Ramar, Kannan

Despite knowledge that EGDT improves outcomes in septic patients, staff education on EGDT and compliance with the CPOE order set has been variable. Based on results of a resident survey to identify barriers to decrease severe sepsis/septic shock mortality in the medical intensive care unit (MICU), multifaceted interventions such as educational interventions to improve awareness to the importance of early goal-directed therapy (EGDT), and the use of the Computerized Physician Order Entry (CPOE) order set, were implemented in July 2013. CPOE order set was established to improve compliance with the EGDT resuscitation bundle elements. Orders were reviewed and compared for patients admitted to the MICU with severe sepsis/septic shock in July and August 2013 (controls) and 2014 (following the intervention). Similarly, educational slide sets were used as interventions for residents before the start of their ICU rotations in July and August 2013. While CPOE order set compliance did not significantly improve (78% vs. 76%, p = 0.74), overall EGDT adherence improved from 43% to 68% ( p = 0.0295). Although there was a trend toward improved mortality, this did not reach statistical significance. This study shows that education interventions can be used to increase awareness of severe sepsis/septic shock and improve overall EGDT adherence.

The approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at home in a confused state. Laboratory analysis revealed serum pH 6.84, bicarbonate 5.8 mmol/L, pCO2 29 mmHg, anion gap 22.2 mmol/L, osmolal gap 17.4 mOsm/kg, elevated beta-hydroxybutyrate (4.2 mmol/L), random blood sugar 213 mg/dL, creatinine 2.1 mg/dL, and potassium 7.5 mmol/L with no electrocardiogram (EKG) changes. Fomepizole and hemodialysis were initiated for presumed ethylene glycol or methanol ingestion. Drug screens returned negative for ethylene glycol, alcohols, and acetaminophen, but there were elevated urine levels of acetone (11 mg/dL). The acetaminophen level was negative, and 5-oxoproline was not analyzed. After 5 days in the intensive care unit (ICU), her mental status improved with supportive care. She was discharged to a nursing facility. Though a diagnosis was not established, our patient’s presentation was likely due to starvation ketosis combined with chronic acetaminophen ingestion. Acetone ingestion is less likely. Overall, our case illustrates the importance of systematically approaching an elevated osmolal and anion gap metabolic acidosis.

We present a case of a young man with severe mucositis following an upper respiratory tract infection limited to the ophthalmic and oral mucosa while sparing the rest of the skin, genitalia and perianal regions. Investigations revealed that the mucositis was a rare extrapulmonary manifestation of Mycoplasma pneumoniae infection. He had progressive vision-threatening symptoms despite antibiotics and best supportive care and thus was treated with intravenous corticosteroids, immunoglobulins, temporary ocular amniotic membrane grafts and tarsorrhaphy. The patient made an almost complete recovery over 6 weeks.

Objectives/Hypothesis Pediatric obstructive sleep apnea syndrome ( OSAS ) is a common disorder with serious clinical implications if left untreated. The recommended initial treatment for pediatric patients with obstructive sleep apnea syndrome ( OSAS ) is adenotonsillectomy. However, recent reports have shown variable surgical results with adenotonsillectomy in the treatment of pediatric OSAS . Study Design Prospective, controlled study. Methods From April 2007 to August 2010, 24 participants were assigned alternatively to either adenotonsillectomy with pillar suturing (intervention group) or adenotonsillectomy alone (control group). Result The average improvement in apnea hypopnea index ( AHI ) was 42.6% in the control group and 79.9% in the intervention group ( P =0.037). The success rate was 50% in the control group and 91.6% in the intervention group ( P =0.034). Six patients (50%) in the intervention group achieved complete resolution of pediatric OSAS , as defined by an AHI <1/hour, compared to 2 patients (16.7%) in the control group ( P =0.097). Conclusion Adenotonsillectomy with pillar suturing showed significant improvement in treating pediatric patients with OSAS compared to adenotonsillectomy alone. The procedure is simple and safe. Level of Evidence 4. Laryngoscope , 123:2574–2578, 2013

Snoring is a common phenomenon and results from vibration of the soft tissue structures in the upper airway. Snoring may occur alone or as a sign of upper airway resistance syndrome (UARS) or obstructive sleep apnea syndrome (OSA). Snoring carries social consequences and has been linked to increased risk for cardiovascular disease, although this relationship may be confounded by undiagnosed OSA. UARS is characterized by daytime dysfunction and repetitive respiratory effort-related arousals, episodes of increasingly intense breathing efforts that terminate with an arousal from sleep before a hypopnea (episode of partial airflow reduction) or apnea (episode of complete airflow reduction) occur. There is controversy whether UARS is a distinct clinical entity or part of the OSA spectrum. Long-term cardiovascular consequences of UARS are unclear. Risk factors for snoring and UARS are similar and include obesity, nasal congestion, ingestion of pharyngeal relaxing substances before bed such as alcohol, hypnotics, and skeletal muscle relaxants, and abnormalities of the bony and soft tissue structures of the head and neck. Treatment options for snoring and UARS overlap and include risk factor modifications, oral appliances to advance the mandible during sleep, continuous positive airway pressure, and upper airway surgeries.

Maxillomandibular advancement (MMA) is a surgical option for obstructive sleep apnea (OSA). MMA involves forward-fixing the maxilla and mandible approximately 10 mm via Le Fort I maxillary and sagittal split mandibular osteotomies. We retrospectively reviewed outcomes from 24 consecutive OSA patients who underwent MMA at our institution. MMA resulted in an 83% reduction in the group mean apnea-hypopnea index (AHI) per polysomnography an average of 6.7 months after surgery. Forty-two percent of patients achieved a post-MMA AHI of less than 5 events/hour sleep and 71% achieved an AHI less than or equal to 10 events/hour sleep. The Epworth Sleepiness Scale score decreased by an average of 5 post-surgery. No parameters predictive of cure for OSA by MMA were identified.

Snoring is the sound of soft tissues vibrating within the upper throat during sleep. The vibration is a result of turbulent air flow through the throat as it narrows during sleep. Snoring is very common in adults and may occur alone or be a feature of other conditions characterized by greater throat narrowing during sleep, namely upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSA). UARS is marked by daytime sleepiness and/or fatigue in the context of frequent respiratory-effort related arousals (RERAs). RERAs are episodic arousals that follow periods of more intense breathing effort as resistance to airflow in the throat increases. Once the throat is very narrow, hypopneas (partial reduction in airflow) and apneas (complete cessation of airflow) occur, and these events comprise OSA. Whether UARS is an entity distinct from OSA remains still debated. Risk factors for snoring and UARS are similar and include obesity, nasal congestion, alcohol and drug consumption before bed, and abnormalities of the bony and soft tissue structures of the head and neck. Snoring can be a nuisance, but generally does not produce daytime sequelae, while UARS may lead to daytime fatigue and sleepiness. Treatment options for snoring and UARS include risk factor modifications, nasal-directed therapies, oral appliances, upper airway surgery, while continuous positive airway pressure (CPAP) is an additional option for UARS.