Association of Race and Ethnicity with Sedation Management in Pediatric Intensive Care

Health Disparities in the Management and Outcomes of Critically Ill Children and Neonates: A Scoping Review

To date, health disparities in critically ill children have largely been studied within, not across, specific intensive care unit (ICU) settings, thus impeding collaboration which may help advance the care of critically ill children. The aim of this scoping review is to summarize the literature intentionally designed to examine health disparities, across 3 primary ICU settings (neonatal ICU, pediatric ICU, and cardiac ICU) in the United States. We included over 50 studies which describe health disparities across race and/or ethnicity, area-level indices, insurance status, socioeconomic position, language, and distance.

Understanding Disparities in the Pediatric ICU: A Scoping Review

BACKGROUND AND OBJECTIVES

Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized.

METHODS

Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables.

RESULTS

The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature.

CONCLUSIONS

Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.

Randomized controlled trial of remimazolam compared with placebo in Japanese patients undergoing upper gastrointestinal endoscopy: Phase III investigator-initiated clinical trial

OBJECTIVES

To assess the effectiveness of remimazolam against normal saline (placebo) as a sedative agent for endoscopy in a multicenter, randomized, double-blind, investigator-initiated phase III controlled trial.

METHODS

We included 48 Japanese patients undergoing upper gastrointestinal endoscopy. For the procedure, an initial remimazolam dose of 3 mg and additional doses of 1 mg were administered, as determined in the phase II clinical study. The primary study end-point was the successful sedation rate during gastrointestinal endoscopy, determined as a Modified Observer's Assessment of Alertness/Sedation score ≤4 before the start of endoscopy, the completion of gastrointestinal endoscopy, and two or fewer additional doses per 6 min.

RESULTS

The successful endoscopy sedation rates were 91.9% and 9.1% in the remimazolam and placebo groups, respectively (P < 0.01). The time from the end of endoscopy to arousal was 0.0 (0.0-0.0) min for both groups. The number of additional doses required to achieve sedation was lower in the remimazolam group than that in the placebo group (P < 0.01).

CONCLUSIONS

Remimazolam demonstrated a significantly higher sedation effect during upper gastrointestinal endoscopy in Japanese patients with safe and fast recovery compared with placebo.

Associations of Race With Sedation Depth Among Mechanically Ventilated Adults: A Retrospective Cohort Study

OBJECTIVES

To evaluate the association of race with proportion of time in deep sedation among mechanically ventilated adults.

DESIGN

Retrospective cohort study from October 2017 to December 2019.

SETTING

Five hospitals within a single health system.

PATIENTS

Adult patients who identified race as Black or White who were mechanically ventilated for greater than or equal to 24 hours in one of 12 medical, surgical, cardiovascular, cardiothoracic, or mixed ICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure was White compared with Black race. The primary outcome was the proportion of time in deep sedation during the first 48 hours of mechanical ventilation, defined as Richmond Agitation-Sedation Scale values of -3 to -5. For the primary analysis, we performed mixed-effects linear regression models including ICU as a random effect, and adjusting for age, sex, English as preferred language, body mass index, Elixhauser comorbidity index, Laboratory-based Acute Physiology Score, Version 2, ICU admission source, admission for a major surgical procedure, and the presence of septic shock. Of the 3337 included patients, 1242 (37%) identified as Black, 1367 (41%) were female, and 1002 (30%) were admitted to a medical ICU. Black patients spent 48% of the first 48 hours of mechanical ventilation in deep sedation, compared with 43% among White patients in unadjusted analysis. After risk adjustment, Black race was significantly associated with more time in early deep sedation (mean difference, 5%; 95% CI, 2-7%; p < 0.01).

CONCLUSIONS

There are disparities in sedation during the first 48 hours of mechanical ventilation between Black and White patients across a diverse set of ICUs. Future work is needed to determine the clinical significance of these findings, given the known poorer outcomes for patients who experience early deep sedation.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

School and Work Absences After Critical Care Hospitalization for Pediatric Acute Respiratory Failure: A Secondary Analysis of a Cluster Randomized Trial

IMPORTANCE

Patients who survive pediatric critical illness and their caregivers commonly experience physical, emotional, and cognitive sequelae. However, the rate and duration of school absence among patients and work absence among their caregivers are unknown.

OBJECTIVE

To determine the rates and duration of school absence among children who survived hospitalization with acute respiratory failure and work absence among their caregivers.

DESIGN, SETTING, AND PARTICIPANTS

The Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) cluster randomized trial included 2449 children from 31 sites to protocolized sedation (intervention) vs usual care (control) from June 6, 2009, to December 2, 2013. In total, 1360 children survived hospitalization and were selected for follow-up at 6 months after pediatric intensive care unit (PICU) discharge, which was completed from January 12, 2010, to April 13, 2015. This secondary analysis was conducted from July 1, 2020, to September 30, 2021.

EXPOSURES

PICU hospitalization for acute respiratory failure, including invasive mechanical ventilation.

MAIN OUTCOMES AND MEASURES

Postdischarge assessments with caregivers of eligible participants at 6 months after PICU discharge, including questions about school and work absence. Risk factors associated with longer absence from school and work were identified.

RESULTS

Postdischarge assessments were completed for 960 children who survived treatment for acute respiratory failure, of whom 443 (46.1%) were girls and 517 (53.9%) were boys; 509 of 957 (53.2%) were non-Hispanic White. Median age was 1.8 years (IQR, 0.4-7.9 years). In total, 399 children (41.6%) were enrolled in school, of whom 279 (69.9%) missed school after discharge. Median duration of postdischarge absence was 9.1 days (IQR, 0-27.9 days) among all children enrolled in school and 16.9 days (IQR, 7.9-43.9 days) among the 279 children with postdischarge absence. Among 960 primary caregivers, 506 (52.7%) were employed outside the home, of whom 277 (54.7%) missed work. Median duration of postdischarge work absence was 2 days (IQR, 0-10 days) among all employed primary caregivers, and 8 days (IQR, 4-20 days) among the 277 caregivers who missed work after discharge. The odds of postdischarge school absence and greater duration of absence increased for children 5 years or older (compared with 0-4 years, odds ratios [ORs] for 5-8 years, 3.20 [95% CI, 1.69-6.05] and 2.09 [95% CI, 1.30-3.37], respectively; ORs for 9-12 years, 2.49 [95% CI, 1.17-5.27] and 2.32 [95% CI, 1.30-4.14], respectively; and ORs for 13-18 years, 2.37 [95% CI, 1.20-4.66] and 1.89 [95% CI, 1.11-3.24], respectively) and those with a preexisting comorbidity (ORs, 1.90 [95% CI, 1.10-3.29] and 1.76 [95% CI, 1.14-2.69], respectively).

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a cluster randomized trial, 2 in 3 children hospitalized for acute respiratory failure missed school after discharge, for a median duration of nearly 2 weeks. In addition, more than half of primary caregivers missed work after discharge. The magnitude of school absenteeism suggests that children may be at increased risk for lower educational achievement, economic hardship, and poor health outcomes in adulthood.