Heather Balch, MD

Clinical question: Does the increasing number of ICU beds in the U.S. affect the use of mechanical ventilation in nursing home patients with advanced dementia?

Background: Some physicians are concerned that increases in ICU beds in the U.S. will translate to increased treatment of advanced dementia in the ICU, which might not line up with their preferences, nor improve mortality.

Study design: Retrospective cohort study.

Setting: Hospitals that completed the American Hospital Association (AHA) annual survey.

Synopsis: From 2000 to 2013, there were 635,008 hospitalizations of 380,060 Medicare patients with advanced dementia who had been in a nursing home in the 120 days prior to hospital admission. ICU admissions increased to 38.5% from 16.9% during the same period. The rate of mechanical ventilation per 1,000 hospital admissions increased to 78 from 39, and 1-year mortality for ventilation was unchanged.

For each increase in 10 ICU beds within a hospital, the adjusted odds ratio for receiving mechanical ventilation was 1.06 (95% CI, 1.05-1.07).

Limitations of the study include that only hospitals completing the AHA annual survey were studied, and also lacked information on individual patients.

Bottom line: The use of mechanical ventilation increased in hospitalized nursing home patients with advanced dementia, correlating with increased ICU bed capacity, yet with no changes in survival.

Citation: Teno JM, Gozalo P, Khandelwal N, et al. Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds [published online ahead of print, Oct. 10, 2016]. JAMA Int Med. 2016;176(12):1809-16.

Dr. Balch is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: Does the increasing number of ICU beds in the U.S. affect the use of mechanical ventilation in nursing home patients with advanced dementia?

Background: Some physicians are concerned that increases in ICU beds in the U.S. will translate to increased treatment of advanced dementia in the ICU, which might not line up with their preferences, nor improve mortality.

Study design: Retrospective cohort study.

Setting: Hospitals that completed the American Hospital Association (AHA) annual survey.

Synopsis: From 2000 to 2013, there were 635,008 hospitalizations of 380,060 Medicare patients with advanced dementia who had been in a nursing home in the 120 days prior to hospital admission. ICU admissions increased to 38.5% from 16.9% during the same period. The rate of mechanical ventilation per 1,000 hospital admissions increased to 78 from 39, and 1-year mortality for ventilation was unchanged.

For each increase in 10 ICU beds within a hospital, the adjusted odds ratio for receiving mechanical ventilation was 1.06 (95% CI, 1.05-1.07).

Limitations of the study include that only hospitals completing the AHA annual survey were studied, and also lacked information on individual patients.

Bottom line: The use of mechanical ventilation increased in hospitalized nursing home patients with advanced dementia, correlating with increased ICU bed capacity, yet with no changes in survival.

Citation: Teno JM, Gozalo P, Khandelwal N, et al. Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds [published online ahead of print, Oct. 10, 2016]. JAMA Int Med. 2016;176(12):1809-16.

Dr. Balch is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: Does the increasing number of ICU beds in the U.S. affect the use of mechanical ventilation in nursing home patients with advanced dementia?

Background: Some physicians are concerned that increases in ICU beds in the U.S. will translate to increased treatment of advanced dementia in the ICU, which might not line up with their preferences, nor improve mortality.

Study design: Retrospective cohort study.

Setting: Hospitals that completed the American Hospital Association (AHA) annual survey.

Synopsis: From 2000 to 2013, there were 635,008 hospitalizations of 380,060 Medicare patients with advanced dementia who had been in a nursing home in the 120 days prior to hospital admission. ICU admissions increased to 38.5% from 16.9% during the same period. The rate of mechanical ventilation per 1,000 hospital admissions increased to 78 from 39, and 1-year mortality for ventilation was unchanged.

For each increase in 10 ICU beds within a hospital, the adjusted odds ratio for receiving mechanical ventilation was 1.06 (95% CI, 1.05-1.07).

Limitations of the study include that only hospitals completing the AHA annual survey were studied, and also lacked information on individual patients.

Bottom line: The use of mechanical ventilation increased in hospitalized nursing home patients with advanced dementia, correlating with increased ICU bed capacity, yet with no changes in survival.

Citation: Teno JM, Gozalo P, Khandelwal N, et al. Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds [published online ahead of print, Oct. 10, 2016]. JAMA Int Med. 2016;176(12):1809-16.

Dr. Balch is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: What is the best management approach for adults who are admitted to the hospital with a calcium channel blocker (CCB) overdose?

Background: There is significant morbidity and mortality from cardiac drug poisoning. Overall, the level of evidence in the literature on the treatment of CCB toxicity is very low. Prior to the current publication there were no guidelines for treating patients admitted to the hospital with a CCB overdose.

Further lower-strength suggestions were made: insulin therapy as monotherapy if cardiac dysfunction present, or in combination with other therapies if there is no cardiac dysfunction; atropine in the setting of symptomatic bradycardia; and dobutamine or epinephrine in the presence of cardiogenic shock.

For refractory CCB, toxicity suggestions included incremental doses of high-dose insulin (if myocardial dysfunction is present, or even if it is not present in periarrest situations), IV lipid emulsion therapy, and pacemaker for unstable bradycardia (if there is no evidence of cardiac dysfunction). If the patient is in refractory shock or periarrest, the panel suggests the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Limitations included the limited availability of evidence.

Bottom line: Management of CCB toxicity should include IV calcium and high-dose IV insulin, with vasopressors for shock, and other additional therapies for refractory cases.

Citation: St-Onge M, Anseeuw K, Cantrell FL, et al. Experts’ consensus recommendations for the management of calcium channel blocker poisoning in adults [published online ahead of print, Oct. 3, 2016]. Crit Care Med. doi: 10.1097/CCM.0000000000002087.

Dr. Balch is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: What is the best management approach for adults who are admitted to the hospital with a calcium channel blocker (CCB) overdose?

Background: There is significant morbidity and mortality from cardiac drug poisoning. Overall, the level of evidence in the literature on the treatment of CCB toxicity is very low. Prior to the current publication there were no guidelines for treating patients admitted to the hospital with a CCB overdose.

Further lower-strength suggestions were made: insulin therapy as monotherapy if cardiac dysfunction present, or in combination with other therapies if there is no cardiac dysfunction; atropine in the setting of symptomatic bradycardia; and dobutamine or epinephrine in the presence of cardiogenic shock.

For refractory CCB, toxicity suggestions included incremental doses of high-dose insulin (if myocardial dysfunction is present, or even if it is not present in periarrest situations), IV lipid emulsion therapy, and pacemaker for unstable bradycardia (if there is no evidence of cardiac dysfunction). If the patient is in refractory shock or periarrest, the panel suggests the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Limitations included the limited availability of evidence.

Bottom line: Management of CCB toxicity should include IV calcium and high-dose IV insulin, with vasopressors for shock, and other additional therapies for refractory cases.

Citation: St-Onge M, Anseeuw K, Cantrell FL, et al. Experts’ consensus recommendations for the management of calcium channel blocker poisoning in adults [published online ahead of print, Oct. 3, 2016]. Crit Care Med. doi: 10.1097/CCM.0000000000002087.

Dr. Balch is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: What is the best management approach for adults who are admitted to the hospital with a calcium channel blocker (CCB) overdose?

Background: There is significant morbidity and mortality from cardiac drug poisoning. Overall, the level of evidence in the literature on the treatment of CCB toxicity is very low. Prior to the current publication there were no guidelines for treating patients admitted to the hospital with a CCB overdose.

Further lower-strength suggestions were made: insulin therapy as monotherapy if cardiac dysfunction present, or in combination with other therapies if there is no cardiac dysfunction; atropine in the setting of symptomatic bradycardia; and dobutamine or epinephrine in the presence of cardiogenic shock.

For refractory CCB, toxicity suggestions included incremental doses of high-dose insulin (if myocardial dysfunction is present, or even if it is not present in periarrest situations), IV lipid emulsion therapy, and pacemaker for unstable bradycardia (if there is no evidence of cardiac dysfunction). If the patient is in refractory shock or periarrest, the panel suggests the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Limitations included the limited availability of evidence.

Bottom line: Management of CCB toxicity should include IV calcium and high-dose IV insulin, with vasopressors for shock, and other additional therapies for refractory cases.

Citation: St-Onge M, Anseeuw K, Cantrell FL, et al. Experts’ consensus recommendations for the management of calcium channel blocker poisoning in adults [published online ahead of print, Oct. 3, 2016]. Crit Care Med. doi: 10.1097/CCM.0000000000002087.

Dr. Balch is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.