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Spiegel MC, Goodwin AJ. Development and implementation of a clinical decision support system-based quality initiative to reduce central line-associated bloodstream infections. J Clin Transl Sci 2024; 8:e132. [PMID: 39345695 PMCID: PMC11428117 DOI: 10.1017/cts.2024.566] [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: 03/28/2024] [Revised: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 10/01/2024] Open
Abstract
Background Central venous lines (CVLs) are frequently utilized in critically ill patients and confer a risk of central line-associated bloodstream infections (CLABSIs). CLABSIs are associated with increased mortality, extended hospitalization, and increased costs. Unnecessary CVL utilization contributes to CLABSIs. This initiative sought to implement a clinical decision support system (CDSS) within an electronic health record (EHR) to quantify the prevalence of potentially unnecessary CVLs and improve their timely removal in six adult intensive care units (ICUs). Methods Intervention components included: (1) evaluating existing CDSS' effectiveness, (2) clinician education, (3) developing/implementing an EHR-based CDSS to identify potentially unnecessary CVLs, (4) audit/feedback, and (5) reviewing EHR/institutional data to compare rates of removal of potentially unnecessary CVLs, device utilization, and CLABSIs pre- and postimplementation. Data was evaluated with statistical process control charts, chi-square analyses, and incidence rate ratios. Results Preimplementation, 25.2% of CVLs were potentially removable, and the mean weekly proportion of these CVLs that were removed within 24 hours was 20.0%. Postimplementation, a greater proportion of potentially unnecessary CVLs were removed (29%, p < 0.0001), CVL utilization decreased, and days between CLABSIs increased. The intervention was most effective in ICUs staffed by pulmonary/critical care physicians, who received monthly audit/feedback, where timely CVL removal increased from a mean of 18.0% to 30.5% (p < 0.0001) and days between CLABSIs increased from 17.3 to 25.7. Conclusions A significant proportion of active CVLs were potentially unnecessary. CDSS implementation, in conjunction with audit and feedback, correlated with a sustained increase in timely CVL removal and an increase in days between CLABSIs.
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Affiliation(s)
- Michelle C Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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2
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Braham D, Adams DWS, Johnson R. Pre-hospital 'dirty adrenaline': A descriptive case series of patients receiving peripheral dilute adrenaline infusions in Central Australian remote nurse-led clinics prior to aeromedical retrieval. Emerg Med Australas 2024. [PMID: 39228290 DOI: 10.1111/1742-6723.14496] [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: 03/07/2024] [Accepted: 08/12/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVES 'Dirty adrenaline' is the informal term used for a rapidly made peripheral dilute adrenaline infusion in the emergency treatment of shock, most commonly 1 mg adrenaline in 1 L 0.9% NaCl. It has long been part of the remote clinician's arsenal despite no supporting scientific literature. Remote clinics in Central Australia can be hours away from critical care support. The region's high prevalence of renal and cardiac disease means that access to early vasopressors and inotropes is a necessity for treating shock. To tackle this, remote clinicians often use 'dirty adrenaline'. We present a review of 'dirty adrenaline' use in this region. METHODS Central Australian Retrieval Service's database was screened to identify cases in which a peripheral dilute adrenaline infusion was administered in a remote clinic prior to patient aeromedical retrieval. A retrospective chart review collected: patient demographics; clinical characteristics; infusion details; adverse events; hospital lengths of stay; and mortality outcomes. RESULTS Fifty-seven cases were identified. Median patient age was 50 (range: 2-96). Septic shock was the most common clinical indication (40/57). Median infusion duration was 155 min. Median systolic BP from commencement until retrieval increased from 75.5 to 91 mmHg. Survival to hospital discharge was 86% (49/57). No significant adverse events associated with 'dirty adrenaline' were recorded. CONCLUSION 'Dirty adrenaline' is safe to administer and appears to considerably improve survival when used to treat fluid-resistant shock in remote nurse-led clinics guided by an off-site critical care physician.
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Affiliation(s)
- David Braham
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Daniel W S Adams
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Richard Johnson
- Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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3
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Gorski LA, Ong J, Van Gerpen R, Nickel B, Kokotis K, Hadaway L. Development of an Evidence-Based List of Non-Antineoplastic Vesicants: 2024 Update. JOURNAL OF INFUSION NURSING 2024; 47:290-323. [PMID: 39250767 DOI: 10.1097/nan.0000000000000568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Infiltration of a vesicant, called extravasation, can result in severe patient injuries. Recognition of vesicants and their relative risk of injury is essential to extravasation prevention, early recognition, and appropriate treatment. In this article, the Vesicant Task Force (VTF) updates the previously published Infusion Nurses Society (INS) vesicant list from 2017. The 2024 INS list diverges from earlier vesicant lists, such as the 2017 VTF list, by adopting a risk stratification approach based upon documented patient outcomes, in contrast to the reliance on expert consensus or only surrogate risk indicators, such as pH and osmolarity. The methodology used to create the updated list is explained, and the criteria for high- and moderate-risk vesicants and cautionary vesicants are defined.
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Affiliation(s)
- Lisa A Gorski
- Author Affiliations: Ascension at Home, Brentwood, Tennessee (Gorski); Bryan Medical Center, Lincoln, Nebraska (Ong); Retired from Bryan Medical Center, Lincoln, Nebraska (Van Gerpen); Omaha, Nebraska (Nickel); Retired from BD Medical, Munster, Indiana (Kokotis); Lynn Hadaway Associates, Inc., Milner, Georgia (Hadaway)
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Hixson R, Jensen KS, Melamed KH, Qadir N. Device associated complications in the intensive care unit. BMJ 2024; 386:e077318. [PMID: 39137947 DOI: 10.1136/bmj-2023-077318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit.
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Affiliation(s)
- Roxana Hixson
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
| | - Kristin Schwab Jensen
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
| | - Kathryn H Melamed
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
| | - Nida Qadir
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
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Bekele S, Kuhnly N, Chen LL. Essential Review of Oncological Emergencies. Crit Care Nurs Q 2024; 47:175-183. [PMID: 38860947 DOI: 10.1097/cnq.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Innovations in oncology have expanded treatment eligibility, leading to a rise in cancer patients requiring critical care. This necessitates that all critical care clinicians possess a fundamental knowledge of prevalent oncological conditions and identify emergent scenarios requiring immediate action. This article will explore key oncological complications and their management approaches.
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Affiliation(s)
- Sara Bekele
- Author Affiliations: Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York (Ms Bekele); Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (Mr Kuhnly and Dr Chen)
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Lathroum CN, Angulo Bracho HL, Alessandrino KM, Walker JM. The use of injectable subcutaneous terbutaline and topical nitroglycerin ointment in the treatment of peripheral vasopressor extravasation in 3 dogs. J Vet Emerg Crit Care (San Antonio) 2024; 34:393-398. [PMID: 39031632 DOI: 10.1111/vec.13393] [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] [Received: 08/22/2022] [Revised: 04/30/2023] [Accepted: 05/12/2023] [Indexed: 07/22/2024]
Abstract
OBJECTIVE To describe the clinical course and treatment of 3 dogs with peripheral vasopressor extravasation. CASE SERIES SUMMARY Although vasopressor extravasation (VE) is a well-documented complication in human medicine, literature describing VE and its management in veterinary patients is sparse. VE increases patient morbidity by causing local tissue injury and necrosis. The gold standard treatment for VE, phentolamine, has been periodically limited in supply in human medicine and is not consistently available for use in veterinary medicine. An alternative protocol proposed for use in people with VE combines topical nitroglycerin application with subcutaneous terbutaline infiltration. In this report, a treatment protocol utilizing these therapies was used to treat 3 dogs with VE and secondary tissue injury. NEW OR UNIQUE INFORMATION PROVIDED This report describes 3 cases of VE-induced tissue injury in dogs. In addition, this report describes the use of perivascular terbutaline infiltration and topical nitroglycerin application as therapeutic management for VE in dogs.
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Affiliation(s)
- Chele N Lathroum
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Kayla M Alessandrino
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Julie M Walker
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [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] [Received: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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Christensen J, Andersson E, Sjöberg F, Hellgren E, Harbut P, Harbut J, Sjövall F, von Bruhn Gufler C, Mårtensson J, Rubenson Wahlin R, Joelsson-Alm E, Cronhjort M. Adverse Events of Peripherally Administered Norepinephrine During Surgery: A Prospective Multicenter Study. Anesth Analg 2024; 138:1242-1248. [PMID: 38180886 DOI: 10.1213/ane.0000000000006806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
BACKGROUND Perioperative treatment of hypotension by intravenous administration of norepinephrine in a peripheral vein can lead to adverse events, for example, tissue necrosis. However, the incidence and severity of adverse events during perioperative administration are unknown. METHODS This was a prospective observational study conducted at 3 Swedish hospitals from 2019 to 2022. A total of 1004 patients undergoing surgery, who met the criteria for perioperative peripheral norepinephrine administration, were included. The infusion site was inspected regularly. If swelling or paleness of skin was detected, the infusion site was changed to a different peripheral line. Systolic blood pressure and pulse frequency were monitored during the infusion time and defined as adverse events at >220 mm Hg and <40 beats•min -1 . In case of adverse events, patients were observed for up to 48 hours. The primary outcome was prevalence of extravasation, defined as swelling around the infusion site. Secondary outcomes were all types of adverse events and associations between predefined clinical variables and risk of adverse events. RESULTS We observed 2.3% (95% confidence interval [CI], 1.4%-3.2%) extravasation of infusion and 0.9% (95% CI, 0.4%-1.7%) bradycardia. No cases of tissue necrosis or severe hypertension were detected. All adverse events had dissipated spontaneously within 48 hours. Proximal catheter placement was associated with more adverse events. CONCLUSIONS Extravasation of peripherally administrated norepinephrine in the perioperative period occurred at similar rates as in previous studies in critically ill patients. In our setting, where we regularly inspected the infusion site and shifted site in case of swelling or paleness of skin, we observed no case of severe adverse events. Given that severe adverse events were absent, the potential benefit of this preventive approach requires confirmation in a larger population.
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Affiliation(s)
- Jens Christensen
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Andersson
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Fredric Sjöberg
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Hellgren
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Piotr Harbut
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| | - Joanna Harbut
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| | - Fredrik Sjövall
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | | | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Eva Joelsson-Alm
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
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Watts S, Apte Y, Holland T, Hatt A, Craswell A, Lin F, Tabah A, Ware R, Byrnes J, Anstey C, Keijzers G, Ramanan M. Randomised, controlled, feasibility trial comparing vasopressor infusion administered via peripheral cannula versus central venous catheter for critically ill adults: A study protocol. PLoS One 2024; 19:e0295347. [PMID: 38739611 PMCID: PMC11090297 DOI: 10.1371/journal.pone.0295347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/11/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND When clinicians need to administer a vasopressor infusion, they are faced with the choice of administration via either peripheral intravenous catheter (PIVC) or central venous catheter (CVC). Vasopressor infusions have traditionally been administered via central venous catheters (CVC) rather than Peripheral Intra Venous Catheters (PIVC), primarily due to concerns of extravasation and resultant tissue injury. This practice is not guided by contemporary randomised controlled trial (RCT) evidence. Observational data suggests safety of vasopressor infusion via PIVC. To address this evidence gap, we have designed the "Vasopressors Infused via Peripheral or Central Access" (VIPCA) RCT. METHODS The VIPCA trial is a single-centre, feasibility, parallel-group RCT. Eligible critically ill patients requiring a vasopressor infusion will be identified by emergency department (ED) or intensive care unit (ICU) staff and randomised to receive vasopressor infusion via either PIVC or CVC. Primary outcome is feasibility, a composite of recruitment rate, proportion of eligible patients randomised, protocol fidelity, retention and missing data. Primary clinical outcome is days alive and out of hospital up to day-30. Secondary outcomes will include safety and other clinical outcomes, and process and cost measures. Specific aspects of safety related to vasopressor infusions such as extravasation, leakage, device failure, tissue injury and infection will be assessed. DISCUSSION VIPCA is a feasibility RCT whose outcomes will inform the feasibility and design of a multicentre Phase-3 trial comparing routes of vasopressor delivery. The exploratory economic analysis will provide input data for the full health economic analysis which will accompany any future Phase-3 RCT.
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Affiliation(s)
| | - Yogesh Apte
- Caboolture Hospital, Caboolture, Australia
- James Mayne Academy of Critical Care, The University of Queensland, Brisbane, Australia
| | | | - April Hatt
- Caboolture Hospital, Caboolture, Australia
| | - Alison Craswell
- Caboolture Hospital, Caboolture, Australia
- School of Health, University of the Sunshine Coast, Sippy Downs, Australia
| | - Frances Lin
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Sunshine Coast Health Institute, School of Health, University of the Sunshine Coast, Sippy Downs, Australia
| | - Alexis Tabah
- James Mayne Academy of Critical Care, The University of Queensland, Brisbane, Australia
- Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Queensland Critical Care Research Network, Herston, Australia
| | - Robert Ware
- Menzies Health Institute Queensland and School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Christopher Anstey
- Menzies Health Institute Queensland and School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Gerben Keijzers
- Menzies Health Institute Queensland and School of Medicine and Dentistry, Griffith University, Southport, Australia
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Southport, Australia
- Faculty of Health Sciences and Medicine Bond University, Robina, Australia
| | - Mahesh Ramanan
- Caboolture Hospital, Caboolture, Australia
- Queensland Critical Care Research Network, Herston, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Kensington, Australia
- Faculty of Health, Queensland of Technology, Brisbane, Australia
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Yoshikawa Y, Maeda M, Kunigo T, Sato T, Takahashi K, Ohno S, Hirahata T, Yamakage M. Effect of using hypotension prediction index versus conventional goal-directed haemodynamic management to reduce intraoperative hypotension in non-cardiac surgery: A randomised controlled trial. J Clin Anesth 2024; 93:111348. [PMID: 38039629 DOI: 10.1016/j.jclinane.2023.111348] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 12/03/2023]
Abstract
STUDY OBJECTIVE It remains unclear whether it is the hypotension prediction index itself or goal-directed haemodynamic therapy that mitigates intraoperative hypotension. DESIGN A single centre randomised controlled trial. SETTING Sapporo Medical University Hospital. PATIENTS A total of 64 adults patients undergoing major non-cardiac surgery under general anaesthesia. INTERVENTIONS Patients were randomly assigned to either group receiving conventional goal-directed therapy (FloTrac group) or combination of the hypotension prediction index and conventional goal-directed therapy (HPI group). To investigate the independent utility of the index, the peak rates of arterial pressure and dynamic arterial elastance were not included in the treatment algorithm for the HPI group. MEASUREMENTS The primary outcome was the time-weighted average of the areas under the threshold. Secondary outcomes were area under the threshold, the number of hypotension events, total duration of hypotension events, mean mean arterial pressure during the hypotension period, number of hypotension events with mean arterial pressure < 50 mmHg, amounts of fluids, blood products, blood loss, and urine output, frequency and amount of vasoactive agents, concentration of haemoglobin during the monitoring period, and 30-day mortality. MAIN RESULTS The time-weighted average of the area below the threshold was lower in the HPI group than in the control group; 0.19 mmHg (interquartile range, 0.06-0.80 mmHg) vs. 0.66 mmHg (0.28-1.67 mmHg), with a median difference of -0.41 mmHg (95% confidence interval, -0.69 to -0.10 mmHg), p = 0.005. Norepinephrine was administered to 12 (40%) and 5 (17%) patients in the HPI and FloTrac groups, respectively (p = 0.045). No significant differences were observed in the volumes of fluid and blood products between the study groups. CONCLUSIONS The current randomised controlled trial results suggest that using the hypotension prediction index independently lowered the cumulative amount of intraoperative hypotension during major non-cardiac surgery.
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Affiliation(s)
- Yusuke Yoshikawa
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan.
| | - Makishi Maeda
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
| | - Tatsuya Kunigo
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
| | - Tomoe Sato
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
| | - Kanako Takahashi
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
| | - Sho Ohno
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
| | - Tomoki Hirahata
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
| | - Michiaki Yamakage
- Department of Anaesthesiology, Sapporo Medical University School of Medicine, South1 West16 291, Chuoku, Sapporo 060-8543, Japan
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Munroe ES, Heath ME, Eteer M, Gershengorn HB, Horowitz JK, Jones J, Kaatz S, Tamae Kakazu M, McLaughlin E, Flanders SA, Prescott HC. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. Chest 2024; 165:847-857. [PMID: 37898185 PMCID: PMC11214906 DOI: 10.1016/j.chest.2023.10.027] [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: 08/18/2023] [Revised: 10/09/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement. RESEARCH QUESTION How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality? STUDY DESIGN AND METHODS This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. RESULTS Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m2 increase], 0.98; 95% CI, 0.97-1.00; P = .015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P = .002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P = .001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line. INTERPRETATION Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.
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Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI.
| | - Megan E Heath
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Mousab Eteer
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Jessica Jones
- Department of Pharmacy, Corewell Health, Dearborn, MI
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Health, Detroit, MI
| | | | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
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Ängeby E, Adrian M, Bozovic G, Borgquist O, Kander T. Central venous catheter tip misplacement: A multicentre cohort study of 8556 thoracocervical central venous catheterisations. Acta Anaesthesiol Scand 2024; 68:520-529. [PMID: 38351546 DOI: 10.1111/aas.14380] [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: 09/14/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND There is a paucity of data on the incidence of central venous catheter tip misplacements after the implementation of ultrasound guidance during insertion. The aims of the present study were to determine the incidence of tip misplacements and to identify independent variables associated with tip misplacement. METHODS All jugular and subclavian central venous catheter insertions in patients ≥16 years with a post-procedural chest radiography at four hospitals were included. Each case was reviewed for relevant catheter data and radiologic evaluations of chest radiographies. Tip misplacements were classified as 'any tip misplacement', 'minor tip misplacement' or 'major tip misplacement'. Multivariable logistic regression analyses were used to investigate associations between predefined independent variables and tip misplacements. RESULTS A total of 8556 central venous catheter insertions in 5587 patients were included. Real-time ultrasound guidance was used in 91% of all insertions. Any tip misplacement occurred (95% confidence interval) in 3.7 (3.3-4.1)% of the catheterisations, and 2.1 (1.8-2.4)% were classified as major tip misplacements. The multivariable logistic regression analyses showed that female patient gender, subclavian vein insertions, number of skin punctures and limited operator experience were associated with a higher risk of major tip misplacement, whereas increasing age and height were associated with a lower risk. CONCLUSIONS In this large prospective multicentre cohort study, performed in the ultrasound-guided era, we demonstrated the incidence of tip misplacements to be 3.7 (3.3-4.1)%. Right internal jugular vein catheterisation had the lowest incidence of both minor and major tip misplacement.
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Affiliation(s)
- Emilia Ängeby
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Maria Adrian
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Gracijela Bozovic
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Medical Imaging and Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Ola Borgquist
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Thomas Kander
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
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13
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Hwang KY, Phoon PHY, Hwang NC. Adverse Clinical Effects Associated With Non-catecholamine Pharmacologic Agents for Treatment of Vasoplegic Syndrome in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:802-819. [PMID: 38218651 DOI: 10.1053/j.jvca.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 01/15/2024]
Abstract
Vasoplegic syndrome is a relatively common complication that can happen during and after major adult cardiac surgery. It is associated with a higher rate of complications, including postoperative renal failure, longer duration of mechanical ventilation, and intensive care unit stay, as well as increased mortality. The underlying pathophysiology of vasoplegic syndrome is that of profound vascular hyporesponsiveness, and involves a complex interplay among inflammatory cytokines, cellular surface receptors, and nitric oxide (NO) production. The pharmacotherapy approaches for the treatment of vasoplegia include medications that increase vascular smooth muscle contraction via increasing cytosolic calcium in myocytes, reduce the vascular effects of NO and inflammation, and increase the biosynthesis of and vascular response to norepinephrine. Clinical trials have demonstrated the clinical efficacy of non-catecholamine pharmacologic agents in the treatment of vasoplegic syndrome. With an increase in their use today, it is important for clinicians to understand the adverse clinical outcomes and patient risk profiles associated with these agents, which will allow better-tailored medical therapy.
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Affiliation(s)
- Kai Yin Hwang
- Department of Anaesthesiology, National University Hospital, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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14
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Yerke JR, Mireles-Cabodevila E, Chen AY, Bass SN, Reddy AJ, Bauer SR, Kokoczka L, Dugar S, Moghekar A. Peripheral Administration of Norepinephrine: A Prospective Observational Study. Chest 2024; 165:348-355. [PMID: 37611862 PMCID: PMC10851275 DOI: 10.1016/j.chest.2023.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Historically, norepinephrine has been administered through a central venous catheter (CVC) because of concerns about the risk of ischemic tissue injury if extravasation from a peripheral IV catheter (PIVC) occurs. Recently, several reports have suggested that peripheral administration of norepinephrine may be safe. RESEARCH QUESTION Can a protocol for peripheral norepinephrine administration safely reduce the number of days a CVC is in use and frequency of CVC placement? STUDY DESIGN AND METHODS This was a prospective observational cohort study conducted in the medical ICU at a quaternary care academic medical center. A protocol for peripheral norepinephrine administration was developed and implemented in the medical ICU at the study site. The protocol was recommended for use in patients who met prespecified criteria, but was used at the treating clinician's discretion. All adult patients admitted to the medical ICU receiving norepinephrine through a PIVC from February 2019 through June 2021 were included. RESULTS The primary outcome was the number of days of CVC use that were avoided per patient, and the secondary safety outcomes included the incidence of extravasation events. Six hundred thirty-five patients received peripherally administered norepinephrine. The median number of CVC days avoided per patient was 1 (interquartile range, 0-2 days per patient). Of the 603 patients who received norepinephrine peripherally as the first norepinephrine exposure, 311 patients (51.6%) never required CVC insertion. Extravasation of norepinephrine occurred in 35 patients (75.8 events/1,000 d of PIVC infusion [95% CI, 52.8-105.4 events/1,000 d of PIVC infusion]). Most extravasations caused no or minimal tissue injury. No patient required surgical intervention. INTERPRETATION This study suggests that implementing a protocol for peripheral administration of norepinephrine safely can avoid 1 CVC day in the average patient, with 51.6% of patients not requiring CVC insertion. No patient experienced significant ischemic tissue injury with the protocol used. These data support performance of a randomized, prospective, multicenter study to characterize the net benefits of peripheral norepinephrine administration compared with norepinephrine administration through a CVC.
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Affiliation(s)
- Jason R Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
| | | | - Alyssa Y Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | | | - Anita J Reddy
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | | | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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15
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De Backer D, Deutschman CS, Hellman J, Myatra SN, Ostermann M, Prescott HC, Talmor D, Antonelli M, Pontes Azevedo LC, Bauer SR, Kissoon N, Loeches IM, Nunnally M, Tissieres P, Vieillard-Baron A, Coopersmith CM. Surviving Sepsis Campaign Research Priorities 2023. Crit Care Med 2024; 52:268-296. [PMID: 38240508 DOI: 10.1097/ccm.0000000000006135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. DESIGN Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. METHODS Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. RESULTS A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? CONCLUSIONS Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Sepsis Research Lab, the Feinstein Institutes for Medical Research, Manhasset, NY
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio-Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Leinster, Dublin, Ireland
| | | | - Pierre Tissieres
- Pediatric Intensive Care, Neonatal Medicine and Pediatric Emergency, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Vieillard-Baron
- Service de Medecine Intensive Reanimation, Hopital Ambroise Pare, Universite Paris-Saclay, Le Kremlin-Bicêtre, France
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16
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Munroe ES. A Case for the Evidence-Based Use of Peripheral Vasopressors. Chest 2024; 165:236-238. [PMID: 38336432 DOI: 10.1016/j.chest.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 02/12/2024] Open
Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
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17
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Abu Sardaneh A, Penm J, Oliver M, Gattas D, McLachlan AJ, James C, Cella C, Aljuhani O, Acquisto NM, Patanwala AE. International pharmacy survey of peripheral vasopressor infusions in critical care (INFUSE). J Crit Care 2023; 78:154376. [PMID: 37536012 DOI: 10.1016/j.jcrc.2023.154376] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The primary objective was to determine the proportion of hospitals that administered norepinephrine peripheral vasopressor infusions (PVIs) in critically ill adult patients. Secondary objectives were to describe how norepinephrine is used such as the maximum duration, infusion rate and concentration, and to determine the most common first-line PVI used by country. MATERIALS AND METHODS An international multi-centre cross-sectional survey study was conducted in adult intensive care units in Australia, US, UK, Canada, and Saudi Arabia. RESULTS Critical care pharmacists from 132 institutions responded to the survey. Norepinephrine PVIs were utilised in 86% of institutions (n = 113/132). The median maximum duration of norepinephrine PVIs was 24 h (IQR 24-24) (n = 57/113). The most common maximum norepinephrine PVI rate was between 11 and 20 μg/min (n = 16/113). The most common maximum norepinephrine PVI concentration was 16 μg/mL (n = 60/113). Half of the institutions had a preference to administer another PVI over norepinephrine as a first-line agent (n = 66/132). The most common alternative PVI used by country was: US (phenylephrine 41%, n = 37/90), Canada (dopamine 31%, n = 5/16), UK (metaraminol 82%, n = 9/11), and Australia (metaraminol 89%, n = 8/9). CONCLUSIONS There is variability in clinical practice regarding PVI administration in critically ill adult patients dependent on drug availability and local institutional recommendations.
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Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Gattas
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Intensive Care Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Andrew J McLachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christie James
- Department of Pharmacy, Grange University Hospital, Cwmbran, Wales, United Kingdom
| | - Christina Cella
- Canadian Society of Hospital Pharmacists, Ottawa, Ontario, Canada
| | - Ohoud Aljuhani
- Pharmacy Practice Department, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pharmacy, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Nicole M Acquisto
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, United States; Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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18
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Peake SL, Delaney A, Finnis M, Hammond N, Knowles S, McDonald S, Williams PJ. Early sepsis in Australia and New Zealand: A point-prevalence study of haemodynamic resuscitation practices. Emerg Med Australas 2023; 35:953-959. [PMID: 37460093 DOI: 10.1111/1742-6723.14283] [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] [Received: 04/23/2023] [Revised: 06/04/2023] [Accepted: 06/12/2023] [Indexed: 11/18/2023]
Abstract
OBJECTIVE Optimal resuscitation of sepsis-induced hypotension is uncertain, particularly the role of restrictive fluid strategies, leading to variability in usual practice. The objective of this study is to understand resuscitation practices in patients presenting to ED with early sepsis. METHODS Design, participants and setting: Prospective, observational, multicentre, single-day, point-prevalence study enrolling adult patients present in 51 Australian and New Zealand ICUs at 10.00 hours, 8 June 2021. MAIN OUTCOME MEASURES Site-level data on sepsis policies and patient-level demographic data, presence of sepsis and fluid and vasopressor administration in the first 24 h post-ED presentation. RESULTS A total of 722 patients were enrolled. ED was the ICU admission source for 222 of 722 patients (31.2%) and 78 of 222 patients (35%) met the criteria for sepsis within 24 h of ED presentation. Median age of the sepsis cohort was 61 (48-72) years, 58% were male and respiratory infection was the commonest cause (53.8%). The sepsis cohort had a higher severity of illness than the non-sepsis cohort (144/222 patients) and chronic immunocompromise was more common. Of 78 sepsis patients, 55 (71%) received ≥1 fluid boluses with 500 and 1000 mL boluses equally common (both 49%). In the first 24 h, 2335 (1409-3125) mL (25.3 [13.2-42.9] mL/kg) was administered. Vasopressors were administered in 53 of 78 patients (68%) and for 25 patients (47%) administration was peripheral. CONCLUSIONS ICU patients presenting to the ED with sepsis receive less fluids than current international recommendations and peripheral vasopressor administration is common. This finding supports the conduct of clinical trials evaluating optimal fluid dose and vasopressor timing for early sepsis-induced hypotension.
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Affiliation(s)
- Sandra L Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anthony Delaney
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Critical Care Program, The George Institute for Global Health and The University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Finnis
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and The University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health and The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen McDonald
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Patricia J Williams
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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19
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Prescott HC, Ostermann M. What is new and different in the 2021 Surviving Sepsis Campaign guidelines. Med Klin Intensivmed Notfmed 2023; 118:75-79. [PMID: 37286842 PMCID: PMC10246868 DOI: 10.1007/s00063-023-01028-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/23/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
The Surviving Sepsis Campaign (SSC) International Guidelines for the Management of Sepsis and Septic Shock provide recommendations on the care of hospitalized adult patients with (or at risk for) sepsis. This review discusses what is new or different in the 2021 SSC adult sepsis guidelines compared to 2016. The guidelines include new weak recommendations for use of balanced fluid over saline 0.9%, use of intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement, and peripheral initiation of intravenous vasopressors over delaying initiation in order to obtain central venous access. As before, there is a strong recommendation to initiate antimicrobials within 1 h of sepsis and septic shock, but there are now additional recommendations when the diagnosis is uncertain. The recommendation for initial fluid resuscitation in septic shock of 30 mL/kg crystalloid has been downgraded from strong to weak. Finally, there are 12 new recommendations addressing long-term outcomes from sepsis, including strong recommendations to screen for economic and social support and to make referrals for follow-up where available; use shared decision-making in post-intensive care unit (ICU) and hospital discharge planning; reconcile medications at both ICU and hospital discharge; provide information about sepsis and its sequelae in written and verbal hospital discharge summary; and to provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.
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Affiliation(s)
- Hallie C Prescott
- Department of Medicine, North Campus Research Center, University of Michigan, 48109-2800, Ann Arbor, MI, USA.
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.
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20
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Kochanek M, David S. [The current sepsis guidelines-What do you need to know?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:939-945. [PMID: 37702781 DOI: 10.1007/s00108-023-01585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/14/2023]
Abstract
The current international sepsis guidelines from 2021 are based on the work of a panel of 60 international experts from various fields. They include a total of 93 recommendations, some of which include new aspects compared to the 2016 version of the guidelines. This article provides a subjective compilation by two internal medicine intensivists who highlight some aspects, especially of changes within the guidelines compared to the previous version. The focus is on the fields of screening, sepsis bundles, fluid and vasopressor treatment and adjuvant treatment. In addition, for the first time these guidelines address the important issue of long-term sequelae for sepsis survivors and their environment.
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Affiliation(s)
- Matthias Kochanek
- Medizinische Fakultät und Universitätsklinikum Köln, Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO), Universität zu Köln, Köln, Deutschland.
| | - Sascha David
- Universitätsspital Zürich, Institut für Intensivmedizin, Zürich, Schweiz
- Medizinische Hochschule Hannover, Nieren- und Hochdruckerkrankungen, Hannover, Deutschland
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21
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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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22
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Asher E, Karameh H, Nassar H, Yosefy C, Marmor D, Perel N, Taha L, Tabi M, Braver O, Shuvy M, Wiener-Well Y, Glikson M, Bruoha S. Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study. J Clin Med 2023; 12:5734. [PMID: 37685801 PMCID: PMC10488618 DOI: 10.3390/jcm12175734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/23/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). METHODS A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. RESULTS A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). CONCLUSIONS The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.
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Affiliation(s)
- Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hani Karameh
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hamed Nassar
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Chaim Yosefy
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - David Marmor
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Nimrod Perel
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Louay Taha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Meir Tabi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Omri Braver
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - Mony Shuvy
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Yonit Wiener-Well
- Infectious Diseases Unit, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel;
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Sharon Bruoha
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
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23
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Matula E, Mastrocco A, Prittie J, Weltman J, Keyserling C. Microorganism colonization of peripheral venous catheters in a small animal clinical setting. J Vet Emerg Crit Care (San Antonio) 2023; 33:509-519. [PMID: 37585353 DOI: 10.1111/vec.13328] [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] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/30/2022] [Indexed: 08/18/2023]
Abstract
OBJECTIVE To compare the incidence of microorganism colonization of peripheral venous catheters (PVCs) placed in the Emergency Department (ED) to those placed in a routine preoperative setting. The relationship between catheter tip colonization and patient urgency (as assessed by triage priority) was also evaluated. DESIGN Prospective, observational study from January 2021 to October 2021. SETTING Emergency room and clinical areas of a large, urban, tertiary referral center. ANIMALS Three hundred dogs and 94 cats with a PVC in place for a minimum of 24 hours were enrolled in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred and eighty-eight PVCs were placed in the ED and 106 were placed preoperatively. The overall colonization rate was 10.4% (41/394). Sixteen bacterial and 1 fungal genera were cultured. Eight of these bacterial genera (25/51 [49%] bacterial isolates) were resistant to at least 1 antimicrobial class. Twenty-nine of 288 (10.1%) catheters positive for colonization were placed in the ED, whereas 12 of 106 (11.3%) were placed preoperatively. There was no association between microorganism growth on catheters and clinical area of catheter placement. There was also no association between ED patient urgency and positive catheter tip culture. No significant risk factors were identified predisposing to colonization of PVCs. CONCLUSIONS The overall incidence of microorganism colonization of PVCs in this study population was equivalent to, or lower than, previously reported in veterinary literature. There was no statistical difference between the catheters placed in the ED and those placed for routine surgical procedures. Patient urgency did not affect the incidence of positivity of peripheral catheter tip cultures.
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Affiliation(s)
- Erica Matula
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Alicia Mastrocco
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Jennifer Prittie
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Joel Weltman
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
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24
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Monnet X, Lai C, Ospina-Tascon G, De Backer D. Evidence for a personalized early start of norepinephrine in septic shock. Crit Care 2023; 27:322. [PMID: 37608327 PMCID: PMC10464210 DOI: 10.1186/s13054-023-04593-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/28/2023] [Indexed: 08/24/2023] Open
Abstract
During septic shock, vasopressor infusion is usually started only after having corrected the hypovolaemic component of circulatory failure, even in the most severe patients. However, earlier administration of norepinephrine, simultaneously with fluid resuscitation, should be considered in some cases. Duration and depth of hypotension strongly worsen outcomes in septic shock patients. However, the response of arterial pressure to volume expansion is inconstant, delayed, and transitory. In the case of profound, life-threatening hypotension, relying only on fluids to restore blood pressure may unduly prolong hypotension and organ hypoperfusion. Conversely, norepinephrine rapidly increases and better stabilizes arterial pressure. By binding venous adrenergic receptors, it transforms part of the unstressed blood volume into stressed blood volume. It increases the mean systemic filling pressure and increases the fluid-induced increase in mean systemic filling pressure, as observed in septic shock patients. This may improve end-organ perfusion, as shown by some animal studies. Two observational studies comparing early vs. later administration of norepinephrine in septic shock patients using a propensity score showed that early administration reduced the administered fluid volume and day-28 mortality. Conversely, in another propensity score-based study, norepinephrine administration within the first hour following shock diagnosis increased day-28 mortality. The only randomized controlled study that compared the early administration of norepinephrine alone to a placebo showed that the early continuous administration of norepinephrine at a fixed dose of 0.05 µg/kg/min, with norepinephrine added in open label, showed that shock control was achieved more often than in the placebo group. The choice of starting norepinephrine administration early should be adapted to the patient's condition. Logically, it should first be addressed to patients with profound hypotension, when the arterial tone is very low, as suggested by a low diastolic blood pressure (e.g. ≤ 40 mmHg), or by a high diastolic shock index (heart rate/diastolic blood pressure) (e.g. ≥ 3). Early administration of norepinephrine should also be considered in patients in whom fluid accumulation is likely to occur or in whom fluid accumulation would be particularly deleterious (in case of acute respiratory distress syndrome or intra-abdominal hypertension for example).
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Affiliation(s)
- Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Christopher Lai
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care Medicine, Fundación Valle del Lili, Av. Simón Bolívar Cra. 98, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad ICESI, Cali, Colombia
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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25
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Gandotra S, Wunsch H, Bosch NA, Walkey AJ, Teja B. Reducing Central Venous Catheter Use through Adoption of Guidelines for Peripheral Catheter-based Vasopressor Delivery. Ann Am Thorac Soc 2023; 20:1219-1223. [PMID: 37220220 DOI: 10.1513/annalsats.202212-1060rl] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/13/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
| | - Hannah Wunsch
- University of Toronto Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre Toronto, Ontario, Canada
| | | | | | - Bijan Teja
- St. Michael's Hospital Toronto, Ontario, Canada
- University of Toronto Toronto, Ontario, Canada
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26
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Abu Sardaneh A, Penm J, Oliver M, Gattas D, Mclachlan A, Patanwala A. Comparison of metaraminol versus no metaraminol on time to resolution of shock in critically ill patients. Eur J Hosp Pharm 2023; 30:214-220. [PMID: 34620686 PMCID: PMC10359804 DOI: 10.1136/ejhpharm-2021-003035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/28/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE There is limited evidence to support metaraminol use in critically ill patients. Metaraminol is not included as a vasopressor choice in international guidelines for the management of shock. Nevertheless, metaraminol is used in rates up to 42% in this patient population. The objective of this study was to investigate the effectiveness of metaraminol for the treatment of critically ill patients with shock. METHODS A single-centre retrospective matched observational study was conducted in a 54-bed intensive care unit of a tertiary hospital. Patients aged 16 years or older who were admitted from 2017 to 2019 with shock were included. Patients treated with metaraminol and norepinephrine (MET-NOR) were compared with those treated with norepinephrine without metaraminol (NOR). The primary outcome was the time to resolution of shock defined as the time to cessation of vasopressors. The secondary outcome was vasopressor-free days until 28 days. RESULTS There were 286 patients included in this study, including 143 patients in each group. The median time to resolution of shock was 44 hours (IQR 28-66 hours) in the MET-NOR group compared with 27 hours (IQR 14-63 hours) in the NOR group (95% CI of median difference 7 to 19 hours; p<0.01). The Cox regression analysis for the time to resolution of shock showed no significant difference between groups (HR 1.24, 95% CI 0.96 to 1.60; p=0.10). However, the proportional hazards assumption was not met (p<0.01). The median number of vasopressor-free days until 28 days was 26 days (IQR 24-27 days) in the MET-NOR group compared with 27 days (IQR 25-27 days) in the NOR group (95% CI of median difference -0.8 to -0.1 day; p<0.01). CONCLUSION In critically ill patients, metaraminol may be associated with a longer time to resolution of shock compared with those who do not receive metaraminol.
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Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Gattas
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Intensive Care Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Andrew Mclachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Asad Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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27
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Gershengorn HB, Basu T, Horowitz JK, McLaughlin E, Munroe E, O'Malley M, Hsaiky L, Flanders SA, Bernstein SJ, Paje D, Chopra V, Prescott HC. The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications. Ann Am Thorac Soc 2023; 20:1003-1011. [PMID: 37166852 DOI: 10.1513/annalsats.202209-814oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/27/2023] [Indexed: 03/02/2023] Open
Abstract
Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.
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Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Tanima Basu
- Division of Hospital Medicine and
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
| | - Jennifer K Horowitz
- Division of Hospital Medicine and
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
| | - Elizabeth McLaughlin
- Division of Hospital Medicine and
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
| | - Elizabeth Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Megan O'Malley
- Division of Hospital Medicine and
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
| | - Lama Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan
| | - Scott A Flanders
- Division of Hospital Medicine and
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
| | - Steven J Bernstein
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan; and
| | - David Paje
- Division of Hospital Medicine and
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
| | - Vineet Chopra
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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28
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Atay S, Üzen Cura Ş, Efil S. Nurses' knowledge and experience related to short peripheral venous catheter extravasation. J Vasc Access 2023; 24:848-853. [PMID: 34590526 DOI: 10.1177/11297298211045589] [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: 11/16/2022] Open
Abstract
BACKGROUND The majority of hospitalized patients receive a Peripheral Venous Catheter (PVC) in the course of their treatment. Extravasation injury is a serious complication of intravenous treatment. OBJECTIVE This cross-sectional survey designed study aims to investigate nurses' knowledge and experience related to short peripheral venous catheter extravasation. METHOD The study sample included 145 nurses working in a university hospital in the west of Turkey. A questionnaire developed in accordance with the literature was used for data collection. The data were assessed by frequency and proportions. RESULTS Of the nurses included in this study, 26.2% reported they had experienced extravasation injury in a patient; 74.5% said they had received no instruction in the management of extravasation during their in-service training program; and 85.5% stated they did not keep a record of extravasation. 89.7% of the nurses reported infused medications as a cause of extravasation, and 81.4% reported catheter sites as a cause. Among the medications reported by the nurses as causing extravasation: 89.7% reported contrast agents; 84.8% TPN solutions; 71.0% cytotoxic agents; and 65.1% mannitol. The symptoms of extravasation reported by nurses included: swelling (97.9%), redness (97.2%), pain (92.4%), rise in temperature (65.5%), and ulceration (60.0%). In responding to the occurrence of extravasation, interventions reported by the nurses included: stopping the flow of fluid (98.6%), elevation (89.7%), cold application (76.6%), and aspiration of drug (40.7%). CONCLUSION Based on these results, it is recommended that guidelines are developed for the management of extravasation, that periodic in-service training programs are provided and that observational studies are carried out into the administration of vesicant drugs.
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Affiliation(s)
- Selma Atay
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Şengül Üzen Cura
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Sevda Efil
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
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Affiliation(s)
- Heather Baid
- School of Sport and Health Sciences, University of Brighton, Brighton, UK
| | - Eleanor Damm
- Intensive Care Medicine and Anaesthesia, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Louise Trent
- Hawke's Bay Hospital, Te Matau a Māui, Te Whatu Ora, New Zealand
| | - Forbes McGain
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Carlton, Australia
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Munroe ES, Hyzy RC, Semler MW, Shankar-Hari M, Young PJ, Zampieri FG, Prescott HC. Evolving Management Practices for Early Sepsis-induced Hypoperfusion: A Narrative Review. Am J Respir Crit Care Med 2023; 207:1283-1299. [PMID: 36812500 PMCID: PMC10595457 DOI: 10.1164/rccm.202209-1831ci] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/22/2023] [Indexed: 02/24/2023] Open
Abstract
Sepsis causes significant morbidity and mortality worldwide. Resuscitation is a cornerstone of management. This review covers five areas of evolving practice in the management of early sepsis-induced hypoperfusion: fluid resuscitation volume, timing of vasopressor initiation, resuscitation targets, route of vasopressor administration, and use of invasive blood pressure monitoring. For each topic, we review the seminal evidence, discuss the evolution of practice over time, and highlight questions for additional research. Intravenous fluids are a core component of early sepsis resuscitation. However, with growing concerns about the harms of fluid, practice is evolving toward smaller-volume resuscitation, which is often paired with earlier vasopressor initiation. Large trials of fluid-restrictive, vasopressor-early strategies are providing more information about the safety and potential benefit of these approaches. Lowering blood pressure targets is a means to prevent fluid overload and reduce exposure to vasopressors; mean arterial pressure targets of 60-65 mm Hg appear to be safe, at least in older patients. With the trend toward earlier vasopressor initiation, the need for central administration of vasopressors has been questioned, and peripheral vasopressor use is increasing, although it is not universally accepted. Similarly, although guidelines suggest the use of invasive blood pressure monitoring with arterial catheters in patients receiving vasopressors, blood pressure cuffs are less invasive and often sufficient. Overall, the management of early sepsis-induced hypoperfusion is evolving toward fluid-sparing and less-invasive strategies. However, many questions remain, and additional data are needed to further optimize our approach to resuscitation.
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Affiliation(s)
- Elizabeth S. Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom
- Department of Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul J. Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Fernando G. Zampieri
- Hospital do Coração (HCor) Research Institute, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; and
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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31
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Wahab A, Smith RJ, Lal A, Flurin L, Malinchoc M, Dong Y, Gajic O. CHARACTERISTICS AND PREDICTORS OF PATIENTS WITH SEPSIS WHO ARE CANDIDATES FOR MINIMALLY INVASIVE APPROACH OUTSIDE OF INTENSIVE CARE UNIT. Shock 2023; 59:702-707. [PMID: 36870069 PMCID: PMC10125105 DOI: 10.1097/shk.0000000000002112] [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] [Received: 12/23/2022] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
ABSTRACT Objective: To identify and describe characteristics of patients with sepsis who could be treated with minimally invasive sepsis (MIS) approach without intensive care unit (ICU) admission and to develop a prediction model to select candidates for MIS approach. Methods: A secondary analysis of the electronic database of patients with sepsis at Mayo Clinic, Rochester, MN. Candidates for the MIS approach were adults with septic shock and less than 48 hours of ICU stay, who did not require advanced respiratory support and were alive at hospital discharge. Comparison group consisted of septic shock patients with an ICU stay of more than 48 hours without advanced respiratory support at the time of ICU admission. Results: Of 1795 medical ICU admissions, 106 patients (6%) met MIS approach criteria. Predictive variables (age >65 years, oxygen flow >4 L/min, temperature <37°C, creatinine >1.6 mg/dL, lactate >3 mmol/L, white blood cells >15 × 10 9 /L, heart rate >100 beats/min, and respiration rate >25 breaths/min) selected through logistic regression were translated into an 8-point score. Model discrimination yielded the area under the receiver operating characteristic curve of 79% and was well fitted (Hosmer-Lemeshow P = 0.94) and calibrated. The MIS score cutoff of 3 resulted in a model odds ratio of 0.15 (95% confidence interval, 0.08-0.28) and a negative predictive value of 91% (95% confidence interval, 88.69-92.92). Conclusions: This study identifies a subset of low-risk septic shock patients who can potentially be managed outside the ICU. Once validated in an independent, prospective sample our prediction model can be used to identify candidates for MIS approach.
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Affiliation(s)
- Abdul Wahab
- Department of Hospital Medicine, Mayo Clinic Health System, Mankato, Minnesota
| | - Ryan J. Smith
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine. Mayo Clinic, Rochester, Minnesota
| | - Laure Flurin
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
- Department of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, France
| | | | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine. Mayo Clinic, Rochester, Minnesota
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32
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Coyer B, Carlucci M. Reducing Central Line Utilization by Peripherally Infusing Vasopressors. Dimens Crit Care Nurs 2023; 42:131-136. [PMID: 36996357 DOI: 10.1097/dcc.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Central line-associated bloodstream infection is a preventable contributor to excess death and excess cost in the health care system. Vasopressor infusion is one of the primary reasons for central line placement. In the medical intensive care unit (MICU) at an academic medical center, there was no standard practice for peripheral versus central infusion of vasopressors. OBJECTIVE The objective of this quality improvement project was to implement an evidence-based, nurse-driven protocol to guide the peripheral infusion of vasopressors. The goal was to reduce central line utilization by 10%. METHODS Education on the protocol was provided to the MICU nurses, MICU residents, and crisis nurses, followed by a 16-week implementation period. Nursing staff were also surveyed preimplementation and postimplementation of the protocol. RESULTS Central line utilization was reduced by 37.9%, and there were no central line-associated bloodstream infections recorded during project implementation. Most of the nursing staff indicated that use of the protocol increased their confidence in administering vasopressors without a central line. No significant extravasation events occurred. DISCUSSION Although a causal link between implementation of this protocol and reduction of central line utilization cannot be established, the reduction is clinically meaningful given the known risks of central lines. Increased nursing staff confidence also provides support for continued use of the protocol. CONCLUSION A nurse-driven protocol to guide the peripheral infusion of vasopressors can be effectively implemented into nursing practice.
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Stefanos SS, Kiser TH, MacLaren R, Mueller SW, Reynolds PM. Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy 2023; 43:321-337. [PMID: 36938775 DOI: 10.1002/phar.2794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 03/21/2023]
Abstract
Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.
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Affiliation(s)
- Sylvia S Stefanos
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, Colorado, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Department of Pharmacy, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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Abstract
Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.
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Affiliation(s)
- Theodore J. Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA,Theodore J. Cios, Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, 500 University Drive, H187, Hershey, PA 17033, USA.
| | - John C. Klick
- Department of Anesthesiology, The University of Vermont Medical Center, Burlington, VT, USA
| | - S. Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
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Teja B, Bosch NA, Walkey AJ. How We Escalate Vasopressor and Corticosteroid Therapy in Patients With Septic Shock. Chest 2023; 163:567-574. [PMID: 36162481 DOI: 10.1016/j.chest.2022.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022] Open
Abstract
Septic shock is defined by the need for vasopressor agents to correct hypotension and lactic acidosis resulting from infection, with 30%-40% case fatality rates. The care of patients with worsening septic shock involves multiple treatment decisions involving vasopressor choices and adjunctive treatments. In this edition of "How I Do It", we provide a case-based discussion of common clinical decisions regarding choice of first-line vasopressor, BP targets, route of vasopressor delivery, use of secondary vasopressors, and adjunctive medications. We also consider diagnostic approaches, treatment, and monitoring strategies for the patient with worsening shock, as well as approaches to difficult weaning of vasopressors.
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Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicholas A Bosch
- The Pulmonary Center, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA
| | - Allan J Walkey
- The Pulmonary Center, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA.
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Fandler M, Böhm L. [Peripheral Intravenous Infusion of Vasopressors - Guideline Summary]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:52-54. [PMID: 36623530 DOI: 10.1055/a-1994-4767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Herbosa GAB, Tho NN, Gapay AA, Lorsomradee S, Thang CQ. Consensus on the Southeast Asian management of hypotension using vasopressors and adjunct modalities during cesarean section under spinal anesthesia. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:56. [PMID: 37386598 DOI: 10.1186/s44158-022-00084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/08/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS This consensus statement presents a comprehensive and evidence-based set of guidelines that modify the general European or US guidelines for hypotension management with vasopressors during cesarean delivery. It is tailored to the Southeast Asian context in terms of local human and medical resources, health system capacity, and local values and preferences. METHODS AND RESULTS These guidelines were prepared using a methodological approach. Two principal sources were used to obtain the evidence: scientific evidence and opinion-based evidence. A team of five anesthesia experts from Vietnam, the Philippines, and Thailand came together to define relevant clinical questions; search for literature-based evidence using the MEDLINE, Scopus, Google Scholar, and Cochrane libraries; evaluate existing guidelines; and contextualize recommendations for the Southeast Asian region. Furthermore, a survey was developed and distributed among 183 practitioners in the captioned countries to gather representative opinions of the medical community and identify best practices for the management of hypotension with vasopressors during cesarean section under spinal anesthesia. CONCLUSIONS This consensus statement advocates proactive management of maternal hypotension during cesarean section after spinal anesthesia, which can be detrimental for both the mother and fetus, supports the choice of phenylephrine as a first-line vasopressor and offers a perspective on the use of prefilled syringes in the Southeast Asian region, where factors such as healthcare features, availability, patient safety, and cost should be considered.
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Affiliation(s)
- Grace Anne B Herbosa
- Department of Anesthesiology, University of the Philippines College of Medicine, Manila, Philippines.
| | - Nguyen Ngoc Tho
- Department of Anesthesiology and Intensive Care, Hanoi French Hospital, Hanoi, Vietnam
| | - Angelina A Gapay
- Department of Anesthesiology, Divine Word Hospital, Tacloban, Philippines
| | - Suraphong Lorsomradee
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University Hospital, Chang Mai, Thailand
| | - Cong Quyet Thang
- Vietnam Society of Anesthesiologists, Head of Department of Anesthesiology and SCIU at HuuNghi Hospital, Hanoi, Vietnam
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Kashiura M, Yasuda H, Oishi T, Kishihara Y, Moriya T, Kotani Y, Kondo N, Sekine K, Shime N, Morikane K. Risk factors for peripheral venous catheter-related phlebitis stratified by body mass index in critically ill patients: A post-hoc analysis of the AMOR-VENUS study. Front Med (Lausanne) 2022; 9:1037274. [DOI: 10.3389/fmed.2022.1037274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
IntroductionPhlebitis is an important complication in patients with peripheral intravascular catheters (PIVCs). Although an association between body mass index (BMI) and phlebitis has been suggested, the risk of phlebitis according to BMI has not been well elucidated. Therefore, in this study, we analyzed the risk of phlebitis according to BMI in patients in the intensive care unit (ICU).Materials and methodsThis study undertook a secondary analysis of the data from a prospective multicenter observational study assessing the epidemiology of phlebitis at 23 ICUs in Japan. Patients admitted into the ICU aged ≥18 years with a new PIVC inserted after ICU admission were consecutively enrolled and stratified into the following groups based on BMI: Underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25.0 kg/m2), and overweight/obese (BMI ≥ 25.0 kg/m2). The primary outcome was phlebitis. The risk factors for phlebitis in each BMI-based group were investigated using a marginal Cox regression model. In addition, hazard ratios and 95% confidence intervals were calculated.ResultsA total of 1,357 patients and 3,425 PIVCs were included in the analysis. The mean BMI for all included patients was 22.8 (standard deviation 4.3) kg/m2. Among the eligible PIVCs, 455; 2,041; and 929 were categorized as underweight, normal weight, and overweight/obese, respectively. In the underweight group, catheter size ≥ 18 G and amiodarone administration were independently associated with the incidence of phlebitis. Drug administration standardization was associated with the reduction of phlebitis. In the normal weight group, elective surgery as a reason for ICU admission, and nicardipine, noradrenaline, and levetiracetam administration were independently associated with the incidence of phlebitis. Heparin administration was associated with the reduction of phlebitis. In the overweight/obese group, the Charlson comorbidity index, catheter size ≥ 18 G, and levetiracetam administration were independently associated with the incidence of phlebitis. Catheters made from PEU-Vialon (polyetherurethane without leachable additives) and tetrafluoroethylene were associated with the reduction of phlebitis.ConclusionWe investigated the risk factors for peripheral phlebitis according to BMI in ICU and observed different risk factors in groups stratified by BMI. For example, in underweight or overweight patients, large size PIVCs could be avoided. Focusing on the various risk factors for phlebitis according to patients’ BMIs may aid the prevention of phlebitis.
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Macdonald S, Peake SL, Corfield AR, Delaney A. Fluids or vasopressors for the initial resuscitation of septic shock. Front Med (Lausanne) 2022; 9:1069782. [PMID: 36507525 PMCID: PMC9729725 DOI: 10.3389/fmed.2022.1069782] [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: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.
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Affiliation(s)
- Stephen Macdonald
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Sandra L. Peake
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Alasdair R. Corfield
- Consultant Emergency Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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Hunter S, Considine J, Manias E. The influence of intensive care unit culture and environment on nurse decision‐making when managing vasoactive medications: A qualitative exploratory study. J Clin Nurs 2022. [DOI: 10.1111/jocn.16561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Stephanie Hunter
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation Deakin University Geelong Victoria Australia
- Eastern Health Centre for Quality and Patient Safety Research – Eastern Health Partnership Box Hill Victoria Australia
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation Deakin University Geelong Victoria Australia
- Eastern Health Centre for Quality and Patient Safety Research – Eastern Health Partnership Box Hill Victoria Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation Deakin University Geelong Victoria Australia
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Yeong YQ, Chan JMF, Chan JKY, Huang HL, Ong GY. Safety and outcomes of short-term use of peripheral vasoactive infusions in critically ill paediatric population in the emergency department. Sci Rep 2022; 12:16340. [PMID: 36175581 PMCID: PMC9523065 DOI: 10.1038/s41598-022-20510-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
Early restoration of oxygen delivery to end organs in paediatric patients experiencing shock states is critical to optimizing outcomes. However, obtaining central access in paediatric patients may be challenging in non-intensive care settings. There is limited literature on the use of peripheral vasoactive infusions in the initial resuscitation of paediatric patients in the emergency department. The aims of this study were to report the associated complications of peripheral vasoactive infusions and describe our local experience on its use. This was a single-centre, retrospective study on all paediatric patients who received peripheral vasoactive infusions at our paediatric emergency department from 2009 to 2016. 65 patients were included in this study. No patients had any local or regional complications. The mean patient age was 8.29 years old (± 5.99). The most frequent diagnosis was septic shock (45, 69.2%). Dopamine was the most used peripheral vasoactive agent (71.2%). The median time to central agents was 2 h (IQR 1-4). 16(24.2%) received multiple peripheral infusions. We reported no complications of peripheral vasoactive infusions. Its use could serve as a bridge till central access is obtained. Considerations on the use of multiple peripheral vasoactive infusions in the emergency department setting needs further research.
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Affiliation(s)
- Y Q Yeong
- SingHealth Emergency Medicine Residency Program, Singapore Health Services, Singapore, Singapore.
| | - J M F Chan
- KK Women's and Children's Hospital, Singapore, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke-NUS Graduate Medical School, Singapore, 8 College Road, Singapore, 169857, Singapore
| | - J K Y Chan
- SingHealth Emergency Medicine Residency Program, Singapore Health Services, Singapore, Singapore
| | - H L Huang
- SingHealth Emergency Medicine Residency Program, Singapore Health Services, Singapore, Singapore
| | - G Y Ong
- KK Women's and Children's Hospital, Singapore, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke-NUS Graduate Medical School, Singapore, 8 College Road, Singapore, 169857, Singapore
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Fustiñana A, Yock-Corrales A, Casson N, Galvis L, Iramain R, Lago P, Da Silva APP, Paredes F, Zamarbide MP, Aprea V, Kohn-Loncarica G. Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America. Pediatr Emerg Care 2022; 38:e1496-e1502. [PMID: 35802481 DOI: 10.1097/pec.0000000000002801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.
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Nath SS, Nachimuthu N. Viewpoint: Weak Scientific Basis for the Recommendation of Executive Summary of Surviving Sepsis Campaign Guidelines 2021. Indian J Crit Care Med 2022; 26:898-899. [PMID: 36042756 PMCID: PMC9363812 DOI: 10.5005/jp-journals-10071-24277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Soumya Sankar Nath
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
- Soumya Sankar Nath, Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9648935430, e-mail:
| | - Nandhini Nachimuthu
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Block JM, Boateng A, Madhok J. Things We Do for No Reason TM : Mandatory central venous catheter placement for initiation of vasopressors. J Hosp Med 2022; 17:565-568. [PMID: 35820039 DOI: 10.1002/jhm.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jason M Block
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Adjoa Boateng
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jai Madhok
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
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Ablordeppey EA, Huang W, Holley I, Willman M, Griffey R, Theodoro DL. Clinical Practices in Central Venous Catheter Mechanical Adverse Events. J Intensive Care Med 2022; 37:1215-1222. [PMID: 35723623 DOI: 10.1177/08850666221076798] [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: 11/15/2022]
Abstract
Background: Over 5 million central venous catheters (CVCs) are placed annually. Pneumothorax and catheter malpositioning are common adverse events (AE) that requires attention. This study aims to evaluate local practices of mechanical complication frequency, type, and subsequent intervention(s) related to mechanical AE with an emphasis on catheter malpositioning. Methods: This is a retrospective review of CVC placements in a tertiary hospital setting from 1/2013 to 12/2013. Pneumothorax and CVC positioning were evaluated on post-insertion chest x-ray (CXR). Malposition was defined as unintended placement of the catheter in a vessel other than the intended superior vena cava on CXR. Catheter reposition was defined as radiographic evidence of a new catheter with removal of the old catheter less than 24hrs after initial placement. Data points analyzed included pneumothorax and thoracostomy rate, CVC malposition frequency, catheter reposition rate, catheter duration, and incidence of complications such as catheter associated venous thrombosis. Result: Among 2045 eligible CVC insertions, pneumothoraces occurred in 14 (0.7%; 95%CI 0.38, 1.17) and malpositions were identified in 275 (13.4%; 95% CI 12.3, 15.3). The proportion of pneumothoraces that required tube thoracostomy was 57%. The proportion of CVCs with malposition that were removed or replaced within 24h was 32.7%. "Malpositioned" catheters that were left in place by the clinical team (n = 185) had an average catheter duration of 8.2 days (95% CI 7.2, 9.3) versus 7.2 days (95% CI 6.17, 8.23) for catheters that were replaced after initial malposition (p = 0.14, t test). The incidence of venous thrombosis in repositioned "malpositioned" catheters was 7.8% versus 4.9% for "malpositioned" catheters that were left in place. Conclusions: Clinically significant catheter malposition and pneumothorax after CVC insertion are low. In this study, replaced and non-replaced "malpositioned" catheters had similar catheter duration and rates of complications, challenging the current dogma of CVC malposition practice.
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Affiliation(s)
- Enyo A Ablordeppey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wendy Huang
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ian Holley
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Willman
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard Griffey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel L Theodoro
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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First-line Vasopressor Use in Septic Shock and Route of Administration: An Epidemiologic Study. Ann Am Thorac Soc 2022; 19:1713-1721. [PMID: 35709214 DOI: 10.1513/annalsats.202203-222oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Norepinephrine is a first-line agent for treatment of hypotension in septic shock. However, its frequency of use, and potential barriers to its use are unclear. OBJECTIVES To evaluate the frequency of use of norepinephrine in septic shock, to identify potential barriers to its use, and to evaluate trends in use of vasopressors over time. METHODS Retrospective population-based cohort study of patients with septic shock in Alberta, Canada between July 1, 2012 and December 31, 2018. The primary outcome was receipt of a first-line vasopressor other than norepinephrine ("non-norepinephrine vasopressor"). Predictors of receiving a non-norepinephrine vasopressor were assessed using a multivariable-adjusted, multilevel logistic regression model with intensive care unit (ICU) as a random effect. RESULTS Among 6343 patients with septic shock, the proportion of patients receiving non-norepinephrine vasopressors as first-line treatment decreased steadily from 11.5% in 2012 to 3.0% in 2018. Two factors most strongly associated with their receipt were having peripheral intravenous access only (adjusted odds ratio (aOR) 6.15, 95% confidence interval (CI) 4.58-8.26, p<0.001) and year of admission (aOR 0.74 per year after 2012, 95% CI 0.69-0.80, p<0.001). Other factors that had associations after adjustment included admission to a non-teaching hospital (aOR 2.19, 95% CI 1.23-3.89, p=0.007), admission to a coronary care unit (aOR 2.56, 95% CI 1.001-6.54, p=0.05), SOFA score (aOR 0.92 per unit increase, 95% CI 0.88-0.96, p<0.001) and heart rate (aOR 0.92 per 10 beat per minute increase, 95% CI 0.87-0.97, p=0.002). CONCLUSIONS In a large cohort of patients in Alberta, Canada, we found a steady decrease in use of first-line vasopressors other than norepinephrine in septic shock. The strongest factor associated with their use was the presence of only peripheral venous access, suggesting this may still be considered a barrier to administration of norepinephrine.
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Marques CG, Mwemerashyaka L, Martin K, Tang O, Uwamahoro C, Ndebwanimana V, Uwamahoro D, Moretti K, Sharma V, Naganathan S, Jing L, Garbern SC, Nkeshimana M, Levine AC, Aluisio AR. Utilisation of peripheral vasopressor medications and extravasation events among critically ill patients in Rwanda: A prospective cohort study. Afr J Emerg Med 2022; 12:154-159. [PMID: 35505668 PMCID: PMC9046616 DOI: 10.1016/j.afjem.2022.03.006] [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] [Received: 10/01/2021] [Revised: 02/14/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction In high-income settings, vasopressor administration to treat haemodynamic instability through a central venous catheter (CVC) is the preferred standard. However, due to lack of availability and potential for complications, CVCs are not widely used in low- and middle-income countries. This prospective cohort study evaluated the use of peripheral vasopressors and associated incidence of extravasation events in patients with haemodynamic instability at the Centre Hospitalier Universitaire Kigali, Rwanda. Methods Patients ≥18 years of age receiving peripheral vasopressors in the emergency centre (EC) or intensive care unit (ICU) for >1 hour were eligible for inclusion. The primary outcome was extravasation events. Patients were followed hourly until extravasation, medication discontinuation, death, or CVC placement. Extravasation incidence with 95% confidence intervals (CI) were calculated using Poisson exact tests. Results 64 patients were analysed. The median age was 49 (Interquartile Range [IQR]:33-65) and 55% were female. Distributive shock was the most frequent aetiology (47%). Intravenous (IV) location was most commonly antecubital fossa/upper arm (31%) and forearm/hand (43%). IV gauges ≤18 were used in 58% of locations. Most patients were treated with adrenaline (66%) and noradrenaline (41%), and 11% received multiple vasopressors. The median treatment duration was 19 hours (IQR:8.5-37). Treatment discontinuation was predominantly due to mortality (41%) or resolution of instability (36%). There were two extravasation events (2.9%), both limited to soft tissue swelling. Extravasation incidence was 0.8 events per 1000 patient-hours (95% CI:0.2-2.2). Conclusion Extravasation incidence with peripheral vasopressors was low, even with long use durations, suggesting peripheral infusions may be an acceptable approach when barriers exist to CVC placement.
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Affiliation(s)
- Catalina G. Marques
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA USA
- Corresponding author.
| | - Lucien Mwemerashyaka
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Kyle Martin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
| | - Oliver Tang
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Chantal Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Vincent Ndebwanimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Doris Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Katelyn Moretti
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Vinay Sharma
- Michigan State University College of Human Medicine, East Lansing, Michigan USA
| | - Sonya Naganathan
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Ling Jing
- Case Western Reserve University School of Medicine, Cleveland, Ohio USA
| | - Stephanie C. Garbern
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Menelas Nkeshimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Adam C. Levine
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
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Hospital Policies on Intravenous Vasopressor Administration and Monitoring: A Survey of Michigan Hospitals. Ann Am Thorac Soc 2022; 19:1769-1772. [PMID: 35608405 DOI: 10.1513/annalsats.202203-197rl] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Marti K, Hartley C, Sweeney E, Mah J, Pugliese N. Evaluation of the safety of a novel peripheral vasopressor pilot program and the impact on central line placement in medical and surgical intensive care units. Am J Health Syst Pharm 2022; 79:S79-S85. [PMID: 35605137 PMCID: PMC9384090 DOI: 10.1093/ajhp/zxac144] [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: 12/02/2022] Open
Abstract
Purpose The purpose of this quality improvement project was to evaluate the safety and feasibility of peripheral vasopressor administration in an attempt to minimize the placement and improve early removal of unnecessary central lines to reduce central line–associated bloodstream infection (CLABSI) rates. Methods A retrospective chart review was conducted on patients who received vasopressors via peripheral infusion over 3 months, starting at the time of guideline implementation. Results We identified 129 vasopressor orders among 79 patients that were administered peripherally. Among these orders, 3 events were documented as possible extravasation events. Forty-five patients (57%) did not require central line placement due to increasing vasopressor requirements. Standard utilization ratio data suggest minimal central line impact of the protocol implementation. December 2020 to February 2021 was associated with a large second peak of coronavirus disease 2019 (COVID-19) in our region. Utilization of central lines was less than predicted in December 2020 to February 2021 in 2 of our 3 intensive care units (ICUs); however, the differences were statistically significant on only 3 occasions. In the third ICU, utilization was greater than predicted, but this unit housed a majority of the most critically ill patients with COVID-19. Conclusion This study suggests that short-term use of select vasopressors at conservative doses is safe for peripheral administration and points toward efficacy at preventing central line placement. Further analysis is required to confirm efficacy.
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Affiliation(s)
- Kristen Marti
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA
| | | | - Elizabeth Sweeney
- Department of Surgical Critical Care, Hartford Hospital, Hartford, CT, USA
| | - John Mah
- Department of Surgical Critical Care, Hartford Hospital, Hartford, CT.,University of Connecticut School of Medicine, Farmington, CT, USA
| | - Nicholas Pugliese
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT.,University of Connecticut School of Pharmacy, Storrs, CT, USA
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Abstract
The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion leading to end organ dysfunction. Septic shock is characterized by hypotension requiring vasopressors after adequate fluid resuscitation with elevated lactate. Early recognition and intervention remain hallmarks for sepsis management. We addressed the current literature and assimilated thought regarding optimum initial resuscitation of the patient with sepsis. A nuanced understanding of the physiology of lactate is provided in our review. Physiologic and practical knowledge of steroid and vasopressor therapy for sepsis is crucial and addressed. As blood purification may interest the nephrologist treating sepsis, we have also added a brief discussion of its status.
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Affiliation(s)
- Sharad Patel
- Department of Critical Care, Rowan University Cooper Medical School, Camden, New Jersey
| | - Nitin Puri
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
| | - R Phillip Dellinger
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
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