BACKGROUND: The Acute Respiratory Distress Syndome (ARDS) Network low tidal volume (V T )trial paved the ground for mechanically ventilating ARDS patients with a V T of 6 mL/kg ideal body weight (IBW). Although there is no consensus that a low V T is advantageous in non-ARDS patients, it is accepted that high V T should be avoided. Because compliance rates with ventilator recommendations are 30%, there is a need for process improvement. We postulated that a computerized screen prompt that recommended V T based on height would improve compliance with low V T . During ventilator order entry, the computerized decision tool prompts the clinician and encourages ventilation of patients at 8 mL/kg IBW, and 6 mL/kg IBW for patients with ARDS. METHODS: A retrospective review was performed on patients who required volume controlled mechanical ventilation over a 3-y period. Subjects were chosen randomly from the respiratory records of 6 different ICUs at a single tertiary care academic center. Half of the charts selected were before intervention of on-screen prompt, and the other half were after implementation of the computerized decision tool. RESULTS: The initial set V T ranged from 6.26 to 13.45 mL/kg IBW, with a mean of 8.92 mL/kg. After implementation of the on-screen prompt, mean V T decreased by 0.84 mL/kg to 8.07 mL/kg (P ‫؍‬ .001) with a lower range of 4.73-11.56 mL/kg IBW. We also noted a significant decrease in the number of subjects placed on an initial V T > 10 mL/kg IBW from 20% to 4% (P ‫؍‬ .003). CONCLUSIONS: A computerized clinical decision tool with the preferred initial V T settings based on the patients' sex and height is a safe and reliable way to increase low V T strategy compliance across multiple ICUs. Its limitations are similar to those shared by other computergenerated prompts.

Pheochromocytomas and extra-adrenal paragangliomas are catecholamine-secreting tumors that rarely occur in pregnancy. The diagnosis of these tumors in pregnancy can be challenging given that many of the signs and symptoms are commonly attributed to preeclampsia or other more common diagnoses. Early diagnosis and appropriate management are essential in optimizing maternal and fetal outcomes. We report a rare case of a catecholamine-secreting tumor in which diagnosis occurring at the time labor was being induced for concomitant preeclampsia with severe features. Her initial presentation in hypertensive crisis with other symptoms led to diagnostic workup for secondary causes of hypertension and led to eventual diagnosis of paraganglioma. Obtaining this diagnosis prior to delivery was essential, as this led to prompt multidisciplinary care, changed the course of her clinical management, and ultimately enabled good maternal and fetal outcomes. This case highlights the importance of maintaining a high index of suspicion for secondary causes of hypertension and in obstetric patients and providing timely multidisciplinary care.

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