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Shahn Z, Jung B, Talmor D, Kennedy EH, Lehman LWH, Baedorf-Kassis E. The impact of aggressive and conservative propensity for initiation of neuromuscular blockade in mechanically ventilated patients with hypoxemic respiratory failure. J Crit Care 2024; 82:154803. [PMID: 38552450 PMCID: PMC11139559 DOI: 10.1016/j.jcrc.2024.154803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Neuromuscular blockade (NMB) in ventilated patients may cause benefit or harm. We applied "incremental interventions" to determine the impact of altering NMB initiation aggressiveness. METHODS Retrospective cohort study of ventilated patients with PaO2/FiO2 ratio < 150 mmHg and PEEP≥ 8cmH2O from the Medical Information Mart of Intensive Care IV database (MIMIC-IV version 1.0) estimating the effect of incremental interventions on in-hospital mortality and ventilator-free days, modifying hourly propensity for NMB initiation to be aggressive or conservative relative to usual care, adjusting for confounding with inverse probability weighting. RESULTS 5221 patients were included (13.3% initiated on NMB). Incremental interventions estimated a strong effect on NMB usage: 5-fold higher hourly odds of initiation increased usage to 36.5% (CI = [34.3%,38.7%]) and 5-fold lower odds decreased usage to 3.8% (CI = [3.3%,4.3%]). Aggressive and conservative strategies demonstrated a U-shaped mortality relationship. 5-fold higher or lower propensity increased in-hospital mortality by 2.6% (0.95 CI = [1.5%,3.7%]) or 1.3% (0.95 CI = [0.1%,2.5%]) respectively. In secondary analysis of a healthier patient cohort, results were similar, however conservative strategies also improved ventilator-free days. INTERPRETATION Aggressive or conservative initiation of NMB may worsen mortality. In healthier populations, marginally conservative NMB initiation strategies may lead to increased ventilator free days with minimal impact on mortality.
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Affiliation(s)
- Zach Shahn
- MIT-IBM Watson AI Lab, Cambridge, MA, United States of America; CUNY Graduate School of Public Health and Health Policy, New York City, NY, United States of America
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier University, Montpellier, France; Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America
| | - Daniel Talmor
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America
| | - Edward H Kennedy
- Department of Statistics & Data Science, Carnegie Mellon University, Pittsburgh, PA 15213, United States of America
| | - Li-Wei H Lehman
- MIT-IBM Watson AI Lab, Cambridge, MA, United States of America; Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, 02142, United States of America
| | - Elias Baedorf-Kassis
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America.
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Esteves AM, Fjeld KJ, Yonan AS, Roginski MA. Neuromuscular Blocking Agent Use in Critical Care Transport Not Associated With Intubation. Air Med J 2024; 43:328-332. [PMID: 38897696 DOI: 10.1016/j.amj.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/01/2024] [Accepted: 03/07/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE Variable indications exist for neuromuscular blocking agents (NMBAs) in the critical care transport setting beyond facilitation of intubation. METHODS This retrospective cohort study included adult patients (≥ 18 years) who underwent critical care transport from July 1, 2020, to May 2, 2023, and received NMBAs during transport that was not associated with intubation. The primary outcome was the indication for NMBA administration. Secondary outcomes included the characterization of NMBA use, mean Richmond Agitation Sedation Scale score before NMBA administration, sedation strategy used, and continuation of NMBAs within 48 hours of hospital admission. RESULTS One hundred twenty-six patients met the inclusion criteria. The most common indication for NMBA administration was ventilator dyssynchrony (n = 71, 56.4%). The majority of patients received rocuronium during transport (n = 113, 89.7%). The mean pre-NMBA Richmond Agitation Sedation Scale score was -3.7 ± 2.4. The most common sedation strategy was a combination of continuous infusion and bolus sedatives (76.2%). One hundred (79.4%) patients had sedation changes in response to NMBA administration. Seventy-two (57.1%) received NMBAs during the first 48 hours of their intensive care unit admission. CONCLUSION NMBAs were frequently administered for ventilator dyssynchrony and continuation of prior therapy. Optimization opportunities exist to ensure adequate deep sedation and reassessment of NMBA indication.
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Affiliation(s)
| | | | | | - Matthew A Roginski
- Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH.
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3
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Davids R, Robinson G, Van Tonder C, Robinson J, Ahmed N, Domingo A. Jehovah's Witness Needing Critical Care: A Narrative Review on the Expanding Arsenal. Crit Care Res Pract 2024; 2024:1913237. [PMID: 38813134 PMCID: PMC11136542 DOI: 10.1155/2024/1913237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/08/2024] [Accepted: 04/13/2024] [Indexed: 05/31/2024] Open
Abstract
Present day Jehovah's Witness (JW) religion accounts for 8.5 million followers. A tenant feature of the JW faith is religious objection to transfusions of blood and blood products. Interpatient variability, as it pertains to blood and blood products may occur; hence, a confidential interview will determine which products individual may consent to (Marsh and Bevan, 2002). This belief and practice place great restrictions on treating medical professionals in scenarios of life-threatening anaemia and active haemorrhage. The review to follow explores the physiological and pathophysiological consequences of severe anaemia. Non-blood transfusion practices are explored, many of which are potentially lifesaving. Particular attention is drawn to the evolving science involving artificial oxygen carriers and their use in emergency situations. A greater safety profile ensures its future use amongst religious objectors to be greatly beneficial. Intravenous iron supplementation has enjoyed a lively debate within the critical care community. A review of recent systematic and meta-analysis supports its use in the ICU; however, more investigation is needed into the complementary use of hepcidin.
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Affiliation(s)
- Ryan Davids
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Gareth Robinson
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Charmé Van Tonder
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Jordan Robinson
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Nadiyah Ahmed
- Department of Critical Care, University of Free State, Bloemfontein, South Africa
| | - Abdurragmaan Domingo
- Department of Anaesthesiology and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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4
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Deitz RL, Thorngren CK, Seese LM, Ryan JP, Ramanan R, Sanchez PG, Murray H. Evolution of extracorporeal membrane oxygenation trigger criteria in COVID-19 acute respiratory distress syndrome. J Thorac Cardiovasc Surg 2024; 167:1333-1343. [PMID: 36481061 PMCID: PMC9625843 DOI: 10.1016/j.jtcvs.2022.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/08/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To understand the implications of a tiered extracorporeal membrane oxygenation (ECMO) criteria framework and the outcomes of patients with COVID-19 acute respiratory distress syndrome who we were consulted on for ECMO but ultimately declined. METHODS All patients declined for ECMO support by a large regional health care system between March 2020 and July 2021 were included. Restrictive selection criteria were enacted midway through the study stratifying the cohort into 2 groups. Primary outcomes included 30-day mortality. Secondary outcomes included reasons for declining ECMO and survival stratified by phase. RESULTS One hundred ninety-three patients with COVID-19 acute respiratory distress syndrome were declined for ECMO within the study period out of 260 ECMO consults. At the time of consult, 71.0% (n = 137) were mechanically ventilated and 38% (n = 74) were proned and chemically paralyzed. Thirty-day mortality was 66% (n = 117), which increased from 53% to 73% (P = .010) when restrictive criteria were enacted. Patients with multisystem organ failure, prolonged ventilator time, and advanced age had respectively an 11-fold (odds ratio, 10.6; 95% CI, 1.7-65.2), 4-fold (odds ratio, 3.5; 95% CI, 1.1-12.0), and 4-fold (odds ratio, 4.4; 95% CI, 1.9-10.2) increase in the odds of mortality. CONCLUSIONS Patients with COVID-19 acute respiratory distress syndrome declined for ECMO represent a critically ill cohort. We observed an increase in the severity of disease and 30-day mortality in consults in the latter phase of our study period. These findings may reflect our use of tiered selection criteria coupled with ongoing education and communication with referring centers, sparing both patients likely to respond to medical therapy and those who were unsalvageable by ECMO.
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Affiliation(s)
- Rachel L Deitz
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Christina K Thorngren
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Laura M Seese
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa; Division of Lung Transplant and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
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5
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Sikora A. Critical Care Pharmacists: A Focus on Horizons. Crit Care Clin 2023; 39:503-527. [PMID: 37230553 DOI: 10.1016/j.ccc.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-118, Augusta, GA 30912, USA; Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.
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Martyn JAJ, Sparling JL, Bittner EA. Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review. Br J Anaesth 2023; 130:39-50. [PMID: 36175185 DOI: 10.1016/j.bja.2022.08.009] [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: 04/11/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/05/2023] Open
Abstract
Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.
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Affiliation(s)
- J A Jeevendra Martyn
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jamie L Sparling
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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8
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Li L, Zhen J, Huang L, Zhou J, Yao L, Xu L, Zhang W, Zhang G, Chen Q, Cheng B, Gong S, Cai G, Jiang R, Yan J. The risk factors for deep venous thrombosis in critically ill older adult patients: a subgroup analysis of a prospective, multicenter, observational study. BMC Geriatr 2022; 22:977. [PMID: 36536310 PMCID: PMC9764582 DOI: 10.1186/s12877-022-03599-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older adult patients mainly suffer from multiple comorbidities and are at a higher risk of deep venous thrombosis (DVT) during their stay in the intensive care unit (ICU) than younger adult patients. This study aimed to analyze the risk factors for DVT in critically ill older adult patients. METHODS This was a subgroup analysis of a prospective, multicenter, observational study of patients who were admitted to the ICU of 54 hospitals in Zhejiang Province from September 2019 to January 2020 (ChiCTR1900024956). Patients aged > 60 years old on ICU admission were included. The primary outcome was DVT during the ICU stay. The secondary outcomes were the 28- and 60-day survival rates, duration of stay in ICU, length of hospitalization, pulmonary embolism, incidence of bleeding events, and 60-day coagulopathy. RESULTS A total of 650 patients were finally included. DVT occurred in 44 (2.3%) patients. The multivariable logistic regression analysis showed that age (≥75 vs 60-74 years old, odds ratio (OR) = 2.091, 95% confidence interval (CI): 1.308-2.846, P = 0.001), the use of analgesic/sedative/muscarinic drugs (OR = 2.451, 95%CI: 1.814-7.385, P = 0.011), D-dimer level (OR = 1.937, 95%CI: 1.511-3.063, P = 0.006), high Caprini risk score (OR = 2.862, 95%CI: 1.321-2.318, P = 0.039), basic prophylaxis (OR = 0.111, 95%CI: 0.029-0.430, P = 0.001), and physical prophylaxis (OR = 0.322, 95%CI: 0.109-0.954, P = 0.041) were independently associated with DVT. There were no significant differences in 28- and 60-day survival rates, duration of stay in ICU, total length of hospitalization, 60-day pulmonary embolism, and coagulation dysfunction between the two groups, while the DVT group had a higher incidence of bleeding events (2.6% vs. 8.9%, P < 0.001). CONCLUSION In critically ill older adult patients, basic prophylaxis and physical prophylaxis were found as independent protective factors for DVT. Age (≥75 years old), the use of analgesic/sedative/muscarinic drugs, D-dimer level, and high Caprini risk score were noted as independent risk factors for DVT. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR1900024956).URL: http://www.chictr.org.cn/listbycreater.aspx .
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Affiliation(s)
- Li Li
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Junhai Zhen
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Liquan Huang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, 54 Youdian Road, Hangzhou, 310013 China
| | - Jia Zhou
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Lina Yao
- grid.411634.50000 0004 0632 4559Department of Critical Care Medicine, Ningbo Yinzhou People’s Hospital, 58 Zhoumeng North Road, Yinzhou, Ningbo City, 315100 China
| | - Lingen Xu
- Department of Critical Care Medicine, Xinchang Hospital of Traditional Chinese Medicine, 188 Jiufeng Road, Xinchang, Shaoxing City, 312500 China
| | - Weimin Zhang
- grid.452237.50000 0004 1757 9098Department of Critical Care Medicine, Dongyang People’s Hospital, 60 Wuning West Road, Dongyang, Jinhua City, 322100 China
| | - Gensheng Zhang
- grid.412465.0Department of Critical Care Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009 China
| | - Qijiang Chen
- Department of Critical Care Medicine, Ninghai First Hospital, 142 Taoyuan Middle Road, Ninghai, Ningbo City, 315600 China
| | - Bihuan Cheng
- grid.268099.c0000 0001 0348 3990Department of Critical Care Medicine, The 2nd School of Medicine, Wenzhou Medical University, 109 West Xueyuan Road, Wenzhou, 325027 China
| | - Shijin Gong
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Guolong Cai
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Ronglin Jiang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, 54 Youdian Road, Hangzhou, 310013 China
| | - Jing Yan
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
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Tsolaki V, Zakynthinos GE, Papadonta ME, Bardaka F, Fotakopoulos G, Pantazopoulos I, Makris D, Zakynthinos E. Neuromuscular Blockade in the Pre- and COVID-19 ARDS Patients. J Pers Med 2022; 12:jpm12091538. [PMID: 36143323 PMCID: PMC9504585 DOI: 10.3390/jpm12091538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/03/2022] [Accepted: 09/15/2022] [Indexed: 11/24/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) accounts for a quarter of mechanically ventilated patients, while during the pandemic, it overwhelmed the capacity of intensive care units (ICUs). Lung protective ventilation (low tidal volume, positive-end expiratory pressure titrated to lung mechanics and oxygenation, permissive hypercapnia) is a non-pharmacological approach that is the gold standard of management. Among the pharmacological treatments, the use of neuromuscular blocking agents (NMBAs), although extensively studied, has not yet been well clarified. The rationale is to minimize the risk for lung damage progression, in the already-injured pulmonary parenchyma. By abolishing rigorous spontaneous efforts, NMBAs may decrease the generation of high transpulmonary pressures that could aggravate patients’ self-inflicted lung injury. Moreover, NMBAs can harmonize the patient–ventilator interaction. Recent randomized controlled trials reported contradictory results and changed the clinical practice in a bidirectional way. NMBAs have not been documented to improve long-term survival; thus, the current guidance suggests their use only in patients in whom a lung protective ventilation protocol cannot be applied, due to asynchrony or increased respiratory efforts. In the present review, we discuss the published data and additionally the clinical practice in the “war” conditions of the COVID-19 pandemic, concerning NMBA use in the management of patients with ARDS.
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Affiliation(s)
- Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
- Correspondence: ; Tel.: +30-2413502964
| | - George E. Zakynthinos
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
- Third Department of Cardiology, Sotiria General Hospital, 11527 Athens, Greece
| | - Maria-Eirini Papadonta
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Fotini Bardaka
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - George Fotakopoulos
- Neurosurgical Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Ioannis Pantazopoulos
- Emergency Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Demosthenes Makris
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Epaminondas Zakynthinos
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
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10
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Rodríguez-Blanco J, Rodríguez-Yanez T, Rodríguez-Blanco JD, Almanza-Hurtado AJ, Martínez-Ávila MC, Borré-Naranjo D, Acuña Caballero MC, Dueñas-Castell C. Neuromuscular blocking agents in the intensive care unit. J Int Med Res 2022; 50:3000605221128148. [PMID: 36173012 PMCID: PMC9528036 DOI: 10.1177/03000605221128148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.
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Affiliation(s)
- Jonathan Rodríguez-Blanco
- Divission of Pain Medicine, Department of Anesthesiology, University of Antioquia, Medellin, Colombia
| | - Tomás Rodríguez-Yanez
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | | | | | - Diana Borré-Naranjo
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | - Carmelo Dueñas-Castell
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
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11
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Gonzalez A, Abrigo J, Achiardi O, Simon F, Cabello-Verrugio C. Intensive care unit-acquired weakness: From molecular mechanisms to its impact in COVID-2019. Eur J Transl Myol 2022; 32. [PMID: 36036350 PMCID: PMC9580540 DOI: 10.4081/ejtm.2022.10511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/08/2022] [Indexed: 01/08/2023] Open
Abstract
Intensive Care Unit-Acquired Weakness (ICU-AW) is a generalized and symmetric neuromuscular dysfunction associated with critical illness and its treatments. Its incidence is approximately 80% in intensive care unit patients, and it manifests as critical illness polyneuropathy, critical illness myopathy, and muscle atrophy. Intensive care unit patients can lose an elevated percentage of their muscle mass in the first days after admission, producing short- and long-term sequelae that affect patients’ quality of life, physical health, and mental health. In 2019, the world was faced with coronavirus disease 2019 (COVID-19), caused by the acute respiratory syndrome coronavirus 2. COVID-19 produces severe respiratory disorders, such as acute respiratory distress syndrome, which increases the risk of developing ICU-AW. COVID-19 patients treated in intensive care units have shown early diffuse and symmetrical muscle weakness, polyneuropathy, and myalgia, coinciding with the clinical presentation of ICU-AW. Besides, these patients require prolonged intensive care unit stays, invasive mechanical ventilation, and intensive care unit pharmacological therapy, which are risk factors for ICU-AW. Thus, the purposes of this review are to discuss the features of ICU-AW and its effects on skeletal muscle. Further, we will describe the mechanisms involved in the probable development of ICU-AW in severe COVID-19 patients.
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12
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Bailey CR. Neuromuscular blockade in the ICU: if you can't measure it, you can't manage it. Anaesthesia 2022; 77:953-955. [PMID: 35837837 DOI: 10.1111/anae.15809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/26/2022]
Affiliation(s)
- C R Bailey
- Department of Anaesthetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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13
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Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060785. [PMID: 35744049 PMCID: PMC9229825 DOI: 10.3390/medicina58060785] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/05/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022]
Abstract
Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.
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Abstract
The care of the critically ill child often includes medications used for the relief of pain and anxiety. Children have key differences in pharmacokinetics and pharmacodynamics compared with adults that should always be considered to achieve safe medication use in this population. Pain must be addressed, and sedative use should be minimized when possible. Our understanding of sedation safety is evolving, and studies have shown that minimizing exposure to multiple medications can reduce the burden of delirium and iatrogenic withdrawal.
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Affiliation(s)
- Kevin Valentine
- Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Suite 4900, Indianapolis, IN 46202, USA.
| | - Janelle Kummick
- Butler University College of Pharmacy and Health Sciences, Riley Hospital for Children, 705 Riley Hospital Drive, Room W6111, Indianapolis, IN 46202, USA
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15
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Fior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med 2022; 43:417-425. [PMID: 35760300 DOI: 10.1055/s-0042-1749450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.
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Affiliation(s)
- Gabriele Fior
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Zasha F Vazquez Colon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Florida, Shands Children's Hospital, Gainesville, Florida
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, Shands Children's Hospital, Gainesville, University of Florida, Gainesville, Florida
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital and The Wesley Hospital, Uniting Care Hospitals, Brisbane, QLD, Australia
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16
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Lin T, Yao Y, Xu Y, Huang HB. Neuromuscular Blockade for Cardiac Arrest Patients Treated With Targeted Temperature Management: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:780370. [PMID: 35685629 PMCID: PMC9171045 DOI: 10.3389/fphar.2022.780370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/02/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Neuromuscular-blocking agents (NMBA) are often administered to control shivering in comatose cardiac arrest (CA) survivors during targeted temperature management (TTM) management. Thus, we performed a systematic review and meta-analysis to investigate the effectiveness and safety of NMBA in such a patient population. Methods: We searched for relevant studies in PubMed, Embase, and the Cochrane Library until 15 Jul 2021. Studies were included if they reported data on any of the predefined outcomes in adult comatose CA survivors managed with any NMBA regimens. The primary outcomes were mortality and neurological outcome. Results were expressed as odds ratio (OR) or mean difference (MD) with an accompanying 95% confidence interval (CI). Heterogeneity, sensitivity analysis, and publication bias were also investigated to test the robustness of the primary outcome. Data Synthesis: We included 12 studies (3 randomized controlled trials and nine observational studies) enrolling 11,317 patients. These studies used NMBA in three strategies: prophylactic NMBA, bolus NMBA if demanded, or managed without NMBA. Pooled analysis showed that CA survivors with prophylactic NMBA significantly improved both outcomes of mortality (OR 0.74; 95% CI 0.64-0.86; I 2 = 41%; p < 0.0001) and neurological outcome (OR 0.53; 95% CI 0.37-0.78; I 2 = 59%; p = 0.001) than those managed without NMBA. These results were confirmed by the sensitivity analyses and subgroup analyses. Only a few studies compared CA survivors receiving continuous versus bolus NMBA if demanded strategies and the pooled results showed no benefit in the primary outcomes between the two groups. Conclusion: Our results showed that using prophylactic NMBA strategy compared to the absence of NMBA was associated with improved mortality and neurologic outcome in CA patients undergoing TTM. However, more high-quality randomized controlled trials are needed to confirm our results.
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Affiliation(s)
- Tong Lin
- Department of Reproductive Endocrinology, Hospital of Traditional Chinese Medicine, Zhaoqing, China
| | - Yan Yao
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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17
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The effect of age on ventilation management and clinical outcomes in critically ill COVID-19 patients--insights from the PRoVENT-COVID study. Aging (Albany NY) 2022; 14:1087-1109. [PMID: 35100136 PMCID: PMC8876900 DOI: 10.18632/aging.203863] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/12/2022] [Indexed: 11/25/2022]
Abstract
Introduction: We analyzed the association of age with ventilation practice and outcomes in critically ill COVID–19 patients requiring invasive ventilation. Methods: Posthoc analysis of the PRoVENT–COVID study, an observational study performed in 22 ICUs in the first 3 months of the national outbreak in the Netherlands. The coprimary endpoint was a set of ventilator parameters, including tidal volume normalized for predicted bodyweight, positive end–expiratory pressure, driving pressure, and respiratory system compliance in the first 4 days of invasive ventilation. Secondary endpoints were other ventilation parameters, the use of rescue therapies, pulmonary and extrapulmonary complications in the first 28 days in the ICU, hospital– and ICU stay, and mortality. Results: 1122 patients were divided into four groups based on age quartiles. No meaningful differences were found in ventilation parameters and in the use of rescue therapies for refractory hypoxemia in the first 4 days of invasive ventilation. Older patients received more often a tracheostomy, developed more frequently acute kidney injury and myocardial infarction, stayed longer in hospital and ICU, and had a higher mortality. Conclusions: In this cohort of invasively ventilated critically ill COVID–19 patients, age had no effect on ventilator management. Higher age was associated with more complications, longer length of stay in ICU and hospital and a higher mortality.
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18
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Bologheanu R, Lichtenegger P, Maleczek M, Laxar D, Schaden E, Kimberger O. A retrospective study of sugammadex for reversal of neuromuscular blockade induced by rocuronium in critically ill patients in the ICU. Sci Rep 2022; 12:897. [PMID: 35042888 PMCID: PMC8766455 DOI: 10.1038/s41598-022-04818-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 12/22/2021] [Indexed: 12/23/2022] Open
Abstract
Sugammadex has been approved for reversal of neuromuscular blockade by vecuronium and rocuronium in adults undergoing surgery. Although widely used in the operating room, sugammadex has not been investigated in the intensive care unit setting. This study aimed to evaluate the use of sugammadex in critically ill patients with a focus on known drug-related adverse reactions. In this single-center, retrospective, observational study, 91 critically ill patients who were administered sugammadex while in the ICU were evaluated. Electronic health records were reviewed, and baseline data, as well as indication and incidence of complications possibly related to sugammadex, were retrospectively collected. The most common procedures requiring neuromuscular blockade followed by reversal with sugammadex were bronchoscopy, percutaneous dilatative tracheostomy, and percutaneous endoscopic gastrostomy. Within 2 h following administration of sugammadex, skin rash and use of antihistamines were reported in 4 patients (4.4%) in total; bradycardia was observed in 9 patients (9.9%), and respiratory adverse events were described in 3 patients (3.3%). New-onset bleeding up to 24 h after sugammadex was reported in 7 patients (7.7%), 3of whom received transfusions of packed red blood cells. Sugammadex was well tolerated in critically ill patients and could be considered for reversal of neuromuscular blockade in this population. Larger prospective studies are required to determine the safety profile and evaluate the potential benefit and indications of sugammadex in the critical care setting.
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Affiliation(s)
- Răzvan Bologheanu
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, Vienna, Austria.
| | - Paul Lichtenegger
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
| | - Daniel Laxar
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
| | - Oliver Kimberger
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
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19
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Comstock B, Lopane CM, Fellows S, Gandhi MA. The Use of Neuromuscular Blockers to Prevent Shivering in the Setting of Postcardiac Arrest Targeted Temperature Management: A Narrative Review of an Off-Label Indication. Ther Hypothermia Temp Manag 2021; 12:1-7. [PMID: 34967667 DOI: 10.1089/ther.2021.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Targeted temperature management (TTM) has become a standard of care over the past two decades for the improvement in neurologic function and mortality in postcardiac arrest patients. There are various mechanisms by which hypothermia helps to improve these outcomes, one of which is by reducing oxygen requirements. Less established is the use of nondepolarizing neuromuscular blockers (NMBs) to prevent shivering during TTM. Shivering can be disadvantageous in this setting as it increases oxygen requirements, which TTM is actively trying to decrease, in an already oxygen-deprived system as well as generates heat making it difficult to maintain hypothermia. Whether NMBs can improve these outcomes is conflicting in the currently available literature and there lacks a consensus on their role in shivering management. The pharmacokinetic and pharmacodynamic responses of these agents may be altered in hypothermic patients, therefore, their standard of monitoring may be unreliable. The accurate dosing and administration of these agents also remain unclear, further complicated by the lack of a standard use protocol. Various studies have been conducted regarding the use of NMBs to prevent shivering in postcardiac arrest patients undergoing TTM; however, it remains an off-label indication requiring further investigation.
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Affiliation(s)
- Brianne Comstock
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Cassandra M Lopane
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Shawn Fellows
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Mona A Gandhi
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
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20
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Management of the patient with the open abdomen. Curr Opin Crit Care 2021; 27:726-732. [PMID: 34561356 DOI: 10.1097/mcc.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to outline the management of the patient with the open abdomen. RECENT FINDINGS An open abdomen approach is used after damage control laparotomy, to decrease risk for postsurgery intra-abdominal hypertension, if reoperation is likely and after primary abdominal decompression.Temporary abdominal wall closure without negative pressure is associated with higher rates of intra-abdominal infection and evisceration. Negative pressure systems improve fascial closure rates but increase fistula formation. Definitive abdominal wall closure should be considered once oedema has subsided and the patient has stabilized. Delayed abdominal closure after trauma (>24-48 h) is associated with less achievement of fascial closure and more complications. Protective lung ventilation should be employed early, particularly if respiratory compromise is evident. Conservative fluid management and less sedation may decrease delirium and increase definitive abdominal closure rates. Extubation may be performed before definitive abdominal closure in selected patients. Antibiotic therapy should be brief, targeted and guideline concordant. Survival depends on the underlying disease, the closure method and the course of hospitalization. SUMMARY Changes in the treatment of patients with the open abdomen include negative temporary closure, conservative fluid management, early protective lung ventilation, decreased sedation and extubation before abdominal closure in selected patients.
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21
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Gao CA, Mylvaganam R, Poor TA, Walter JM. Recommended Reading from the Northwestern University Fellows. Am J Respir Crit Care Med 2021; 204:473-475. [PMID: 34192505 DOI: 10.1164/rccm.202009-3722rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Catherine A Gao
- Northwestern University Feinberg School of Medicine, 12244, Chicago, Illinois, United States
| | - Ruben Mylvaganam
- Northwestern University Feinberg School of Medicine, 12244, Pulmonary and Critical Care, Chicago, Illinois, United States
| | - Taylor A Poor
- Northwestern University Feinberg School of Medicine, 12244, Chicago, Illinois, United States
| | - James M Walter
- Northwestern University Feinberg School of Medicine, Division of Pulmonary and Critical Care Medicine, Chicago, Illinois, United States;
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22
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Balakrishna A, Walsh EC, Hamidi A, Berg S, Austin D, Pino RM, Hanidziar D, Chang MG, Bittner EA. An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19. Am J Health Syst Pharm 2021; 78:1952-1961. [PMID: 33993212 PMCID: PMC8194529 DOI: 10.1093/ajhp/zxab202] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with non-mechanically ventilated patients. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center. METHODS A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated. RESULTS Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, as a group patients requiring more than 3 agents were of younger age, had an increased body mass index, increased serum ferritin and lactate dehydrogenase concentrations, had a lower PaO2:FIO2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade. CONCLUSION Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.
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Affiliation(s)
- Aditi Balakrishna
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisa C Walsh
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Arzo Hamidi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sheri Berg
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Austin
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard M Pino
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dusan Hanidziar
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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24
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Donato M, Carini FC, Meschini MJ, Saubidet IL, Goldberg A, Sarubio MG, Olmos D, Reina R. Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome. Rev Bras Ter Intensiva 2021; 33:48-67. [PMID: 33886853 PMCID: PMC8075332 DOI: 10.5935/0103-507x.20210005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
Objective To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients’ families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. Methods A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. Results Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. Discussion Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.
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Affiliation(s)
- Manuel Donato
- Hospital General de Agudos José María Penna - Buenos Aires, Argentina.,Ministerio de Salud de la Nación Argentina - Buenos Aires, Argentina.,Instituto de Efectividad Clínica y Sanitaria - Buenos Aires, Argentina
| | | | | | - Ignacio López Saubidet
- Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" - Buenos Aires, Argentina
| | - Adela Goldberg
- Sanatorio de La Trinidad Mitre - Buenos Aires, Argentina
| | | | - Daniela Olmos
- Hospital Municipal Príncipe de Asturias - Córdoba, Argentina
| | - Rosa Reina
- Hospital Interzonal General de Agudos General San Martín - La Plata, Argentina
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25
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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26
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Dolgner SJ, Keeshan BC, Burke CR, McMullan DM, Chan T. Outcomes of Adults with Congenital Heart Disease Supported with Extracorporeal Life Support After Cardiac Surgery. ASAIO J 2021; 66:1096-1104. [PMID: 33136596 DOI: 10.1097/mat.0000000000001141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Patients with adult congenital heart disease (ACHD) who undergo cardiac surgery may require extracorporeal life support (ECLS) for cardiopulmonary support, but outcomes after ECLS support have not been well described. This study aimed to identify risk factors for ECLS mortality in this population. We identified 368 ACHD patients who received ECLS after cardiac surgery between 1994 and 2016 in the Extracorporeal Life Support Organization (ELSO) database, a multicenter international registry of ECLS centers. Risk factors for mortality were assessed using multivariate logistic regression. Overall mortality was 61%. In a multivariate model using precannulation characteristics, Fontan physiology (odds ratio [OR]: 5.7; 95% CI: 1.6-20.0), weight over 100 kg (OR: 2.6; 95% CI: 1.3-5.4), female gender (OR: 1.6; 95% CI: 1.001-2.6), delayed ECLS cannulation (OR: 2.0; 95% CI: 1.2-3.2), and neuromuscular blockade (OR: 1.9; 95% CI: 1.1-3.3) were associated with increased mortality. Adding postcannulation characteristics to the model, renal complications (OR: 3.0; 95% CI: 1.7-5.2), neurologic complications (OR, 4.7; 95% CI: 1.5-15.2), and pulmonary hemorrhage (OR: 6.4; 95% CI: 1.3-33.2) were associated with increased mortality, whereas Fontan physiology was no longer associated, suggesting the association of Fontan physiology with mortality may be mediated by complications. Fontan physiology was also a risk factor for neurologic complications (OR: 8.2; 95% CI: 3.3-20.9). Given the rapid increase in ECLS use, understanding risk factors for ACHD patients receiving ECLS after cardiac surgery will aid clinicians in decision-making and preoperative planning.
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Affiliation(s)
- Stephen J Dolgner
- From the Division of Cardiology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
- The Heart Center, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Britton C Keeshan
- Pediatric Cardiology, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - David Michael McMullan
- Division of Pediatric Cardiac Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Titus Chan
- The Heart Center, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
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Carrai R, Spalletti M, Scarpino M, Lolli F, Lanzo G, Cossu C, Bonizzoli M, Socci F, Lazzeri C, Amantini A, Grippo A. Are neurophysiologic tests reliable, ultra-early prognostic indices after cardiac arrest? Neurophysiol Clin 2021; 51:133-144. [PMID: 33573889 DOI: 10.1016/j.neucli.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Determining early and reliable prognosis in comatose subjects after cardiac arrest is a central component of post-cardiac arrest care both for developing realistic prognostic expectations for families, and for better determining which resources are mobilized or withheld for individual patients. The aim of the study was to evaluate the prognostic accuracy of EEG and SEP patterns during the very early period (within the first 6 h) after cardiac arrest. METHODS We retrospectively analysed comatose patients after CA, either inside or outside the hospital, in which prognostic evaluation was made during the first 6 h from CA. Prognostic evaluation comprised clinical evaluation (GCS and pupillary light reflex) and neurophysiological (electroencephalography (EEG) and somatosensory evoked potentials (SEP)) studies. Prognosis was evaluated with regards to likelihood of recovery of consciousness and also likelihood of failure to regain consciousness. RESULTS Forty-one comatose patients after cardiac arrest were included. All patients with continuous and nearly continuous EEG recovered consciousness. Isoelectric EEG was always associated with poor outcome. Burst-suppression, suppression and discontinuous patterns were usually associated with poor outcome although some consciousness recovery was observed. Bilaterally absent SEP responses were always associated with poor outcome. Continuous and nearly continuous EEG patterns were never associated with bilaterally absent SEP. CONCLUSIONS During the very early period following cardiac arrest (first 6 h), EEG and SEP maintain their high predictive value to predict respectively recovery and failure of recovery of consciousness. A very early EEG exam allows identification of patients with very high probability of a good outcome, allowing rapid use of the most appropriate therapeutic procedures.
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Affiliation(s)
- Riccardo Carrai
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy.
| | - Maddalena Spalletti
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Maenia Scarpino
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Francesco Lolli
- Dipartimento di Scienze Biomediche Mario Serio, Università di Firenze, Florence, Italy
| | - Giovanni Lanzo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Cesarina Cossu
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Unità di Terapia Intensiva, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Filippo Socci
- Unità di Terapia Intensiva, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Chiara Lazzeri
- Unità di Terapia Intensiva, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Aldo Amantini
- IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Antonello Grippo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
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Domingo-Chiva E, Monsalve-Naharro JÁ, Gerónimo-Pardo M. Myopathy, residual effect of rocuronium, or both? A possible ritonavir-rocuronium interaction interfering weaning from mechanical ventilation in a patient with COVID-19 pneumonia. J Anaesthesiol Clin Pharmacol 2021; 36:556-558. [PMID: 33840941 PMCID: PMC8022060 DOI: 10.4103/joacp.joacp_346_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/21/2020] [Accepted: 11/01/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Esther Domingo-Chiva
- Department of Pharmacy, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - José Ángel Monsalve-Naharro
- Department of Anesthesiology and Critical Care Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Manuel Gerónimo-Pardo
- Department of Anesthesiology and Critical Care Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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Shao S, Kang H, Tong Z. Early neuromuscular blocking agents for adults with acute respiratory distress syndrome: a systematic review, meta-analysis and meta-regression. BMJ Open 2020; 10:e037737. [PMID: 33444180 PMCID: PMC7678372 DOI: 10.1136/bmjopen-2020-037737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether neuromuscular blocking agents (NMBAs) can decrease the mortality of patients with acute respiratory distress syndrome (ARDS) and improve their clinical outcomes. DESIGN Systematic review, meta-analysis and meta-regression. DATA SOURCES PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov. METHODS Randomised controlled trials (RCTs) comparing the treatment effect of NMBAs with that of placebo (or traditional treatment) in patients with ARDS were carefully selected. The primary outcome was 90-day mortality. The secondary outcomes were 21-28 days mortality, NMBA-related complications (barotrauma, pneumothorax and intensive care unit (ICU)-acquired muscle weakness), days free of ventilation and days not in the ICU by day 28, Medical Research Council score, Acute Physiology and Chronic Health Evaluation II score and arterial oxygen tension (PaO2)/fractional inspired oxygen (FiO2) (at 48 hours and 72 hours). Random-effects meta-regression was used to explore models involving potential moderators. Trial sequential analysis was performed to estimate the cumulative effect on mortality across RCTs. RESULTS NMBAs were not associated with reduced 90-day mortality (risk ratio (RR) 0.85; 95% CI 0.66 to 1.09; p=0.20). However, they decreased the 21-28 days mortality (RR 0.71; 95% CI 0.53 to 0.96; p=0.02) and the rates of pneumothorax (RR 0.46; 95% CI 0.28 to 0.77; p=0.003) and barotrauma (RR 0.56; 95% CI 0.37 to 0.86; p=0.008). In addition, NMBAs increased PaO2/FiO2 at 48 hours (mean difference (MD) 18.91; 95% CI 4.29 to 33.53; p=0.01) and 72 hours (MD 12.27; 95% CI 4.65 to 19.89; p=0.002). Meta-regression revealed an association between sample size (p=0.042) and short-term mortality. Publication year (p=0.050), sedation strategy (p=0.047) and sample size (p=0.046) were independently associated with PaO2/FiO2 at 48 hours. CONCLUSIONS In summary, the results suggested that use of NMBAs might reduce 21-28 days mortality, NMBA-related complications and oxygenation. However, NMBAs did not reduce the 90-day mortality of patients with ARDS, which contradicts a previous meta-analysis. PROSPERO REGISTRATION NUMBER CRD42019139440.
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Affiliation(s)
- Shuai Shao
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hanyujie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Kanji S, Burry L, Williamson D, Pittman M, Dubinsky S, Patel D, Natarajan S, MacLean R, Huh JH, Scales DC, Neilipovitz D. Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force. Can J Anaesth 2020; 67:1405-1416. [PMID: 32458267 PMCID: PMC8297429 DOI: 10.1007/s12630-020-01713-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 01/09/2023] Open
Abstract
During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.
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Affiliation(s)
- Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, The Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
| | - Lisa Burry
- Mount Sinai Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - David Williamson
- Sacré Coeur Hospital, Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | | | | | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Center, Toronto, ON, Canada
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Rubulotta F, Soliman-Aboumarie H, Filbey K, Geldner G, Kuck K, Ganau M, Hemmerling TM. Technologies to Optimize the Care of Severe COVID-19 Patients for Health Care Providers Challenged by Limited Resources. Anesth Analg 2020; 131:351-364. [PMID: 32433248 PMCID: PMC7258840 DOI: 10.1213/ane.0000000000004985] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
Health care systems are belligerently responding to the new coronavirus disease 2019 (COVID-19). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a specific condition, whose distinctive features are severe hypoxemia associated with (>50% of cases) normal respiratory system compliance. When a patient requires intubation and invasive ventilation, the outcome is poor, and the length of stay in the intensive care unit (ICU) is usually 2 or 3 weeks. In this article, the authors review several technological devices, which could support health care providers at the bedside to optimize the care for COVID-19 patients who are sedated, paralyzed, and ventilated. Particular attention is provided to the use of videolaryngoscopes (VL) because these can assist anesthetists to perform a successful intubation outside the ICU while protecting health care providers from this viral infection. Authors will also review processed electroencephalographic (EEG) monitors which are used to better titrate sedation and the train-of-four monitors which are utilized to better administer neuromuscular blocking agents in the view of sparing limited pharmacological resources. COVID-19 can rapidly exhaust human and technological resources too within the ICU. This review features a series of technological advancements that can significantly improve the care of patients requiring isolation. The working conditions in isolation could cause gaps or barriers in communication, fatigue, and poor documentation of provided care. The available technology has several advantages including (a) facilitating appropriate paperless documentation and communication between all health care givers working in isolation rooms or large isolation areas; (b) testing patients and staff at the bedside using smart point-of-care diagnostics (SPOCD) to confirm COVID-19 infection; (c) allowing diagnostics and treatment at the bedside through point-of-care ultrasound (POCUS) and thromboelastography (TEG); (d) adapting the use of anesthetic machines and the use of volatile anesthetics. Implementing technologies for safeguarding health care providers as well as monitoring the limited pharmacological resources are paramount. Only by leveraging new technologies, it will be possible to sustain and support health care systems during the expected long course of this pandemic.
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Affiliation(s)
- Francesca Rubulotta
- From the Department of Anaesthesia and Intensive Care Medicine, Imperial College London, London, United Kingdom
| | - Hatem Soliman-Aboumarie
- Department of Anaesthetics and Critical Care, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Kevin Filbey
- Department of Anesthesia, Intensive Care Medicine, Chronic Pain and Emergency Medicine, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Goetz Geldner
- Department of Anesthesia, Intensive Care Medicine, Chronic Pain and Emergency Medicine, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Kai Kuck
- Department of Anesthesiology and Bioengineering, University of Utah
| | - Mario Ganau
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Kim SH, Sul YH, Lee JY, Ye JB, Lee JS, Yoon SY, Kim JS. Veno-Veno Extracorporeal Membrane Oxygenation in Post-Traumatic Acute Lung Injury. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
Objectives: To identify the prevalence of and evaluate factors associated with down-titration of sedation in patients receiving neuromuscular blockade. Design: Retrospective cohort study. Setting: Tertiary care teaching hospital in Boston, MA. Patients: All patients over 18 years old admitted to the medical, surgical, or cardiac ICUs from 2013 to 2016, and who received cisatracurium for at least 24 hours. Interventions: We examined patients for whom sedation was decreased despite accompanying ongoing neuromuscular blockade administration. Measurements and Main Results: Of the 300 patients who met inclusion criteria (39% female, mean age of 57 yr old), 168 (56%) had sedation down-titrated while receiving neuromuscular blockade with a mean decrease in sedation dose of 18.7%. Factors associated with down-titration of sedation were bispectral index usage (90/168 [53.6%] vs 50/168 [29.8%] patients; p < 0.01; odds ratio, 1.82; 1.12–2.94), and bolus dose of neuromuscular blockade prior to continuous infusion (138/168 [82.1%] vs 79/168 [47.0%] patients; p < 0.0001). Conclusions: Down-titration of sedation among mechanically ventilated patients receiving neuromuscular blockade was common and was correlated with bispectral index monitor usage. Clinicians should be aware of the limitations of quantitative electroencephalography monitoring devices and recognize their potential to cause inappropriate down-titration of sedation. Substantial opportunity exists to improve the quality of care of patients receiving neuromuscular blockade through development of guidelines and standardized care pathways.
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Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
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Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
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Blanchard F, Perbet S, James A, Verdonk F, Godet T, Bazin JE, Pereira B, Lambert C, Constantin JM. Minimal alveolar concentration for deep sedation (MAC-DS) in intensive care unit patients sedated with sevoflurane: A physiological study. Anaesth Crit Care Pain Med 2020; 39:429-434. [PMID: 32376244 DOI: 10.1016/j.accpm.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Volatile anaesthetic agents, especially sevoflurane, could be an alternative for sedating ICU patients. In the operating theatre, volatile anaesthetic agents are monitored using minimal alveolar concentration (MAC). In ICU, MAC may be used to assess sedation level and may replace clinical scale especially when they are unusable. Therefore, we sought to investigate the minimal sevoflurane end-tidal concentration to achieved deep sedation in critical ill patients: MAC-deep sedation (MAC-DS). METHODS In a prospective interventional study, we included patients with a Richmond Assessment Sedation Score (RASS) of 0 without any sedation. We stepwise increased sevoflurane concentration level before assessing for deep sedation (RASS≤-3). MAC-DS was defined as the minimal sevoflurane MAC fraction or sevoflurane expiratory fraction (FeSevo) to get 90% and 95% of patients in deep sedation (MAC-DS 90 and MAC-DS 95, respectively). RESULTS Between June and November 2014, 30 patients were included (median age=60 years [interquartile range: 47-69]). Increasing sevoflurane MAC was correlated with a decrease in RASS values (r=-0.83, P<0.001). MAC-DS 90 and MAC-DS 95 were achieved at 0.42 MAC (CI 95 [0.38-0.46]) and 0.46 MAC (CI 95 [0.42-0.51]), respectively. FeSevo to achieve MAC-DS 90 and MAC-DS 95 was 0.72 (CI 95 [0.65-0.79]) and 0.80 (CI 95 [0.72-0.89]), respectively. CONCLUSION In this physiological study involving 30 ICU patients, MAC-DS, end-tidal sevoflurane concentration to get 95% of patients in deep sedation determined over more than 500 observations, is achieved at 0.8% of expired fraction of sevoflurane or at 0.5 age-adjusted MAC.
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Affiliation(s)
- Florian Blanchard
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Sébastien Perbet
- CHU Clermont-Ferrand, Department of Peri-Operative Medicine, 63000 Clermont-Ferrand, France
| | - Arthur James
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Franck Verdonk
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and critical care, Saint-Antoine university Hospital, Paris, France
| | - Thomas Godet
- CHU Clermont-Ferrand, Department of Peri-Operative Medicine, 63000 Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- CHU Clermont-Ferrand, Department of Peri-Operative Medicine, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Clermont Université, Université d'Auvergne, Laboratoire de Biopharmacie et de Technologie Pharmaceutique, 63000 Clermont-Ferrand, France
| | - Celine Lambert
- Clermont Université, Université d'Auvergne, Laboratoire de Biopharmacie et de Technologie Pharmaceutique, 63000 Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France.
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Picetti E, Pelosi P, Taccone FS, Citerio G, Mancebo J, Robba C. VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:158. [PMID: 32303255 PMCID: PMC7165367 DOI: 10.1186/s13054-020-02875-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
Abstract
Background Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure. Methods An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150–300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. Results There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6–8 ml/kg of predicted body weight (PBW) in scenarios 1–2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150–300) and 4–6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150–300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150–300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36–40 mmHg whereas the most common PaO2 target was 81–100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. Conclusions Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy.
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy
| | - Jordi Mancebo
- Department of Intensive Care, Sant Pau Hospital, Barcelona, Spain
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy
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Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med 2020; 46:637-653. [PMID: 32076765 PMCID: PMC7224132 DOI: 10.1007/s00134-020-05944-4] [Citation(s) in RCA: 276] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 01/04/2023]
Abstract
Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short- and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of “neuropathy”, “myopathy”, “neuromyopathy”, or “weakness” with “critical illness”, “critically ill”, “ICU”, “PICU”, “sepsis” or “burn”. ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short- and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.
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Affiliation(s)
- Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Using a Laryngeal Mask Airway During Percutaneous Dilatational Tracheostomy is Safe and Obviates the Need for Paralytics. J Bronchology Interv Pulmonol 2020; 26:179-183. [PMID: 30741843 DOI: 10.1097/lbr.0000000000000547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bedside percutaneous tracheostomy (PT) placement in critically ill patients is performed in a variety of ways, largely driven by institutional preference. We have recently transitioned to primarily extubating the patient and placing a laryngeal mask airway (LMA) before tracheostomy insertion in lieu of retracting the endotracheal tube (ETT) in place. This allows for lower sedative use and provides a superior view of the operative field. Here, we seek to describe the safety and efficiency of that approach. METHODS This is a single-center cross-sectional study from 2014 to 2016 comparing patients who underwent PT with the ETT in place retracted to the proximal larynx versus those who were extubated and had a LMA placed. Procedural length, sedative totals, and safety outcomes were recorded. RESULTS In total, 125 patients underwent PT during the study period, 75 via a LMA and 50 via existing ETT. There was no difference in procedural duration (LMA: 53.5±21.4 min vs. ETT: 50.4±16.8; P=0.41), total complications (LMA: 29.3% vs. 16%; P=0.09) or major complications (4% in both groups). Cisatracurium use was significantly lower in the LMA arm (LMA: 1.0±3.6 mg vs. ETT: 11.5±5.9 mg; P<0.01). CONCLUSION Replacing the ETT with an LMA before PT is equally safe, does not increase total procedural duration, and all but eliminates the need for paralytic agents.
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Tezcan B, Turan S, Özgök A. Current Use of Neuromuscular Blocking Agents in Intensive Care Units. Turk J Anaesthesiol Reanim 2019; 47:273-281. [PMID: 31380507 DOI: 10.5152/tjar.2019.33269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 10/08/2018] [Indexed: 11/22/2022] Open
Abstract
Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation-associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report.
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Affiliation(s)
- Büşra Tezcan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Sema Turan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
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Lukannek C, Shaefi S, Platzbecker K, Raub D, Santer P, Nabel S, Lecamwasam HS, Houle TT, Eikermann M. The development and validation of the Score for the Prediction of Postoperative Respiratory Complications (SPORC-2) to predict the requirement for early postoperative tracheal re-intubation: a hospital registry study. Anaesthesia 2019; 74:1165-1174. [PMID: 31222727 DOI: 10.1111/anae.14742] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2019] [Indexed: 01/24/2023]
Abstract
Postoperative pulmonary complications are associated with an increase in mortality, morbidity and healthcare utilisation. The Agency for Healthcare Research and Quality recommends risk assessment for postoperative respiratory complications in patients undergoing surgery. In this hospital registry study of adult patients undergoing non-cardiac surgery between 2005 and 2017 at two independent healthcare networks, a prediction instrument for early postoperative tracheal re-intubation was developed and externally validated. This was based on the development of the Score for Prediction Of Postoperative Respiratory Complications. For predictor selection, stepwise backward logistic regression and bootstrap resampling were applied. Development and validation cohorts were represented by 90,893 patients at Partners Healthcare and 67,046 patients at Beth Israel Deaconess Medical Center, of whom 699 (0.8%) and 587 (0.9%) patients, respectively, had their tracheas re-intubated. In addition to five pre-operative predictors identified in the Score for Prediction Of Postoperative Respiratory Complications, the final model included seven additional intra-operative predictors: early post-tracheal intubation desaturation; prolonged duration of surgery; high fraction of inspired oxygen; high vasopressor dose; blood transfusion; the absence of volatile anaesthetic use; and the absence of lung-protective ventilation. The area under the receiver operating characteristic curve for the new score was significantly greater than that of the original Score for Prediction Of Postoperative Respiratory Complications (0.84 [95%CI 0.82-0.85] vs. 0.76 [95%CI 0.75-0.78], respectively; p < 0.001). This may allow clinicians to develop and implement strategies to decrease the risk of early postoperative tracheal re-intubation.
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Affiliation(s)
- C Lukannek
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - S Shaefi
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - K Platzbecker
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - D Raub
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - P Santer
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - S Nabel
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - H S Lecamwasam
- Department of Anesthesia, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA.,Talis Clinical, LLC, USA
| | - T T Houle
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Duisburg-Essen University, Essen, Germany
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Developmental outcome at 3 years of age of infants following surgery for infantile hypertrophic pyloric stenosis. Pediatr Surg Int 2019; 35:357-363. [PMID: 30402682 DOI: 10.1007/s00383-018-4408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The study compared neurodevelopmental outcome at 3 years of age of infants with infantile hypertrophic pyloric stenosis (IHPS) who underwent pyloromyotomy with healthy control infants in New South Wales, Australia. METHODS Infants with IHPS as well as controls were recruited between August 2006 and July 2008. Developmental assessments were performed using the Bayley scales of infant and toddler development (version III) (BSITD-III) at 1 and 3 years of age. RESULTS Of the 43 infants originally assessed at 1 year, 39 returned for assessment at 3 years (90%). The majority were term infants (77%). Assessments were also performed on 156 control infants. Infants with IHPS scored significantly lower on four of the five Bayley subsets (cognitive, receptive and expressive language and fine motor) compared to control infants. Analysis of co-variance showed statistically significant results in favour of the control group for these four subsets. CONCLUSION Compared with the outcomes at 1 year, infants with IHPS at 3 years of age continue to score below controls in four of the BSITD-III subscales. This suggests they should have developmental follow-up with targeted clinical intervention. There is a need for further studies into functional impact and longer term outcomes.
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Lee BK, Cho IS, Oh JS, Choi WJ, Wee JH, Kim CS, Kim WY, Youn CS. Continuous neuromuscular blockade infusion for out-of-hospital cardiac arrest patients treated with targeted temperature management: A multicenter randomized controlled trial. PLoS One 2018; 13:e0209327. [PMID: 30557377 PMCID: PMC6296517 DOI: 10.1371/journal.pone.0209327] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 12/04/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction The aim of this trial was to investigate the effect of a continuous infusion of a neuromuscular blockade (NMB) in comatose out-of-hospital cardiac arrest (OHCA) subjects who underwent targeted temperature management (TTM). Methods In this open-label, multicenter trial, subjects resuscitated from OHCA were randomly assigned to receive either NMB (38 subjects) or placebo (43 subjects) for 24 hours. Sedatives and analgesics were given according to the protocol of each hospital during TTM. The primary outcome was serum lactate levels at 24 hours after drug infusion. The secondary outcomes included in-hospital mortality, a poor neurological outcome at hospital discharge, changes in lactate levels, changes in the PaO2:FiO2 ratio over time and muscle weakness as assessed by the Medical Research Council (MRC) scale. Results Eighty-one subjects (NMB group: median age, 65.5 years, 30 male patients; placebo group: median age, 61.0 years, 29 male patients) were enrolled in this trial. No difference in the serum lactate level at 24 hours was observed between the NMB (2.8 [1.2–4.0]) and placebo (3.6 [1.8–5.2]) groups (p = 0.238). In-hospital mortality and a poor neurologic outcome at discharge did not differ between the two groups. No significant difference in the PaO2:FiO2 ratio over time (p = 0.321) nor the MRC score (p = 0.474) was demonstrated. Conclusions In OHCA subjects who underwent TTM, a continuous infusion of NMB did not reduce lactate levels and did not improve survival or neurological outcome at hospital discharge. Our results indicated a limited potential for the routine use of NMB during early TTM. However, this trial may be underpowered to detect clinical differences, and future research should be conducted.
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Affiliation(s)
- Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - In Soo Cho
- Department of Emergency Medicine, Hanil General Hospital, Korea Electric Power Medical Corporation, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Wook Jin Choi
- Department of Emergency Medicine, Ulsan University College of Medicine, Ulsan, Korea
| | - Jung Hee Wee
- Department of Emergency Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Chang Sun Kim
- Department of Emergency Medicine, Hanyang University of Korea, Guri, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chun Song Youn
- Department of Emergency Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- * E-mail:
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Alviar CL, Miller PE, McAreavey D, Katz JN, Lee B, Moriyama B, Soble J, van Diepen S, Solomon MA, Morrow DA. Positive Pressure Ventilation in the Cardiac Intensive Care Unit. J Am Coll Cardiol 2018; 72:1532-1553. [PMID: 30236315 PMCID: PMC11032173 DOI: 10.1016/j.jacc.2018.06.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/16/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.
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Affiliation(s)
- Carlos L Alviar
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Dorothea McAreavey
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill, Chapel Hill, North Carolina
| | - Burton Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brad Moriyama
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jeffrey Soble
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Review of Continuous Infusion Neuromuscular Blocking Agents in the Adult Intensive Care Unit. Crit Care Nurs Q 2017; 40:323-343. [PMID: 28834856 DOI: 10.1097/cnq.0000000000000171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of continuous infusion neuromuscular blocking agents remains controversial. The clinical benefit of these medications may be overshadowed by concerns of propagating intensive care unit-acquired weakness, which may prolong mechanical ventilation and impair the inability to assess neurologic function or pain. Despite these risks, the use of neuromuscular blocking agents in the intensive care unit is indicated in numerous clinical situations. Understanding pharmacologic nuances and clinical roles of these agents will aid in facilitating safe use in a variety of acute disease processes. This article provides clinicians with information regarding pharmacologic differences, indication for use, adverse effects, recommended doses, ancillary care, and monitoring among agents used for continuous neuromuscular blockade.
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