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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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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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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [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: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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Hassan E, Mathew B, Poehler J, Kopischke K, Zoesch G, Attallah N, Jama AB, Jain NK, Gomez Urena EO, Khan SA. Quality Improvement Initiative in a Community Hospital to Reduce Central Line Device Utilization Rate. Cureus 2023; 15:e41037. [PMID: 37519512 PMCID: PMC10373900 DOI: 10.7759/cureus.41037] [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] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Background The intensive care unit (ICU) in a community hospital in southwest Minnesota saw a steady increase in central line-associated bloodstream infections (CLABSI) and an increase in the utilization of central lines. The baseline CLABSI rate was 11.36 at the start of the project, which was the highest in the last five years. The corresponding device utilization rate (DUR) was 64%, which increased from a pre-COVID pandemic rate of 45%. Aim The aim of this project was to decrease the ICU DUR by 37.5% from a baseline of 64% to 40% within six months without adversely impacting staff satisfaction. Methods A multidisciplinary team using the define, measure, analyze, improve, and control (DMAIC) methodology reviewed the potential causes of the increased use of central lines in the ICU. The team identified the following major causal themes: process, communication, education, and closed-loop feedback. Once the root causes were determined, suitable countermeasures were identified and implemented to address these barriers. These included reviewing current guidelines, enhanced care team rounding, staff education, and the creation of a vascular access indication algorithm. The team met biweekly to study the current state, determine the future state, evaluate feedback, and guide implementation. Results The pandemic saw a surge in the number of severely ill patients in the ICU, which may have caused an increase in the DUR. The project heightened the awareness of the increased DUR and its impact on the CLABSI rate. The initiation of discussion around this project led to an immediate decline in DUR via increased awareness and focus. As interventions were introduced and implemented, the DUR continued to decrease at a steady rate. Post implementation, the DUR met the project goal of less than 40%. The team continued to track progress and monitor feedback. The DUR continued to meet the goal for three months post implementation. Since the start of the project, there have been no CLABSI events reported. This effort has positively impacted safety and patient outcomes. Conclusions Through a defined process, the central line utilization rate in our ICU was decreased to 37.5% to meet the target goal and has been sustained.
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Affiliation(s)
- Esraa Hassan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
| | - Bijoy Mathew
- Strategy Consulting Services, Mayo Clinic, Rochester, USA
| | - Jessica Poehler
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
| | | | - Greta Zoesch
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
| | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
| | - Nitesh K Jain
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
| | | | - Syed Anjum Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
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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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Butler K, Winters M. The Physiologically Difficult Intubation. Emerg Med Clin North Am 2022; 40:615-627. [DOI: 10.1016/j.emc.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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