1. Dr. David R. Barnum Research Lecture
The Use of Beta Blockers in Patients with COPD on Long Term Oxygen Therapy
Dr. David R. Barnum Research Lecture
May 26, 2017
Author: John Matera, MD

2. Objectives To provide background information on COPD
To discuss the research methods used in this study
To examine the effect of beta-blockers on mortality in Chronic Obstructive Pulmonary Disease Patients on Long Term Oxygen Therapy.

3. Background Chronic Obstructive Pulmonary Disease (COPD)
Disease characterized by airflow obstruction
3rd ranked cause of death in the United States
Mortality 120,000 deaths per year
Airflow obstruction is treated with inhaled beta-agonists
Non-selective beta-blockade can worsen airflow obstruction

4. GOLD Treatment Guidelines
Long-term oxygen therapy
usually indicated severe
disease
Short-acting bronchodilators
usually are beta-agonists

5. Why This Question
The effects of beta blockers in COPD has controversial effects on mortality rate
McGarvey et al. in 2007 studied severe COPD and causes of mortality findings included:
26% of patients with a cardiovascular source of death
35% with a respiratory cause of death
21% caused by malignancy- so we know cardiac disease is a significant contributor to all cause mortality (but there was no risk stratification correlating this with long term oxygen therapy)
A meta-analysis by Etminan et al in 2012 showed:
Improved mortality in patient’s with COPD on beta blockers
But as with any meta-analysis there is the risk for confounding by indication (i.e. clinicians would only prescribe beta-blockers to patients with mild COPD due to theoretical risks of beta-blockade upon lung function)
Note to self, mention the opening of a Christmas carol and “marley was dead, that must be abundantly clear or nothing thereafter will make any sense” as the reason for the thorough explanation of why this question is being asked, its not enough to say the literature is unclear- show them
in this context as people are hesitant to prescribe beta blockers to patient’s with COPD, so when they are knowingly withheld from patient’s with severe COPD it appears that there is a potentially beneficial effect when treating comorbid conditions)

6. Increased mortality with use of beta-blockade in COPD
Ekstrom et al. in 2013 studied the effects of cardiovascular drugs in patients with COPD using long term oxygen:
Drugs included ACE inhibitors, ARBS, antiplatelet agents, and beta blockers
All patients had severe COPD on long term oxygen
Used probability of drug exposure
If a prescription was placed it was assumed to be exposure for 3 months
Results showed worsening mortality rate with use of beta blockade when controlled for ischemic heart disease
Keep in mind this study also demonstrated
Increased hazard ratio with use of oral glucocorticoids
Findings may reflect severity of disease and exacerbations rather than the drugs themselves
Any 1 diagnosis was sufficient to qualify for heart disease, including heart failure or ischemic disease
A-fib was not considered as a diagnosis for heart disease
In first study, all patient’s had severe COPD, and 50% of the subjects diet, this was severe

7. Confounding Information
No mention of A-fib as a diagnosis pertaining to heart disease
Ekstrom et al. in 2013 – diagnosis codes used to define heart disease

8. And Yet…beta-blockers could be useful in COPD to lower mortality
COPD patients who have atrial fibrillation have an increased risk of mortality [Varun Shah et al 2016]
Elevated heart rate is an independent predictor of mortality [Jensen, M.T., et al., 2013]
Post myocardial infarction, use of beta-blockers [carvedilol] can decrease atrial fibrillation [McMurray, J., et al, 2005]

9. Confounding Information
Heart Disease (including A-fib)
Mortality ?
Beta Blocker Use
The question becomes

10. Despite This
Current GOLD guidelines endorse the treatment of heart disease as if COPD did not exist.
Beta blockers may worsen airflow obstruction, but may reduce cardiac related mortality in a number of ways
So really we are discussing possible cardioprotective effects of beta blockers, vs possible effects on lung function

11. To Summarize: Comorbid Conditions with COPD
COPD is associated with
Heart disease (including CHF, coronary artery disease and A-fib)
Hypoxia
Mortality from COPD is typical caused by
Coronary artery disease

12. Research Design Retrospective study based on chart review.
Patient charts from April 2009 to April 2015 for patients with a diagnosis of COPD who are on long term oxygen therapy (LTOT) age 18-95
COPD was defined by:
Pulmonary function tests showing FEV1/FVC ratio less than 0.70 or less than the lower limit of normal [LLN] plus an FEV1 less than 80 percent of predicted and only partially reversible with bronchodilator therapy
Clinical diagnosis

13. Definitions
Long term oxygen therapy (LTOT) was defined by a diagnosis of COPD and one of the following
PaO2 of <55mmHg (O2 sats <88%) on rest or ambulation
PaO2 of mmHg (O2 sats <89%) and who exhibit signs of tissue hypoxia
eg, pulmonary hypertension, cor pulmonale, erythrocytosis, edema from right heart failure or impaired mental status.
Beta blocker use was defined as
Current use of any class of beta blocker (selective or nonselective)
Present in the ambulatory encounter
For a minimum duration of 6 months

14. Definitions Coronary Artery Disease Heart Failure Atrial Fibrillation
Defined by evidence of obstruction on cardiac angiogram, the presence of calcified plaques on CT imaging, or by clinical history
Heart Failure
Left sided heart failure defined by clinical symptoms or supporting echocardiography demonstrating impaired left sided systolic or diastolic cardiac function.
Atrial Fibrillation
We define atrial fibrillation as the presence of an irregularly irregular rhythm without the presence of p-waves captured on an electrocardiogram. A single episode of this event is enough to diagnose a subject as having a history of atrial fibrillation.

15. Main Group Analysis Subdividing our subjects into two groups:
Patients who have used any beta blocker in the outpatient setting for 6 months or more
Patients who have not been a beta blocker for 6 months or more
Secondary sub-group analysis with respect to co-morbidities including
Atrial fibrillation,
Congestive heart failure (either systolic or diastolic)
CAD.

16. Outcomes Primary outcome: all-cause mortality rates
3 year survival propensity match, patients will be deemed alive if they were alive on 1/1/16 (given potential lag from social security office reporting deaths)
This guarantees that all patients had a minimum of 6 months of beta blocker use prior to the end of the study, or prior to death
Secondary analysis includes
Hospital admission and exacerbation rates

17. Data Gathering
Initial screening found > 4000 patients with COPD in the NorthShore system with the dates and ages defined
Further screening was performed to identify patients on long term oxygen with a documented indication [excluded home oxygen for comfort, OSA, or palliative measures]
Cohort was assessed for the presence or absence of:
A-fib
CHF
CAD
PFT results

18. Results
Filler pending ed results from data scientist

19. Conclusions
Filler pending ed results from data scientist

20. Acknowledgements
Thank you to the following people for all of your help with this project
Dr. Shashi Bellam
Mohammad Imran Beig
Daniel Chertok
Shad Mahmood

21. References
1. Centers for Disease, C. and Prevention, Chronic obstructive pulmonary disease among adults--United States, MMWR Morb Mortal Wkly Rep, (46): p
2. Soriano, J.B., et al., Patterns of comorbidities in newly diagnosed COPD and asthma in primary care. Chest, (4): p
3. Mannino, D.M., et al., Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J, (4): p
4. McGarvey, L.P., et al., Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint Committee. Thorax, (5): p
5. Rutten, F.H., et al., Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease. Arch Intern Med, (10): p
6. Dransfield, M.T., et al., Use of beta blockers and the risk of death in hospitalised patients with acute exacerbations of COPD. Thorax, (4): p
7. van Gestel, Y.R., et al., Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis. Am J Respir Crit Care Med, (7): p
8. Stefan, M.S., et al., Association between beta-blocker therapy and outcomes in patients hospitalised with acute exacerbations of chronic obstructive lung disease with underlying ischaemic heart disease, heart failure or hypertension. Thorax, (11): p
9. Etminan, M., et al., Beta-blocker use and COPD mortality: a systematic review and meta-analysis. BMC Pulm Med, : p. 48.
10. Jensen, M.T., et al., Resting heart rate is a predictor of mortality in COPD. Eur Respir J, (2): p

22. References
11. Chhabra, S.K. and S. De, Cardiovascular autonomic neuropathy in chronic obstructive pulmonary disease. Respir Med, (1): p
12. Bangalore, S., et al., Clinical outcomes with beta-blockers for myocardial infarction: a meta-analysis of randomized trials. Am J Med, (10): p
13. Behar, S., et al., Long-term prognosis of patients with paroxysmal atrial fibrillation complicating acute myocardial infarction. SPRINT Study Group. Eur Heart J, (1): p
14. Pedersen, O.D., et al., The occurrence and prognostic significance of atrial fibrillation/-flutter following acute myocardial infarction. TRACE Study group. TRAndolapril Cardiac Evalution. Eur Heart J, (10): p
15. McMurray, J., et al., Antiarrhythmic effect of carvedilol after acute myocardial infarction: results of the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) trial. J Am Coll Cardiol, (4): p
16. Ekstrom, M.P., A.B. Hermansson, and K.E. Strom, Effects of cardiovascular drugs on mortality in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med, (7): p
17. Minino, A.M., et al., Deaths: final data for Natl Vital Stat Rep, (10): p
 18. Varun Shah, et al., The Association Between Chronic Obstructive Pulmonary Disease (COPD) and Atrial Fibrillation: A Review. Chronic Obstructive Pulmoanry Disease: Open Access, 2016
19. UpToDate, Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging;
20. UpToDate, Management of stable chronic obstructive pulmonary disease;

23. Alan Moreno MD Louisa Tammy Ho MD 5/26/2017
Empiric cefazolin and ceftazidime in outpatient treatment of peritonitis in peritoneal dialysis patients
Alan Moreno MD
Louisa Tammy Ho MD
5/26/2017

24. Objectives Background on peritoneal dialysis Peritonitis
Current treatment guidelines
Results
Conclusions and future consideration

25. Peritoneal Dialysis – the dominant method of home dialysis
Background
Peritoneal Dialysis – the dominant method of home dialysis

26. Background Benefits Drawbacks Flexible Cheaper
Afford active lifestyle
Less fluid/dietary restrictions
Cheaper
No adverse vascular events
No survival/mortality difference between HD and PD
Higher health literacy required
Preexisting conditions
Previous abdominal surgeries
Psychiatric conditions
Cumbersome hardware
PD fluid
Cyclers
Cost comparison of peritoneal dialysis versus hemodialysis in end-stage renal disease.

27. Background
Types
Continuous ambulatory peritoneal dialysis (CAPD)
Typically 4 exchanges throughout the day
Automated peritoneal dialysis (APD)
A “CYCLER” does multiple exchanges for you while asleep
All forms of PD require patient or family access of indwelling catheter to connect to a system of dialysis

30. Background
Northshore has a greater number of ESRD patients performing PD
Approximately 10% of ESRD patients nationally perform PD. In USRDS data as of 2016:
421,219 HD
46,121 PD
In our system 20% of ESRD as of 2016 perform PD
289 HD patients
75 PD patients

31. Background
There is a growing number of both incident and prevalent home dialysis patients
Centers for Medicare & Medicaid
2011 financial incentives increased favoring home dialysis
In 2011, IHI published a case study of Swedish dialysis patients who had taken on self-management of their own dialysis and care. The operating costs of the unit dropped 33% because of reduced complications, and patient satisfaction was undeniably improved.
Net profits are greater
In 2011, Medicare began bundling dialysis care payments in an attempt to better control expenses, paying about $240 per treatment, or around $37,000 a year to empower patients in managing overall costs.

32. Figure Trends in number of prevalent ESRD cases (in thousands) using home dialysis, by type of therapy, in the United States,
Data Source: Reference Table D.1. December 31 prevalent ESRD patients; Peritoneal dialysis consists of CAPD and CCPD only. Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; CCPD, continuous cycler peritoneal dialysis; ESRD, end-stage renal disease.
2016 Annual Data Report, Vol 2, ESRD, Ch 1

33. Figure Trends in the number of incident ESRD cases (in thousands) using home dialysis, by type of therapy, in the U.S. population,
Data Source: Reference Table D.1. Abbreviations: ESRD, end-stage renal disease; PD, peritoneal dialysis.
2016 Annual Data Report, Vol 2, ESRD, Ch 1

34. Peritonitis
The number one cause of loss of patient from PD to HD is peritonitis
peritoneal inflammation and changes in peritoneal transport can lead to therapy failure
Early and effective management of peritonitis is essential to any home program
Peritonitis incidence is variable from center to center
significant differences in rates are seen in different countries
Hsieh Y-P, Chang C-C, Wen Y-K, Chiu P-F, Yang Y. Predictors of Peritonitis and the Impact of Peritonitis on Clinical Outcomes of Continuous Ambulatory Peritoneal Dialysis Patients in Taiwan—10 Years’ Experience in a Single Center. Peritoneal Dialysis International : Journal of the International Society for Peritoneal Dialysis. 2014;34(1): doi: /pdi
Peritonitis is associated with peritoneal inflammation leading to hyperemia and changes in peritoneal transport. The changes of impaired ultrafiltration increased peritoneal transport of low-molecular-weight solutes and increased rates of glucose absorption, are usually transient and typically resolve within a month after resolution of the peritonitis

35. Peritonitis Etiology of infection Interluminal Periluminal
Secondary to non-sterile techniques with exchanges
Periluminal
Skin infections at the catheter exit site
Spontaneous bacterial peritonitis
Bacterial translocation
Hematologous
Rare
Transvaginal
Grading of exit site infections - Keane WF, Bailie GR, Boeschoten E, Gokal R, Golper TA, Holmes CJ, Kawaguchi Y, Piraino B, Riella M, Vas S, International Society for Peritoneal Dialysis SOPerit Dial Int. 2000;20(4):396. 

36. Peritonitis Most common international infections Gram positive
Coagulase negative staphylococci
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus sp.
Enterococcus sp.
Gram negative
Pseudomonas sp.
Klebsiella sp.
Proteus sp.
Bianchi P, Buoncristiani E, Buoncristiani U. Antisepsis. Contrib Nephrol. 2007;154:1–6. 
Brook NR, White SA, Waller JR, Nicholson ML. The surgical management of peritoneal dialysis catheters. Ann R Coll Surg Engl. 2004;86:190–195. 
Renaud CJ, Subramanian S, Tambyah PA, Lee EJ. The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review. Nephrology (Carlton) 2011;16:174–179. 
Gupta S, Muralidharan S, Gokulnath H. Epidemiology of culture isolates from peritoneal dialysis peritonitis patients in southern India using an automated blood culture system to culture peritoneal dialysate. Nephrology (Carlton) 2011;16:63–67. 
Davies S. Clinical practice guidelines module 3b: peritoneal dialysis, UK Renal Association Third Edition, Available from:
Epidemiology of PD related infections etc - Akoh JA. Peritoneal dialysis associated infections: An update on diagnosis and management. World Journal of Nephrology. 2012;1(4): doi: /wjn.v1.i4.106.
- prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care

37. Northshore-Wellbound
An outpatient training and management clinic for home dialysis
Started
Current PD population: 75 patients
Peritonitis rates: 0.21 patient-years between

38. Peritonitis Rates in Patient-Years

39. Peritonitis Rates in Patient-Years

40. Peritonitis
“A team approach for continuous quality improvement (CQI) is the key to a successful PD program”

41. Treatment
GOAL: rapid resolution of inflammation to preserve peritoneal membrane function
Empiric antibiotic broad spectrum antibiotics to cover gram negative and gram positive organisms
Bender FH, Bernardini J, Piraino B. Prevention of infectious complications in peritoneal dialysis: best demonstrated practices. Kidney Int Suppl. 2006;70:S44–S54. 
Campos RP, Chula DC, Riella MC. Complications of the peritoneal access and their management. Contrib Nephrol. 2009;163:183–197. 
Dalrymple LS, Johansen KL, Chertow GM, Cheng SC, Grimes B, Gold EB, Kaysen GA. Infection-related hospitalizations in older patients with ESRD. Am J Kidney Dis. 2010;56:522–530. 

42. Current Guidelines Per ISPD 2016:
“IP antibiotics be the preferred route of administration unless the patient has features of systemic sepsis (1B).”
“…empirical antibiotic therapy be initiated as soon as possible after appropriate microbiological specimens have been obtained (1C).”
“…empirical antibiotic regimens be center-specific and cover both gram-positive and gram-negative organisms (1C).”
“…gram-positive organisms be covered by vancomycin or a first generation cephalosporin (1B)”
“…gram-negative organisms by a third-generation cephalosporin or an aminoglycoside(1B).”
ISPD international society of peritoneal dialysis

43. A study of treatment success of inpatient peritonitis was conducted
From a retrospective review of 71 inpatient peritonitis cases
Primary outcome was to determine whether initial, empiric treatment with vancomycin or cefazolin in inpatient PD patients with peritonitis had effect on the rate of clinical resolution of infection caused by gram positive organisms

44. Vancomycin had statistical and clinically significant benefits over cefazolin
Compared outcomes when using vancomycin or cefazolin for gram + infection
Excluded gram negative organisms, “no growth”
Darya Kupershteyn, PharmD, Mira Suseno, PharmD, BCPS-ID, George Kim, MD, L Tammy Ho, MD, Kevin Nash, MD

45. Current empiric out patient treatment of PD associated peritonitis
Peritonitis empiric protocols:
1g cefazolin IP
1g ceftazidime IP
Fluconazole +/- at physician discretion
There is a disconnect between OP and IP treatment protocols
The patient pool is the same as Wellbound

46. Clinical Questions of Current Study
What are the current rates of failure amongst patients being treated with empiric cefazolin and ceftazidime?
Is our rationale for avoiding Vancomycin use reasonable?
Concern for VRE rates

47. Objectives Primary objective Secondary objectives
To assess failure rates of current empiric treatments with cefazolin and ceftazidime
Secondary objectives
Identification of the most common outpatient organisms
Assess rates of repeat, recurrent, relapsing or refractory peritonitis with current empiric treatments
Assess peritonitis hospital admission rates

48. Methods
Empiric Treatment failure defined as any of the following subsets:
Hospitalization
Switching antibiotics: for any reason including resistance, intolerance to medications
Removal of peritoneal dialysis catheter
Recurrence: episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism
Relapse: episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or one sterile episode
Refractory failure: failure of the effluent to clear after 5 days of appropriate antibiotics
Hospitalization for peritonitis related complications

49. Methods
Retrospective chart review of outpatient Wellbound/Northshore patients on peritoneal dialysis treated for peritonitis between 1/1/2010 and 6/1/2016
Multiple infections on the same patient are treated as independent events

50. Methods Inclusion Criteria Age >18
Receiving outpatient peritoneal dialysis at Wellbound
Diagnosed peritonitis
Defined as 2 or more of the following:
Abdominal pain or cloudy peritoneal dialysis effluent (PDE)
White blood cell count >100/mL in PDE
Positive gram stain or culture from PDE
peritoneal inflammation leading to hyperaemia and changes in peritoneal transport

51. Non-protocol treatment
Results
Variable
Protocol treatment
Non-protocol treatment
Patients [n(%)] 22 36
Cases [n(%)] 27 46
Sex [n(% men)]
17(63%)
33(62.3%)
Mean age (range)
65.0
62.0
APD use
25 (92.6%)
42 (91.0%)
Of the non-protocol:
- 2 prior allergies to medications
- (quantify ED treated cases) -

52. Non-protocol treatment
Results
Variable
Protocol treatment
Non-protocol treatment
Recurrence [n(%)]
2 (7.4%)
3 (6.5%)
Relapse [n(%)]
2 (4.3%)
PD catheter removal [n(%)]
4 (14.8%)

53. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393–423 [Erratum in: Perit Dial Int 2011; 31:512] [PubMed]

54. Clinical Questions of Current Study
What are the current rates of failure amongst patients being treated with empiric cefazolin and ceftazidime?
Is our rationale for avoiding Vancomycin use reasonable?
Concern for VRE rates

55. Results: Failure in those receiving empiric antibiotic protocol as OP
Variable
Protocol treatment
Cases [n(%)] 27
Treatment failure [n(%)]
13 (48%)
Hospitalization
9 (33%)
Recurrences
2 (7.4%)
Relapse
Medication change
10 (37%)
Catheter removal
4 (14.8%)
2 recurrences – different patients one each. Both involved enterococcus  candida or corynebacterium
2 relapses – from same patient. The relapses were MSSA
Enterococcal and candida infections were automatic failures

57. Comparisons of susceptibilities
Cefazolin
% Susceptible in protocol treated %
Susceptible NS antibiogram
Coagulase-negative staphylococci (n=12)
83%
62%
Enterococcus faecalis (n=3)
0% (IR)
Staphylococcus aureus* (n=3)
100%
No cases
72%
Streptococcus viridans (n=1)
*All staph aureus cultures were MSSA

58. Comparisons of susceptibilities
Cefazolin
% Susceptible in protocol treated %
Susceptible NS antibiogram
Coagulase-negative staphylococci (n=12)
83%
62%
Enterococcus faecalis (n=3)
0% (IR)
Staphylococcus aureus* (n=3)
100%
No cases
72%
Streptococcus viridans (n=1)
Klebsiella spp (n=2) -
35%
Citrobacter koseri (n=1)
88%
*All staph aureus cultures were MSSA

59. Comparisons of susceptibilities
Cefazolin
Ceftazidime
% Susceptible in protocol treated %
Susceptible NS antibiogram
Coagulase-negative staphylococci (n=12)
83%
62% -
Enterococcus faecalis (n=3)
0% (IR)
Staphylococcus aureus* (n=3)
100%
No cases
72%
Streptococcus viridans (n=1)
Klebsiella spp (n=2)
35%
98%
Citrobacter koseri (n=1)
88%
*All staph aureus cultures were MSSA

60. Comparisons of susceptibilities
Cefazolin
Ceftazidime
% Susceptible in protocol treated %
Susceptible NS antibiogram
Coagulase-negative staphylococci (n=12)
83%
62% -
Enterococcus faecalis (n=3)
0% (IR)
Staphylococcus aureus* (n=3)
100%
No cases
72%
Streptococcus viridans (n=1)
Klebsiella spp (n=2)
35%
98%
Citrobacter koseri (n=1)
88%
*All staph aureus cultures were MSSA

61. Degree of Vancomycin susceptibility of organisms cultured in OP protocol treated peritonitis
Cefazolin
% Susceptible in protocol treated %
Susceptible NS antibiogram
Coagulase-negative staphylococci (n=12)
83%
62%
Enterococcus faecalis (n=3)
0% (IR)
Staphylococcus aureus (n=3)
100%
Streptococcus viridans (n=1) ND
Nnt = 1.3?
*adequately covered by ceftazidime

62. Degree of Vancomycin susceptibility of organisms cultured in OP protocol treated peritonitis
Cefazolin
Vancomycin
% Susceptible in protocol treated %
Susceptible NS antibiogram
Coagulase-negative staphylococci (n=12)
83%
62%
100%
MSSA
Enterococcus faecalis (n=3)
0% (IR)
97%
Staphylococcus aureus (n=3)
Streptococcus viridans (n=1) ND
Nnt = 1.3?
*adequately covered by ceftazidime

63. Clinical Questions of Current Study
What are the current rates of failure amongst patients being treated with empiric cefazolin and ceftazidime?
Is our rationale for avoiding Vancomycin use reasonable?
Concern for VRE rates

64. Trend of Enterococci Susceptibility 2002-2016

65. Trend of Enterococci Susceptibility 2002-2016

66. Discussion
Current outpatient protocol for empiric treatment is associated with failure in 48% patients
Again defined as hospitalization and antibiotic changes
This is despite that the susceptibilities to cefazolin of OP cultured coagulase negative Staph is better than seen on the in patient level
Trend of VRE has not increased in the last 14 years
The majority of patients with OP peritonitis are sent to the ED for initial evaluation and are admitted

67. Discussion No one died from a peritonitis event Limitations
We could obtain other quantifiable morbidity data aside from hospitalizations, catheter removal or antibiotic changes
Limitations
Tiny sample size (far fewer cases of peritonitis in general)
Single center
No population data
No adequate comparison

68. Conclusions
This was a quality assurance study looking at whether current out patient empiric antibiotic protocols effectively treated outpatient PD-associated peritonitis
Do the very low rates of peritonitis in general lead to a sicker sub-group of patients on presentation?
Do nurses feel less comfortable with more ill patients and send to ED for evaluation
GI hx and peritonitis - Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, et al. Colonic diverticulosis as a risk factor for peritonitis in Chinese peritoneal dialysis patients. Perit Dial Int 2010; 30(2):187–91.

69. References
Ballinger AE Treatment for peritoneal dialysis-associated peritonitis. Cochrane Database Syst Rev 2014; 4:CD
Li PKT, Szeto CC, Piraino B, Bernardini J, Figueiredo A, Gupta A, Johnson DW, Kuijper EJ, Lye WC, Salzer W, Schaefer F, Struijk DG PDI 2010; 30:
(for epidemiology)
Bender FH, Bernardini J, Piraino B. Prevention of infectious complications in peritoneal dialysis: best demonstrated practices. Kidney Int Suppl. 2006;70:S44–S54. 
Macchini F, Valadè A, Ardissino G, Testa S, Edefonti A, Torricelli M, Luzzani S. Chronic peritoneal dialysis in children: catheter related complications. A single centre experience. Pediatr Surg Int. 2006;22:524–528. 
Campos RP, Chula DC, Riella MC. Complications of the peritoneal access and their management. Contrib Nephrol. 2009;163:183–197. 
Dalrymple LS, Johansen KL, Chertow GM, Cheng SC, Grimes B, Gold EB, Kaysen GA. Infection-related hospitalizations in older patients with ESRD. Am J Kidney Dis. 2010;56:522–530. 
Beth Piraino, Perit Dial Int November-December 2011 31: ; published ahead of print August 31, 2011, doi: /pdi
Keane WF, Bailie GR, Boeschoten E, Gokal R, Golper TA, Holmes CJ, Kawaguchi Y, Piraino B, Riella M, Vas S, International Society for Peritoneal Dialysis SOPerit Dial Int. 2000;20(4):396. 
Bianchi P, Buoncristiani E, Buoncristiani U. Antisepsis. Contrib Nephrol. 2007;154:1–6. 
Brook NR, White SA, Waller JR, Nicholson ML. The surgical management of peritoneal dialysis catheters. Ann R Coll Surg Engl. 2004;86:190–195. 
Renaud CJ, Subramanian S, Tambyah PA, Lee EJ. The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review. Nephrology (Carlton) 2011;16:174–179. 
Gupta S, Muralidharan S, Gokulnath H. Epidemiology of culture isolates from peritoneal dialysis peritonitis patients in southern India using an automated blood culture system to culture peritoneal dialysate. Nephrology (Carlton) 2011;16:63–67. 
Davies S. Clinical practice guidelines module 3b: peritoneal dialysis, UK Renal Association Third Edition, 2006.
Akoh JA. Peritoneal dialysis associated infections: An update on diagnosis and management. World Journal of Nephrology. 2012;1(4): doi: /wjn.v1.i4.106.

70. misc Attrition rate Chicago PD epidemiology
Davita/fresinius information
Prophylactic antibiotics - people who undergo dental procedures and colonoscopy
Adequacy after infection
Northshore empiric protocol

71. misc A lack of adequate physician training
Provider infrastructure-related issues
Unanticipated financial incentives that had favored use of in-center HD.

72. misc
Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, et al. Colonic diverticulosis as a risk factor for peritonitis in Chinese peritoneal dialysis patients. Perit Dial Int 2010; 30(2):187–91.
(gut in older patients with PD)

73. misc
PD function
A single, isolated episode of peritonitis (n = 86) had no significant effect on longitudinal peritoneal function, whereas recurrences or clusters of infection (n = 70) caused increases in dialysate/plasma ratio of creatinine and reductions in ultrafiltration, the significance of which increased with the number of episodes. Davies et al[115] demonstrated that solute transfer increases and ultrafiltration declines with time on PD. This process is exacerbated and accelerated by peritonitis, and appears to be proportional to the degree of associated inflammation and number of infections in close proximity.

74. Comparison of Arterial and Venous Blood Gases: Correlation in a General Patient Population
Paul Chung, DO
Anthony Scavone, DO, Asrar Ahmed, DO, Kristine Kuchta, MS, Shashi Bellam, MD
Research Grand Rounds

75. Disclosures No financial disclosures
Poster presented at: International ATS Conference 2016, San Francisco, CA

76. Objectives Review previous literature
Review correlation of arterial and venous blood gases
Review data on using venous blood gas as a screening tool

77. Background
Blood gas analysis is an important part of the assessment of severe respiratory and metabolic derangements
Acid-base
Ventilation
Oxygen

78. Background Arterial blood gas is gold standard
Problems with obtaining an ABG:
Technically difficult
Increase patient discomfort (additional needle stick)
Arterial injury, hemorrhage and hematoma
Thrombosis and ischemic injury to digits
Infection
Median nerve injury
Reflex sympathetic dystrophy
Can venous blood gas replace arterial blood gas analysis?

79. Background Previous studies have shown mixed results
Specific patient populations
Trauma
Lumbar surgery
DKA
COPD
Specific locations
Emergency Room
ICU

80. Background Meta-analyses comparing VBG to ABG Zeserson et al. 2016.
Byrne et al
pH compared well
pCO2 sufficiently different
Bloom et al
pH and –HCO3 agree reasonably well
pCO2 agree poorly
Zeserson et al
VBG plus SpO2 accurate for undifferentiated critically ill patients

81. Purpose
What is the correlation of arterial and venous blood gases in a general population?
Does the correlation change at extremes of pH and pCO2?
Can venous blood gas analysis replace arterial blood gas analysis?
Can venous blood gases be used as a screening tool?

82. Methods Retrospective, observational study
January 1, 2006 to May 1, 2017
Inclusion criteria:
Arterial and venous blood gases in the same patient obtained within 30 min of each other
Deidentified data

83. Results Mean time between ABG and VBG: 2713 paired pH results
± min
2713 paired pH results
2817 paired pCO2 results
2864 paired -HCO3 results
0.7 to 1.0 – strong
0.5 to 0.7 – moderate
0.3 to 0.5 – weak
0.1 to 0.3 – poor/none
Evans (1996)
0.0 to 0.19 – very weak
0.2 to 0.39 – weak
0.4 to 0.59 – moderate
0.6 to 0.79 – strong
0.8 to 1.0 – very strong

84. pH
Pearson Correlation (p<0.001)

85. pH
Mean Difference: (95% CI: , )

86. pH pH N Pearson Correlation p-value VBG<7.35 1652 0.7682 <0.0001
925
0.7599
VBG<7.20
277
0.7804
ABG
<7.35
>=7.35
VBG
1185
467
171
890
Sensitivity
87.4%
Specificity
65.6%
Negative Predictive Value
83.9%
Positive Predictive Value
71.7%

87. pCO2
Pearson Correlation (p<0.001)

88. pCO2
Mean Difference: (95% CI: , )

89. pCO2 pCO2 N Pearson Correlation P-value VBG>45 1161 0.6848
<0.0001
VBG>50
640
0.7153
VBG>60
205
0.6929
ABG
<45
>=45
VBG
1380
249
561
627
Sensitivity
71.1%
Specificity
71.6%
Negative Predictive Value
52.8%
Positive Predictive Value
84.7%
ABG
<45
>=45
VBG
<30
182 2
>=30
1759
874
Sensitivity
9.4%
Specificity
99.8%
Negative Predictive Value
33.2%
Positive Predictive Value
98.9%

90. -HCO3
Pearson Correlation (p<0.001)

91. -HCO3
Mean Difference: (95% CI: , )

92. Discussion Venous pH Good correlation when all values included
Correlation decreases for pH<7.35 (acidemia)
Confidence interval large enough to affect management
Useful for screening
VBG pH>7.35: no need for confirmatory ABG
VBG pH<7.35: confirm with ABG

93. Discussion Venous pCO2 Good correlation when all values included
Moderate correlation with pCO2>45mmHg
Confidence intervals markedly large and cannot accurately replace an ABG
Useful for screening
pCO2<45mmHg: 71.0% sensitive
pCO2<30mmHg: 98.9% ppv for arterial pCO2<45mmHg

94. Discussion -HCO3 Excellent correlation No other testing done
Calculated value
Accurate measurement of –HCO3 with basic labs

95. Limitations Retrospective, observational study
Central versus peripheral VBG not differentiated
Deidentified data – no sub-population analysis

96. Conclusions VBGs can be used as a screening tool
A venous pH < 7.35 or pCO2 > 30mmHg cannot reliably replace arterial blood measurements

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