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Mendez SR, Frank RC, Stevenson EK, Chung M, Silverman MG. Dihydropyridine Calcium Channel Blockers and the Risk of Severe COVID-19. Chest 2021; 160:89-93. [PMID: 33548220 PMCID: PMC7857077 DOI: 10.1016/j.chest.2021.01.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/15/2021] [Accepted: 01/30/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sean R Mendez
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Rachel C Frank
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Elizabeth K Stevenson
- Division of Pulmonary, Critical Care, and Sleep Medicine, North Shore Medical Center, Salem, MA
| | - Mabel Chung
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA; Heart Center Intensive Care Unit, Massachusetts General Hospital, Boston, MA; Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael G Silverman
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA; Heart Center Intensive Care Unit, Massachusetts General Hospital, Boston, MA.
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Wilcox SR, Richards JB, Stevenson EK. Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making. J Emerg Med 2020; 58:11-17. [PMID: 31708311 DOI: 10.1016/j.jemermed.2019.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care. OBJECTIVES The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts. METHODS We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents. RESULTS Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001). CONCLUSIONS In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.
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Wardi G, Joel I, Villar J, Lava M, Gross E, Tolia V, Seethala RR, Owens RL, Sell RE, Montesi SB, Rahaghi FN, Bose S, Rai A, Stevenson EK, McSparron J, Tolia V, Beitler JR. Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure: Results of a Multicenter Clinician Survey. J Intensive Care Med 2019; 35:1338-1345. [PMID: 31446829 DOI: 10.1177/0885066619871247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. METHODS We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. RESULTS A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P < .01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. CONCLUSIONS Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.
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Affiliation(s)
- Gabriel Wardi
- Department of Emergency Medicine, 8784University of California, San Diego, CA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, 8784University of California, San Diego, CA, USA
| | - Ian Joel
- Division of Pulmonary, Critical Care, and Sleep Medicine, 8784University of California, San Diego, CA, USA
| | - Julian Villar
- Department of Emergency Medicine, Kaiser Oakland, CA, USA
| | - Michael Lava
- 194441Wellstar Medical Group Pulmonary Medicine, Marietta, GA, USA
| | - Eric Gross
- Department of Emergency Medicine, 8784University of California, Davis, CA, USA
| | - Vaishal Tolia
- Department of Emergency Medicine, 8784University of California, San Diego, CA, USA
| | - Raghu R Seethala
- Department of Emergency Medicine, 1861Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care, and Sleep Medicine, 8784University of California, San Diego, CA, USA
| | - Rebecca E Sell
- Division of Pulmonary, Critical Care, and Sleep Medicine, 8784University of California, San Diego, CA, USA
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care Medicine, 1861Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Somnath Bose
- Department of Anesthesia, Critical Care, and Pain Medicine, 1859Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ashish Rai
- Department of Pulmonary, Critical Care, and Sleep Medicine, 25218North Shore Medical Center, MA, USA
| | - Elizabeth K Stevenson
- Department of Pulmonary, Critical Care, and Sleep Medicine, 25218North Shore Medical Center, MA, USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care Medicine, 1259University of Michigan, Ann Arbor, MI, USA
| | - Vaishal Tolia
- Department of Emergency Medicine, 8784University of California, San Diego, CA, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, 5798Columbia University, New York, NY
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Abstract
OBJECTIVES Trends in severe sepsis mortality derived from administrative data may be biased by changing International Classification of Diseases, 9th Revision, Clinical Modification, coding practices. We sought to determine temporal trends in severe sepsis mortality using clinical trial data that does not rely on International Classification of Diseases, 9th Revision, Clinical Modifications coding and compare mortality trends in trial data with those observed from administrative data. DESIGN We searched MEDLINE for multicenter randomized trials that enrolled patients with severe sepsis from 1991 to 2009. We calculated standardized mortality ratios for each trial from observed 28-day mortality of usual care participants and predicted mortality from severity-of-illness scores. To compare mortality trends from clinical trials to administrative data, we identified adult severe sepsis hospitalizations in the Nationwide Inpatient Sample, 1993-2009, using two previously validated algorithms. SETTING In-patient. PATIENTS Patients with severe sepsis or septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 3,244 potentially eligible articles, we included 36 multicenter severe sepsis trials, with a total of 14,418 participants in a usual care arm. Participants with severe sepsis receiving usual care had a 28-day mortality of 33.2%. Observed mortality decreased 3.0% annually (95% CI, 0.8%-5.0%; p = 0.009), decreasing from 46.9% (standardized mortality ratio 0.94; 95% CI, 0.86-1.03) during years 1991-1995 to 29% (standardized mortality ratio 0.53; 95% CI, 0.50-0.57) during years 2006-2009 (3.0% annual change). Trends in hospital mortality among patients with severe sepsis identified from administrative data (Angus definition, 4.7% annual change; 95% CI, 4.1%-5.3%; p = 0.69 and Martin definition, 3.5% annual change; 95% CI, 3.0%-4.1%; p = 0.97) were similar to trends identified from clinical trials. CONCLUSION Since 1991, patients with severe sepsis enrolled in usual care arms of multicenter randomized trials have experienced decreasing mortality. The mortality trends identified in clinical trial participants appear similar to those identified using administrative data and support the use of administrative data to monitor mortality trends in patients with severe sepsis.
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Affiliation(s)
- Elizabeth K Stevenson
- 1The Pulmonary Center, Boston University School of Medicine, Boston, MA. 2Division of Pulmonary, Allergy, and Critical Care Medicine Internal Medicine, Boston Medical Center, Boston, MA. 3Department of Medicine, Boston Medical Center, Boston, MA. 4Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA. 5The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
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