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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [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] [Indexed: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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2
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Devlin JW, Train SE, Burns KEA, Massaro A, Wu TT, Castor T, Vassaur J, Selvan K, Kress JP, Erstad BL. Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS. Ann Pharmacother 2023; 57:1282-1290. [PMID: 36946587 DOI: 10.1177/10600280231160437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Current critical care pharmacist (CCP) practices and perceptions related to neuromuscular infusion (NMBI) use for acute respiratory distress syndrome (ARDS) maybe different with the COVID-19 pandemic and the publication of 2020 NMBI practice guidelines. OBJECTIVE To evaluate CCP practices and perceptions regarding NMBI use for patients with moderate-severe ARDS. METHODS We developed, tested, and electronically administered a questionnaire (7 parent-, 42 sub-questions) to 409 American College of Clinical Pharmacy (ACCP) Critical Care Practice and Research Network members in 12 geographically diverse states. The questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2<150) whose causes of dyssynchrony were addressed. Two reminders were sent at 10-day intervals. RESULTS Respondents [131/409 (32%)] primarily worked in a medical intensive care unit (ICU) 102 (78%). Compared to COVID-negative(-) ARDS patients, COVID positive(+) ARDS patients were twice as likely to receive a NMBI (34 ± 18 vs.16 ± 17%; P < 0.01). Respondents somewhat/strongly agreed a NMBI should be reserved until after trials of deep sedation (112, 86%) or proning (92, 81%) and that NMBI reduced barotrauma (88, 67%), dyssynchrony (87, 66%), and plateau pressure (79, 60%). Few respondents somewhat/strongly agreed that a NMBI should be initiated at ARDS onset (23, 18%) or that NMBI reduced 90-day mortality (12, 10%). Only 2/14 potential NMBI risks [paralysis awareness (101, 82%) and prolonged muscle weakness (84, 68%)] were frequently reported to be of high/very high concern. Multiple NMBI titration targets were assessed as very/extremely important including arterial pH (109, 88%), dyssynchrony (107, 86%), and PaO2: FiO2 ratio (82, 66%). Train-of-four (55, 44%) and BIS monitoring (36, 29%) were deemed less important. Preferred NMBI discontinuation criteria included absence of dysschrony (84, 69%) and use ≥48 hour (72, 59%). CONCLUSIONS AND RELEVANCE Current critical care pharmacists believe NMBI for ARDS patients are best reserved until after trials of deep sedation or proning; unique considerations exist in COVID+ patients. Our results should be considered when ICU NMBI protocols are being developed and bedside decisions regarding NMBI use in ARDS are being formulated.
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Affiliation(s)
- John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Sarah E Train
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karen E A Burns
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anthony Massaro
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ting Ting Wu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Timothy Castor
- Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - John Vassaur
- University of Arizona Medical Center, Tucson, AZ, USA
| | | | - John P Kress
- University of Chicago Medical Center, Chicago, IL, USA
| | - Brian L Erstad
- College of Pharmacy, The University of Arizona, Tucson, AZ, USA
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Barreto EF, Chitre PN, Pine KH, Shepel KK, Rule AD, Alshaer MH, Abdul Aziz MH, Roberts JA, Scheetz MH, Ausman SE, Moreland-Head LN, Rivera CG, Jannetto PJ, Mara KC, Boehmer KR. Why is the Implementation of Beta-Lactam Therapeutic Drug Monitoring for the Critically Ill Falling Short? A Multicenter Mixed-Methods Study. Ther Drug Monit 2023; 45:508-518. [PMID: 37076424 PMCID: PMC10348918 DOI: 10.1097/ftd.0000000000001059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/02/2022] [Indexed: 04/21/2023]
Abstract
BACKGROUND Beta-lactam therapeutic drug monitoring (BL TDM; drug level testing) can facilitate improved outcomes in critically ill patients. However, only 10%-20% of hospitals have implemented BL TDM. This study aimed to characterize provider perceptions and key considerations for successfully implementing BL TDM. METHODS This was a sequential mixed-methods study from 2020 to 2021 of diverse stakeholders at 3 academic medical centers with varying degrees of BL TDM implementation (not implemented, partially implemented, and fully implemented). Stakeholders were surveyed, and a proportion of participants completed semistructured interviews. Themes were identified, and findings were contextualized with implementation science frameworks. RESULTS Most of the 138 survey respondents perceived that BL TDM was relevant to their practice and improved medication effectiveness and safety. Integrated with interview data from 30 individuals, 2 implementation themes were identified: individual internalization and organizational features. Individuals needed to internalize, make sense of, and agree to BL TDM implementation, which was positively influenced by repeated exposure to evidence and expertise. The process of internalization appeared more complex with BL TDM than with other antibiotics (ie, vancomycin). Organizational considerations relevant to BL TDM implementation (eg, infrastructure, personnel) were similar to those identified in other TDM settings. CONCLUSIONS Broad enthusiasm for BL TDM among participants was found. Prior literature suggested that assay availability was the primary barrier to implementation; however, the data revealed many more individual and organizational attributes, which impacted the BL TDM implementation. Internalization should particularly be focused on to improve the adoption of this evidence-based practice.
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Affiliation(s)
| | - Pooja N. Chitre
- School for the Future of Innovation in Society, Arizona State University, Tempe, AZ
| | - Kathleen H. Pine
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | | | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| | - Mohd Hafiz Abdul Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital, Australia
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital, Australia
| | - Marc H. Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
| | - Sara E. Ausman
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, WI
| | | | | | - Paul J. Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Kristin C. Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Kasey R. Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
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May HP, Krauter AK, Finnie DM, McCoy RG, Kashani KB, Griffin JM, Barreto EF. Acute Kidney Injury Survivor Care Following Hospital Discharge: A Mixed-Methods Study of Nephrologists and Primary Care Providers. Kidney Med 2023; 5:100586. [PMID: 36970221 PMCID: PMC10034506 DOI: 10.1016/j.xkme.2022.100586] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rationale & Objective Widespread delivery of high-quality care for acute kidney injury (AKI) survivors after hospital discharge requires a multidisciplinary team. We aimed to compare management approaches between nephrologists and primary care providers (PCPs) and explored strategies to optimize collaboration. Study Design Explanatory sequential mixed-methods study using a case-based survey followed by semi-structured interviews. Setting & Participants Nephrologists and PCPs providing AKI survivor care at 3 Mayo Clinic sites and the Mayo Clinic Health System were included. Outcomes Survey questions and interviews elucidated participants' recommendations for post-AKI care. Analytical Approach Descriptive statistics were used to summarize survey responses. Qualitative data analysis used deductive and inductive strategies. A connecting and merging approach was used for mixed-methods data integration. Results 148 of 774 (19%) providers submitted survey responses (24/72 nephrologists and 105/705 PCPs). Nephrologists and PCPs recommended laboratory monitoring and follow-up with a PCP shortly after hospital discharge. Both indicated that the need for nephrology referral, and its timing should be dictated by clinical and non-clinical patient-specific factors. There were opportunities for improvement in medication and comorbid condition management in both groups. Incorporation of multidisciplinary specialists (eg, pharmacists) was recommended to expand knowledge, optimize patient-centered care, and alleviate provider workload. Limitations Survey findings may have been affected by non-response bias and the unique challenges facing clinicians and health systems during the COVID-19 pandemic. Participants were from a single health system, and their views or experiences may differ from those in other health systems or serving different populations. Conclusions A multidisciplinary team-based model of post-AKI care may facilitate implementation of a patient-centered care plan, improve adherence to best practices, and reduce clinician and patient burden. Individualizing care for AKI survivors based on clinical and non-clinical patient-specific factors is needed to optimize outcomes for patients and health systems.
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Affiliation(s)
- Heather P. May
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | | | - Dawn M. Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G. McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joan M. Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
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5
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Train SE, Burns KEA, Erstad BL, Massaro A, Wu TT, Vassaur J, Selvan K, Kress JP, Devlin JW. Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS. J Crit Care 2022; 72:154165. [PMID: 36209698 DOI: 10.1016/j.jcrc.2022.154165] [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: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The perceptions and practices of ICU physicians regarding initiating neuromuscular blocker infusions (NMBI) in acute respiratory distress syndrome (ARDS) may not be evidence-based amidst the surge of severe ARDS during the SARS-CoV-2 pandemic and new practice guidelines. We identified ICU physicians' perspectives and practices regarding NMBI use in adults with moderate-severe ARDS. MATERIALS AND METHODS After extensive development and testing, an electronic survey was distributed to 342 ICU physicians from three geographically-diverse U.S. health systems(n = 12 hospitals). RESULTS The 173/342 (50.5%) respondents (75% medical) somewhat/strongly agreed a NMBI should be reserved until: after a trial of deep sedation (142, 82%) or proning (59, 34%) and be dose-titrated based on train-of-four monitoring (107, 62%). Of 14 potential NMBI risks, 2 were frequently reported to be of high/very high concern: prolonged muscle weakness with steroid use (135, 79%) and paralysis awareness due to inadequate sedation (114, 67%). Absence of dyssychrony (93, 56%) and use ≥48 h (87, 53%) were preferred NMBI stopping criteria. COVID-19 + ARDS patients were twice as likely to receive a NMBI (56 ± 37 vs. 28 ± 19%, p < 0.01). CONCLUSIONS Most intensivists agreed NMBI in ARDS should be reserved until after a deep sedation trial. Stopping criteria remain poorly defined. Unique considerations exist regarding the role of paralysis in COVID-19+ ARDS.
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Affiliation(s)
- Sarah E Train
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Karen E A Burns
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Brian L Erstad
- College of Pharmacy, University of Arizona, Tucson, AZ, United States of America
| | - Anthony Massaro
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Ting Ting Wu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Bouve College of Health Sciences, Northeastern University, Boston, MA, United States of America
| | - John Vassaur
- Division of Pulmonary and Critical Care Medicine, University of Arizona Medical Center, Tucson, AZ, United States of America
| | - Kavitha Selvan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Chicago Medical Center, Chicago, IL, United States of America
| | - John P Kress
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Chicago Medical Center, Chicago, IL, United States of America
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Bouve College of Health Sciences, Northeastern University, Boston, MA, United States of America.
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6
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Abraham S, Lussier BL. Bundled Bispectral Index Monitoring and Sedation During Paralysis in Acute Respiratory Distress Syndrome. AACN Adv Crit Care 2022; 33:253-261. [PMID: 36067265 DOI: 10.4037/aacnacc2022240] [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: 11/01/2022]
Abstract
BACKGROUND Clinical assessments of depth of sedation are insufficient for patients undergoing neuromuscular blockade during treatment of acute respiratory distress syndrome (ARDS). This quality initiative was aimed to augment objective assessment and improve sedation during therapeutic paralysis using the bispectral index (BIS). METHODS This quality improvement intervention provided education and subsequent implementation of a BIS monitoring and sedation/analgesia bundle in a large, urban, safety-net intensive care unit. After the intervention, a retrospective review of the first 70 admissions with ARDS assessed use and documented sedation changes in response to BIS. RESULTS Therapeutic neuromuscular blockade was initiated for 58 of 70 patients (82.8%) with ARDS, of whom 43 (74%) had BIS monitoring and 29.3% had bundled BIS sedation-titration orders. Explicit documentation of sedation titration in response to BIS values occurred in 27 (62.8%) of those with BIS recordings. CONCLUSIONS BIS sedation/analgesia bundled order sets are underused, but education and access to BIS monitoring led to high use of monitoring alone and subsequent sedation changes.
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Affiliation(s)
- Sunitha Abraham
- Sunitha Abraham is Nurse Practitioner, Neurointensive Care Unit, Parkland Memorial Hospital, Dallas, Texas
| | - Bethany L Lussier
- Bethany L. Lussier is Assistant Professor of Pulmonary and Critical Care, Neurocritical Care in the Department of Medicine and the Department of Neurology and Neurosurgery, Parkland Memorial Hospital, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, CS-08417, Dallas, TX 75370
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7
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Applefeld WN, Wang J, Cortés-Puch I, Klein HG, Eichacker PQ, Cooper D, Danner RL, Natanson C. Modeling current practices in critical care comparative effectiveness research. CRIT CARE RESUSC 2022; 24:150-162. [PMID: 38045594 PMCID: PMC10692606 DOI: 10.51893/2022.2.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether contemporaneous practices are adequately represented in recent critical care comparative effectiveness research studies. Design: All critical care comparative effectiveness research trials published in the New England Journal of Medicine from April 2019 to March 2020 were identified. To examine studies published in other high impact medical journals during the same period, such trials were subsequently also identified in the Journal of the American Medical Association and The Lancet. All cited sources were reviewed, and the medical literature was searched to find studies describing contemporary practices. Then, the designated control group or the comparable therapies studied were examined to determine if they represented contemporaneous critical care practices as described in the medical literature. Results: Twenty-five of 332 randomised clinical trials published in these three journals during this 1-year period described critical care comparative effectiveness research that met our inclusion criteria. Seventeen characterised current practices before enrolment (using surveys, observational studies and guidelines) and then incorporated current practices into one or more study arm. In the other eight, usual care arms appeared insufficient. Four of these trials randomly assigned patients to one of two fixed approaches at either end of a range of usually titrated care. However, due to randomisation, different subgroups within each arm received care that was inappropriate for their specific clinical conditions. In the other four of these trials, common practices influencing treatment choice were not reflected in the trial design, despite a prior effort to characterise usual care. Conclusion: One-third of critical care comparative effectiveness research trials published in widely read medical journals during a recent year did not include a designated control arm or comparable therapies representative of contemporary practices. Failure to incorporate contemporary practices into critical care comparative effectiveness trials appears to be a widespread design weakness.
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Affiliation(s)
- Willard N. Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortés-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Q. Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Diane Cooper
- National Institutes of Health Library, Office of Research Services, National Institutes of Health, Bethesda, MD, USA
| | - Robert L. Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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8
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Yuan Z, Pan L, Wang Y, Wang W. Continuously protracted infusion of cisatracurium besilate in patients with ARDS. Ann Med Surg (Lond) 2022; 77:103718. [PMID: 35638041 PMCID: PMC9142704 DOI: 10.1016/j.amsu.2022.103718] [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: 03/10/2022] [Revised: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is still associated with significant mortality, especially the elderly and those with comorbidities are at highest risk of death. Neuromuscular blocking agents (NMBAs) are used in a large but highly variable proportion of patients with ARDS. Case presentation We describe the case of one critically ill patient with serious ARDS, because of virus pneumonia. In spite of the reduced tidal volume to 4–6 mL/kg of predicted body weight (PBW) and prone position were applied timely, the irresistible progress of disease leaded to an amazing prolonged application of deep sedation and analgesia, as well as NMBA, for the purpose of lung-protective mechanical ventilation. Result The clinical and biochemical parameters guided us toward the recognition that cisatracurium, bolus of 0.1 mg/kg followed by a median infusion rate of 1.91 (1.43–9.52) μg/kg.min, combined with continuous infusion of midazolam 3.43 (2.06–6.17) mg/kg.d and remifentanil 3.79 (3.43–8.57) μg/kg.h is efficacious and suitable for continuous muscle paralysis. Conclusion The intensive care unit (ICU)-acquired weakness (ICU-AW) was inevitable. Besides, an increased demand on drug concentration with the extension of medication time was observed as well. The continuous infusion of cisatracurium is safety and efficacy. The drug concentration of cisatracurium is time-dependent. ICU-acquired weakness (ICU-AW) is inevitable for the critical illness.
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Barreto EF, Rule AD, Alshaer MH, Roberts JA, Abdul Aziz MH, Scheetz MH, Mara KC, Jannetto PJ, Gajic O, O'Horo JC, Boehmer KR. Provider perspectives on beta-lactam therapeutic drug monitoring programs in the critically ill: a protocol for a multicenter mixed-methods study. Implement Sci Commun 2021; 2:34. [PMID: 33762025 PMCID: PMC7992791 DOI: 10.1186/s43058-021-00134-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Beta-lactams (i.e., penicillins, cephalosporins, carbapenems, monobactams) are the most widely used class of antibiotics in critically ill patients. There is substantial interpatient variability in beta-lactam pharmacokinetics which renders their effectiveness and safety largely unpredictable. One strategy to ensure achievement of therapeutic concentrations is drug level testing (“therapeutic drug monitoring”; TDM). While studies have suggested promise with beta-lactam TDM, it is not yet widely available or implemented. This protocol presents a mixed-methods study designed to examine healthcare practitioners’ perspectives on the use and implementation of beta-lactam TDM in the critically ill. Methods An explanatory sequential mixed-methods design will be used [QUANT → qual]. First, quantitative data will be collected through a web-based questionnaire directed at clinicians at three academic medical centers at different phases of beta-lactam TDM implementation (not yet implemented, partially implemented, fully implemented). The sampling frame will include providers from a variety of disciplines that interact with drug level testing and interpretation in the critical care environment including pharmacists, intensivists, infectious diseases experts, medical/surgical trainees, and advanced practice providers. Second, approximately 30 individuals will be purposively sampled from survey respondents to conduct in-depth qualitative interviews to explain and expand upon the results from the quantitative strand. Normalization Process Theory and the Consolidated Framework for Implementation Science will be used to guide data analysis. Discussion These data will be used to answer two specific questions: “What are ICU practitioners’ perspectives on implementing beta-lactam TDM?” and “What factors contribute to the success of beta-lactam TDM program implementation?” Results of this study will be used to design future implementation strategies for beta-lactam TDM programs in the critically ill. Trial registration NCT04755777. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00134-9.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Andrew D Rule
- Division of Epidemiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Nephrology and Hypertension, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Mohd Hafiz Abdul Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA.,Pharmacometrics Center of Excellence, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - John C O'Horo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Infectious Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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Worsham CM, Banzett RB, Schwartzstein RM. Dyspnea, Acute Respiratory Failure, Psychological Trauma, and Post-ICU Mental Health: A Caution and a Call for Research. Chest 2020; 159:749-756. [PMID: 33011205 PMCID: PMC7528739 DOI: 10.1016/j.chest.2020.09.251] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 11/01/2022] Open
Abstract
Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.
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Affiliation(s)
- Christopher M Worsham
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Robert B Banzett
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Richard M Schwartzstein
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
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Merkel A, Massey K, Bellamy C, Miano T, Fuchs B, Candeloro C. Predictors of Cisatracurium Continuous Infusion Dose in Acute Respiratory Distress Syndrome. J Pharm Pract 2019; 34:600-605. [PMID: 31736402 DOI: 10.1177/0897190019888103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Neuromuscular blockade (NMB) with cisatracurium may improve outcomes in the acute respiratory distress syndrome (ARDS) population; however, optimal dosing strategy remains unknown. Factors affecting pharmacokinetics and pharmacodynamics of cisatracurium may impact the dose required to achieve adequate train-of-four (TOF) response. The aims of this study were to determine cisatracurium dose requirements in a critically ill ARDS population and to identify clinical factors that affect dosing. This was a single-center, retrospective cohort study of medical intensive care patients who received cisatracurium infusion for treatment of ARDS. "Stable dose" was defined as the infusion rate producing 2 consecutive TOFs of 1/4 to 2/4. Factors examined for association with dose were temperature, pH, age, and the presence of acute kidney injury (AKI). The analysis included 39 patients. The median stable dose of cisatracurium was 2.8 (2.0, 3.1) μg/kg/min. Multivariable linear regression model for weight-normalized dose identified AKI as a factor independently associated with steady-state dose requirements (% change -31.4, 95% confidence interval [CI]: -51.9, -2.3). Our study provides information on cisatracurium doses required in patients with ARDS to reduce time required to reach goal TOF. Further studies are needed to determine effect of AKI on cisatracurium dose requirements and clinical outcomes.
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Affiliation(s)
- Alison Merkel
- Department of Pharmacy, 6618Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kyle Massey
- Department of Pharmacy, 21798Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Cassandra Bellamy
- Department of Pharmacy, 21798Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Todd Miano
- Center for Clinical Epidemiology and Biostatistics, 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Barry Fuchs
- Division of Pulmonology, Allergy, and Critical Care, Department of Medicine, 21798Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Candeloro
- Department of Pharmacy, 21798Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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12
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Neuromuscular blocking agents for acute respiratory distress syndrome. J Crit Care 2019; 49:179-184. [PMID: 30396789 PMCID: PMC10014082 DOI: 10.1016/j.jcrc.2018.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 01/09/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is an acute inflammatory process that impairs the ability of the lungs to oxygenate thereby resulting in respiratory failure. Treatment of ARDS is often a multimodal approach using both nonpharmacologic and pharmacologic treatment strategies in addition to trying to reverse the underlying cause of ARDS. Neuromuscular blocking agents (NMBAs) have been prescribed to patients with ARDS as they are thought to decrease inflammation, oxygen consumption, and cardiac output and help facilitate ventilator synchrony. NMBAs have only been evaluated in patients with early, severe ARDS in three multicenter, randomized, controlled trials (n = 432), but have resulted in decreased inflammation and improved oxygenation, ventilator-free days, and mortality. Despite reports of NMBAs being associated with adverse effects like postparalytic quadriparesis, myopathy, and prolonged recovery, these effects have not been seen in patients receiving short courses of NMBAs for ARDS. A large multicenter, prospective, randomized, placebo-controlled trial is ongoing to confirm benefit of NMBAs in early, severe ARDS when adjusting for limitations of the previous studies. The current available literature suggests that 48 h of NMBA therapy in patients with early, severe ARDS improves mortality, without resulting in additional patient harm.
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13
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Bourenne J, Hraiech S, Roch A, Gainnier M, Papazian L, Forel JM. Sedation and neuromuscular blocking agents in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:291. [PMID: 28828366 DOI: 10.21037/atm.2017.07.19] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Mechanical ventilation (MV) is the cornerstone of acute respiratory distress syndrome (ARDS) management. The use of protective ventilation is a priority in this acute phase of lung inflammation. Neuromuscular blocking agents (NMBAs) induce reversible muscle paralysis. Their use in patients with ARDS remains controversial but occurs frequently. NMBAs are used in 25-45% of ARDS patients for a mean period of 1±2 days. The main indications of NMBAs are hypoxemia and facilitation of MV. For ethical reasons, NMBA use is inseparable from sedation in the management of early ARDS. During paralysis, sedation monitoring seems to be necessary to avoid awareness with recall. Three randomized controlled trials (RCTs) have demonstrated that the systematic use of NMBAs in the early management of ARDS patients improves oxygenation. Furthermore, the most recent trial reported a reduction of mortality at 90 days when NMBAs were infused over 48 hours. Spontaneous ventilation (SV) during MV at the acute phase of ARDS could improve oxygenation and alveolar recruitment, but it may not allow protective ventilation. The major risk is an increase in ventilator-induced lung injury. However, the adverse effects of NMBAs are widely discussed, particularly the occurrence of intensive care unit (ICU)-acquired weakness. This review analyses the recent findings in the literature concerning sedation and paralysis in managing ARDS.
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Affiliation(s)
- Jeremy Bourenne
- APHM, Hôpital la Timone, Réanimation des urgences et médicale, Marseille, France.,Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Sami Hraiech
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
| | - Antoine Roch
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
| | - Marc Gainnier
- APHM, Hôpital la Timone, Réanimation des urgences et médicale, Marseille, France.,Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Laurent Papazian
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
| | - Jean-Marie Forel
- Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, CEReSS, Aix-Marseille Université, Faculté de Médecine, Marseille, France.,APHM, Hôpital Nord, Réanimation Détresses respiratoires et Infections sévères (DRIS), Marseille, France
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