Pub Date : 2024-08-17DOI: 10.1016/j.chstcc.2024.100096
Salman Abdulaziz MBBS, FRCP , Vivek Kakar MD, FRCA , Huda Alfoudri MBChB, FCARCSI , Mohammed Shalaby MD , Mikaela V. Allen NMD , Shameena Beegom RN, MSc , John F. Fraser MBChB, PhD, FRCP, FRCA, FFARCSI, FCICM, FELSO , Saleh Fares Al Ali MD, MPH
High-risk pulmonary embolism (PE), defined as obstruction of the pulmonary arterial tree that leads to hemodynamic instability, is a common cause of cardiac arrest, with a mortality rate of up to 50%. The obstruction of the pulmonary circulation interferes with gas exchange and causes hemodynamic disturbances in both the right and left sides of the heart. Some international guidelines have suggested the use of extracorporeal membrane oxygenation (ECMO), in combination with definitive therapy, in patients with PE with refractory circulatory collapse or cardiac arrest. Furthermore, several observational studies have shown that ECMO may be beneficial in stabilizing patients with high-risk PE, especially as a form of bridging therapy in patients for whom common reperfusion methods may be insufficient or have delayed efficacy. We present the case of a patient with acute high-risk PE and the role of ECMO in addressing the physiologic derangements caused by PE and improving patient outcomes. We reviewed the literature reporting the experience on ECMO use in conjunction with various forms of definitive treatment for PE. We describe the various ECMO cannulation strategies applicable for patients with high-risk PE, the role of adjunct mechanical circulatory support, practical guidance on ECMO weaning, and the interaction between the PE response team and the ECMO team in the setting of high-risk PE.
高危肺栓塞（PE）是指导致血液动力学不稳定的肺动脉树阻塞，是心脏骤停的常见原因，死亡率高达 50%。肺循环受阻会影响气体交换，导致心脏左右两侧血流动力学紊乱。一些国际指南建议，对于出现难治性循环衰竭或心跳骤停的 PE 患者，可使用体外膜肺氧合（ECMO），并结合确定性疗法。此外，一些观察性研究表明，ECMO 有助于稳定高危 PE 患者的病情，尤其是作为一种桥接疗法，用于普通再灌注方法可能不足或疗效延迟的患者。我们介绍了一名急性高危 PE 患者的病例，以及 ECMO 在解决 PE 引起的生理失调和改善患者预后方面的作用。我们回顾了有关 ECMO 与各种形式的 PE 最终治疗结合使用的文献。我们介绍了适用于高危 PE 患者的各种 ECMO 插管策略、辅助机械循环支持的作用、ECMO 断流的实用指南以及 PE 反应团队与 ECMO 团队在高危 PE 情况下的互动。
{"title":"Circulatory Extracorporeal Membrane Oxygenation Support for High-Risk Acute Pulmonary Embolism","authors":"Salman Abdulaziz MBBS, FRCP , Vivek Kakar MD, FRCA , Huda Alfoudri MBChB, FCARCSI , Mohammed Shalaby MD , Mikaela V. Allen NMD , Shameena Beegom RN, MSc , John F. Fraser MBChB, PhD, FRCP, FRCA, FFARCSI, FCICM, FELSO , Saleh Fares Al Ali MD, MPH","doi":"10.1016/j.chstcc.2024.100096","DOIUrl":"10.1016/j.chstcc.2024.100096","url":null,"abstract":"<div><div>High-risk pulmonary embolism (PE), defined as obstruction of the pulmonary arterial tree that leads to hemodynamic instability, is a common cause of cardiac arrest, with a mortality rate of up to 50%. The obstruction of the pulmonary circulation interferes with gas exchange and causes hemodynamic disturbances in both the right and left sides of the heart. Some international guidelines have suggested the use of extracorporeal membrane oxygenation (ECMO), in combination with definitive therapy, in patients with PE with refractory circulatory collapse or cardiac arrest. Furthermore, several observational studies have shown that ECMO may be beneficial in stabilizing patients with high-risk PE, especially as a form of bridging therapy in patients for whom common reperfusion methods may be insufficient or have delayed efficacy. We present the case of a patient with acute high-risk PE and the role of ECMO in addressing the physiologic derangements caused by PE and improving patient outcomes. We reviewed the literature reporting the experience on ECMO use in conjunction with various forms of definitive treatment for PE. We describe the various ECMO cannulation strategies applicable for patients with high-risk PE, the role of adjunct mechanical circulatory support, practical guidance on ECMO weaning, and the interaction between the PE response team and the ECMO team in the setting of high-risk PE.</div></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"2 4","pages":"Article 100096"},"PeriodicalIF":0.0,"publicationDate":"2024-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553387","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-10DOI: 10.1016/j.chstcc.2024.100094
Eamon P. Raith MBBS, PhD, FCICM , See Kay Choong , Mark Nicholls , Wong Wai Tat , Sheila Nainan Myatra , Erwin Pradian MD, PhD , Moritoki Egi MD, PhD , Gee-Young Suh MD, PhD , Shanti Rudra Deva , Naranpurev Mendsaikhan , Shital Adhikari , Jose Melanio Grayda , Ming-Cheng Chan , Suthat Rungruanghiranya , Sean Loh FCCP, FRCP , David Ku FCICM
The COVID-19 pandemic presented the greatest challenge to modern intensive care medicine since its founding as a specialty in 1952, with its effects felt across health care services in all regions, including low-resourced settings. A paucity of data remains regarding the provision of intensive care medicine across the globe, particularly after the COVID-19 pandemic. To determine the broad state of critical care medicine after the pandemic in the Asia-Pacific region, the inaugural Asia-Pacific Critical Care Societies Summit was held in Singapore as a satellite meeting of the Asia-Pacific Intensive Care Symposium on August 18, 2023. This article summarizes this summit and provides key health and economic data for representative countries before detailing the resolutions and planned actions arising from this initiative. Fourteen critical care societies participated in the inaugural summit and consented to publication of societal reports. Common challenges and priorities for participating societies included issues around education and training, specialty and workforce advocacy, and collaboration and research. As a result of this summit, societies resolved to establish an Asia-Pacific education forum, to encourage the development of Asia-Pacific critical care trials, and to support engagement in multinational studies. A second Asia-Pacific Critical Care Societies Summit will be convened in 2024, with a focus on safety and quality challenges within ICUs represented by the societies present and discussion of the listed priority areas.
{"title":"Reshaping Postpandemic Critical Care Collaboration in the Asia-Pacific Region","authors":"Eamon P. Raith MBBS, PhD, FCICM , See Kay Choong , Mark Nicholls , Wong Wai Tat , Sheila Nainan Myatra , Erwin Pradian MD, PhD , Moritoki Egi MD, PhD , Gee-Young Suh MD, PhD , Shanti Rudra Deva , Naranpurev Mendsaikhan , Shital Adhikari , Jose Melanio Grayda , Ming-Cheng Chan , Suthat Rungruanghiranya , Sean Loh FCCP, FRCP , David Ku FCICM","doi":"10.1016/j.chstcc.2024.100094","DOIUrl":"10.1016/j.chstcc.2024.100094","url":null,"abstract":"<div><div>The COVID-19 pandemic presented the greatest challenge to modern intensive care medicine since its founding as a specialty in 1952, with its effects felt across health care services in all regions, including low-resourced settings. A paucity of data remains regarding the provision of intensive care medicine across the globe, particularly after the COVID-19 pandemic. To determine the broad state of critical care medicine after the pandemic in the Asia-Pacific region, the inaugural Asia-Pacific Critical Care Societies Summit was held in Singapore as a satellite meeting of the Asia-Pacific Intensive Care Symposium on August 18, 2023. This article summarizes this summit and provides key health and economic data for representative countries before detailing the resolutions and planned actions arising from this initiative. Fourteen critical care societies participated in the inaugural summit and consented to publication of societal reports. Common challenges and priorities for participating societies included issues around education and training, specialty and workforce advocacy, and collaboration and research. As a result of this summit, societies resolved to establish an Asia-Pacific education forum, to encourage the development of Asia-Pacific critical care trials, and to support engagement in multinational studies. A second Asia-Pacific Critical Care Societies Summit will be convened in 2024, with a focus on safety and quality challenges within ICUs represented by the societies present and discussion of the listed priority areas.</div></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"2 4","pages":"Article 100094"},"PeriodicalIF":0.0,"publicationDate":"2024-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142659378","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-08DOI: 10.1016/j.chstcc.2024.100092
Scott T. Vasher MD, MSCR , Jeff Laux PhD , Shannon S. Carson MD , Blair Wendlandt MD, MSCR
Background
Medical mistrust may worsen communication between ICU surrogate decision-makers and intensivists. The prevalence of and risk factors for medical mistrust among surrogate decision-makers are not known.
Research Question
What are the potential sociodemographic risk factors for high medical mistrust among surrogate decision-makers of critically ill patients at high risk of death?
Study Design and Methods
In this pilot cross-sectional study conducted at a single academic medical center between August 2022 and August 2023, adult patients admitted to the medical ICU and their surrogate decision-makers were enrolled. All patients were incapacitated at enrollment with Sequential Organ Failure Assessment scores of ≥ 7 or required mechanical ventilation with vasopressor infusion. Surrogate decision-maker sociodemographic characteristics were age, race, sex, education, relationship to the patient, employment, prior exposure to a loved one transitioning to hospice or comfort-focused care, and religiousness. The primary outcome was surrogate decision-maker medical mistrust, measured using the Medical Mistrust Multiformat Scale. Multiple linear regression was used to determine sociodemographic characteristics associated with higher medical mistrust.
Results
Thirty-one patients and their surrogate decision-makers were enrolled during the study period, surpassing our goal of 30 pairs and indicating recruitment feasibility. Mean ± SD surrogate age was 53.8 ± 14.5 years, 24 surrogates were female, and mean medical mistrust score was 17.1 ± 5.4. Race was associated with medical mistrust, with Black participants showing higher medical mistrust compared with White participants (β =10.21; 95% CI, 3.40-17.02; P = .010). Religiousness was associated with lower medical mistrust (β = –2.94; 95% CI, –4.43 to –1.41; P = .003). Prior exposure to hospice or comfort-focused care was associated with higher medical mistrust (β = 7.06; 95% CI, 1.21-12.91; P = .025).
Interpretation
We found that recruiting ICU surrogates and measuring medical mistrust within 48 h of ICU admission was feasible. Several surrogate sociodemographic characteristics were associated with changes in medical mistrust. These preliminary findings will inform the design of future studies.
{"title":"Predictors of Medical Mistrust Among Surrogate Decision-Makers of Patients in the ICU at High Risk of Death","authors":"Scott T. Vasher MD, MSCR , Jeff Laux PhD , Shannon S. Carson MD , Blair Wendlandt MD, MSCR","doi":"10.1016/j.chstcc.2024.100092","DOIUrl":"10.1016/j.chstcc.2024.100092","url":null,"abstract":"<div><h3>Background</h3><div>Medical mistrust may worsen communication between ICU surrogate decision-makers and intensivists. The prevalence of and risk factors for medical mistrust among surrogate decision-makers are not known.</div></div><div><h3>Research Question</h3><div>What are the potential sociodemographic risk factors for high medical mistrust among surrogate decision-makers of critically ill patients at high risk of death?</div></div><div><h3>Study Design and Methods</h3><div>In this pilot cross-sectional study conducted at a single academic medical center between August 2022 and August 2023, adult patients admitted to the medical ICU and their surrogate decision-makers were enrolled. All patients were incapacitated at enrollment with Sequential Organ Failure Assessment scores of ≥ 7 or required mechanical ventilation with vasopressor infusion. Surrogate decision-maker sociodemographic characteristics were age, race, sex, education, relationship to the patient, employment, prior exposure to a loved one transitioning to hospice or comfort-focused care, and religiousness. The primary outcome was surrogate decision-maker medical mistrust, measured using the Medical Mistrust Multiformat Scale. Multiple linear regression was used to determine sociodemographic characteristics associated with higher medical mistrust.</div></div><div><h3>Results</h3><div>Thirty-one patients and their surrogate decision-makers were enrolled during the study period, surpassing our goal of 30 pairs and indicating recruitment feasibility. Mean ± SD surrogate age was 53.8 ± 14.5 years, 24 surrogates were female, and mean medical mistrust score was 17.1 ± 5.4. Race was associated with medical mistrust, with Black participants showing higher medical mistrust compared with White participants (β =10.21; 95% CI, 3.40-17.02; <em>P</em> = .010). Religiousness was associated with lower medical mistrust (β = –2.94; 95% CI, –4.43 to –1.41; <em>P = .</em>003). Prior exposure to hospice or comfort-focused care was associated with higher medical mistrust (β = 7.06; 95% CI, 1.21-12.91; <em>P = .</em>025).</div></div><div><h3>Interpretation</h3><div>We found that recruiting ICU surrogates and measuring medical mistrust within 48 h of ICU admission was feasible. Several surrogate sociodemographic characteristics were associated with changes in medical mistrust. These preliminary findings will inform the design of future studies.</div></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"2 4","pages":"Article 100092"},"PeriodicalIF":0.0,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142538303","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-08DOI: 10.1016/j.chstcc.2024.100091
Tessa A. Mulder MD , Linda Becude MD , Jorge E. Lopez Matta MD , Wilbert B. van den Hout PhD , David J. van Westerloo MD, PhD , Martijn P. Bauer MD, PhD
Background
Estimating central venous pressure (CVP) is essential in the diagnostic evaluation and treatment guidance of most hospitalized patients. It is unknown how different noninvasive bedside methods to estimate CVP correlate with each other and which method has the best accuracy.
Research Question
Which noninvasive bedside method to estimate CVP has the best accuracy to detect elevated CVP?
Study Design and Methods
During this prospective, single-center, observational study, we included patients admitted to the ward or ICU who already had an indwelling central venous catheter and who did not undergo positive pressure ventilation. We measured height of the fluid column in the external jugular vein (EJV) according to the Lewis and Borst method (EJV height), maximum and minimum diameters and height of the fluid column of the internal jugular vein (IJV; IJV height) using ultrasound, and diameters of the inferior vena cava (IVC) throughout a respiratory cycle and sniffing. We then compared these measurements with intravenously measured CVP.
Results
Ninety patients were included. Twenty-seven patients (30%) showed CVP of ≥ 10 mm Hg. All measurements had a significant correlation with CVP, except for the diameter of the IJV. Areas under the receiver operating characteristic curve for IJV height, EJV height, maximum diameter, and collapsibility on inspiration of the IVC were 0.85, 0.80, 0.78, and 0.76 respectively. The interobserver agreement was good to excellent. We estimated continuous likelihood ratios for the measurements to aid clinical decision-making.
Interpretation
Our results indicated that EJV height, IJV height, IVC diameter, and IVC collapsibility can be used to identify an elevated CVP in hospitalized patients. Among these, ultrasonographic estimation of the height of the fluid column in the IJV is quick and easy and allows identification of an elevated CVP with the best reproducibility and accuracy.
Clinical Trial Registration
National Trial Register; ID: NL-OMON22937; URL: https://onderzoekmetmensen.nl/en/trial/22937
{"title":"The SONIC CENTRAL Study","authors":"Tessa A. Mulder MD , Linda Becude MD , Jorge E. Lopez Matta MD , Wilbert B. van den Hout PhD , David J. van Westerloo MD, PhD , Martijn P. Bauer MD, PhD","doi":"10.1016/j.chstcc.2024.100091","DOIUrl":"10.1016/j.chstcc.2024.100091","url":null,"abstract":"<div><h3>Background</h3><div>Estimating central venous pressure (CVP) is essential in the diagnostic evaluation and treatment guidance of most hospitalized patients. It is unknown how different noninvasive bedside methods to estimate CVP correlate with each other and which method has the best accuracy.</div></div><div><h3>Research Question</h3><div>Which noninvasive bedside method to estimate CVP has the best accuracy to detect elevated CVP?</div></div><div><h3>Study Design and Methods</h3><div>During this prospective, single-center, observational study, we included patients admitted to the ward or ICU who already had an indwelling central venous catheter and who did not undergo positive pressure ventilation. We measured height of the fluid column in the external jugular vein (EJV) according to the Lewis and Borst method (EJV height), maximum and minimum diameters and height of the fluid column of the internal jugular vein (IJV; IJV height) using ultrasound, and diameters of the inferior vena cava (IVC) throughout a respiratory cycle and sniffing. We then compared these measurements with intravenously measured CVP.</div></div><div><h3>Results</h3><div>Ninety patients were included. Twenty-seven patients (30%) showed CVP of ≥ 10 mm Hg. All measurements had a significant correlation with CVP, except for the diameter of the IJV. Areas under the receiver operating characteristic curve for IJV height, EJV height, maximum diameter, and collapsibility on inspiration of the IVC were 0.85, 0.80, 0.78, and 0.76 respectively. The interobserver agreement was good to excellent. We estimated continuous likelihood ratios for the measurements to aid clinical decision-making.</div></div><div><h3>Interpretation</h3><div>Our results indicated that EJV height, IJV height, IVC diameter, and IVC collapsibility can be used to identify an elevated CVP in hospitalized patients. Among these, ultrasonographic estimation of the height of the fluid column in the IJV is quick and easy and allows identification of an elevated CVP with the best reproducibility and accuracy.</div></div><div><h3>Clinical Trial Registration</h3><div>National Trial Register; ID: NL-OMON22937; URL: <span><span>https://onderzoekmetmensen.nl/en/trial/22937</span><svg><path></path></svg></span></div></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"2 4","pages":"Article 100091"},"PeriodicalIF":0.0,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142578326","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-08DOI: 10.1016/j.chstcc.2024.100093
Julia A. Stevenson BA , Terrence E. Murphy PhD , Baylah Tessier-Sherman MPH , Margaret A. Pisani MD, MPH , Thomas M. Gill MD , Lauren E. Ferrante MD, MHS
Background
A recent international consensus conference called for the development of risk prediction models to identify ICU survivors at increased risk of each of the post-ICU syndrome domains. We previously developed and validated a risk prediction tool for functional impairment after ICU admission among older adults.
Research Question
In this pilot study, we assessed the feasibility of administering the risk prediction tool in the hospital to older adults who had just survived critical illness. An exploratory objective was to evaluate whether augmentation of the model with additional hospital-related factors improved discrimination.
Study Design and Methods
Between January and October 2020, 50 adults aged 65 years and older underwent in-hospital administration of the risk prediction tool. Survivors were called monthly for 6 months after discharge. Feasibility was defined as completion of all tool components by ≥ 70% of enrolled participants. Persistent functional impairment was defined as failure to return to the functional baseline from before the ICU stay at the 6-month interview based on seven daily activities. The model was sequentially refit after adding three in-hospital factors as predictors, one at a time and then all together. Model discrimination was assessed with receiver operating characteristic curves.
Results
The tool met the a priori feasibility threshold, with 92.0% of enrolled participants completing all eight components. In the exploratory analysis, the addition of Acute Physiology and Chronic Health Evaluation II score, presence of delirium, and maximum in-hospital mobility resulted in a 5% gain in discrimination that did not achieve statistical significance (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.68-0.82; P = .09).
Interpretation
Our results indicate that the risk prediction tool is feasible for use in the hospital setting, enabling the identification of ICU survivors at high risk of persistent functional impairment at 6 months after discharge. Augmentation with hospital-related factors improved model discrimination, but did not achieve statistical significance in this pilot study. Future studies should evaluate the augmented model in larger cohorts.
{"title":"Feasibility of In-Hospital Administration of a Tool to Predict Persistent Post-ICU Functional Impairment Among Older ICU Survivors","authors":"Julia A. Stevenson BA , Terrence E. Murphy PhD , Baylah Tessier-Sherman MPH , Margaret A. Pisani MD, MPH , Thomas M. Gill MD , Lauren E. Ferrante MD, MHS","doi":"10.1016/j.chstcc.2024.100093","DOIUrl":"10.1016/j.chstcc.2024.100093","url":null,"abstract":"<div><h3>Background</h3><div>A recent international consensus conference called for the development of risk prediction models to identify ICU survivors at increased risk of each of the post-ICU syndrome domains. We previously developed and validated a risk prediction tool for functional impairment after ICU admission among older adults.</div></div><div><h3>Research Question</h3><div>In this pilot study, we assessed the feasibility of administering the risk prediction tool in the hospital to older adults who had just survived critical illness. An exploratory objective was to evaluate whether augmentation of the model with additional hospital-related factors improved discrimination.</div></div><div><h3>Study Design and Methods</h3><div>Between January and October 2020, 50 adults aged 65 years and older underwent in-hospital administration of the risk prediction tool. Survivors were called monthly for 6 months after discharge. Feasibility was defined as completion of all tool components by ≥ 70% of enrolled participants. Persistent functional impairment was defined as failure to return to the functional baseline from before the ICU stay at the 6-month interview based on seven daily activities. The model was sequentially refit after adding three in-hospital factors as predictors, one at a time and then all together. Model discrimination was assessed with receiver operating characteristic curves.</div></div><div><h3>Results</h3><div>The tool met the a priori feasibility threshold, with 92.0% of enrolled participants completing all eight components. In the exploratory analysis, the addition of Acute Physiology and Chronic Health Evaluation II score, presence of delirium, and maximum in-hospital mobility resulted in a 5% gain in discrimination that did not achieve statistical significance (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.68-0.82; <em>P</em> = .09).</div></div><div><h3>Interpretation</h3><div>Our results indicate that the risk prediction tool is feasible for use in the hospital setting, enabling the identification of ICU survivors at high risk of persistent functional impairment at 6 months after discharge. Augmentation with hospital-related factors improved model discrimination, but did not achieve statistical significance in this pilot study. Future studies should evaluate the augmented model in larger cohorts.</div></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"2 4","pages":"Article 100093"},"PeriodicalIF":0.0,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142534039","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-06DOI: 10.1016/j.chstcc.2024.100089
Isabel A. Mangaoang PharmD , Kendra J. Schomer PharmD , Rachelle L. Firestone PharmD , Jeremiah J. Duby PharmD
Background
Induction agents are administered to decrease the risk of discomfort, awareness, and psychological sequelae during procedural paralysis (eg, rapid sequence intubation). The expected duration of nondepolarizing neuromuscular blocking agents exceeds that of induction sedatives. The resulting sedation gap may increase the risk of awake paralysis.
Research Question
The objective of this study was to elucidate the prevalence and duration of sedation gaps in critically ill patients undergoing bedside procedural paralysis.
Study Design and Methods
This was a retrospective cross-sectional study of critically ill adults who received rocuronium for a bedside procedure. The primary outcome was the sedation gap, which was the cumulative time of inadequate sedation during presumed paralysis (ie, 60 min after rocuronium). Secondary outcomes included the sedation gap when a pharmacist was present at the bedside. Descriptive statistics were used for baseline characteristics and the primary outcome. Log-rank and Mann-Whitney U tests were used to analyze secondary outcomes.
Results
Eighty patients were included in the final analysis. The average age was 60 years and 57% of patients were male. The most common indication for procedural paralysis was rapid sequence intubation (99%). Most procedures were performed in the ED (55%), followed by the ICU (43.8%). Eighty-five percent of patients experienced a sedation gap of any duration. The median sedation gap was 19 min (interquartile range [IQR], 4-47.5 min). The probability of initiating adequate sedation was higher when a pharmacist was present at the bedside (hazard ratio, 1.49 [95% CI, 1.42-1.55], bootstrapping log-rank test). The median sedation gap with a pharmacist (11 min [IQR, 3-27.5 min]) was significantly lower than without a pharmacist (40 min [IQR, 17-55 min]; P = .0115, Mann-Whitney U test).
Interpretation
In this critically ill cohort, a substantial prevalence and duration of inadequate sedation was experienced after receiving rocuronium for bedside procedures. Further study is needed to identify if sedation gaps correlate with an increased risk of psychological morbidities.
{"title":"Mind the Gap","authors":"Isabel A. Mangaoang PharmD , Kendra J. Schomer PharmD , Rachelle L. Firestone PharmD , Jeremiah J. Duby PharmD","doi":"10.1016/j.chstcc.2024.100089","DOIUrl":"10.1016/j.chstcc.2024.100089","url":null,"abstract":"<div><h3>Background</h3><p>Induction agents are administered to decrease the risk of discomfort, awareness, and psychological sequelae during procedural paralysis (eg, rapid sequence intubation). The expected duration of nondepolarizing neuromuscular blocking agents exceeds that of induction sedatives. The resulting sedation gap may increase the risk of awake paralysis.</p></div><div><h3>Research Question</h3><p>The objective of this study was to elucidate the prevalence and duration of sedation gaps in critically ill patients undergoing bedside procedural paralysis.</p></div><div><h3>Study Design and Methods</h3><p>This was a retrospective cross-sectional study of critically ill adults who received rocuronium for a bedside procedure. The primary outcome was the sedation gap, which was the cumulative time of inadequate sedation during presumed paralysis (ie, 60 min after rocuronium). Secondary outcomes included the sedation gap when a pharmacist was present at the bedside. Descriptive statistics were used for baseline characteristics and the primary outcome. Log-rank and Mann-Whitney <em>U</em> tests were used to analyze secondary outcomes.</p></div><div><h3>Results</h3><p>Eighty patients were included in the final analysis. The average age was 60 years and 57% of patients were male. The most common indication for procedural paralysis was rapid sequence intubation (99%). Most procedures were performed in the ED (55%), followed by the ICU (43.8%). Eighty-five percent of patients experienced a sedation gap of any duration. The median sedation gap was 19 min (interquartile range [IQR], 4-47.5 min). The probability of initiating adequate sedation was higher when a pharmacist was present at the bedside (hazard ratio, 1.49 [95% CI, 1.42-1.55], bootstrapping log-rank test). The median sedation gap with a pharmacist (11 min [IQR, 3-27.5 min]) was significantly lower than without a pharmacist (40 min [IQR, 17-55 min]; <em>P</em> = .0115, Mann-Whitney <em>U</em> test).</p></div><div><h3>Interpretation</h3><p>In this critically ill cohort, a substantial prevalence and duration of inadequate sedation was experienced after receiving rocuronium for bedside procedures. Further study is needed to identify if sedation gaps correlate with an increased risk of psychological morbidities.</p></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"2 3","pages":"Article 100089"},"PeriodicalIF":0.0,"publicationDate":"2024-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2949788424000431/pdfft?md5=d3ad7f3d4078c5c0f5f838adea87b630&pid=1-s2.0-S2949788424000431-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142084168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-22DOI: 10.1016/j.chstcc.2024.100088
Burton H. Shen MD , Aaron C. Dobie MD , Sara L. Shusterman MD , Mine Duzgol MD , Collin Homer-Bouthiette MD , Lauren E. Kearney MD , Julia Newman MD , Brandon Pang MD , Divya A. Shankar MD , Jingzhou Zhang MD, MPH , Kari R. Gillmeyer MD , Nicholas A. Bosch MD , Anica C. Law MD
Background
More than 90,000 children and adults in the United States are hospitalized with an asthma exacerbation annually, and between 5% and 34% of these hospitalizations include admission to an ICU. It is unclear how adolescent and young adults with severe asthma exacerbations are triaged in the inpatient setting between PICUs and adult ICUs. Using a large multicenter US cohort, we characterized how hospitals triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs.
Research Question
How do hospitals across the United States triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs?
Study Design and Methods
This was a retrospective cohort study carried out from 2016 through 2022 using the enhanced-claims PINC AI database. Participants were patients aged 12 to 26 years who were hospitalized with an asthma exacerbation and admitted to a PICU or adult ICU. We used nested hierarchical multivariable regression models to quantify changes in the intraclass correlation coefficient (ICC; a measure of variation in triage decisions attributable to hospital of admission after accounting for covariables).
Results
Analyses included 3,946 admissions from 93 hospitals. Stratified by age, the percent of patients admitted to PICUs dropped by 26.9% between 17 and 18 years of age. In the nested models, the ICC showed a large decrease going from the empty model (28.7%) to the age-adjusted model (4.5%), but was similar between the age-adjusted and fully adjusted model (3.4%).
Interpretation
Our results showed that among adolescents and young adults with asthma exacerbations, age of 18 years or younger was a strong determinant of PICU triage. Further research is needed to understand differences in asthma care and outcomes between PICUs and adult ICUs, as well as how intermediate care units affect triage decision-making from wards and the ED.
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