- Critical Care
Clinical Associate Professor, Anesthesiology, Perioperative and Pain Medicine
Honors & Awards
Rathmann Fellow, E4C Medical Education Fellowship in Patient Centered Care. (July 2014 - June 2015)
Medical Education: Stanford University School of Medicine (2008) CA
Residency: Stanford University Anesthesiology Residency (2012) CA
Internship: Kaiser Permanente Oakland Internal Medicine Residency (2009) CA
Fellowship: Stanford University Critical Care Medicine Fellowship (2013) CA
Board Certification: American Board of Anesthesiology, Critical Care Medicine (2013)
Board Certification: American Board of Anesthesiology, Anesthesia (2013)
Safety and Efficacy of Polymyxin B Hemoperfusion (PMX) for Septic Shock
To compare the safety and efficacy of the PMX cartridge based on mortality at 28-days in subjects with septic shock who have high levels of endotoxin and are treated with standard medical care plus use of the PMX cartridge, versus subjects who receive standard medical care alone.
Graduate and Fellowship Programs
Critical Care Medicine (Fellowship Program)
Use of the Change in Weaning Parameters as a Predictor of Successful Re-Extubation.
Journal of intensive care medicine
OBJECTIVE: Weaning parameters are well studied in patients undergoing first time extubation. Fewer data exists to guide re-extubation of patients who failed their first extubation attempt. It is reasonable to postulate that improved weaning parameters between the first and second extubation attempt would lead to improved rates of re-extubation success. To investigate, we studied a cohort of patients who failed their first extubation attempt and underwent a second attempt at extubation. We hypothesized that improvement in weaning parameters between the first and the second extubation attempt is associated with successful reextubation.INTERVENTIONS: Rapid shallow breathing index (RSBI), maximum inspiratory pressure (MIP), vital capacity (VC), and the blood partial pressure of CO2 (PaCO2) were measured and recorded in the medical record prior to extubation along with demographic information. We examined the relationship between the change in extubation and re-extubation weaning parameters and re-extubation success.MEASUREMENTS AND MAIN RESULTS: A total of 1283 adult patients were included. All weaning parameters obtained prior to re-extubation differed between those who were successful and those who required a second reintubation. Those with reextubation success had slightly lower PaCO2 values (39.5 ± 7.4 mmHg vs. 41.6 ± 9.1 mmHg, p = 0.0045) and about 13% higher vital capacity volumes (1021 ± 410 mL vs. 907 ± 396 mL, p = 0.0093). Lower values for RSBI (53 ± 32 breaths/min/L vs. 69 ± 42 breaths/min/L, p < 0.001) and MIP (-41 ± 12 cmH2O vs. -38 ± 13 cm H2O), p = 0.0225) were seen in those with re-extubation success. Multivariable logistical regression demonstrates lack of independent associated between the change in parameters between the 2 attempts and re-extubation success.CONCLUSIONS: The relationship between the changes in extubation parameters through successive attempts is driven primarily by the value obtained immediately prior to re-extubation. These findings do not support waiting for an improvement in extubation parameters to extubate patients who failed a first attempt at extubation if extubation parameters are compatible with success.
View details for DOI 10.1177/0885066620988675
View details for PubMedID 33461374
- Perioperative Care and Airway Management for a Patient With Sagliker Syndrome CUREUS 2020; 12 (9)
Electrical Storm in COVID-19.
JACC. Case reports
2020; 2 (9): 1256–60
COVID-19 is a global pandemic caused by SARS-CoV-2. Infection is associated with significant morbidity and mortality. Individuals with pre-existing cardiovascular disease or evidence of myocardial injury are at risk for severe disease and death. Little is understood about the mechanisms of myocardial injury or life-threatening cardiovascular sequelae. (Level of Difficulty: Intermediate.).
View details for DOI 10.1016/j.jaccas.2020.05.032
View details for PubMedID 32835266
View details for PubMedCentralID PMC7259914
Modified percutaneous tracheostomy in patients with COVID-19
Trauma Surg Acute Care Open
2020; 5 (1)
View details for DOI 10.1136/tsaco-2020-000625
Perioperative Care and Airway Management for a Patient With Sagliker Syndrome.
2020; 12 (9): e10691
In this report, we present a case of a patient with a history of complex airway anatomy secondary to Sagliker syndrome (SS) who presented with acute exacerbation of chronic respiratory failure. The patient's difficult airway, complicated medical comorbidities, and poor psychosocial status posed a unique challenge for providing safe care during an emergency. The perioperative anesthesia service (PAS), led by critical care anesthesiologists, coordinated a multidisciplinary airway management plan. The PAS team also assisted this medically complex patient with her decision-making process. A 37-year-old female with SS, which is characterized by irreversible disfiguring of head and neck anatomy secondary to end-stage renal disease (ESRD) and poorly controlled hyperparathyroidism, presented with acute exacerbation of chronic respiratory failure due to hypervolemia. The patient's respiratory status rapidly deteriorated despite aggressive hemodialysis, requiring transfer to the ICU. Given the challenging anatomy and poor respiratory reserve in this patient, the PAS team helped coordinate a comprehensive airway plan that involved transnasal fiberoptic intubation, and in case of emergency, extracorporeal membrane oxygenation (ECMO) as a bridge to a surgical airway. During the decision-making process, the patient was found to be in psychological distress and had limited insights into her condition. The PAS team helped facilitated multidisciplinary goals-of-care discussions for the patient and her family. Fortunately, the patient's oxygenation improved with noninvasive oxygen support and aggressive hemodialysis without the need for intubation. She was discharged with outpatient follow-up appointments arranged to discuss long-term management. This is the first reported case of SS in the United States. The early involvement by the PAS team helped coordinate a multidisciplinary care plan for this patient with a difficult airway and complex comorbidities. This report highlights an innovative airway algorithm for a potentially "cannot-intubate, cannot ventilate" complex airway, and the PAS team's role in providing support for the patient's physical and psychological needs, suggesting that a comprehensive perioperative service can improve the quality and safety of care, not only for surgical patients but also for medically complex patients as well.
View details for DOI 10.7759/cureus.10691
View details for PubMedID 33133856
View details for PubMedCentralID PMC7593211
BENZODIAZEPINE-SPARING REGIMEN FOR MANAGEMENT OF ALCOHOL WITHDRAWAL IN THE INTENSIVE CARE UNIT
LIPPINCOTT WILLIAMS & WILKINS. 2020
View details for Web of Science ID 000530000201325
- Unique Uses of Cooling Strategies. Therapeutic hypothermia and temperature management 2020
USE OF THE CHANGE IN WEANING PARAMETERS AS PREDICTORS OF SUCCESSFUL REEXTUBATION
LIPPINCOTT WILLIAMS & WILKINS. 2019
View details for Web of Science ID 000498593400028
Alterations in Spanish Language Interpretation During Pediatric Critical Care Family Meetings
CRITICAL CARE MEDICINE
2017; 45 (11): 1915–21
To characterize alterations in Spanish language medical interpretation during pediatric critical care family meetings.Descriptive, observational study using verbatim transcripts of nine PICU family meetings conducted with in-person, hospital-employed interpreters.A single, university-based, tertiary children's hospital.Medical staff, family members, ancillary staff, and interpreters.None.Interpreted speech was compared with original clinician or family speech using the qualitative research methods of directed content analysis and thematic analysis. Alterations occurred in 56% of interpreted utterances and included additions, omissions, substitutions, editorializations, answering for the patient/clinician, confessions, and patient advocacy. Longer utterances were associated with more alterations.To minimize interpreter alterations during family meetings, physicians should speak in short utterances (fewer than 20 words) and ask interpreters to interrupt in order to facilitate accurate interpretation. Because alterations occur, physicians may also regularly attempt to assess the family's understanding.
View details for PubMedID 28777199
Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit.
2015; 33 (4): 753-770
As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.
View details for DOI 10.1016/j.anclin.2015.07.012
View details for PubMedID 26610628