Erlanger Health System

Introduction: Available literature suggests albumin resuscitation in septic shock (SS) may reduce vasopressor requirements and cumulative fluid balance, but albumin timing varies. The purpose of this study was to assess optimal timing of albumin within 72 hours of initial SS crystalloid resuscitation. Methods: This retrospective study included SS patients that received guideline-recommended 30 mL/kg of crystalloid resuscitation. The primary objective was to assess the impact of albumin timing on vasopressor alive-and-free days. Secondary endpoints included vasopressor-free days, time to shock resolution, shock recurrence, need for new renal replacement therapy, ICU length of stay, hospital length of stay, and 28-day mortality. Results: Of patients included, 59 received albumin within 72 hours after initial crystalloid resuscitation, while 27 patients did not. Patients received a median of 31.9 mL/kg of initial crystalloid resuscitation that consisted mostly of lactated ringers (54.7%). For patients that received albumin, the median initial dose was 25 g at a concentration of 5% (79.7%). When albumin and no albumin groups were compared, results found no difference in vasopressor alive-and-free days, time to shock resolution, ICU and hospital length of stay (LOS), and 28-day mortality. However, there were significant differences in shock recurrence (13.6% vs 44.4%) and new renal replacement therapy (10.2% vs 0.0%). When albumin is given for SS, optimal timing was found to be 8.75 to 72 hours after initial crystalloid resuscitation for a perceived 6.92 day improvement in vasopressor alive-and-free days compared to those outside the perceived optimal timing. Conclusions: Patients that received albumin within 72 hours of initial SS crystalloid resuscitation had similar vasopressor alive-and-free days with reduced shock recurrence when compared to patients that did not receive albumin. Findings suggest optimal timing for albumin may be 8.75 to 72 hours after crystalloid resuscitation warranting further investigation.

Disclosure: N.R. Brott: None. L. Kandimalla: None. M. Hollie: None.Background: Pituitary metastases are rare (∼0.4% of intracranial metastases) and often asymptomatic. Over 60% originate from lung or breast cancer, while ∼2.6% arise from renal cell carcinoma (RCC). We present a rare case of panhypopituitarism due to pituitary metastasis from RCC. Case Report: A 65-year-old male with primary hypothyroidism and recent recurrence of RCC with stage 4 metastasis presented with shock and acute encephalopathy requiring intubation. He had reported headaches, fatigue, and lightheadedness. Seven months prior, an MRI showed a 2.4 cm pituitary mass, presumed to be a macroadenoma. MRI at admission showed interval growth to 3.2 cm with suprasellar extension, optic chiasm compression, hydrocephalus, and cavernous sinus invasion. Labs revealed panhypopituitarism: secondary adrenal insufficiency, central diabetes insipidus (CDI), hypogonadism, and low IGF-1, with mildly elevated prolactin. Pertinent labs included undetectable cortisol at 8 AM (Normal (N): 3.7-19.4mcg/dL), which peaked at 1.4 mcg/dL 60 minutes after administrations of ACTH; undetectable LH and Testosterone; low IGF-1 15 ng/ml (N: 64-240); elevated prolactin 15.68 ng/m (N: 2.64-13.13); TSH 3.3 uIU/ml (N: 0.34-5.60); free T4 0.60 ng/dL (N: 0.54-1.24); low total T3 37 ng/dL (N: 71-180); normal potassium, hypernatremia up to 164 mmol/L (N: 136-145) and inappropriately low urine osmolality at 132 mOsm/kg (N: 150-1150). He was stabilized with hydrocortisone and DDAVP, then underwent transsphenoidal resection. Pathology confirmed metastatic PAX-8-positive RCC. He was discharged with endocrinology and oncology follow-up. Discussion: Pituitary metastases usually occur between ages 60–70 and affect both sexes equally. Most are asymptomatic (93%). CDI is the most common symptom (∼45%), followed by ophthalmoplegia, hemianopsia, headache, fatigue, or hyperprolactinemia. Differentiating metastases from macroadenomas can be difficult—FDG-PET shows no clear distinction, and MRI may be nonspecific. Features suggesting metastasis include rapid growth, thickened stalk, cavernous sinus invasion, sclerotic sella, and suprasellar migration. Conclusion: RCC metastasis to the pituitary is rare but should be considered in cancer patients with new neurologic issues or signs of endocrinopathy. Early recognition enables appropriate endocrine and oncologic management.

A practice management guideline was established calling for a thromboelastography with platelet mapping (TEG-PM) on all adult trauma patients with an intracranial hemorrhage. Patients were then categorized per the mBIG as 1, 2, or 3. Data was retrospectively collected from December 2019 to December 2021. Patients were considered to have platelet inhibition if the percent arachidonic acid (AA) or percent adenosine diphosphate (ADP) inhibition was ≥60% on TEG-PM. Between December 2019 and December 2021, 768 patients underwent TEG-PM. AA inhibition was more likely to occur in mBIG 3 patients (26.3%) compared to mBIG 1 or mBIG 2 patients (P = 0.08),. ADP and combined AA/ADP inhibition were similar between mBIG scores. Modified BIG 3 patients were more likely to experience bleed progression compared to mBIG 1 or 2 (46.4%; P < 0.001) and to require neurosurgical intervention (16.5%; p < 0.001). Our study suggests that the higher the mBIG scores, the more likely patients will have worse outcomes regardless of platelet inhibition. Patients with TBI who experience worse outcomes is multifactorial in nature. TEG-PM should be used in conjunction with clinical judgement for treatment guidance.

Background In 2009, the Erlanger Hospital System (EHS) in Tennessee introduced a Communications-and-Resolution Program (CRP) for addressing adverse medical outcomes. The program requires transparency from their medical staff whenever a patient suffers an unexpected outcome. Healthcare professionals often fear that such transparency could lead to worse liability outcomes, especially increased litigation and reporting to the National Practitioner Data Bank (NPDB). Methods Using a difference-in-difference model, we compared the liability outcomes of EHS to all healthcare entities in the state of Tennessee from 2005 to 2015. We reviewed charts after CRP was implemented to determine whether there was a written request for compensation or only a verbal request for compensation. Results After introducing the CRP, EHS defense costs fell by 58% ( p &lt; 0.001) and the number of claims filed fell by 42% ( p = 0.01), compared to that in Tennessee. We found a statistically insignificant impact on compensation at EHS after CRP was implemented compared to compensation in Tennessee. We find weak evidence of relative reductions in Total Liability Costs ( p = 0.34; 95% CI = −81% to +31%). Under the CRP, 40% of paid compensations resulted from only a verbal request for money, not a written request. Conclusion Our results provide the first evidence using a comparison group to demonstrate that CRP can lower defense costs and claims filed in court while not significantly increasing other compensation or total liability costs. The large fraction of cases with only a verbal request for compensation suggests that there could be less reporting to the NPDB when a hospital implements CRP.

Background: Hypertonic saline (HTS) is essential pharmacologic treatment for traumatic brain injury (TBI). Previous studies associate HTS with acute kidney injury (AKI), however evidence in TBIs is limited. Objective: This study examines factors associated with AKI in patients requiring HTS for TBI. Methods: This retrospective study was performed at a Level-1 Trauma, Academic Medical Center. Inclusion criteria were TBI, age ≥12 years, ICU length of stay ≥72 hours, and administration of ≥24 hours of continuous HTS or 500 mL of HTS boluses. The primary outcome was identifying factors associated with AKI. Secondary outcomes included correlation between chloride load and level with development of AKI. Chloride load was calculated from HTS and non-HTS sources. Results: Of 129 patients included, 18 (14%) developed AKI. Maximum sodium level was higher in the AKI group (P < 0.0001). Hyperchloremia (Cl ≥ 115 mEq/L) was more common in the AKI group (100% vs 81%, P = 0.0428). Maximum and change in serum chloride were higher in the AKI group (median 128 vs 123 mEq/L, P = 0.0026 and +24 mEq/L vs +17 mEq/L, P = 0.0084, respectively). Logistic regression analysis indicated an OR 1.095 times higher [95% CI (1.022, 1.172)] for developing AKI for every one mEq/L increase in maximum chloride level and an OR 1.032 [95% CI (1.006, 1.058)] for developing AKI for every 1-year increase in age. There was no difference in total chloride load between groups (P = 0.2143). Non-HTS sources provided more than 40% of total chloride load in both groups. Conclusion: Chloride level, and age may be associated with AKI in TBI patients treated with HTS.