= 10 cm H2O, with best PEEP guided by PESO. Baseline characteristics, demographics, mechanical ventilatory and weaning data were obtained. RESULTS: Nine patients met inclusion criteria with 5 patients in the low PEEP group and 4 patients in the high PEEP group.. Average body mass index (BMI) was higher in the high PEEP group (50.2 vs 70 kg/m2). The high PEEP SBT group averaged 8 days on the ventilator vs 12.8 days in the low PEEP group. The average PEEP at extubation for the high PEEP group was 13.5 cm H2O (range 10-18) vs 4.4 cm H2O (range 0-7) in the low PEEP group. SBTs were done with variable amounts of pressure augmentation, ranging from 0-12 in the low PEEP group to 5-15 in the high PEEP group. All high PEEP SBT patients were extubated directly to non-invasive positive pressure ventilation (NIPPV). No high PEEP SBT patients required re-intubation. 2 patients in the low PEEP group were successfully extubated; 1 to NIPPV and 1 to nasal cannula oxygen. 1 low PEEP SBT patient was extubated but required re-intubation and eventual tracheostomy, while two additional low PEEP SBT patients required tracheostomy due to repeated failure of SBTs. The high PEEP group had increased average ICU length of stay (18.75 days vs 15.2 days). CONCLUSIONS: A physiology based approach to PEEP titration, guided by PESO, may increase extubation success in morbidly obese patients and decrease the need for tracheostomy. Future larger studies should address the efficacy of PESO guided PEEP titration for SBT and the safety of routinely extubating obese patients on higher PEEP levels. CLINICAL IMPLICATIONS: Spontaneous breathing trials with elevated PEEP guided by PESO, may increase ventilator liberation success in morbidly obese patients. DISCLOSURES: No relevant relationships by Jacob Fiocchi No relevant relationships by Alexandra Fuher No relevant relationships by Sara Green No relevant relationships by Kathryn Pendleton No relevant relationships by Ronald Reilkoff

Background: Since its emergence in early 2020, coronavirus disease 2019 (COVID-19)-associated pneumonia has caused a global strain on intensive care unit (ICU) resources with many intubated patients requiring prolonged ventilatory support. Outcomes for patients with COVID-19 who receive prolonged intubation (>21 days) and possible predictors of mortality in this group are not well established. Patients and Methods: Data were prospectively collected from adult patients with COVID-19 requiring mechanical ventilation from March 2020 through December 2021 across a system of 11 hospitals. The primary end point was in-hospital mortality. Factors associated with mortality were evaluated using univariable and multivariable logistic regression analyses. Results: Six hundred six patients were placed on mechanical ventilation for COVID-19 pneumonia during the study period, with in-hospital mortality of 40.3% (n = 244). Increased age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.09), increased creatinine (OR, 1.40; 95% CI, 1.08-1.82), and receiving corticosteroids (OR, 2.68; 95% CI, 1.20-5.98) were associated with mortality. Intubations lasting longer than 21 days (n = 140) had a lower in-hospital mortality of 25.7% (n = 36; p < 0.001). Increasing Elixhauser comorbidity index (OR, 1.12; 95% CI, 1.04-1.19) and receiving corticosteroids (OR, 1.92; 95% CI, 1.06-3.47) were associated with need for prolonged ventilation. In this group, increased age (OR, 1.06; 95% CI, 1.01-1.08) and non-English speaking (OR, 3.74; 95% CI, 1.13-12.3) were associated with mortality. Conclusions: In-hospital mortality in mechanically ventilated patients with COVID-19 pneumonia occurs primarily in the first 21 days after intubation, possibly related to the early active inflammatory process. In patients on prolonged mechanical ventilation, increased age and being non-English speaking were associated with mortality.

Diffuse alveolar hemorrhage (DAH) is a life-threatening condition requiring prompt recognition. Conventional therapy, even when initiated early, may not have an immediate effect, and in severe cases, bleeding can persist despite treatment. We report the case of a previously healthy 33-year-old male who developed DAH secondary to granulomatosis with polyangiitis, resulting in respiratory failure and the need for mechanical ventilation. High-dose corticosteroids, plasma exchange, and remission induction with cyclophosphamide failed to control bleeding, leading to severely impaired gas exchange. 20 mcg/kg of systemic recombinant activated Factor VII (rFVIIa), a dose lower than previously reported for management of DAH, resulted in hemostasis and improved oxygenation after only three doses. No complications were observed, and our patient was liberated from ventilatory support eight days later. In the setting of DAH with refractory bleeding, hemostasis may be achievable with a lower dose of rFVIIa than commonly used, potentially mitigating the risk of dose-dependent side effects.

3627 Background: Blood-based colorectal cancer (CRC) screening tests can improve adherence to screening guidelines. Yet, current commercially available options have poor sensitivity and specificity inhibiting incorporation into routine clinical care. Here we report the validation of a blood-based test for the detection of colorectal cancer and advanced neoplasia. Methods: This blood-based test aims to detect colorectal neoplasia by identifying tumor-associated biomarkers including genomic or epigenomic (methylation and fragmentomics) signatures in cell-free DNA (cfDNA). cfDNA is partitioned based on methylation level, enriched for informative genomic regions, and sequenced. This novel workflow enables high-fidelity analysis of multi-modal information in majority of extracted cfDNA molecules. Results are integrated into a binary “detected” versus “not-detected” result using a proprietary bioinformatic pipeline (Guardant Health, USA). The assay was trained on samples obtained from >6,000 unique individuals (2,685 cancer-free and 1,698 with advanced colorectal neoplasia (ACN) for training, 1,072 cancer-free and 551 with ACN for threshold setting). The thresholds were frozen prior to validation targeting a specificity of > 91.5%. Each aspect of the validation study followed Nex-StoCT CLIA working group and CLSI guidelines. Results: Limit of detection (LoD) was established across six dilutions. Even for low cfDNA mass inputs of less than 4ng, the 95% LoD was determined to be less than 1 tumor-derived genomic equivalent (0.5), indicating over at least 10-fold increase in assay sensitivity compared to best-in-class assays for somatic mutation detection. Precision studies in 60 positive and negative replicates from clinical samples yielded >90% average positive and negative percent agreement both within and between batches. Endogenous interference studies yielded > 90% positive and negative percent agreement between reference control and common endogenous substances, including albumin, bilirubin, hemoglobin, triglycerides, and genomic DNA, in clinical positive and negative samples and minimally manipulated samples. The clinical validation of the test was conducted in > 300 cases (biobanked pre-operative cohort for CRC cases and screening cohort for advanced adenoma and negative cases). Conclusions: Here we present the validation of a multi-modal blood-based test for the detection of colorectal cancer. This test is currently being evaluated in a registrational study (ECLIPSE: NCT04136002).

3542 Background: Cancer screening in asymptomatic individuals who meet guideline criteria has yielded reductions in cancer death rates. However, adherence to screening guidelines remains below targets set forth by leading health-care organizations. A blood-based multi-cancer screening assay with clinically meaningful sensitivity and specificity, in cancer types where early detection and intervention can save lives, that is integrated with existing clinical pathways may increase access to and adherence with guideline recommendations, ensuring more individuals benefit from these proven interventions. We evaluated the performance of a blood-based multi-cancer screening assay that interrogates cell-free DNA (cfDNA) methylation signatures for cancer detection and tissue of origin prediction in a set of tumor types where cancer screening can save lives. Methods: Whole blood from 1,607 individuals with and 3,298 individuals without cancer was obtained from multiple unique cohorts. Plasma-derived cfDNA was profiled using a custom assay that enriches fragments with dense CpG methylation and further depletes uninformative background molecules containing unmethylated CpGs. We utilized a broad genomic panel (16 Mb) targeting regions with low rates of methylation in individuals without cancer. The panel captures tumor-associated molecules and allows for high sensitivity of detection at low sequencing costs. A cross-validated analysis was used to estimate the performance of the predictive model upon the sample set. Classification thresholds corresponding to 90%, 95%, and 98% specificities were established using samples from individuals without a cancer diagnosis. Results: At 90% specificity, overall sensitivity for lung cancer detection was 92.1% (95% CI: 80-100%; 90.2% in Stage I/II disease (N = 82) and 93.1% in Stage III/IV disease (N = 159)) and 93.1% (CI: 88-98%) for CRC detection (92% in Stage I/II disease (N = 743) and 94.5% in Stage III/IV disease (N = 623)). Tissue of origin prediction evaluated at 98% specificity yielded accurate identification in 99% of CRC and 98% of lung cancers. Lung cancer histology was known for approximately 74% of the cohort. Across Stage I – IV cancers, at 90% specificity, sensitivity was 97.3% in lung squamous cancer (N = 73) and 86.8% in lung adenocarcinoma (N = 106). At 95% and 98% specificity thresholds, overall sensitivity was 86.3% (CI: 75-98%) and 66.4% (CI: 56-77%) for lung cancer and 85.7% (CI:81-91%) and 71.6% (CI: 67-76%) for CRC, respectively. Conclusions: This blood-based multi-cancer screening assay yields clinically meaningful sensitivity and specificity for early-stage cancers. This assay is undergoing further development to expand detection capabilities to additional cancer types where screening can save lives. Clinical evaluation in registrational screening trials is ongoing (SHIELD; NCT05117840).

Background: Improving care of critically ill patients requires using an interprofessional care model and care standardisation. Objectives: Determine whether collaborative patient care rounds in the intensive care unit increases practice consistency with respect to common considerations such as delirium prevention, device use, and indicated prophylaxis, among others. Secondary objective to assess whether collaborative interprofessional format improved nursing perceptions of collaboration. Methods: Single centre, pre- and post- intervention design. collaborative patient care rounding format implemented in three intensive care units in an academic tertiary care centre. format consisted of scripted nursing presentation, provider checklist of additional practice considerations, and daily priority goals documentation. measurements included nursing participation, consideration of selected practice items, daily goal verbalisation, and nursing perception of collaboration. Results: Pre- and post-intervention measurements indicate gains in consideration of eight of thirteen bundle items (p < 0.05), with the greatest gains seen in nurse-presented items. Increases were observed in verbalisation of daily goals (59.8% versus 89.1%, p < 0.0001), nurse participation (83.9% versus 91.8%, p = 0.056), and nurse collaboration ratings (p < 0.0001). Conclusion: This study describes implementation of collaborative patient care rounds with corresponding increases in consideration of selected practice items, verbalisation of daily goals, and perceptions of collaboration. Background: Improving care of critically ill patients requires using an interprofessional care model and care standardisation. Objectives: Determine whether collaborative patient care rounds in the intensive care unit increases practice consistency with respect to common considerations such as delirium prevention, device use, and indicated prophylaxis, among others. Secondary objective to assess whether collaborative interprofessional format improved nursing perceptions of collaboration. Methods: Single centre, pre-and post-intervention design. collaborative patient care rounding format implemented in three intensive care units in an academic tertiary care centre. format consisted of scripted nursing presentation, provider checklist of additional practice considerations, and daily priority goals documentation. measurements included nursing participation, consideration of selected practice items, daily goal verbalisation, and nursing perception of collaboration. Results: Pre-and post-intervention measurements indicate gains in consideration of eight of thirteen bundle items (p < 0.05), with the greatest gains seen in nurse-presented items. Increases were observed in verbalisation of daily goals (59.8% versus 89.1%, p < 0.0001), nurse participation (83.9% versus 91.8%, p = 0.056), and nurse collaboration ratings (p < 0.0001). Conclusion: This study describes implementation of collaborative patient care rounds with corresponding increases in consideration of selected practice items, verbalisation of daily goals, and perceptions of collaboration. (c) 2020 Elsevier Ltd. All rights reserved.