THE UTILIZATION OF HIGH FREQUENCY PERCUSSIVE VENTILATION TO REDUCE EXTRACORPOREAL OXYGENATION MEMBRANE SUPPORT.

To minimize the chance of ventilator induced lung injury (VILI), in patients who develop adult respiratory distress syndrome ARDS), Extracorporeal Oxygenation Membrane (ECMO) is a common clinical intervention. The goal of venous-venous ECMO is to provide stable gas exchange, while the goal of the ventilator is to preserve the patient\u27s pulmonary mechanics and minimize VILI. When ECMO parameters are maximized and gas exchange is marginal, often then the ventilator is called upon to help improve or maintain gas exchange often requiring high pressures and oxygen delivery (FI02). An alternative strategy to meet this objective is to utilized high frequency percussive ventilation (HFPV) via the VDR-4 (Sandpoint, Idaho). HFPV provides both an endobronchial wedge via the percussive rate and an oscillatory plateau via the connective rate. With this strategy lower pressures and oxygen delivery can be employed and ECMO parameters can be often reduced. From Jan 2015 to Feb 2016 we utilized the VDR on fifteen V-V ECMO patients. Thirteen (86.7%) of fifteen patients both ECMO FIO2 and sweep were reduced with in twenty-four hours. (Table 1) HFPV pressures and FIO2 were maintain lower than 60% and airway pressure ≤ 40cmH20. (Table 1) Prior to placing on HFPV a pressure/tool measurement was performed to determine starting airway pressure and PEEP parameters to set on the VDR. Based on the above results, HFPV can help ECMO maintain gas exchange for patients at a lower FIO2 and sweep settings

Assessment of Emergency Medicine Resident Performance in an Adult Simulation Using a Multisource Feedback Approach.

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) specifically notes multisource feedback (MSF) as a recommended means of resident assessment in the emergency medicine (EM) Milestones. High-fidelity simulation is an environment wherein residents can receive MSF from various types of healthcare professionals. Previously, the Queen\u27s Simulation Assessment Tool (QSAT) has been validated for faculty to assess residents in five categories: assessment; diagnostic actions; therapeutic actions; interpersonal communication, and overall assessment. We sought to determine whether the QSAT could be used to provide MSF using a standardized simulation case. Methods: Prospectively after institutional review board approval, residents from a dual ACGME/osteopathic-approved postgraduate years (PGY) 1-4 EM residency were consented for participation. We developed a standardized resuscitation after overdose case with specific 1-5 Likert anchors used by the QSAT. A PGY 2-4 resident participated in the role of team leader, who completed a QSAT as self-assessment. The team consisted of a PGY-1 peer, an emergency medical services (EMS) provider, and a nurse. Two core faculty were present to administer the simulation case and assess. Demographics were gathered from all participants completing QSATs. We analyzed QSATs by each category and on cumulative score. Hypothesis testing was performed using intraclass correlation coefficients (ICC), with 95% confidence intervals. Interpretation of ICC results was based on previously published definitions. Results: We enrolled 34 team leader residents along with 34 nurses. A single PGY-1, a single EMS provider and two faculty were also enrolled. Faculty provided higher cumulative QSAT scores than the other sources of MSF. QSAT scores did not increase with team leader PGY level. ICC for inter-rater reliability for all sources of MSF was 0.754 (0.572-0.867). Removing the self-evaluation scores increased inter-rater reliability to 0.838 (0.733-0.910). There was lesser agreement between faculty and nurse evaluations than from the EMS or peer evaluation. Conclusion: In this single-site cohort using an internally developed simulation case, the QSAT provided MSF with excellent reliability. Self-assessment decreases the reliability of the MSF, and our data suggest self-assessment should not be a component of MSF. Use of the QSAT for MSF may be considered as a source of data for clinical competency committees

The Neurocircuitry of Fear, Stress, and Anxiety Disorders

Anxiety disorders are a significant problem in the community, and recent neuroimaging research has focused on determining the brain circuits that underlie them. Research on the neurocircuitry of anxiety disorders has its roots in the study of fear circuits in animal models and the study of brain responses to emotional stimuli in healthy humans. We review this research, as well as neuroimaging studies of anxiety disorders. In general, these studies have reported relatively heightened amygdala activation in response to disorder-relevant stimuli in post-traumatic stress disorder, social phobia, and specific phobia. Activation in the insular cortex appears to be heightened in many of the anxiety disorders. Unlike other anxiety disorders, post-traumatic stress disorder is associated with diminished responsivity in the rostral anterior cingulate cortex and adjacent ventral medial prefrontal cortex. Additional research will be needed to (1) clarify the exact role of each component of the fear circuitry in the anxiety disorders, (2) determine whether functional abnormalities identified in the anxiety disorders represent acquired signs of the disorders or vulnerability factors that increase the risk of developing them, (3) link the findings of functional neuroimaging studies with those of neurochemistry studies, and (4) use functional neuroimaging to predict treatment response and assess treatment-related changes in brain function