Publications by authors named "John M Litell"

11 Publications

  • Page 1 of 1

Treatment of Severe Hypercapnic Respiratory Failure Caused by SARS-CoV-2 Lung Injury with ECCOR Using the Hemolung Respiratory Assist System.

Case Rep Crit Care 2021 29;2021:9958343. Epub 2021 Jun 29.

Minneapolis Heart Institute Foundation, Minneapolis, MN 55407, USA.

Acute respiratory distress syndrome (ARDS) due to COVID-19 leads to a high rate of mortality in the intensive care unit (ICU). A lung-protective mechanical ventilation strategy using low tidal volumes is a cornerstone to management, but uncontrolled hypercapnia is a life-threatening consequence among severe cases. A mechanism to prevent progressive hypercapnia may offset hemodynamic instability among patients who develop hypercapnia. We present the case of a woman in her mid-60's with severe acute hypercapnic respiratory failure secondary to COVID-19 pneumonia who was successfully treated with early implementation of lung-protective ventilation facilitated by extracorporeal carbon dioxide removal (ECCOR). This patient's multiple comorbid conditions included obesity, hypertension, type 2 diabetes mellitus, and hypercholesterolemia. On her fifth day of admission at the referring hospital, her worsening hypoxemia prompted endotracheal intubation during which she developed pneumothorax. She was transferred to our institution for advanced care where upon arrival, she had profound hypercapnia and respiratory acidosis. She met the criteria for treatment with an investigational ECCOR device (Hemolung Respiratory Assist System) available through FDA Emergency Use Authorization. ECCOR is similar to extracorporeal membrane oxygenation (ECMO) but operates at much lower blood flows (350-550 mL/min) through a smaller 15.5 French central venous catheter. Standard heparinization was provided intravenously to achieve appropriate levels of anticoagulation during ECCOR therapy. Unlike ECMO, ECCOR does not provide clinically meaningful oxygenation but is simpler to implement and manage. The use of ECCOR successfully corrected and controlled the patient's hypercapnia and acidosis and enabled meaningful reductions in ventilator tidal volumes, respiratory rates, and mean airway pressures. The patient was weaned from ECCOR after 17 days and from mechanical ventilation 10 days later. With low tidal volume ventilation facilitated by expeditious implementation of ECCOR, the patient survived to discharge despite her many risk factors for a poor outcome and an extended duration of invasive mechanical ventilation.
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http://dx.doi.org/10.1155/2021/9958343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245249PMC
June 2021

Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge.

Acad Emerg Med 2021 07 8;28(7):745-752. Epub 2021 May 8.

Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA.

Objectives: Effective sepsis resuscitation depends on useful criteria for prompt identification of eligible patients. These criteria should reliably predict a discharge diagnosis of sepsis, ensuring that interventions are triggered for those who need it while avoiding potentially harmful interventions in those who do not. We sought to determine the proportion of patients meeting sepsis criteria in the emergency department (ED) that was ultimately diagnosed with sepsis and to quantify the subset of nonseptic patients with risk factors for harm from fluid resuscitation.

Methods: This retrospective cohort study of adult ED patients at a tertiary academic medical center included vital signs and laboratory results from the first 6 hours, plus administration of intravenous antibiotics, to determine if patients met 2016 Sepsis-3 consensus criteria. If these patients also had hypotension and lactic acidosis, we categorized them as Sepsis-3 plus shock. We used discharge ICD-9 codes to determine if patients were ultimately diagnosed with sepsis.

Results: Over 8 years, 3,121 ED patients met 2016 Sepsis-3 criteria in the first 6 hours. Of these, only 25% and 48% met explicit and implicit criteria for a discharge diagnosis of sepsis. Of 1,032 patients with Sepsis-3 plus shock, 48% and 62% met explicit and implicit criteria. Overall, 60% to 75% of ED patients meeting Sepsis-3 criteria with or without shock did not receive a sepsis discharge diagnosis. At least one plausible risk factor for harm from large-volume fluid resuscitation was identified among 19% to 36% of patients meeting sepsis criteria in the ED but not ultimately diagnosed with sepsis at discharge.

Conclusions: Most patients meeting sepsis criteria in the ED were not diagnosed with sepsis at discharge. Urgent treatment bundles triggered by consensus criteria in the early phase of ED care may be administered to several patients without sepsis, potentially exposing some to interventions of uncertain benefit and possible harm.
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http://dx.doi.org/10.1111/acem.14265DOI Listing
July 2021

Extracorporeal Membrane Oxygenation for Poisonings Reported to U.S. Poison Centers from 2000 to 2018: An Analysis of the National Poison Data System.

Crit Care Med 2020 08;48(8):1111-1119

Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN.

Objectives: To assess trends in the use of extracorporeal membrane oxygenation for poisoning in the United States.

Design: Retrospective cohort study.

Setting: The National Poison Data System, the databased owned and managed by the American Association of Poison Control Centers, the organization that supports and accredits all 55 U.S. Poison Centers, 2000-2018.

Patients: All patients reported to National Poison Data System treated with extracorporeal membrane oxygenation.

Interventions: None.

Measurements And Main Results: In total, 407 patients met final inclusion criteria (332 adults, 75 children). Median age was 27 years (interquartile range, 15-39 yr); 52.5% were male. Median number of ingested substances was three (interquartile range, 2-4); 51.5% were single-substance exposures. Extracorporeal membrane oxygenation use in poisoned patients in the United States has significantly increased over time (z = 3.18; p = 0.001) in both adults (age > 12 yr) and children (age ≤ 12 yr), increasing by 9-100% per year since 2008. Increase in use occurred more commonly in adults. We found substantial geographical variation in extracorporeal membrane oxygenation use by geospatially mapping the ZIP code associated with the initial call, with large, primarily rural areas of the United States reporting no cases. Overall survival was 70% and did not vary significantly over the study period for children or adults. Patients with metabolic and hematologic poisonings were less likely to survive following extracorporeal membrane oxygenation than those with other poisonings (49% vs 72%; p = 0.004).

Conclusions: The use of extracorporeal membrane oxygenation to support critically ill, poisoned patients in the United States is increasing, driven primarily by increased use in patients greater than 12 years old. We observed no trends in survival over time. Mortality was higher when extracorporeal membrane oxygenation was used for metabolic or hematologic poisonings. Large, predominantly rural regions of the United States reported no cases of extracorporeal membrane oxygenation for poisoning. Further research should focus on refining criteria for the use of extracorporeal membrane oxygenation in poisoning.
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http://dx.doi.org/10.1097/CCM.0000000000004401DOI Listing
August 2020

Regional Planning for Extracorporeal Membrane Oxygenation Allocation During Coronavirus Disease 2019.

Chest 2020 08 25;158(2):603-607. Epub 2020 Apr 25.

Department of Emergency Medicine, Hennepin Healthcare and the University of Minnesota Medical School, Minneapolis, MN.

Health systems confronting the coronavirus disease 2019 (COVID-19) pandemic must plan for surges in ICU demand and equitably distribute resources to maximize benefit for critically ill patients and the public during periods of resource scarcity. For example, morbidity and mortality could be mitigated by a proactive regional plan for the triage of mechanical ventilators. Extracorporeal membrane oxygenation (ECMO), a resource-intensive and potentially life-saving modality in severe respiratory failure, has generally not been included in proactive disaster preparedness until recently. This paper explores underlying assumptions and triage principles that could guide the integration of ECMO resources into existing disaster planning. Drawing from a collaborative framework developed by one US metropolitan area with multiple adult and pediatric extracorporeal life support centers, this paper aims to inform decision-making around ECMO use during a pandemic such as COVID-19. It also addresses the ethical and practical aspects of not continuing to offer ECMO during a disaster.
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http://dx.doi.org/10.1016/j.chest.2020.04.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182515PMC
August 2020

Emergency physicians should be shown all triage ECGs, even those with a computer interpretation of "Normal".

J Electrocardiol 2019 May - Jun;54:79-81. Epub 2019 Mar 21.

Hennepin County Medical Center, Department of Emergency Medicine, 701 Park Ave, Minneapolis, MN 55415, United States of America; University of Minnesota, Department of Emergency Medicine, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.

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http://dx.doi.org/10.1016/j.jelectrocard.2019.03.003DOI Listing
September 2020

"Concordance" Revisited: A Multispecialty Appraisal of "Concordant" Preliminary Abdominopelvic CT Reports.

J Am Coll Radiol 2016 Sep 20;13(9):1111-7. Epub 2016 Jun 20.

Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan; Michigan Radiology Quality Collaborative, Ann Arbor, Michigan. Electronic address:

Purpose: To determine whether resident abdominopelvic CT reports considered prospectively concordant with the final interpretation are also considered concordant by other blinded specialists and abdominal radiologists.

Methods: In this institutional review board-approved retrospective cohort study, 119 randomly selected urgent abdominopelvic CT examinations with a resident preliminary report deemed prospectively "concordant" by the signing faculty were identified. Nine blinded specialists from Emergency Medicine, Internal Medicine, and Abdominal Radiology reviewed the preliminary and final reports and scored the preliminary report with respect to urgent findings as follows: 1.) concordant; 2.) discordant with minor differences; 3.) discordant with major differences that do not alter patient management; or 4.) discordant with major differences that do alter patient management. Predicted management resulting from scores of 4 was recorded. Consensus was defined as majority agreement within a specialty. Consensus major discrepancy rates (ie, scores 3 or 4) were compared to the original major discrepancy rate of 0% (0/119) using the McNemar test.

Results: Consensus scores of 4 were assigned in 18% (21/119, P < .001, Emergency Medicine), 5% (6/119, P = .03, Internal Medicine), and 13% (16/119, P < .001, Abdominal Radiology) of examinations. Consensus scores of 3 or 4 were assigned in 31% (37/119, P < .001, Emergency Medicine), 14% (17/119, P < .001, Internal Medicine), and 18% (22/119, P < .001, Abdominal Radiology). Predicted management alterations included hospital status (0-4%), medical therapy (1%-4%), imaging (1%-10%), subspecialty consultation (3%-13%), nonsurgical procedure (3%), operation (1%-3%), and other (0-3%).

Conclusions: The historical low major discrepancy rate for urgent findings between resident and faculty radiologists is likely underreported.
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http://dx.doi.org/10.1016/j.jacr.2016.04.019DOI Listing
September 2016

A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial.

Crit Care Med 2015 Mar;43(3):621-9

1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. 2Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN. 3Department of Critical Care Medicine, University of Hawaii, John A. Burns School of Medicine, Honolulu, HI. 4Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN. 5Divisions of Emergency and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA. 6Division of General Internal Medicine, Mayo Clinic, Rochester, MN. 7Divisions of Nephrology and Critical Care Medicine, Mayo Clinic, Rochester, MN.

Objective: To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU.

Design: Randomized, unblinded trial.

Setting: Single medical ICU.

Patients: Patients and surrogate decision makers in the ICU.

Interventions: The usual care group received a standard pamphlet about cardiopulmonary resuscitation and cardiopulmonary resuscitation preference options plus routine code status discussions with clinicians. The video group received usual care plus an 8-minute video that depicted cardiopulmonary resuscitation, showed a simulated hospital code, and explained resuscitation preference options.

Measurements And Main Results: One hundred three patients and surrogates were randomized to usual care. One hundred five patients and surrogates were randomized to video plus usual care. Median total knowledge scores (0-15 points possible for correct answers) in the video group were 13 compared with 10 in the usual care group, p value of less than 0.0001. Video group participants had higher rates of understanding the purpose of cardiopulmonary resuscitation and resuscitation options and terminology and could correctly name components of cardiopulmonary resuscitation. No statistically significant differences in documented resuscitation preferences following the interventions were found between the two groups, although the trial was underpowered to detect such differences. A majority of participants felt that the video was helpful in cardiopulmonary resuscitation decision making (98%) and would recommend the video to others (99%).

Conclusions: A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.
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http://dx.doi.org/10.1097/CCM.0000000000000749DOI Listing
March 2015

Development, validation, and results of a survey to measure understanding of cardiopulmonary resuscitation choices among ICU patients and their surrogate decision makers.

BMC Anesthesiol 2014 Mar 8;14:15. Epub 2014 Mar 8.

Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

Background: Shared-decision-making about resuscitation goals of care for intensive care unit (ICU) patients depends on a basic understanding of cardiopulmonary resuscitation (CPR). Our objective was to develop and validate a survey to assess comprehension of CPR among ICU patients and surrogate decision-makers.

Methods: We developed a 12-item verbally-administered survey incorporating input from patients, clinicians, and expert focus groups.

Results: We administered the survey to 32 ICU patients and 37 surrogates, as well as to 20 resident physicians to test discriminative validity. Median (interquartile range) total knowledge scores were 7 (5-10) for patients, 9 (7-12) for surrogates, and 14.5 (14-15) for physicians (p <.001). Forty-four percent of patients and 24% of surrogates could not explain the purpose of CPR. Eighty-eight percent of patients and 73% of surrogates could not name chest compressions and breathing assistance as two components of CPR in the hospital. Forty-one percent of patients and 24% of surrogates could not name a single possible complication of CPR. Forty-three percent of participants could not specify that CPR would be performed with a full code order and 25% of participants could not specify that CPR would not be performed with a do-not-resuscitate order. Internal consistency (Cronbach's alpha = 0.97) and test-retest reliability (Pearson correlation = 0.96, p < .001) were high.

Conclusions: This easily administered survey, developed to measure knowledge of CPR and resuscitation preference options among ICU patients and surrogates, showed strong face validity, content validity, internal consistency, test-retest reliability, and discriminative validity. A substantial proportion of ICU patients and surrogates decision-makers have poor knowledge of CPR and basic resuscitation options.
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http://dx.doi.org/10.1186/1471-2253-14-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975319PMC
March 2014

The role of potentially preventable hospital exposures in the development of acute respiratory distress syndrome: a population-based study.

Crit Care Med 2014 Jan;42(1):31-9

1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. 2Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN. 3Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN. 4Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN.

Objective: Acute respiratory distress syndrome is a common complication of critical illness, with high mortality and limited treatment options. Preliminary studies suggest that potentially preventable hospital exposures contribute to acute respiratory distress syndrome development. We aimed to determine the association between specific hospital exposures and the rate of acute respiratory distress syndrome development among at-risk patients.

Design: Population-based, nested, Matched case-control study.

Patients: Consecutive adults who developed acute respiratory distress syndrome from January 2001 through December 2010 during their hospital stay (cases) were matched to similar-risk patients without acute respiratory distress syndrome (controls). They were matched for 6 baseline characteristics.

Interventions: None.

Measurements And Main Results: Trained investigators blinded to outcome of interest reviewed medical records for evidence of specific exposures, including medical and surgical adverse events, inadequate empirical antimicrobial treatment, hospital-acquired aspiration, injurious mechanical ventilation, transfusion, and fluid and medication administration. Conditional logistic regression was used to calculate the risk associated with individual exposures. During the 10-year period, 414 patients with hospital-acquired acute respiratory distress syndrome were identified and matched to 414 at-risk, acute respiratory distress syndrome-free controls. Adverse events were highly associated with acute respiratory distress syndrome development (odds ratio, 6.2; 95% CI, 4.0-9.7), as were inadequate antimicrobial therapy, mechanical ventilation with injurious tidal volumes, hospital-acquired aspiration, and volume of blood products transfused and fluids administered. Exposure to antiplatelet agents during the at-risk period was associated with a decreased risk of acute respiratory distress syndrome. Rate of adverse hospital exposures and prevalence of acute respiratory distress syndrome decreased during the study period.

Conclusions: Prevention of adverse hospital exposures in at-risk patients may limit the development of acute respiratory distress syndrome.
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http://dx.doi.org/10.1097/CCM.0b013e318298a6dbDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3844124PMC
January 2014

Clinical review: the hospital of the future - building intelligent environments to facilitate safe and effective acute care delivery.

Crit Care 2012 Dec 12;16(2):220. Epub 2012 Dec 12.

Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

The translation of knowledge into rational care is as essential and pressing a task as the development of new diagnostic or therapeutic devices, and is arguably more important. The emerging science of health care delivery has identified the central role of human factor ergonomics in the prevention of medical error, omission, and waste. Novel informatics and systems engineering strategies provide an excellent opportunity to improve the design of acute care delivery. In this article, future hospitals are envisioned as organizations built around smart environments that facilitate consistent delivery of effective, equitable, and error-free care focused on patient-centered rather than provider-centered outcomes.
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http://dx.doi.org/10.1186/cc11142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681335PMC
December 2012

Acute lung injury: prevention may be the best medicine.

Respir Care 2011 Oct;56(10):1546-54

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.

Acute lung injury affects a subset of hospitalized patients but is not universal. This syndrome can substantially delay ventilator liberation, prolong intensive care unit (ICU) stay, and increase mortality. As with many critical illness syndromes, the available treatment options are limited in number and impact. Once a patient develops lung injury, the best known strategy is supportive care. Observational studies have identified potential risk factors and have suggested that the use and timing of certain critical care interventions may influence the likelihood of developing lung injury. These findings suggest that a well designed screening tool and the systematic application of best practices in critical care may limit the risk of lung injury. An effective prediction score may also facilitate enrollment in pharmacopreventive trials. Development of such tools is accelerated by multicenter collaboration.
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http://dx.doi.org/10.4187/respcare.01361DOI Listing
October 2011
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