|
Critical Care Explorations
Number of Followers: 3  Open Access journalISSN (Online) 2639-8028 Published by LWW Wolters Kluwer  [297 journals]
|
- Association Between Acute Kidney Injury During Invasive Mechanical
Ventilation and ICU Outcomes and Respiratory System Mechanics
Authors: Vemuri; Sneha V.; Rolfsen, Mark L.; Sykes, Alexandra V.; Takiar, Puja G.; Leonard, Austin J.; Malhotra, Atul; Spragg, Roger G.; Macedo, Etienne; Hepokoski, Mark L.
Abstract:
OBJECTIVES: Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation.DESIGNS: Retrospective cohort study.SETTINGS: ICUs of the University of California, San Diego, from January 1, 2014, to November 30, 2016.PATIENTS: Five groups of patients were compared based on the need for invasive mechanical ventilation, presence or absence of acute kidney injury per the Kidney Disease: Improving Global Outcomes criteria, and the temporal relationship between the development of acute kidney injury and initiation of invasive mechanical ventilation.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: A total of 9,704 patients were included and 4,484 (46%) required invasive mechanical ventilation; 2,009 patients (45%) had acute kidney injury while being treated with invasive mechanical ventilation, and the mortality rate for these patients was 22.4% compared with 5% in those treated with invasive mechanical ventilation without acute kidney injury (p < 0.01). Adjusted hazard of mortality accounting for baseline disease severity was 1.58 (95% CI, 1.22–2.03; p < 0.001]. Patients with acute kidney injury during invasive mechanical ventilation had a significant increase in total ventilator days and length of ICU stay with the same comparison (both p < 0.01). Acute kidney injury during mechanical ventilation was also associated with significantly higher plateau pressures, lower respiratory system compliance, and higher driving pressures (all p < 0.01). These differences remained significant in patients with net negative cumulative fluid balance.CONCLUSIONS: Acute kidney injury during invasive mechanical ventilation is associated with increased ICU mortality, increased ventilator days, increased length of ICU stay, and impaired respiratory system mechanics. These results emphasize the need for investigations of ventilatory strategies in the setting of acute kidney injury, as well as mechanistic studies of crosstalk between the lung and kidney in the critically ill.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Postintensive Care Syndrome-Family Associated With COVID-19 Infection
Authors: Shirasaki; Kasumi; Hifumi, Toru; Isokawa, Shutaro; Hashiuchi, Shinsuke; Tanaka, Shinobu; Yanagisawa, Yaeko; Takahashi, Osamu; Otani, Norio
Abstract:
OBJECTIVES: To assess the prevalence of and risk factors for postintensive care syndrome in family (PICS-F) in the COVID-19 era.DESIGN: A single-center retrospective study using questionnaires and telephone calls.SETTING: An ICU at St. Luke’s International Hospital.PATIENTS: Patients who were treated for COVID-19–related acute respiratory distress syndrome between March 23, 2020, and September 30, 2021, and their family members participated.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: PICS-F refers to the psychologic distress such as anxiety, depression, and posttraumatic stress disorder (PTSD) experienced by the patient’s family. The primary outcome was PICS-F occurrence. Furthermore, factors related to PICS-F development were identified using statistical analysis. Of 85 patients with COVID-19 who were admitted to the ICU, 57 family members consented to the study and completed the survey, and 54 family members’ data were analyzed. The median age of family members was 53.5 years, 68.5% were female, and 46.3% were spouses. The median age of patients was 55.5 years, and 83.3% were male. During their ICU stay, 68.5% received invasive mechanical ventilation, 11.1% received venovenous extracorporeal membrane oxygenation, and 11.1% underwent tracheostomy. The median ICU and hospital stays were 7 and 22 days, respectively. Overall PICS-F occurred in 33%. Anxiety, depression, and PTSD occurred in 24%, 26%, and 4% of family members, respectively. The prevalence of all three components of PICS-F was 4%. Multivariable analysis showed that Family Satisfaction with the ICU Survey (FS-ICU) scores were independently associated with PICS-F development (odds ratio, 0.941; 95% CI, 0.891–0.983; p = 0.005).CONCLUSIONS: One-third of family members of COVID-19 patients admitted to the ICU had symptoms of PICS-F. These results suggest that measurement of FS-ICU may be helpful as a predictor of PICS-F development. In addition, increasing the level of ICU care satisfaction of the family members may prevent PICS-F.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Adoption and Deadoption of Medications to Treat Hospitalized Patients With
COVID-19
Authors: Barbash; Ian J.; Davis, Billie S.; Minturn, John S.; Kahn, Jeremy M.
Abstract:
OBJECTIVES: The COVID-19 pandemic was characterized by rapidly evolving evidence regarding the efficacy of different therapies, as well as rapidly evolving health policies in response to that evidence. Data on adoption and deadoption are essential as we learn from this pandemic and prepare for future public health emergencies.DESIGN: We conducted an observational cohort study in which we determined patterns in the use of multiple medications to treat COVID-19: remdesivir, hydroxychloroquine, IV corticosteroids, tocilizumab, heparin-based anticoagulants, and ivermectin. We analyzed changes both overall and within subgroups of critically ill versus Noncritically ill patients.SETTING: Data from Optum’s deidentified Claims-Clinical Dataset, which contains multicenter electronic health record data from U.S. hospitals.PATIENTS: Adults hospitalized with COVID-19 from January 2020 to June 2021.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Of 141,533 eligible patients, 34,515 (24.4%) required admission to an ICU, 14,754 (10.4%) required mechanical ventilation, and 18,998 (13.4%) died during their hospitalization. Averaged over the entire time period, corticosteroid use was most common (47.0%), followed by remdesivir (33.2%), anticoagulants (19.3%), hydroxychloroquine (7.3%), and tocilizumab (3.4%). Usage patterns varied substantially across treatments. For example, hydroxychloroquine use peaked in March 2020 and leveled off to near zero by June 2020, whereas the use of remdesivir, corticosteroids, and tocilizumab all increased following press releases announcing positive results of large international trials. Ivermectin use increased slightly over the study period but was extremely rare overall (0.4%).CONCLUSIONS: During the COVID-19 pandemic, medication treatment patterns evolved reliably in response to emerging evidence and changes in policy. These findings may inform efforts to promote optimal adoption and deadoption of treatments for acute care conditions.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Defining Objective Measures of Physician Stress in Simulated Critical
Communication Encounters
Authors: Wolfe; Amy H. J.; Hinds, Pamela S.; du Plessis, Adre J.; Gordish-Dressman, Heather; Arnold, Robert M.; Soghier, Lamia
Abstract:
OBJECTIVES: This study had three aims: 1) quantify the difference in stress levels between low and high stress roles during simulated critical communication encounters using objective physiologic data (heart rate variability [HRV]) and subjective measures (State-Trait Anxiety Inventory [STAI]), 2) define the relationship between subjective and objective measures of stress, and 3) define the impact of trainee preparedness and reported self-efficacy on stress levels.DESIGN: Mixed methods simulation-based study.SETTING: Single center.PATIENTS: Pediatric critical care fellows and faculty (n = 12).INTERVENTIONS: Subjects participated in six simulated scenarios in both high stress “hot seat” and low stress “observer” roles.MEASUREMENTS AND MAIN RESULTS: Subjective stress was measured using the STAI at baseline and after each scenario. Objective stress was measured continuously using a wearable biometric device measuring HRV. Previous residency communication training and self-confidence surrounding various communication topics were collected via questionnaire. Significant changes in subjective (STAI) and objective stress (HRV) measurements in the low- versus high-stress roles were observed. STAI scores increased 8 points during low stress and 12 points during high stress role (p = 0.021) compared with baseline. Two specific HRV markers, root mean square of successive differences between normal heartbeats, a marker of parasympathetic tone, and the low frequency/high frequency (LF/HF) ratio, a marker of sympathetic activation, were significantly correlated with STAI levels (–0.032, p = 0.001; 1.030, p = 0.002, respectively). Participants who reported increased confidence in discussing code status had a significant decrease in stress response (measured via LF/HF ratio) during both the observer (p = 0.033) and hot seat roles (p =
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Addressing Futility: A Practical Approach
Authors: Kopar; Piroska K.; Visani, Adrienne; Squirrell, Kyler; Brown, Douglas E.
Abstract: OBJECTIVES: Limiting or withdrawing nonbeneficial medical care is considered ethically responsible throughout most of critical care and medical ethics literature. Practically, however, setting limits to treatment is often challenging. We review the literature to identify best practices for using the definition of futility as an anchoring concept to aid the ethical practice of ICU clinicians.DATA SOURCES: Source data were obtained from a PubMed literature review.STUDY SELECTION: English language articles were chosen based on relevance to medical futility ethics, end-of-life care in the ICU, or communication and conflict mitigation strategies.DATA EXTRACTION: Independent evaluation of selected articles for recurrent content themes as relevant to our clinical case were compared among authors and based on consensus, quantitative and qualitative data from these sources were referenced directly.DATA SYNTHESIS: When life-sustaining treatment is unlikely to achieve a meaningful benefit such as symptom improvement, continued care may be discordant with the patient’s goals. Institutional and cultural norms, unconscious biases, and difficulty with navigating conflicts all influence how un(comfortable) clinicians feel in setting limits to futile care. Defining futility in light of the patient’s goals and values, focusing on outcomes rather than interventions, and being proactive in communication with families are the staples of medically meaningful critical care. Palliative measures should be framed affirmatively, and clinicians should be transparent about the limits of medicine.CONCLUSIONS: Clinicians have an ethical obligation not to provide futile care. To practice accordingly, we must clearly understand the nature and forms of futility. Armed with this understanding, our discussions with family and surrogates in the ICU should fundamentally comprise 1) eliciting the patient’s values and goals, 2) communicating which interventions serve those values and goals and which do not, and 3) offering only those interventions whose likely outcomes are in line with said values and goals.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Brain Shock—Toward Pathophysiologic Phenotyping in Traumatic Brain
Injury
Authors: Lazaridis; Christos
Abstract:
Severe traumatic brain injury (TBI) is a heterogeneous pathophysiologic entity where multiple interacting mechanisms are operating. This viewpoint offers an emerging, clinically actionable understanding of the pathophysiologic heterogeneity and phenotypic diversity that comprise secondary brain injury based on multimodality neuromonitoring data. This pathophysiologic specification has direct implications for diagnostic, monitoring, and therapeutic planning. Cerebral shock can be helpfully subanalyzed into categories via an examination of the different types of brain tissue hypoxia and substrate failure: a) ischemic or flow dependent; b) flow-independent, which includes oxygen diffusion limitation, mitochondrial failure, and arteriovenous shunt; c) low extraction; and d) hypermetabolic. This approach could lead to an alternative treatment paradigm toward optimizing cerebral oxidative metabolism and energy crisis avoidance. Our bedside approach to TBI should respect the pathophysiologic diversity involved; operationalizing it in types of “brain shock” can be one such approach.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing
the Challenges and Opportunities to Assess Clinical Value
Authors: Dilworth; Thomas J.; Schulz, Lucas T.; Micek, Scott T.; Kollef, Marin H.; Rose, Warren E.
Abstract:
OBJECTIVE: β-lactams are the cornerstone of empiric and targeted antibiotic therapy for critically ill patients. Recently, there have been calls to use β-lactam therapeutic drug monitoring (TDM) within 24–48 hours after the initiation of therapy in critically ill patients. In this article, we review the dynamic physiology of critically ill patients, β-lactam dose response in critically ill patients, the impact of pathogen minimum inhibitory concentration (MIC) on β-lactam TDM, and pharmacokinetics in critically ill patients. Additionally, we highlight available clinical data to better inform β-lactam TDM for critically ill patients.DATA SOURCES: We retrospectively analyzed patients admitted for sepsis or septic shock at a single academic medical center who were treated with β-lactam antibiotics.STUDY SELECTION: Indexed studies in PubMed in English language were selected for review on topics relative to critical care physiology, β-lactams, pharmacokinetics/pharmacodynamics, TDM, and antibiotic susceptibility.DATA EXTRACTION: We reviewed potentially related studies on β-lactams and TDM and summarized their design, patients, and results. This is a synthetic, nonsystematic, review.DATA SYNTHESIS: In the retrospective analysis of patients treated with β-lactam antibiotics, approximately one-third of patients received less than 48 hours of β-lactam therapy. Of those who continued beyond 48 hours, only 13.7% had patient-specific factors (augmented renal clearance, fluid overload, morbid obesity, and/or surgical drain), suggesting a potential benefit of β-lactam TDM.CONCLUSIONS: These data indicate that a strategy of comprehensive β-lactam TDM for critically ill patients is unwarranted as it has not been shown yet to improve patient-oriented outcomes. This review demonstrates that β-lactam TDM in the ICU, while laudable, layers ambiguous β-lactam exposure thresholds upon uncertain/unknown MIC data within a dynamic, unpredictable patient population for whom TDM results will not be available fast enough to significantly affect care. Judicious, targeted TDM for those with risk factors for β-lactam over- or underexposure is a better approach but requires further study. Clinically, choosing the correct antibiotic and dosing β-lactams aggressively, which have a wide therapeutic index, to overcome critical illness factors appears to give critically ill patients the best likelihood of survival.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Chemokines in ICU Delirium: An Exploratory Study
Authors: Smith; Ryan J.; Rabinstein, Alejandro A.; Cartin-Ceba, Rodrigo; Singh, Vijay P.; Lachner, Christian; Khatua, Biswajit; Trivedi, Shubham; Gajic, Ognjen
Abstract:
OBJECTIVES: The pathophysiology of delirium is complex and incompletely understood. Inflammation is hypothesized to be integral to its development due to effects on blood brain barrier integrity, facilitation of leukocyte extravasation into brain parenchyma, and propagation of neuroinflammation. Septic shock is the prototypical condition associated with ICU delirium; however, the relative contribution of resultant hypotension and systemic inflammation to the development of delirium is unknown.DESIGN: This was a prospective exploratory study.SETTING: A multidisciplinary ICU at an academic medical center in Phoenix, AZ.PATIENTS: Critically ill patients older than or equal to 18 years old admitted to the ICU.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Screening for delirium was performed using the Confusion Assessment Method for the ICU tool. The levels of C-C motif ligand 2 (CCL2), C-C motif ligand 3, C-X-C motif chemokine ligand 1, C-X-C motif chemokine ligand 10, and interleukin-8 were measured in serum samples obtained within 12 hours of ICU admission. Univariate and multivariate analyses were performed to assess the association of delirium with patient data pertaining to hospital course, laboratory values, vital signs, medication administration, and levels of the aforementioned chemokines. Forty-one of 119 patients (34.5%) in the study cohort developed ICU delirium. Each chemokine studied was associated with delirium on univariate analyses; however, CCL2 was the only chemokine found to be independently associated with the development of delirium on multivariable analysis. The association of increased CCL2 levels with delirium remained robust in various models controlling for age, presence of shock, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation IV score, mean arterial pressure at presentation, lowest mean arterial pressure, and total opioid, midazolam, propofol, and dexmedetomidine exposure.CONCLUSIONS: The demonstrated relationship between CCL2 and delirium suggests this chemokine may play a role in the development of delirium and warrants further investigation.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Social Determinants of Health Associated With the Development of Sepsis in
Adults: A Scoping Review
Authors: Sheikh; Fatima; Douglas, William; Catenacci, Vanessa; Machon, Christina; Fox-Robichaud, Alison E.
Abstract:
OBJECTIVE: Evaluating risk for sepsis is complicated due to limited understanding of how social determinants of health (SDoH) influence the occurence of the disease. This scoping review aims to identify gaps and summarize the existing literature on SDoH and the development of sepsis in adults.DATA SOURCES: A literature search using key terms related to sepsis and SDoH was conducted using Medline and PubMed.STUDY SELECTION: Studies were screened by title and abstract and then full text in duplicate. Articles were eligible for inclusion if they: 1) evaluated at least one SDoH on the development of sepsis, 2) participants were 18 years or older, and 3) the studies were written in English between January 1970 and January 2022. Systematic reviews, meta-analyses, editorials, letters, commentaries, and studies with nonhuman participants were excluded.DATA EXTRACTION: Data were extracted in duplicate using a standardized data extraction form. Studies were grouped into five categories according to the SDoH they evaluated (race, socioeconomic status [SES], old age and frailty, health behaviors, and social support). The study characteristics, key outcomes related to incidence of sepsis, mortality, and summary statements were included in tables.DATA SYNTHESIS: The search identified 637 abstracts, 20 of which were included after full-text screening. Studies evaluating SES, old age, frailty, and gender demonstrated an association between sepsis incidence and the SDoH. Studies that examined race demonstrated conflicting conclusions as to whether Black or White patients were at increased risk of sepsis. Overall, a major limitation of this analysis was the methodological heterogeneity between studies.CONCLUSIONS: There is evidence to suggest that SDoH impacts sepsis incidence, particularly SES, gender, old age, and frailty. Future prospective cohort studies that use standardized methods to collect SDoH data, particularly race-based data, are needed to inform public health efforts to reduce the incidence of sepsis and help clinicians identify the populations most at risk.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Characterization of Platelet Biologic Markers in the Early Pathogenesis of
Postoperative Acute Respiratory Distress Syndrome
Authors: Yadav; Hemang; Meade, Laurie A.; Carter, Rickey E.; Knutson, Keith; Gajic, Ognjen; Kor, Daryl J.
Abstract:
IMPORTANCE: Animal models and limited human studies have suggested a plausible role for platelets in the pathogenesis and resolution of acute respiratory distress syndrome (ARDS). However, there are little data regarding the role of platelets in ARDS development.OBJECTIVES: The objective of this study was to characterize the role of platelets in a postoperative ARDS model through an analysis of two platelet-specific biologic markers: thromboxane A2 (TxA2) and soluble CD-40-ligand (sCD40L).DESIGN, SETTING, AND PARTICIPANTS: This was a nested case-control study of ARDS cases matched to non-ARDS controls. Blood samples were collected from a cohort of 500 patients undergoing thoracic, aortic vascular, or cardiac surgery that placed them at high-risk of developing postoperative ARDS.MAIN OUTCOMES AND MEASURES: TxA2 and sCD40L were analyzed at baseline (prior to surgical incision) as well as 2 hours and 6 hours after the key intraoperative events believed to be associated with increased risk of postoperative ARDS.RESULTS: Of 500 patients enrolled, 20 ARDS cases were matched 1:2 to non-ARDS controls based on age, sex, surgical procedure, and surgical lung injury prediction score. Those who developed ARDS had longer surgeries, greater fluid administration, and higher peak inspiratory pressures. There were no significant differences in levels of TxA2 or sCD40L at baseline, at 2 hours, or at 6 hours. There was also no difference in the change in biomarker concentration between baseline and 2 hours or baseline and 6 hours.CONCLUSIONS: Two novel platelet-associated biologic markers (TxA2 and sCD40L) were not elevated in patients who developed ARDS in a postoperative ARDS model. Although limited by the relatively small study size, these results do not support a clear role for platelets in the early pathogenesis of postoperative ARDS.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Resting Energy Expenditure of Patients on Venovenous Extracorporeal
Membrane Oxygenation for Adult Respiratory Distress Syndrome: A Pilot
Study
Authors: Ong; Chin Siang; Brown, Patricia; Shou, Benjamin L.; Wilcox, Christopher; Cho, Sung-Min; Mendez-Tellez, Pedro Alejandro; Kim, Bo Soo; Whitman, Glenn J. R.; on behalf of the HERALD Investigators
Abstract:
OBJECTIVES: The objectives of this study were to 1) in patients without pulmonary function, determine resting energy expenditure (REE) in venovenous extracorporeal membrane oxygenation (ECMO) acute respiratory distress syndrome (ARDS) patients by paralysis status and 2) determine the threshold tidal volume (TV) associated with meaningful gas exchange as determined by measurable end-tidal carbon dioxide elimination (etV̇co2).DESIGN: Retrospective observational study.SETTING: A tertiary high ECMO volume academic institution.PATIENTS/SUBJECTS: Ten adult ARDS patients on venovenous ECMO.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The modified Weir equation, Fick principle, Henderson-Hasselbalch equation, ECMO flow, hemoglobin, and pre and post oxygenator blood gases were used to determine ECMO carbon dioxide production (V̇co2), ECMO oxygen consumption, and REE. REE values were matched to patients’ paralysis status based on medication flowsheets and compared using a paired t test. Linear regression was performed to determine the threshold TV normalized to ideal body weight (IBW) associated with measurable ventilator etV̇co2, above which meaningful ventilation occurs. When lungs were not functioning, patients had significantly lower mean REE when paralyzed (23.4 ± 2.8 kcal/kg/d) than when not paralyzed (29.2 ± 5.8 kcal/kg/d) (p = 0.02). Furthermore, mean REE was not similar between patients and varied as much as 1.7 times between patients when paralyzed and as much as 1.4 times when not paralyzed. Linear regression showed that ventilator V̇co2 was measurable and increased linearly when TV was greater than or equal to 0.7 mL/kg.CONCLUSIONS: REE is patient-specific and varies significantly with and without patient paralysis. When TV exceeds 0.7 mL/kg IBW, ventilator V̇co2 increases measurably and must be considered in determining total REE.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- The Association of Selective Serotonin Reuptake Inhibitors With Delirium
in Critically Ill Adults: A Secondary Analysis of the Bringing to Light
the Risk Factors and Incidence of Neuropsychologic Dysfunction in ICU
Survivors ICU Study
Authors: Austin; C. Adrian; Yi, Joe; Lin, Feng-Chang; Pandharipande, Pratik; Ely, E. Wesley; Busby-Whitehead, Jan; Carson, Shannon S.
Abstract:
OBJECTIVES: To assess the association between selective serotonin reuptake inhibitors (SSRI) and delirium in the subsequent 24 hours after drug administration in critically ill adults.DESIGN: Retrospective cohort study utilizing the Bringing to Light the Risk Factors and Incidence of Neuropsychologic Dysfunction in ICU Survivors dataset.SETTING: Two large U.S. ICUs.PATIENTS: Critically ill adults admitted to a medical or surgery ICU between March 2007 and May 2010 with respiratory failure or shock.INTERVENTIONS: Our primary outcome was the occurrence rate of delirium or coma during each day in the ICU. Our exposure variable was SSRI administration on the prior day in the ICU. As a secondary question, we assessed the association of SSRI administration and delirium the same day of SSRI administration in the ICU.MEASUREMENTS AND MAIN RESULTS: We analyzed 821 patients. The median age was 61.2 years old (interquartile range, 50.9–70.7), and 401 (48.8%) were female. A total of 233 patients (28.4%) received prescribed SSRIs at least once during their ICU admission. Delirium was present in 606 (74%) of the patients at some point during hospitalization in the ICU. Coma was present in 532 (64.8%) of the patients at some point during hospitalization in the ICU. After adjusting for multiple potential confounding factors, we found that SSRI administration in the ICU was associated with lower odds of delirium/coma (odds ratio [OR], 0.75; 95% CI, 0.57–1.00) the next day. An SSRI administered on the same day reduced the odds of delirium/coma as well (OR, 0.66; 95% CI, 0.50–0.87).CONCLUSIONS: SSRI administration is associated with decreased risk of delirium/coma in 24 hours and on the same day of administration in critically ill patients in a medical or surgical ICU.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Baseline Anxiety and Depression and Risk for ICU Delirium: A Prospective
Cohort Study
Authors: Wu; Ting Ting; Kooken, Rens; Zegers, Marieke; Ko, Sally; Bienvenu, O. Joseph; Devlin, John W.; van den Boogaard, Mark
Abstract:
OBJECTIVES: Anxiety and depression are common mental disorders in adults admitted to the ICU. Although depression increases postsurgical delirium and anxiety does not, their associations with ICU delirium in critically ill adults remain unclear. We evaluated the association between ICU baseline anxiety and depression and ICU delirium occurrence.DESIGN: Subgroup analysis of a prospective cohort study.SETTING: Single, 36-bed mixed ICU.PATIENTS: Nine-hundred ninety-one ICU patients admitted with or without delirium between July 2016 and February 2020; patients admitted after elective surgery or not assessed for anxiety/depression were excluded.INTERVENTION: None.MEASUREMENTS AND MAIN RESULTs: The Hospital Anxiety and Depression Scale questionnaire was administered at ICU admission to determine baseline anxiety and depression. All patients were assessed with the Confusion Assessment Method for the ICU (CAM-ICU) q8h; greater than or equal to 1 +CAM-ICU assessment and/or scheduled antipsychotic use represented a delirium day. Multivariable logistic and Quasi-Poisson regression models, adjusted for ICU days and nine delirium risk variables (“Pre-ICU”: age, Charlson Comorbidity Index, cognitive impairment; “ICU baseline”: Acute Physiology and Chronic Health Evaluation-IV, admission type; “Daily ICU”: opioid and/or benzodiazepine use, Sequential Organ Failure Assessment score, coma), were used to evaluate associations between baseline anxiety and/or depression and ICU delirium. Among the 991 patients, 145 (14.6%) had both anxiety and depression, 78 (7.9%) had anxiety only, 91 (9.2%) had depression only, and 677 (68.3%) had neither. Delirium occurred in 406 of 991 total cohort (41.0%) patients; in the baseline anxiety and depression group, it occurred in 78 of 145 (53.8%), in the anxiety only group, 37 of 78 (47.4%), in the depression only group, 39 of 91 (42.9%), and in the group with neither in 252 of 677 (37.2%). Presence of both baseline anxiety and depression was associated with greater delirium occurrence (adjusted odds ratio, 1.99; 95% CI, 1.10–3.53; p = 0.02) and duration (adjusted risk ratio, 1.62; 95% CI, 1.17–2.23; p < 0.01).CONCLUSIONS: Baseline anxiety and depression are associated with increased ICU delirium occurrence and should be considered when delirium risk reduction strategies are being formulated.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Systematic Review of the “Pragmatism” of Pragmatic Critical
Care Trials
Authors: Palakshappa; Jessica A.; Gibbs, Kevin W.; Lannan, Margo T.; Cranford, Anna R.; Taylor, Stephanie P.
Abstract:
OBJECTIVES: To assess the pragmatism of published critical care randomized controlled trials self-described as pragmatic using a validated tool.DATA SOURCES: Medical Literature Analysis and Retrieval Online database and PubMed interface from inception to November 1, 2021.STUDY SELECTION: We performed a systematic search of randomized controlled trials evaluating interventions for critically ill adults that self-identified as pragmatic in title or abstract.DATA EXTRACTION: Reviewers independently performed study selection and data extraction in duplicate; discrepancies were resolved by consensus. Pragmatism was assessed independently in duplicate by trained reviewers using the Pragmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2), a validated tool designed to represent how explanatory/pragmatic a trial is on the pragmatic to explanatory continuum. Trials were scored in nine domains on a 5-point continuum (from 1 = very explanatory to 5 = very pragmatic). Discrepancies of greater than 2 points were adjudicated by consensus discussion.DATA SYNTHESIS: The search resulted in 284 studies; 56 met eligibility criteria. Forty-one of the trials had a discrepancy in at least one domain that required consensus discussion, most commonly in domains of eligibility and follow-up. Twelve studies (21.4%) were scored as “overall pragmatic,” defined as score of greater than 4 in five domains provided the scores in the remaining domains were three. The overall PRECIS-2 score of self-identified pragmatic studies increased from 1995 to 2021 suggesting increasing pragmatism over time. Pragmatic trials were more likely to have a waiver of informed consent (p = 0.05).CONCLUSIONS: The number and pragmatism of self-identified pragmatic trials have increased, particularly in the past decade. However, less than one-quarter of these trials that use the term pragmatic in title or abstract were retrospectively rated as pragmatic. Our results support the concept that trials are designed on a spectrum of pragmatic to explanatory. Advances in the design and reporting of critical care trials are needed to ensure their real-world applicability.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- The Association of Modifiable Postresuscitation Management and Annual Case
Volume With Survival After Extracorporeal Cardiopulmonary Resuscitation
Authors: Tonna; Joseph E.; Selzman, Craig H.; Bartos, Jason A.; Presson, Angela P.; Ou, Zhining; Jo, Yeonjung; Becker, Lance; Youngquist, Scott T.; Thiagarajan, Ravi R.; Johnson, M. Austin; Rycus, Peter; Keenan, Heather T.
Abstract:
IMPORTANCE: It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes.OBJECTIVES: To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival.DESIGN: Observational cohort study using case-mix adjusted survival analysis.SETTING AND PARTICIPANTS: Adult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019.MAIN OUTCOMES AND MEASURES: Generalized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR.RESULTS: Case-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44–64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08–1.55; p = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11– 1.61; p = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05–1.84; p = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04–1.45; p = 0.015) versus medium- and low-volume centers.CONCLUSIONS AND RELEVANCE: Modifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesis-generating associations are causal in nature.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Comparison of Clinical Profiles and Mortality Outcomes Between Influenza
and COVID-19 Patients Invasively Ventilated in the ICU: A Retrospective
Study From All Paris Public Hospitals From 2016 to 2021
Authors: Marois; Clémence; Nedelec, Thomas; Pelle, Juliette; Rozes, Antoine; Durrleman, Stanley; Dufouil, Carole; Demoule, Alexandre
Abstract:
OBJECTIVES: Studies comparing outcomes of ICU patients admitted for either COVID-19 or seasonal influenza are limited. Our objective was to describe baseline clinical profiles, care procedures, and mortality outcomes by infection status (influenza vs COVID-19) of patients who received invasive mechanical ventilation in the ICU.DESIGN: Retrospective observational study.SETTING: Data were extracted from the Assistance Publique—Hopitaux de Paris database from September 1, 2016, to April 20, 2021. It includes data from the 39 university hospitals.PATIENTS: A total of 752 influenza adult patients and 3,465 COVID-19 adult patients received invasive mechanical ventilation in one of the ICUs of the Paris area university hospitals, France.INTERVENTION: The characteristics and outcome by infection status were compared. Factors associated with mortality were assessed using Cox proportional hazard models after controlling for potential confounders, including infection status.MEASUREMENTS AND MAIN RESULTS: The median age at admission to the ICU was 67 (interquartile range [IQR], 57–77) and 63 yr (IQR, 54–71 yr) for influenza and COVID-19 patients, respectively. At ICU admission, COVID-19 patients were more frequently obese, more frequently had diabetes mellitus or high blood pressure, and were less likely to have chronic heart failure, chronic respiratory disease, chronic kidney failure, or active cancer than influenza patients. The overall survival at 90 days was 57% for COVID-19 patients and 66% for influenza patients (p < 0.001). In a multivariable Cox model, higher age, organ transplant, severe acute respiratory syndrome coronavirus 2 infection, and chronic kidney failure were associated with shorter survival, whereas obesity and high blood pressure were associated with longer survival after invasive ventilation.CONCLUSIONS: COVID-19 and influenza patients requiring mechanical ventilation in the ICU differed by many characteristics. COVID-19 patients showed lower survival independently of potential confounders.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Opioid Prescribing Patterns Before, During, and After Critical Illness: An
Observational Study
Authors: Wampole; Chelsea; McKenna, Ariel; Riker, Richard R.; May, Teresa L.; Seder, David B.; Abram, Dawn; Fraser, Gilles L.; Gagnon, David J.
Abstract:
OBJECTIVES: The association between opioid therapy during critical illness and persistent opioid use after discharge is understudied relative to ICU opioid exposure and modifiable risk factors. Our objectives were to compare persistent opioid use after discharge among patients with and without chronic opioid use prior to admission (OPTA) and identify risk factors associated with persistent use.DESIGN: Retrospective cohort study.SETTING: Medical, trauma/surgical, or neurologic ICU at an academic hospital.PARTICIPANTS: Adult patients surviving hospital admission.INTERVENTIONS: Opioid use during the ICU and post-ICU stays.MEASUREMENTS AND MAIN RESULTS: The primary outcome was persistent opioid use accounting for greater than 70% of days 4–6 months after discharge. Among 2,975 included patients, 257 (8.6%) were classified as OPTA, and 305 (10.2%) persistently filled opioid prescriptions, including 186/257 (72%) OPTA and 119/2,718 (4.4%) with no chronic opioid fills prior to admission. Among all patients, OPTA was strongly associated with persistent opioid use (odds ratio, 57.2 [95% CI, 41.4–80.0]). Multivariable logistic regression revealed that male sex, surgical procedure, and ICU opioid-free days were associated with reduced persistent opioid use for OPTA patients. Age and ICU opioid-free days were associated with reduced persistent opioid use for non-OPTA patients. Total ICU opioid dose and dose per day of ICU exposure were not associated with persistent use for either group.CONCLUSIONS: In this mixed cohort of ICU patients, 10.2% persistently filled opioid prescriptions 4–6 months after discharge. Although ICU opioid doses were not associated with persistent use, duration of ICU opioid administration is a modifiable risk factor that may reduce persistent opioid use after critical illness.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
- Surviving Sepsis Guideline–Directed Fluid Resuscitation: An Assessment
of Practice Patterns and Impact on Patient Outcomes
Authors: Govero; Austin B.; Yarrarapu, Siva Naga S.; Harrison, Michael F.; Baig, Hassan Z.; Guru, Pramod; Moreno Franco, Pablo; Caples, Sean M.; Grek, Ami A.; Vizzini, Michael R.; Ball, Colleen T.; Khan, Syed A.; Heise, Katherine J.; Sekiguchi, Hiroshi; Cantrell, Warren L.; Sanghavi, Devang K.
Abstract:
IMPORTANCE: Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage.OBJECTIVES: Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation.DESIGN: Large, multisite retrospective cohort study.SETTING AND PARTICIPANTS: The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis.MAIN OUTCOMES AND MEASURES: Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0–29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay.RESULTS: We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight).CONCLUSIONS AND RELEVANCE: IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
