Renin-Angiotensin System Modulation With Synthetic Angiotensin (1-7) and Angiotensin II Type 1 Receptor-Biased Ligand in Adults With COVID-19: Two Randomized Clinical Trials

Importance

Preclinical models suggest dysregulation of the renin-angiotensin system (RAS) caused by SARS-CoV-2 infection may increase the relative activity of angiotensin II compared with angiotensin (1-7) and may be an important contributor to COVID-19 pathophysiology.

Objective

To evaluate the efficacy and safety of RAS modulation using 2 investigational RAS agents, TXA-127 (synthetic angiotensin [1-7]) and TRV-027 (an angiotensin II type 1 receptor-biased ligand), that are hypothesized to potentiate the action of angiotensin (1-7) and mitigate the action of the angiotensin II.

Design, Setting, and Participants

Two randomized clinical trials including adults hospitalized with acute COVID-19 and new-onset hypoxemia were conducted at 35 sites in the US between July 22, 2021, and April 20, 2022; last follow-up visit: July 26, 2022.

Interventions

A 0.5-mg/kg intravenous infusion of TXA-127 once daily for 5 days or placebo. A 12-mg/h continuous intravenous infusion of TRV-027 for 5 days or placebo.

Main Outcomes and Measures

The primary outcome was oxygen-free days, an ordinal outcome that classifies a patient's status at day 28 based on mortality and duration of supplemental oxygen use; an adjusted odds ratio (OR) greater than 1.0 indicated superiority of the RAS agent vs placebo. A key secondary outcome was 28-day all-cause mortality. Safety outcomes included allergic reaction, new kidney replacement therapy, and hypotension.

Results

Both trials met prespecified early stopping criteria for a low probability of efficacy. Of 343 patients in the TXA-127 trial (226 [65.9%] aged 31-64 years, 200 [58.3%] men, 225 [65.6%] White, and 274 [79.9%] not Hispanic), 170 received TXA-127 and 173 received placebo. Of 290 patients in the TRV-027 trial (199 [68.6%] aged 31-64 years, 168 [57.9%] men, 195 [67.2%] White, and 225 [77.6%] not Hispanic), 145 received TRV-027 and 145 received placebo. Compared with placebo, both TXA-127 (unadjusted mean difference, -2.3 [95% CrI, -4.8 to 0.2]; adjusted OR, 0.88 [95% CrI, 0.59 to 1.30]) and TRV-027 (unadjusted mean difference, -2.4 [95% CrI, -5.1 to 0.3]; adjusted OR, 0.74 [95% CrI, 0.48 to 1.13]) resulted in no difference in oxygen-free days. In the TXA-127 trial, 28-day all-cause mortality occurred in 22 of 163 patients (13.5%) in the TXA-127 group vs 22 of 166 patients (13.3%) in the placebo group (adjusted OR, 0.83 [95% CrI, 0.41 to 1.66]). In the TRV-027 trial, 28-day all-cause mortality occurred in 29 of 141 patients (20.6%) in the TRV-027 group vs 18 of 140 patients (12.9%) in the placebo group (adjusted OR, 1.52 [95% CrI, 0.75 to 3.08]). The frequency of the safety outcomes was similar with either TXA-127 or TRV-027 vs placebo.

Conclusions and Relevance

In adults with severe COVID-19, RAS modulation (TXA-127 or TRV-027) did not improve oxygen-free days vs placebo. These results do not support the hypotheses that pharmacological interventions that selectively block the angiotensin II type 1 receptor or increase angiotensin (1-7) improve outcomes for patients with severe COVID-19.

Trial Registration

ClinicalTrials.gov Identifier: NCT04924660.

Neutralizing COVID-19 Convalescent Plasma in Adults Hospitalized With COVID-19: A Blinded, Randomized, Placebo-Controlled Trial

BACKGROUND

Convalescent plasma has been one of the most common treatments for COVID-19, but most clinical trial data to date have not supported its efficacy.

RESEARCH QUESTION

Is rigorously selected COVID-19 convalescent plasma with neutralizing anti-SARS-CoV-2 antibodies an efficacious treatment for adults hospitalized with COVID-19?

STUDY DESIGN AND METHODS

This was a multicenter, blinded, placebo-controlled randomized clinical trial among adults hospitalized with SARS-CoV-2 infection and acute respiratory symptoms for < 14 days. Enrolled patients were randomly assigned to receive one unit of COVID-19 convalescent plasma (n = 487) or placebo (n = 473). The primary outcome was clinical status (disease severity) 14 days following study infusion measured with a seven-category ordinal scale ranging from discharged from the hospital with resumption of normal activities (lowest score) to death (highest score). The primary outcome was analyzed with a multivariable ordinal regression model, with an adjusted odds ratio (aOR) < 1.0 indicating more favorable outcomes with convalescent plasma than with placebo. In secondary analyses, trial participants were stratified according to the presence of endogenous anti-SARS-CoV-2 antibodies ("serostatus") at randomization. The trial included 13 secondary efficacy outcomes, including 28-day mortality.

RESULTS

Among 974 randomized patients, 960 were included in the primary analysis. Clinical status on the ordinal outcome scale at 14 days did not differ between the convalescent plasma and placebo groups in the overall population (aOR, 1.04; one-seventh support interval [1/7 SI], 0.82-1.33), in patients without endogenous antibodies (aOR, 1.15; 1/7 SI, 0.74-1.80), or in patients with endogenous antibodies (aOR, 0.96; 1/7 SI, 0.72-1.30). None of the 13 secondary efficacy outcomes were different between groups. At 28 days, 89 of 482 (18.5%) patients in the convalescent plasma group and 80 of 465 (17.2%) patients in the placebo group had died (aOR, 1.04; 1/7 SI, 0.69-1.58).

INTERPRETATION

Among adults hospitalized with COVID-19, including those seronegative for anti-SARS-CoV-2 antibodies, treatment with convalescent plasma did not improve clinical outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT04362176; URL: www.

CLINICALTRIALS

gov.

Oxygen-Free Days as an Outcome Measure in Clinical Trials of Therapies for COVID-19 and Other Causes of New-Onset Hypoxemia

Mortality historically has been the primary outcome of choice for acute and critical care clinical trials. However, undue reliance on mortality can limit the scope of trials that can be performed. Large sample sizes are usually needed for trials powered for a mortality outcome, and focusing solely on mortality fails to recognize the importance that reducing morbidity can have on patients' lives. The COVID-19 pandemic has highlighted the need for rapid, efficient trials to rigorously evaluate new therapies for hospitalized patients with acute lung injury. Oxygen-free days (OFDs) is a novel outcome for clinical trials that is a composite of mortality and duration of new supplemental oxygen use. It is designed to characterize recovery from acute lung injury in populations with a high prevalence of new hypoxemia and supplemental oxygen use. In these populations, OFDs captures two patient-centered consequences of acute lung injury: mortality and hypoxemic lung dysfunction. Power to detect differences in OFDs typically is greater than that for other clinical trial outcomes, such as mortality and ventilator-free days. OFDs is the primary outcome for the Fourth Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV-4) Host Tissue platform, which evaluates novel therapies targeting the host response to COVID-19 among adults hospitalized with COVID-19 and new hypoxemia. This article outlines the rationale for use of OFDs as an outcome for clinical trials, proposes a standardized method for defining and analyzing OFDs, and provides a framework for sample size calculations using the OFD outcome.

A non-invasive, automated diagnosis of Menière's disease using radiomics and machine learning on conventional magnetic resonance imaging: A multicentric, case-controlled feasibility study

Purpose

This study investigated the feasibility of a new image analysis technique (radiomics) on conventional MRI for the computer-aided diagnosis of Menière’s disease.

Materials and methods

A retrospective, multicentric diagnostic case–control study was performed. This study included 120 patients with unilateral or bilateral Menière’s disease and 140 controls from four centers in the Netherlands and Belgium. Multiple radiomic features were extracted from conventional MRI scans and used to train a machine learning-based, multi-layer perceptron classification model to distinguish patients with Menière’s disease from controls. The primary outcomes were accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the classification model.

Results

The classification accuracy of the machine learning model on the test set was 82%, with a sensitivity of 83%, and a specificity of 82%. The positive and negative predictive values were 71%, and 90%, respectively.

Conclusion

The multi-layer perceptron classification model yielded a precise, high-diagnostic performance in identifying patients with Menière’s disease based on radiomic features extracted from conventional T2-weighted MRI scans. In the future, radiomics might serve as a fast and noninvasive decision support system, next to clinical evaluation in the diagnosis of Menière’s disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11547-021-01425-w.

Passive Immunity Trial for Our Nation (PassITON): study protocol for a randomized placebo-control clinical trial evaluating COVID-19 convalescent plasma in hospitalized adults

BACKGROUND

Convalescent plasma is being used widely as a treatment for coronavirus disease 2019 (COVID-19). However, the clinical efficacy of COVID-19 convalescent plasma is unclear.

METHODS

The Passive Immunity Trial for Our Nation (PassITON) is a multicenter, placebo-controlled, blinded, randomized clinical trial being conducted in the USA to provide high-quality evidence on the efficacy of COVID-19 convalescent plasma as a treatment for adults hospitalized with symptomatic disease. Adults hospitalized with COVID-19 with respiratory symptoms for less than 14 days are eligible. Enrolled patients are randomized in a 1:1 ratio to 1 unit (200-399 mL) of COVID-19 convalescent plasma that has demonstrated neutralizing function using a SARS-CoV-2 chimeric virus neutralization assay. Study treatments are administered in a blinded fashion and patients are followed for 28 days. The primary outcome is clinical status 14 days after study treatment as measured on a 7-category ordinal scale assessing mortality, respiratory support, and return to normal activities of daily living. Key secondary outcomes include mortality and oxygen-free days. The trial is projected to enroll 1000 patients and is designed to detect an odds ratio ≤ 0.73 for the primary outcome.

DISCUSSION

This trial will provide the most robust data available to date on the efficacy of COVID-19 convalescent plasma for the treatment of adults hospitalized with acute moderate to severe COVID-19. These data will be useful to guide the treatment of COVID-19 patients in the current pandemic and for informing decisions about whether developing a standardized infrastructure for collecting and disseminating convalescent plasma to prepare for future viral pandemics is indicated.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04362176 . Registered on 24 April 2020.

Alcohol Use As a Risk Factor in Infections and Healing: A Clinician's Perspective

Physicians have recognized for more than a century that alcohol use is associated with infections and that alcoholics are especially at risk for pneumonia. Clear evidence now indicates that alcohol has a systemic effect on every organ. This review first presents a clinical case to describe a patient with immunity issues complicated by alcohol use-a setting familiar to many clinicians. This is followed by a description of the molecular mechanisms that explain the secondary immune deficiency produced by alcohol in the host, focusing mostly on the gut and lower respiratory mucosal immunity. The goal of this review is to increase awareness of the new mechanisms being investigated to understand how alcohol affects the human immune system and the development of new strategies to attenuate adverse outcomes in the affected population.

Relationship between alcohol use disorders, cortisol concentrations, and cytokine levels in patients with sepsis

INTRODUCTION

Patients with alcohol use disorders (AUD) are at increased risk of developing sepsis and have higher mortality. AUD are associated with higher cortisol and anti-inflammatory cytokine profile. Higher cortisol increases risk of death in septic patients. The relationship between AUD and cortisol in septic patients is unknown. We aimed to study this relationship and postulated that AUD would be associated with higher cortisol and anti-inflammatory cytokine profile.

METHODS

This was a prospective cohort study of 40 medical intensive care unit (ICU) patients admitted with sepsis. Cortisol, anti-inflammatory interleukin (IL) 10, and pro-inflammatory IL1β, IL6, tumor necrosis factor (TNF) α were measured.

RESULTS

Thirteen (32%) out of 40 patients had AUD. AUD patients had higher cortisol by univariate (39 microg/dl versus 24, P = 0.04) and multivariable analyses (44 microg/dl versus 23, P = 0.004). By univariate analyses, AUD patients had higher IL10 (198 picog/dl versus 47, P = 0.02) and IL6 (527 picog/ml versus 156, P = 0.048), but similar IL1β and TNFα. By multivariable analyses, AUD patients had higher IL10 (182 picog/dl versus 23, P = 0.049) but similar IL1β, IL6, and TNFα. AUD patients had lower IL1β/IL10 (univariate 0.01 versus 0.10, P = 0.04; multivariable 0.01 versus 0.03, P = 0.04), lower TNFα/IL10 (univariate 0.15 versus 0.52, P = 0.03; multivariable 0.11 versus 0.63, P = 0.01), but similar IL6/IL10.

CONCLUSIONS

AUD are common diagnoses among medical ICU patients with sepsis. Patients with AUD have higher cortisol concentrations and have differences in cytokine expression. Future studies should seek to determine if these differences may explain the higher severity of illness seen in patients with sepsis and AUD.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00615862.

Alcohol-use disorders in the critically ill patient

Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs. This review discusses the development and progression of critical illness in patients with AUDs. In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies. In particular, surgical patients with AUDs experience higher rates of postoperative hemorrhage, cardiac complications, sepsis, and need for repeat surgery. Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes. AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis. The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome. The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs. Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.

Predictors for daily interruption of sedation therapy by nurses: a prospective, multicenter study

PURPOSE

The aim of the study was to identify the nurse and patient-related factors predicting daily interruption of sedation (DIS) performance by nurses in the intensive care unit (ICU).

METHODS

Nurses, caring for a mechanically ventilated patient receiving 24 hours or more of a continuously infused sedative, were interviewed at the bedside to determine their willingness to perform DIS on this patient and to determine the influence of 20 nurse- and 47 patient-related factors on DIS completion.

RESULTS

The 57 (44%) of 130 of nurses willing to perform DIS had performed DIS at least once in the past (P < .0001) and were not targeting deep sedation (ie, Sedation Agitation Scale [SAS] ≤ 2 [P = .03]). The DIS performance was less likely with use of higher-dose continuous midazolam (P = .006), a fraction of inspired oxygen (Fio(2)) greater than 50% (P = .03), or positive end-expiratory pressure greater than 5 mm Hg (P = .006) and in patients either deeply sedated (SAS ≤ 2) (P = .05) or agitated (SAS ≥ 5) in the past 24 hours (P = .003). Prior DIS experience (odds ratio [OR], 2.54; P = .004), hours of sedation-related continuing education (OR, 1.13; P = .02), and a target of deep sedation (OR, 0.49; P = .02) were independent nurse-related factors for DIS performance. Nurse's willingness to conduct DIS ranged from 45% to 80% based on the interaction between patient sex, current Fio(2), and agitation in past 24 hours.

CONCLUSIONS

Educational strategies and institutional protocols focused on improving use of DIS need to consider the various nurse- and patient-related factors that affect DIS performance by nurses in the ICU.

Observational study of patient-ventilator asynchrony and relationship to sedation level

PURPOSE

Clinicians frequently administer sedation to facilitate mechanical ventilation. The purpose of this study was to examine the relationship between sedation level and patient-ventilator asynchrony.

MATERIALS AND METHODS

Airway pressure and airflow were recorded for 15 minutes. Patient-ventilator asynchrony was assessed by determining the number of breaths demonstrating ineffective triggering, double triggering, short cycling, and prolonged cycling. Ineffective triggering index (ITI) was calculated by dividing the number of ineffectively triggered breaths by the total number of breaths (triggered and ineffectively triggered). Sedation level was assessed by the following 3 methods: Richmond Agitation-Sedation Scale (RASS), awake (yes or no), and delirium (Confusion Assessment Method for the intensive care unit [CAM-ICU]).

RESULTS

Twenty medical ICU patients underwent 35 observations. Ineffective triggering was seen in 17 of 20 patients and was the most frequent asynchrony (88% of all asynchronous breaths), being observed in 9% +/- 12% of breaths. Deeper levels of sedation were associated with increasing ITI (awake, yes 2% vs no 11%; P < .05; CAM-ICU, coma [15%] vs delirium [5%] vs no delirium [2%]; P < .05; RASS, 0, 0% vs -5, 15%; P < .05). Diagnosis of chronic obstructive pulmonary disease, sedative type or dose, mechanical ventilation mode, and trigger method had no effect on ITI.

CONCLUSIONS

Asynchrony is common, and deeper sedation level is a predictor of ineffective triggering.

Drug withdrawal, cocaine and sedative use disorders increase the need for mechanical ventilation in medical patients

AIMS

Alcohol use disorders increase the need for mechanical ventilation (MV) in critically ill medical, surgical and trauma patients. Studies examining other drug use disorders (DUD) in trauma patients have not demonstrated heightened rates of intensive care unit (ICU) complications. Patients with asthma and concurrent cocaine or heroin use disorders have an increased need for MV. The objective of this study is to determine if the presence of DUD and drug withdrawal syndromes are associated with increased need for MV in medical patients.

DESIGN

Analysis of a national database.

SETTING

The Nationwide Inpatient Sample, the largest all-payer in-patient database was utilized for the years 2002-2004.

PARTICIPANTS

Adult patients with one of the six common diagnoses associated with medical ICU admission were included.

INTERVENTION

None.

MEASUREMENTS

Univariate analysis and multivariate logistic regression were performed to determine if DUD and drug withdrawal were associated independently with the use of MV.

FINDINGS

A total 1 218 875 patients fulfilled one of the six diagnoses; 22 827 (1.9%) had DUD, and 102 841 (8.4%) underwent MV. Independent of the medical diagnosis, DUD was associated with an increased risk for requiring MV by univariate analysis (relative risk = 1.50, P < 0.0001). By multivariate analyses, sedative and cocaine use disorders remained associated with increased need for MV. Independent of medical diagnosis and substance, drug withdrawal was associated with increased odds of MV by both univariate and multivariate analysis (odds ratio = 2.94, P < 0.0001).

CONCLUSIONS

DUD are associated with increased need for MV in medical patients. This study demonstrates the importance of screening all medical patients for DUD.

Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey

BACKGROUND

Although use of sedation protocols and daily sedation interruption (DSI) improve outcome, their current use and barriers affecting their use are unclear.

METHODS

We designed a multidisciplinary, Web-based survey to determine current use of sedation protocols and DSI and the perceived barriers to each, and administered it to members of the Society of Critical Care Medicine.

RESULTS

The 904 responders were physicians (60%), nurses (14%), or pharmacists (12%); 45% worked in a university hospital. Of 64% having a sedation protocol, 78% used it for >or=50% of ventilated patients. Reasons for lack of protocol use included no physician order (35%), lack of nursing support (11%), and a fear of oversedation (7%). Daily sedation interruption was used by only 40%. Barriers to DSI included lack of nursing acceptance (22%), concern about risk of patient-initiated device removal (19%), and inducement of either respiratory compromise (26%) or patient discomfort (13%). Clinicians who prefer propofol were more likely to use DSI than those who prefer benzodiazepines (55% vs 40, P < .0001).

CONCLUSIONS

Current intensive care unit sedation practices are heterogeneous, and the barriers preventing the use of both sedation protocols and DSI are numerous. These barriers should be addressed on an institutional basis to boost the use of these evidence-based practices.

Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients

Introduction

Daily interruption of sedation (DIS) and sedation algorithms (SAs) have been shown to decrease mechanical ventilation (MV) duration. We conducted a randomized study comparing these strategies.

Methods

Mechanically ventilated adults 18 years old or older in the medical intensive care unit (ICU) were randomly assigned to DIS or SA. Exclusion criteria were severe neurocognitive dysfunction, administration of neuromuscular blockers, and tracheostomy. Study endpoints were total MV duration and 28-day ventilator-free survival.

Results

The study was terminated prematurely after 74 patients were enrolled (DIS 36 and SA 38). The two groups had similar age, gender, racial distribution, Acute Physiology and Chronic Health Evaluation II score, and reason for MV. The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified. Interim analysis demonstrated a significant difference in primary endpoint, and study termination was recommended. The DIS group had longer total duration of MV (median 6.7 versus 3.9 days; P = 0.0003), slower improvement of Sequential Organ Failure Assessment over time (0.70 versus 0.23 units per day; P = 0.025), longer ICU length of stay (15 versus 8 days; P < 0.0001), and longer hospital length of stay (23 versus 12 days; P = 0.01).

Conclusion

In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS. Based on these results, DIS may not be appropriate in all mechanically ventilated patients.

Trial registration

ClinicalTrials.gov NCT00205517.

Alcohol use disorders increase the risk for mechanical ventilation in medical patients

BACKGROUND

Annually, more than 300,000 patients receive mechanical ventilation in an intensive care unit in the United States. The hospital mortality for ventilated patients may approach 50%, depending on the primary diagnosis. In trauma and surgical patients, a diagnosis of alcohol use disorder (AUD) is common and is associated with a prolonged duration of mechanical ventilation. The objective of this study is to determine whether the presence of AUD and the development of alcohol withdrawal are associated with an increased use and duration of mechanical ventilation in patients with medical disorders that commonly require intensive care unit admission.

METHODS

We performed a retrospective cohort study using the Nationwide Inpatient Sample, a large all-payer inpatient database representing approximately 1,000 hospitals. For the years 2002 to 2003, adult patients with 1 of the 6 most common diagnoses associated with medical intensive care unit admission were included in the study. Both univariate analysis and multivariable logistic regression were performed to determine whether AUD and alcohol withdrawal were independently associated with the use and duration of mechanical ventilation in these patients.

RESULTS

There were a total 785,602 patients who fulfilled 1 of the 6 diagnoses, 26,577 (3.4%) had AUD, 3,967 (0.5%) had alcohol withdrawal, and 65,071 (8.3%) underwent mechanical ventilation (53% <96 hours, 47%> or =96 hours). Independent of the medical diagnosis, AUD was associated with an increased risk of requiring mechanical ventilation (13.7 vs 8.1%, odds ratio=1.49, 95% confidence interval [1.414; 1.574], p<0.0001) but was not associated with a prolonged duration of mechanical ventilation. However, the presence of alcohol withdrawal was associated with a longer duration of mechanical ventilation (57 vs 47%> or =96 hours, odds ratio=1.48, 95% confidence interval [1.266; 1.724], p<0.0001).

CONCLUSIONS

In patients with medical diagnoses associated with intensive care unit admission, AUD increases the risk for mechanical ventilation while the development of alcohol withdrawal is associated with a longer duration of mechanical ventilation.

Prevalence and impact of alcohol and other drug use disorders on sedation and mechanical ventilation: a retrospective study

Background

Experience suggests that patients with alcohol and other drug use disorders (AOD) are commonly cared for in our intensive care units (ICU's) and require more sedation. We sought to determine the impact of AOD on sedation requirement and mechanical ventilation (MV) duration.

Methods

Retrospective review of randomly selected records of adult patients undergoing MV in the medical ICU. Diagnoses of AOD were identified using strict criteria in Diagnostic and Statistical Manual of Mental Disorders, and through review of medical records and toxicology results.

Results

Of the 70 MV patients reviewed, 27 had AOD (39%). Implicated substances were alcohol in 22 patients, cocaine in 5, heroin in 2, opioids in 2, marijuana in 2. There was no difference between AOD and non-AOD patients in age, race, or reason for MV, but patients with AOD were more likely to be male (21 versus 15, p < 0.0001) and had a lower mean Acute Physiology and Chronic Health Evaluation II (22 versus 26, p = 0.048). While AOD patients received more lorazepam equivalents (0.5 versus 0.2 mg/kg.day, p = 0.004), morphine equivalents (0.5 versus 0.1 mg/kg.day, p = 0.03) and longer duration of infusions (16 versus 10 hours/day. medication, p = 0.002), they had similar sedation levels (Richmond Agitation-Sedation Scale (RASS) -2 versus -2, p = 0.83), incidence of agitation (RASS ≥ 3: 3.0% versus 2.4% of observations, p = 0.33), and duration of MV (3.6 versus 3.9 days, p = 0.89) as those without AOD.

Conclusion

The prevalence of AOD among medical ICU patients undergoing MV is high. Patients with AOD receive higher doses of sedation than their non-AOD counterparts to achieve similar RASS scores but do not undergo longer duration of MV.

Administration of Sedatives and Level of Sedation: Comparative Evaluation via the Sedation-Agitation Scale and the Bispectral Index

• Objectives To compare levels of sedation in patients receiving continuous intravenous infusions of sedative/hypnotic or narcotic agents with levels in patients not receiving infusions and to compare subjective (Sedation-Agitation Scale) and objective (Bispectral Index) evaluations of sedation.

• Methods Patients receiving mechanical ventilation in a medical intensive care unit were evaluated prospectively. Level of sedation was assessed with the Sedation-Agitation Scale (range 1–7, unarousable to dangerous agitation) and the Bispectral Index (range 0–100, flat line to awake waveform) recorded before and after stimulation. Patients were classified as receiving continuous infusions if an infusion had been administered within 24 hours preceding assessment.

• Results Nineteen patients were evaluated on 80 occasions. Scores on the Sedation-Agitation Scale ranged from 1 to 5 (mean 2.6 and median 2) and correlated highly with values for the Bispectral Index (R2 = 0.48 before and 0.44 after stimulation, P &lt; .001). Patients receiving continuous infusions were more deeply sedated than were patients receiving boluses or no medication (mean [SD] scores, Sedation-Agitation Scale: 2.1 [1.2] vs 3.3 [1.0], P &lt; .001; Bispectral Index before stimulation: 63 [24] vs 86 [13], P &lt; .001). Patients receiving continuous infusions were more likely to have a score of 2 or less on the Sedation-Agitation Scale (32/44 vs 8/35, P &lt; .001).

• Conclusion Objective and subjective assessments of sedation are highly correlated. Use of continuous infusions is associated with deeper levels of sedation, and patients receiving continuous infusions are more likely to be oversedated. Sedation therapy should be guided by subjective or objective assessment.

Administration of sedatives and level of sedation: comparative evaluation via the Sedation-Agitation Scale and the Bispectral Index

OBJECTIVES

To compare levels of sedation in patients receiving continuous intravenous infusions of sedative/hypnotic or narcotic agents with levels in patients not receiving infusions and to compare subjective (Sedation-Agitation Scale) and objective (Bispectral Index) evaluations of sedation.

METHODS

Patients receiving mechanical ventilation in a medical intensive care unit were evaluated prospectively. Level of sedation was assessed with the Sedation-Agitation Scale (range 1-7, unarousable to dangerous agitation) and the Bispectral Index (range 0-100, flat line to awake waveform) recorded before and after stimulation. Patients were classified as receiving continuous infusions if an infusion had been administered within 24 hours preceding assessment.

RESULTS

Nineteen patients were evaluated on 80 occasions. Scores on the Sedation-Agitation Scale ranged from 1 to 5 (mean 2.6 and median 2) and correlated highly with values for the Bispectral Index (R2 = 0.48 before and 0.44 after stimulation, P < .001). Patients receiving continuous infusions were more deeply sedated than were patients receiving boluses or no medication (mean [SD] scores, Sedation-Agitation Scale: 2.1 [1.2] vs 3.3 [1.0], P < .001; Bispectral Index before stimulation: 63 [24] vs 86 [13], P < .001). Patients receiving continuous infusions were more likely to have a score of 2 or less on the Sedation-Agitation Scale (32/44 vs 8/35, P < .001).

CONCLUSION

Objective and subjective assessments of sedation are highly correlated. Use of continuous infusions is associated with deeper levels of sedation, and patients receiving continuous infusions are more likely to be oversedated. Sedation therapy should be guided by subjective or objective assessment.