Functional recovery in a cohort of ECMO and non-ECMO acute respiratory distress syndrome survivors

BACKGROUND

The mortality benefit of VV-ECMO in ARDS has been extensively studied, but the impact on long-term functional outcomes of survivors is poorly defined. We aimed to assess the association between ECMO and functional outcomes in a contemporaneous cohort of survivors of ARDS.

METHODS

Multicenter retrospective cohort study of ARDS survivors who presented to follow-up clinic. The primary outcome was FVC% predicted. Univariate and multivariate regression models were used to evaluate the impact of ECMO on the primary outcome.

RESULTS

This study enrolled 110 survivors of ARDS, 34 of whom were managed using ECMO. The ECMO cohort was younger (35 [28, 50] vs. 51 [44, 61] years old, p < 0.01), less likely to have COVID-19 (58% vs. 96%, p < 0.01), more severely ill based on the Sequential Organ Failure Assessment (SOFA) score (7 [5, 9] vs. 4 [3, 6], p < 0.01), dynamic lung compliance (15 mL/cmH20 [11, 20] vs. 27 mL/cmH20 [23, 35], p < 0.01), oxygenation index (26 [22, 33] vs. 9 [6, 11], p < 0.01), and their need for rescue modes of ventilation. ECMO patients had significantly longer lengths of hospitalization (46 [27, 62] vs. 16 [12, 31] days, p < 0.01) ICU stay (29 [19, 43] vs. 10 [5, 17] days, p < 0.01), and duration of mechanical ventilation (24 [14, 42] vs. 10 [7, 17] days, p < 0.01). Functional outcomes were similar in ECMO and non-ECMO patients. ECMO did not predict changes in lung function when adjusting for age, SOFA, COVID-19 status, or length of hospitalization.

CONCLUSIONS

There were no significant differences in the FVC% predicted, or other markers of pulmonary, neurocognitive, or psychiatric functional recovery outcomes, when comparing a contemporaneous clinic-based cohort of survivors of ARDS managed with ECMO to those without ECMO.

Systematic review and meta‐analysis of the correlation between bispectral index ( BIS ) and clinical sedation scales: Toward defining the role of BIS in critically ill patients

INTRODUCTION

The bispectral index (BIS) is an attractive approach for monitoring level of consciousness in critically ill patients, particularly during paralysis, when commonly used sedation scales cannot be used.

OBJECTIVES

As a first step toward establishing the utility of BIS during paralysis, this review examines the strength of correlation between BIS and clinical sedation scales in a broad population of non-paralyzed, critically ill adults.

METHODS

We included studies evaluating the strength of correlation between concurrent assessments of BIS and Richmond Agitation Sedation Scale (RASS), Ramsay Sedation Scale (RSS), or Sedation Agitation Scale (SAS) in critically ill adult patients. Studies involving assessment of depth sedation periperative or procedural time periods, and those reporting BIS and sedation scale assessments conducted >5 min apart or while neuromuscular blocking agents (NMBA) were administered, were excluded. Data were abstracted on sedation scale, correlation coefficients, setting, patient characteristics, and BIS assessment characteristics that could impact the quality of the studies.

RESULTS

Twenty-four studies which enrolled 1235 patients met inclusion criteria. The correlation between BIS and RASS, RSS, and SAS overall was 0.68 (95% confidence interval, 0.61-0.74, Ƭ²  = 0.06 I²  = 71.26%). Subgroup analysis by sedation scale indicated that the correlation between BIS and RASS, RSS, and SAS were 0.66 (95% confidence interval 0.58-0.73, Ƭ²  = 0.01 I²  = 30.20%), 0.76 (95% confidence interval 0.69-0.82, Ƭ²  = 0.04 I²  = 67.15%), and 0.53 (95% confidence interval 0.42-0.63, Ƭ²  = 0.01 I²  = 26.59%), respectively. Factors associated with significant heterogeneity included comparator clinical sedation scale, neurologic injury, and the type of intensive care unit (ICU) population.

CONCLUSIONS

BIS demonstrated moderate to strong correlation with clinical sedation scales in adult ICU patients, providing preliminary evidence for the validity of BIS as a measure of sedation intensity when clinical scales cannot be used. Future studies should determine whether BIS monitoring is safe and effective in improving outcomes in patients receiving NMBA treatment.

Medication Changes and Diagnosis of New Chronic Illnesses in COVID-19 Intensive Care Unit Survivors

Background

Currently, there is limited literature on the impact of the COVID-19 infection on medications and medical conditions in COVID-19 intensive care unit (ICU) survivors. Our study is, to our knowledge, the first multicenter study to describe the prevalence of new medical conditions and medication changes at hospital discharge in COVID-19 ICU survivors.

Objective

To determine the number of medical conditions and medications at hospital admission compared to at hospital discharge in COVID-19 ICU survivors.

Methods

Retrospective multicenter observational study (7 ICUs) evaluated new medical conditions and medication changes at hospital discharge in patients with COVID-19 infection admitted to an ICU between March 1, 2020, to March 1, 2021. Patient and hospital characteristics, baseline and hospital discharge medication and medical conditions, ICU and hospital length of stay, and Charlson comorbidity index were collected. Descriptive statistics were used to describe patient characteristics and number and type of medical conditions and medications. Paired t-test was used to compare number of medical conditions and medications from hospital discharge to admission.

Results

Of the 973 COVID-19 ICU survivors, 67.4% had at least one new medical condition and 88.2% had at least one medication change. Median number of medical conditions (increased from 3 to 4, P < .0001) and medications (increased from 5 to 8, P < .0001) increased from admission to discharge. Most common new medical conditions at discharge were pulmonary disorders, venous thromboembolism, psychiatric disorders, infection, and diabetes. Most common therapeutic categories associated with medication change were cardiology, gastroenterology, pain, hematology, and endocrinology.

Conclusion and Relevance

Our study found that the number of medical conditions and medications increased from hospital admission to discharge. Our results provide additional data to help guide providers on using targeted approaches to manage medications and diseases in COVID-19 ICU survivors after hospital discharge.

Optimizing ceftaroline dosing in critically ill patients undergoing continuous renal replacement therapy

BACKGROUND AND OBJECTIVES

Currently, no dosing information exists for ceftaroline fosamil in patients undergoing continuous renal replacement therapy (CRRT). The objectives of this study are to characterize the pharmacokinetics of ceftaroline in critically ill patients undergoing CRRT modalities and to derive individualized dosing recommendations.

METHODS

This pharmacokinetic study aimed to enroll critically ill patients receiving ceftaroline fosamil and any CRRT modality from adult intensive care units. Selection of the specific CRRT modality and dosing regimen was based on clinical discretion. Pre-filter, post-filter, and ultrafiltrate samples were obtained before the administration of the fourth dose, after the completion of the infusion, and up to five additional time points post-infusion. Plasma concentrations were measured using a validated ultra-high performance liquid chromatography assay. Individual pharmacokinetic parameters were calculated using non-compartmental analysis.

RESULTS

Four patients were enrolled to investigate the need for dosing adjustments. The average sieving coefficient for ceftaroline was 0.81 ± 0.1, indicating high filter efficiency. The average volume of distribution was 41.8 L (0.48 L/kg) and is within the previously reported range in patients with normal renal function. Non-renal clearance accounted for more than 50% of the total clearance observed in patients. The observed pharmacokinetic profiles suggest that the pharmacodynamic target for 2-log10  CFU reduction from baseline (%fT >1 mg/L of 50%) was met for each patient. Due to the impact of CRRT and non-renal clearance, dosing recommendations were derived for different ranges of effluent flow rates and adjusted body weights. For a patient with an adjusted body weight of 70 kg and receiving CRRT at an effluent flow rate of 3 L/h, a ceftaroline fosamil dosing regimen of 400 mg every 12 h is proposed.

CONCLUSION

Ceftaroline is cleared extensively in critically ill patients receiving CRRT and may impact pharmacodynamic target achievement. Dose adjustments should be based on the intensity of the CRRT regimen, patient weight, and the clinical status of the patient.

Continuation of Opioid Therapy at Transitions of Care in Critically Ill Patients

PURPOSE

Opioids are one of the high-risk medication classes that are administered to critically ill patients during their intensive care unit (ICU) stay. However, little attention has been given to inpatient opioid prescribing practices, especially in critically ill patients. The purpose of our study was to characterize opioid prescribing practices across 2 transitions of care during an inpatient hospital stay: medical ICU (MICU)/intermediate care unit (IMC) to floor and floor to hospital discharge and identify potential patient-specific factors that impact opioid continuation.

METHODS

This is a retrospective cohort study evaluating opioid-naive adult patients with new opioid therapy initiated in MICU/IMC at a tertiary care academic medical center from December 1, 2016, to November 30, 2017. Opioid continuation rate was assessed twice: transition 1 (MICU/IMC to floor) and transition 2 (floor to hospital discharge).

RESULTS

In total, 112 opioid-naive patients with initial opioid administration in the MICU/IMC were included. Opioid therapy was continued in 56.1% (37/66) at transition 1 and 56.8% of patients (21/37) at transition 2. Patients with opioids continued at transition 1 had a longer hospital length of stay compared to those not continued on opioids, 22 (interquartile range [IQR] 11-36) vs 8 (IQR 6-14; P = .0004). Among the patients continued on opioids at hospital discharge, intubation during hospital stay and cumulative opioid dosage were greater than those not continued on opioids (17 [80.9%] vs 7 [43.8%], P = .019; and 3482 mcg [IQR 1690-9530] vs 732.5 mcg [IQR 187.5-1360.9], P = .0018, respectively).

CONCLUSIONS

Opioid-naive patients receiving opioid therapy in the MICU/IMC had a continuation rate of >56% during transitions of care, including hospital discharge. Factors that contributed to the continuation of opioids at transitions of care included longer hospital length of stay, intubation, and cumulative hospital opioid dosage. These findings may help to provide health systems with guidance on targeted opioid stewardship programs.

Review of Emerging Pharmacotherapy for the Treatment of Coronavirus Disease 2019

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved into an emergent global pandemic. Coronavirus disease 2019 (COVID-19) can manifest on a spectrum of illness from mild disease to severe respiratory failure requiring intensive care unit admission. As the incidence continues to rise at a rapid pace, critical care teams are faced with challenging treatment decisions. There is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19. Urgent identification of potential treatment strategies is a priority. Therapies include novel agents available in clinical trials or through compassionate use, and other drugs, repurposed antiviral and immunomodulating therapies. Many have demonstrated in vitro or in vivo potential against other viruses that are similar to SARS-CoV-2. Critically ill patients with COVID-19 have additional considerations related to adjustments for organ impairment and renal replacement therapies, complex lists of concurrent medications, limitations with drug administration and compatibility, and unique toxicities that should be evaluated when utilizing these therapies. The purpose of this review is to summarize practical considerations for pharmacotherapy in patients with COVID-19, with the intent of serving as a resource for health care providers at the forefront of clinical care during this pandemic.

Comparison of Two Weight-Based Desmopressin Dosing Strategies for Spontaneous Bleeding

BACKGROUND

The pharmacokinetics and pharmacodynamics of desmopressin are appropriate for adjusted body weight-based dosing, particularly in obese patients.

OBJECTIVE

The objective of this study was to describe desmopressin dosing strategies, with emphasis on hemostatic outcomes among patients without preexisting bleeding disorders.

METHODS

This was a single-center, retrospective cohort study of patients who received intravenous weight-based desmopressin for a hemostatic indication. Demographics, comorbidities, treatment setting, indication, site of bleeding, and outcomes were collected from the medical record. Primary outcomes included need for procedural intervention to achieve hemostasis, transfusion requirement, and death. Association between desmopressin dose and outcome was evaluated using χ² or Fischer's exact tests and logistic and linear regression models. Multiple regression analysis was conducted to identify other predictors of outcome in the data set.

RESULTS

A total of 109 patients were included (n = 26, dose adjustment; n = 83, no dose adjustment). Baseline characteristics were well-matched between groups: mean (SD) age of 57.0 (13.5) years; mean (SD) Charlson Comorbidity Score of 6.5 (2.8); 37% were obese; 76% were critically ill; 81% were actively bleeding without differences in site of bleeding; and crude mortality was 39%. No differences in death, mean units of packed red blood cells transfused, or need for procedural hemostasis were observed between adjusted weight- and actual weight-based desmopressin dosing.

CONCLUSIONS

When used adjunctively to blood product transfusion in actively bleeding patients, use of adjusted body weight-based desmopressin did not negatively affect clinical outcomes. More data are needed to confirm this dosing strategy.

Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation

OBJECTIVE

To determine the rate of compliance to the 2006 and 2009 ADA DKA guidelines in the medical intensive care unit (MICU) at a large academic medical centre after the implementation of a computerised DKA order set and protocol.

METHODS

Retrospective chart review of adult patients with DKA admitted to the MICU. Results of pre-order set (PRE) were compared to those of data post-order set (POST). The primary outcome was a composite administration of intravenous fluid resuscitation in the first 24 h, insulin bolus and initial insulin infusion rate.

KEY FINDINGS

Twelve of 60 patients (20%) in the PRE group received treatment compliant with the 2006 guidelines versus 14 of 55 patients (25.5%) in the POST group (OR 1.22 95% CI 0.44 to 3.4, P = 0.51). Compliance to the 2009 guidelines was significantly higher in the POST group (31.7% versus 65.5%, OR 4.44 95% CI 1.8 to 10.92, P = 0.0004). Compliance for individual components was 26.7% versus 70.9% for fluid resuscitation (P = 0.0001), 55% versus 49.1% for insulin bolus (P = 0.58) and 60% versus 81.3% for initial insulin infusion rate (P = 0.014), respectively. Time to DKA resolution was decreased (P = 0.04), and hypoglycaemia was increased (P = 0.0022).

CONCLUSION

Implementation of a computerised DKA order set and protocol was associated with improved compliance to the 2009 ADA DKA guidelines, 24-h fluid resuscitation, initial insulin infusion rate, time to DKA resolution and appropriate transition to subcutaneous insulin. However, patients in the POST implementation group were more likely to exhibit hypoglycaemia. Future assessment is warranted.

Evaluation of the treatment of diabetic ketoacidosis in the medical intensive care unit

OBJECTIVE

To determine if treatment of DKA in a sample of adult medical intensive care unit (MICU) patients was consistent with the 2006 ADA Hyperglycemic Crises in Adult Patients with Diabetes Clinical Guidelines.

METHODS

Medical records were reviewed for all adult patients admitted to a MICU with a diagnosis of DKA between July 1, 2007 and June 30, 2010. The primary composite endpoint assessed fluid resuscitation (total mL/kg) at 24 hours, insulin bolus dose, and continuous insulin infusion (units/kg or units/kg/hour) to determine whether the 2006 ADA clinical guidelines for Hyperglycemic Crises in Adult Patients with Diabetes were followed. Secondary outcome measures were DKA resolution, ICU length of stay, frequency of rebound DKA within 48 hours, frequency of hypoglycemia, and time to transition to subcutaneous insulin.

RESULTS

A total of 60 patients met inclusion criteria. For patients treated in compliance with the clinical guidelines compared to those that were not, total volume IV fluid infused during the first 24 hours (4.88 ± 0.77 mL/kg/hour and 2.74 ± 1.08 mL/kg/hour), mean dose of the insulin bolus (0.13 ± 0.04 units/kg and 0.06 ± 0.06 units/kg) and initial rate of the insulin infusions (0.11 ± 0.02 units/kg/hour and 0.08 ± 0.03 units/kg/hour) were significantly different (p <0.001). Treatment of 12 patients (20%) followed the 2006 ADA clinical guidelines, and mean time to resolution of DKA and MICU length of stay trended toward a shorter duration in these patients.

CONCLUSION

Compliance with the 2006 ADA Hyperglycemic Crises in Adult Patients with Diabetes clinical guidelines was low for treatment of DKA in a sample of adult patients admitted to a MICU. Institutional guidelines for the management of diabetic ketoacidosis should be investigated as a strategy to improve compliance with national guidelines.