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Hofmaenner DA, Singer M. Challenging management dogma where evidence is non-existent, weak, or outdated: part II. Intensive Care Med 2024:10.1007/s00134-024-07634-x. [PMID: 39320462 DOI: 10.1007/s00134-024-07634-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 08/24/2024] [Indexed: 09/26/2024]
Abstract
Many dogmas influence daily clinical practice, and critical care medicine is no exception. We previously highlighted the weak, questionable, and often contrary evidence base underpinning four established medical managements-loop diuretics for acute heart failure, routine use of heparin thromboprophylaxis, rate of sodium correction for hyponatremia, and 'every hour counts' for treating bacterial meningitis. We now provide four further examples in this "Dogma II" piece (a week's course of antibiotics, diabetic ketoacidosis algorithms, sodium bicarbonate to improve ventricular contractility during severe metabolic acidosis, and phosphate replacement for hypophosphatemia) where routine practice warrants re-appraisal.
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Affiliation(s)
- Daniel A Hofmaenner
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK.
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK.
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Gottlieb E, Celi LA. A Reassessment of Sodium Correction Rates and Hospital Length of Stay Accounting for Admission Diagnosis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.08.24303993. [PMID: 38559087 PMCID: PMC10980130 DOI: 10.1101/2024.03.08.24303993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Slow correction of severe hyponatremia has been historically recommended due to the risk of rare but catastrophic neurologic events with rapid correction. A recent study challenging this paradigm reported that rapid correction is associated with shorter hospital length of stay, but that study did not control for admission diagnosis. The objective of this study was to determine whether rapid correction is associated with shorter length of stay when controlling for admission diagnosis. Methods This retrospective cohort study is based on the fourth edition of the Medical Information Mart for Intensive Care, MIMIC-IV, a deidentified, publicly available clinical research database which includes admissions from 2008-2019. Patients were identified who presented to the hospital with initial sodium <120 mEq/L and were categorized according to total sodium correction achieved in the first day (<6 mEq/L; 6-10 mEq/L; >10 mEq/L). Linear regression was used to assess for an association between correction rate and hospital length of stay, and to determine if this association was significant when controlling for admission diagnosis classifications based on diagnosis related groups (DRGs). Results There were 419 patients with severe hyponatremia (<120 mEq/L) included in this study, of whom 374 survived to discharge. Median [IQR] hospital length of stay was 6 [4, 11] days. In a univariable linear regression, there was a trend towards a significant association between the highest rate of correction (>10 mEq/L) and shorter length of stay, as compared with a moderate rate of correction (coef. -2.764, 95% CI [-5.791, 0.263], p=0.073), but the association was not significant when controlling for admission diagnosis group (coef. -1.561, 95% CI [-4.398, 1.276], p=0.280). There was a significant association in the survivor subset (coef. -3.455, 95% CI [-6.668, -0.242], p=0.035), but it was also not significant when controlling for admission diagnosis group (coef. -2.200, 95% CI [-5.144, 0.743], p=0.142). Conclusions Rapid correction is not associated with shorter length of stay when controlling for admission diagnosis, suggesting that the disease state confounds this association. Findings from prior and future studies reporting this association should not drive clinical decision making if the confounding effect of hospital admission diagnosis and competing risk of death are not fully accounted for.
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Kinoshita T, Mlodzinski E, Xiao Q, Sherak R, Raines NH, Celi LA. Effects of correction rate for severe hyponatremia in the intensive care unit on patient outcomes. J Crit Care 2023; 77:154325. [PMID: 37187000 PMCID: PMC10524223 DOI: 10.1016/j.jcrc.2023.154325] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/19/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Limited evidence exists regarding outcomes associated with different correction rates of severe hyponatremia. MATERIALS AND METHODS This retrospective cohort analysis employed a multi-center ICU database to identify patients with sodium ≤120 mEq/L during ICU admission. We determined correction rates over the first 24 h and categorized them as rapid (> 8 mEq/L/day) or slow (≤ 8 mEq/L/day). The primary outcome was in-hospital mortality. Secondary outcomes included hospital-free days, ICU-free days, and neurological complications. We used inverse probability weighting for confounder adjustment. RESULTS Our cohort included 1024 patients; 451 rapid and 573 slow correctors. Rapid correction was associated with lower in-hospital mortality (absolute difference: -4.37%; 95% CI, -8.47 to -0.26%), longer hospital-free days (1.80 days; 95% CI, 0.82 to 2.79 days), and longer ICU-free days (1.16 days; 95% CI, 0.15 to 2.17 days). There was no significant difference in neurological complications (2.31%; 95% CI, -0.77 to 5.40%). CONCLUSION Rapid correction (>8 mEq/L/day) of severe hyponatremia within the first 24 h was associated with lower in-hospital mortality and longer ICU and hospital-free days without an increase in neurological complication. Despite major limitations, including the inability to identify the chronicity of hyponatremia, the results have important implications and warrant prospective studies.
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Affiliation(s)
| | - Eric Mlodzinski
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
| | - Qian Xiao
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Raphael Sherak
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT 06510, USA
| | - Nathan H Raines
- Division of Nephrology, Department of Medicine Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
| | - Leo A Celi
- MIT Critical Data, Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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Huttner BD, Sharland M, Huttner A. On culture and blood cultures. Clin Microbiol Infect 2023; 29:1100-1102. [PMID: 37263416 DOI: 10.1016/j.cmi.2023.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Benedikt D Huttner
- Secretariat of the Model List of Essential Medicines, Department of Health Product Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University London, London, UK
| | - Angela Huttner
- Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland
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vonRosenberg J, Thomson DP. Dogmalysis. Air Med J 2023; 42:280-282. [PMID: 37356891 DOI: 10.1016/j.amj.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 06/27/2023]
Abstract
Air medical and critical care providers encounter the extremes of being both in-hospital and out-of-hospital clinicians, work in unpredictable environments, and treat patients with the most significant injury patterns and diagnoses. These demands highlight the need to recognize unique mental challenges for those who work in the air medical environment and the process by which providers make decisions. Patients who present with a high-acuity/low-volume pathology generate particularly difficult situations with abundant opportunity for both celebrations of performance and learning from mistakes. There are times when the desired option of therapy is not available, the most appropriate destination is not feasible, or the crew is unable to address every aspect of patient care with resources that are immediately available. Although it is logical to make decisions based on anatomic and physiological knowledge, the absence of an actual answer does not necessitate the acceptance of consensus. Dogmalysis refers to the dissolution of authoritative tenets held as established opinion without adequate grounds. This article highlights the importance of dogmalysis, the value of honest scientific reflection, and the aggressive seeking of evidence-based answers as it pertains to the air medical environment.
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Affiliation(s)
| | - David P Thomson
- Human Performance Clinical Research Laboratory, Colorado State University, Department of Health and Exercise Science, Fort Collins, CO.
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Piwowarczyk P, Szczukocka M, Cios W, Okuńska P, Raszewski G, Borys M, Wiczling P, Czuczwar M. Population Pharmacokinetics and Probability of Target Attainment Analysis of Nadroparin in Different Stages of COVID-19. Clin Pharmacokinet 2023; 62:835-847. [PMID: 37097604 PMCID: PMC10126531 DOI: 10.1007/s40262-023-01244-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVE The risk of thrombotic complications in critical patients with COVID-19 remains extremely high, and multicenter trials failed to prove a survival benefit of escalated doses of low-molecular-weight heparins (nadroparin calcium) in this group. The aim of this study was to develop a pharmacokinetic model of nadroparin according to different stages of COVID-19 severity. METHODS Blood samples were obtained from 43 patients with COVID-19 who received nadroparin and were treated with conventional oxygen therapy, mechanical ventilation, and extracorporeal membrane oxygenation. We recorded clinical, biochemical, and hemodynamic variables during 72 h of treatment. The analyzed data comprised 782 serum nadroparin concentrations and 219 anti-Xa levels. We conducted population nonlinear mixed-effects modeling (NONMEM) and performed Monte Carlo simulations of the probability of target attainment for reaching 0.2-0.5 IU/mL anti-Xa levels in study groups. RESULTS We successfully developed a one-compartment model to describe the population pharmacokinetics of nadroparin in different stages of COVID-19. The absorption rate constant of nadroparin was 3.8 and 3.2 times lower, concentration clearance was 2.22 and 2.93 times higher, and anti-Xa clearance was 0.87 and 1.1 times higher in mechanically ventilated patients and the extracorporeal membrane oxygenation group compared with patients treated with conventional oxygen, respectively. The newly developed model indicated that 5.900 IU of nadroparin given subcutaneously twice daily in the mechanically ventilated patients led to a similar probability of target attainment of 90% as 5.900 IU of subcutaneous nadroparin given once daily in the group supplemented with conventional oxygen. CONCLUSIONS Different nadroparin dosing is required for patients undergoing mechanical ventilation and extracorporeal membrane oxygenation to achieve the same targets as those for non-critically ill patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier no. NCT05621915.
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Affiliation(s)
- Paweł Piwowarczyk
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Marta Szczukocka
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Wojciech Cios
- Department of Infectious Diseases, Medical University of Lublin, Lublin, Poland
| | - Paulina Okuńska
- Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdańsk, Al. Gen. Hallera 107, 80-416 Gdańsk, Poland
| | - Grzegorz Raszewski
- Department of Physiopathology, Institute of Rural Health, Lublin, Poland
| | - Michał Borys
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Paweł Wiczling
- Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdańsk, Al. Gen. Hallera 107, 80-416 Gdańsk, Poland
| | - Mirosław Czuczwar
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
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Davidson BL. "Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism": comment. J Thromb Haemost 2023; 21:1388-1389. [PMID: 37121621 DOI: 10.1016/j.jtha.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 05/02/2023]
Affiliation(s)
- Bruce L Davidson
- Department of Medicine, Washington State University Floyd College of Medicine, Everett, Washington, USA.
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Pisciotta W, Arina P, Hofmaenner D, Singer M. Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. Anaesthesia 2023; 78:501-509. [PMID: 36633483 DOI: 10.1111/anae.15897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/13/2023]
Abstract
Dealing with an uncertain or missed diagnosis is commonplace in the intensive care unit setting. Affected patients are subject to a potential decrease in quality of care and a greater risk of a poor outcome. The diagnostic process is a complex task that starts with information gathering, followed by integration and interpretation of data, hypothesis generation and, finally, confirmation of a (hopefully correct) diagnosis. This may be particularly challenging in the patient who is critically ill where a good history may not be forthcoming and/or clinical, laboratory and imaging features are non-specific. The aim of this narrative review is to analyse and describe common causes of diagnostic error in the intensive care unit, highlighting the multiple types of cognitive bias, and to suggest a diagnostic framework. To inform this review, we performed a literature search to identify relevant articles, particularly those pertinent to unclear diagnoses in patients who are critically ill. Clinicians should be cognisant as to how they formulate diagnoses and utilise debiasing strategies. Multidisciplinary teamwork and more time spent with the patient, supported by effective and efficient use of electronic healthcare records and decision support resources, is likely to improve the quality of the diagnostic process, patient care and outcomes.
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Affiliation(s)
- W Pisciotta
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK.,IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - P Arina
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK
| | - D Hofmaenner
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK.,Institute of Intensive Care Medicine, University Hospital Zurich, Switzerland
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK
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Hofmaenner DA, Singer M. The challenge of pharmacological thromboprophylaxis in ICU patients: anti-FXa activity does not constitute the simple solution. Author's reply. Intensive Care Med 2022; 48:1118-1119. [PMID: 35713667 PMCID: PMC9204360 DOI: 10.1007/s00134-022-06768-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel A Hofmaenner
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London, WC1E 6BT, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London, WC1E 6BT, UK.
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The challenge of pharmacological thromboprophylaxis in ICU patients: anti-FXa activity does not constitute a simple solution. Intensive Care Med 2022; 48:1116-1117. [PMID: 35614321 DOI: 10.1007/s00134-022-06744-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 11/05/2022]
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