Research Snapshot Theater: Quality/Resuscitation/Pulmonary
1274
A SURVEY OF PHYSICIAN-PERCEIVED BARRI-
ERS TO TARGETED TEMPERATURE MANAGE-
MENT
Selina Sutchu1, Dacia Ticas1, Tierra Smith1, John Dollerschell1, Caleb
Harrell1, Madelaine Mills1, Shreya Patel1, Torben Becker1
Introduction/Hypothesis: Neurologic prognosis following car-
diac arrest remains poor. In 2015, the American Heart Associa-
tion updated their guideline that comatose adult patients with
return of spontaneous circulation after cardiac arrest should
have targeted temperature management (TTM) for at least 24
hours. The aim of this study was to explore practice pattern
and views of physicians within an academic medical center re-
garding TTM for patients resuscitated from cardiac arrest.
Methods: We conducted an anonymous survey of physicians
who make decisions about TTM initiation and continuation at
the University of Florida. The survey questions were developed
following a literature review of guideline adherence research
and refined during review by a multidisciplinary cardiac arrest
research team. The survey was disseminated electronically with
advertisement at educational conferences.
Results: The response rate was 64% (80/125). The respondents
were emergency physicians (34%), medical intensivists (30%),
cardiologists (24%), surgical and anesthesiology intensivists
(6%) and neurointensivists (5%). The majority of the respon-
dents reported managing patients after cardiac arrest weekly
to monthly (71%) and having personally initiated TTM for
a patient (75%). Almost one third of respondents (29%) had
discontinued TTM orders prior to a full 24 hours of TTM. Rea-
sons of discontinuation included skepticism in the evidence of
cooling patients with non- shockable rhythms (24%), lack of
consensus within and between departments (19%), lack of re-
sources (18%), concern for prolonging neuroprognostication
(9%), fear of bleeding complications (5%), and difficulties with
the electronic health record (1%).
Conclusions: This study highlights the lack of consensus about
TTM implementation at our large academic medical center.
Discrepancies in reasons for guideline nonadherence were evi-
dent between departments. This study emphasizes the need for
more collaboration on initiating and continuing TTM in the
post-arrest period. Future study will involve both local groups
and national critical care organizations in overcoming barriers
to best practices in post-cardiac arrest care.
University of Florida, Gainesville, FL
1
Critical Care Medicine • Volume 48 • Number 1 (Supplement) www.ccmjournal.org
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
1275
TRANSIENT ISCHEMIC ATTACK SECOND-
ARY TO AIR EMBOLISM FROM RIGHT RADIAL
CATHETER
Emma Nash1, Brooke Veer-Sundermeier2, James Sullivan2, Daniel
Johnson3
Introduction: Invasive blood pressure monitoring via an arte-
rial line is frequently performed in the ICU for hemodynamic
monitoring and frequent lab draws. Here we describe a previ-
ously unreported complication of radial arterial air embolism
resulting in transient ischemic attack.
Description: A 25 year-old man underwent aortic and mitral
valve replacement with mechanical valves due to recurrent
bacterial endocarditis and was subsequently anticoagulated
on a heparin infusion. On postoperative day 1, he remained
intubated, on vasopressors, sedated and was able to move all
extremities to command. Overnight the patient had an acute
change in mental status, and the nurse practitioner and physi-
cian were called to bedside. Per report, the nurse was attempting
to flush a malfunctioning arterial line when the patient became
unresponsive with bilateral nystagmus. The nurse practitioner
then noted that the tubing from the pressurized saline was dis-
connected and now full of air. They suspected neurologic de-
cline was related to air being pushed into the right radial artery.
A code stroke was called and the patient was taken for head CT,
where several small air emboli were found within the vascula-
ture of the right hemisphere. The patient did begin moving his
right side but was still unable to move the left. Arrangements
were made to undergo emergency hyperbaric oxygen (HBO)
therapy, however the patient began improving so therapy was
held given the risks for critically ill patients. Within 8 hours the
patient was fully neurologically intact.
Discussion: Air anywhere in the arterial tree is a severe risk for
devastating embolism, and there is extensive literature describ-
ing this in cardiopulmonary bypass and ECMO cases. Distal
arterial line cannulation is very safe by comparison, and in
fact there are no reported cases involving distal arterial lines in
humans, and only one report of using cows as a model for iat-
rogenic embolism. This patient’s outcome was likely due to his
youth and healthy collateral vasculature, as well as his short is-
chemic time that likely spared the penumbra contributing to his
functional recovery. This case demonstrates that air embolism,
even from a distal arterial line, can cause devastating conse-
quences, and a high level of vigilance is required when manipu-
lating these common tools.
1
Omaha, NE, 2University of Nebraska Medical Center, Omaha, NE, 3University
of Nebraska, Omaha