2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia

RATIONALE

New evidence is available examining the use of corticosteroids in sepsis, acute respiratory distress syndrome (ARDS) and community-acquired pneumonia (CAP), warranting a focused update of the 2017 guideline on critical illness-related corticosteroid insufficiency.

OBJECTIVES

To develop evidence-based recommendations for use of corticosteroids in hospitalized adults and children with sepsis, ARDS, and CAP.

PANEL DESIGN

The 22-member panel included diverse representation from medicine, including adult and pediatric intensivists, pulmonologists, endocrinologists, nurses, pharmacists, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. We followed Society of Critical Care Medicine conflict of interest policies in all phases of the guideline development, including task force selection and voting.

METHODS

After development of five focused Population, Intervention, Control, and Outcomes (PICO) questions, we conducted systematic reviews to identify the best available evidence addressing each question. We evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach and formulated recommendations using the evidence-to-decision framework.

RESULTS

In response to the five PICOs, the panel issued four recommendations addressing the use of corticosteroids in patients with sepsis, ARDS, and CAP. These included a conditional recommendation to administer corticosteroids for patients with septic shock and critically ill patients with ARDS and a strong recommendation for use in hospitalized patients with severe CAP. The panel also recommended against high dose/short duration administration of corticosteroids for septic shock. In response to the final PICO regarding type of corticosteroid molecule in ARDS, the panel was unable to provide specific recommendations addressing corticosteroid molecule, dose, and duration of therapy, based on currently available evidence.

CONCLUSIONS

The panel provided updated recommendations based on current evidence to inform clinicians, patients, and other stakeholders on the use of corticosteroids for sepsis, ARDS, and CAP.

Adverse Effects Related to Corticosteroid Use in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis

OBJECTIVES

We postulate that corticosteroid-related side effects in critically ill patients are similar across sepsis, acute respiratory distress syndrome (ARDS), and community-acquired pneumonia (CAP). By pooling data across all trials that have examined corticosteroids in these three acute conditions, we aim to examine the side effects of corticosteroid use in critical illness.

DATA SOURCES

We performed a comprehensive search of MEDLINE, Embase, Centers for Disease Control and Prevention library of COVID research, CINAHL, and Cochrane center for trials.

STUDY SELECTION

We included randomized controlled trials (RCTs) that compared corticosteroids to no corticosteroids or placebo in patients with sepsis, ARDS, and CAP.

DATA EXTRACTION

We summarized data addressing the most described side effects of corticosteroid use in critical care: gastrointestinal bleeding, hyperglycemia, hypernatremia, superinfections/secondary infections, neuropsychiatric effects, and neuromuscular weakness.

DATA SYNTHESIS

We included 47 RCTs (n = 13,893 patients). Corticosteroids probably have no effect on gastrointestinal bleeding (relative risk [RR], 1.08; 95% CI, 0.87-1.34; absolute risk increase [ARI], 0.3%; moderate certainty) or secondary infections (RR, 0.97; 95% CI, 0.89-1.05; absolute risk reduction, 0.5%; moderate certainty) and may have no effect on neuromuscular weakness (RR, 1.22; 95% CI, 1.03-1.45; ARI, 1.4%; low certainty) or neuropsychiatric events (RR, 1.19; 95% CI, 0.82-1.74; ARI, 0.5%; low certainty). Conversely, they increase the risk of hyperglycemia (RR, 1.21; 95% CI, 1.11-1.31; ARI, 5.4%; high certainty) and probably increase the risk of hypernatremia (RR, 1.59; 95% CI, 1.29-1.96; ARI, 2.3%; moderate certainty).

CONCLUSIONS

In ARDS, sepsis, and CAP, corticosteroids are associated with hyperglycemia and probably with hypernatremia but likely have no effect on gastrointestinal bleeding or secondary infections. More data examining effects of corticosteroids, particularly on neuropsychiatric outcomes and neuromuscular weakness, would clarify the safety of this class of drugs in critical illness.

Corticosteroids in Sepsis and Septic Shock: A Systematic Review, Pairwise, and Dose-Response Meta-Analysis

OBJECTIVES

To perform a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in patients with sepsis.

DATA SOURCES

We searched PubMed, Embase, and the Cochrane Library, up to January 10, 2023.

STUDY SELECTION

We included randomized controlled trials (RCTs) comparing corticosteroids with placebo or standard care with sepsis.

DATA EXTRACTION

The critical outcomes of interest included mortality, shock reversal, length of stay in the ICU, and adverse events.

DATA ANALYSIS

We performed both a pairwise and dose-response meta-analysis to evaluate the effect of different corticosteroid doses on outcomes. We used Grading of Recommendations Assessment, Development and Evaluation to assess certainty in pooled estimates.

DATA SYNTHESIS

We included 45 RCTs involving 9563 patients. Corticosteroids probably reduce short-term mortality (risk ratio [RR], 0.93; 95% CI, 0.88-0.99; moderate certainty) and increase shock reversal at 7 days (RR, 1.24; 95% CI, 1.11-1.38; high certainty). Corticosteroids may have no important effect on duration of ICU stay (mean difference, -0.6 fewer days; 95% CI, 1.48 fewer to 0.27 more; low certainty); however, probably increase the risk of hyperglycemia (RR, 1.13; 95% CI, 1.08-1.18; moderate certainty) and hypernatremia (RR, 1.64; 95% CI, 1.32-2.03; moderate certainty) and may increase the risk of neuromuscular weakness (RR, 1.21; 95% CI, 1.01-1.45; low certainty). The dose-response analysis showed a reduction in mortality with corticosteroids with optimal dosing of approximately 260 mg/d of hydrocortisone (RR, 0.90; 95% CI, 0.83-0.98) or equivalent.

CONCLUSIONS

We found that corticosteroids may reduce mortality and increase shock reversal but they may also increase the risk of hyperglycemia, hypernatremia, and neuromuscular weakness. The dose-response analysis indicates optimal dosing is around 260 mg/d of hydrocortisone or equivalent.

Elevated brain natriuretic peptide in a patient with metastatic cancer without heart failure: A case study

ABSTRACT

Brain natriuretic peptide (BNP) is a well-established biomarker for heart failure (HF). However, its diagnostic utility can be limited in patients with comorbidities that independently elevate serum BNP levels, including chronic renal failure and sepsis. We describe a rare occurrence of significantly elevated serum BNP levels in a patient with metastatic urothelial cancer without HF or obvious signs of sepsis. The report highlights the need for considering alternative causes for increased serum BNP levels, especially in the presence of malignancy.

Flow-Sizing Critical Care Resources

OBJECTIVES

To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions.

DATA SOURCES

PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed.

STUDY SELECTION

Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected.

DATA EXTRACTION

The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to "flow-sizing" critical care services.

DATA SYNTHESIS

The approach of CCOs to "flow-sizing" critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of "flow-sizing" capability by a CCO within a healthcare organization are provided.

CONCLUSIONS

We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective "flow-sizing" of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to "flow-sizing" has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.

Sepsis and Adrenal Insufficiency

In sepsis, dysregulation of the hypothalamic-pituitary-adrenal axis, alterations in cortisol metabolism, and tissue resistance to glucocorticoids can all result in relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI). The symptoms and signs of CIRCI during sepsis are nonspecific, generally including decreased mental status, unexplained fever, or hypotension refractory to fluids, and the requirement of vasopressor therapy to maintain adequate blood pressure. While we have been aware of this syndrome for over a decade, it remains a poorly understood condition, challenging to diagnose, and associated with significantly diverging practices among clinicians, particularly regarding the optimal dosing and duration of corticosteroid therapy. The existing literature on corticosteroid use in patients with sepsis and septic shock is vast with dozens of randomized controlled trials conducted across the past 4 decades. These studies have universally demonstrated reduced duration of shock, though the effects of corticosteroids on mortality have been inconsistent, and their use has been associated with adverse effects including hyperglycemia, neuromuscular weakness, and an increased risk of infection. In this article, we aim to provide a thorough, evidence-based, and practical review of the current recommendations for the diagnosis and management of patients with sepsis who develop CIRCI, explore the controversies surrounding this topic, and highlight what lies on the horizon as new evidence continues to shape our practice.

Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU

RATIONALE

Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation.

OBJECTIVES

This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

PANEL DESIGN

The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline.

METHODS

We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements.

RESULTS

The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data.

CONCLUSIONS

The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.

Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis

INTRODUCTION

International guidelines provide heterogenous guidance on use of corticosteroids for community-acquired pneumonia (CAP).

METHODS

We performed a systematic review of randomized controlled trials examining corticosteroids in hospitalized adult patients with suspected or probable CAP. We performed a pairwise and dose-response meta-analysis using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed the certainty of the evidence using GRADE methodology and the credibility of subgroups using the ICEMAN tool.

RESULTS

We identified 18 eligible studies that included 4661 patients. Corticosteroids probably reduce mortality in more severe CAP (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) with possibly no effect in less severe CAP (RR 1.08 [95% CI 0.83 to 1.42]; low certainty). We found a non-linear dose-response relationship between corticosteroids and mortality, suggesting an optimal dose of approximately 6 mg of dexamethasone (or equivalent) for a duration of therapy of 7 days (RR 0.44 [95% 0.30 to 0.66]). Corticosteroids probably reduce the risk of requiring invasive mechanical ventilation (RR 0.56 [95% CI 0.42 to 74] and probably reduce intensive care unit (ICU) admission (RR 0.65 [95% CI 0.43 to 0.97]) (both moderate certainty). Corticosteroids may reduce the duration of hospitalization and ICU stay (both low certainty). Corticosteroids may increase the risk of hyperglycemia (RR 1.76 [95% CI 1.46 to 2.14]) (low certainty).

CONCLUSION

Moderate certainty evidence indicates that corticosteroids reduce mortality in patients with more severe CAP, the need for invasive mechanical ventilation, and ICU admission.

Feasibility Assessment of a Biomarker-Guided Kidney-Sparing Sepsis Bundle: The Limiting Acute Kidney Injury Progression In Sepsis Trial

OBJECTIVES

To determine the feasibility, safety, and efficacy of a biomarker-guided implementation of a kidney-sparing sepsis bundle (KSSB) of care in comparison with standard of care (SOC) on clinical outcomes in patients with sepsis.

DESIGN

Adaptive, multicenter, randomized clinical trial.

SETTING

Five University Hospitals in Europe and North America.

PATIENTS

Adult patients, admitted to the ICU with an indwelling urinary catheter and diagnosis of sepsis or septic shock, without acute kidney injury (acute kidney injury) stage 2 or 3 or chronic kidney disease.

INTERVENTIONS

A three-level KSSB based on Kidney Disease: Improving Global Outcomes (KDIGOs) recommendations guided by serial measurements of urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 used as a combined biomarker [TIMP2]•[IGFBP7].

MEASUREMENTS AND MAIN RESULTS

The trial was stopped for low enrollment related to the COVID-19 pandemic. Nineteen patients enrolled in five sites over 12 months were randomized to the SOC (n = 8, 42.0%) or intervention (n = 11, 58.0%). The primary outcome was feasibility, and key secondary outcomes were safety and efficacy. Adherence to protocol in patients assigned to the first two levels of KSSB was 15 of 19 (81.8%) and 19 of 19 (100%) but was 1 of 4 (25%) for level 3 KSSB. Serious adverse events were more frequent in the intervention arm (4/11, 36.4%) than in the control arm (1/8, 12.5%), but none were related to study interventions. The secondary efficacy outcome was a composite of death, dialysis, or progression of greater than or equal to 2 stages of acute kidney injury within 72 hours after enrollment and was reached by 3 of 8 (37.5%) patients in the control arm, and 0 of 11 (0%) patients in the intervention arm. In the control arm, two patients experienced progression of acute kidney injury, and one patient died.

CONCLUSIONS

Although the COVID-19 pandemic impeded recruitment, the actual implementation of a therapeutic strategy that deploys a KDIGO-based KSSB of care guided by risk stratification using urinary [TIMP2]•[IGFBP7] seems feasible and appears to be safe in patients with sepsis.

Gender, Race, and Ethnicity in Critical Care Fellowship Programs in the United States From 2016 to 2021

A diverse and inclusive critical care workforce is vital to the provision of culturally appropriate and effective care to critically ill patients of all backgrounds.

OBJECTIVES

The purpose of this study is to determine the trends in gender, race, and ethnicity of U.S. critical care fellowships over the past 6 years (2016-2021).

METHODS

Data on gender, race, and ethnicity of critical care fellows in five Accreditation Council on Graduate Medical Education-accredited training programs (internal medicine, pulmonary and critical care, anesthesiology, surgery, and pediatrics) from 2015 to 2016 to 2020-2021 were obtained from the joint reports of the American Medical Association (AMA) and Association of American Medical Colleges published annually in the Journal of the AMA.

RESULTS

From 2016 to 2021, the number of U.S. critical care fellows increased annually, up 23.8%, with the largest number of fellows in pulmonary critical care medicine (60.1%). The percentage of female critical care fellows slightly increased from 38.7% to 39.4% (p = 0.57). White fellows significantly decreased from 57.4% to 49.3% (p = 0.0001); similarly, Asian fellows significantly decreased from 30.8% to 27.5% (p = 0.004). The percentage of Black or African American fellows was not statistically significantly different (4.9% vs 4.4%; p = 0.44). The number of fellows who self-identified as multiracial significantly increased from 52 (1.9%) to 91 (2.7%) (p = 0.043). The percentage of fellows who identified as Hispanic was not significantly different (6.7% vs 7.5%; p = 0.23).

CONCLUSIONS

The percentage of women and racially and ethnically minoritized fellows (Black and Hispanic) remain underrepresented in critical care fellowship programs. Additional research is needed to better understand these demographic trends in our emerging critical care physician workforce and enhance diversity.

Steroids in the acutely ill: Evolving recommendations and practice

Critical illness-related corticosteroid insufficiency (CIRCI) is a state of systemic inflammation involving dysregulation of the hypothalamic-pituitary-adrenal axis, altered cortisol metabolism, and tissue resistance to corticosteroids. Many conditions may be associated with CIRCI, including sepsis, septic shock, acute respiratory distress syndrome, and severe community-acquired pneumonia. Recommendations and practice for diagnosing and treating this condition have evolved as information has emerged. Here, the author reviews the current thinking.

Analysis of Intent and Reason for Oncologic Therapy Administration in Cancer Patients Admitted to the Intensive Care Unit

PURPOSE

To investigate the intent of, and reason for, administration of oncologic therapies in the intensive care unit (ICU).

METHODS

Single center, retrospective, cohort study of patients with cancer who received oncologic therapies at a tertiary cancer center ICU between April 1, 2019 and March 31, 2020. Oncologic therapies included traditional cytotoxic chemotherapy, targeted therapy, immunotherapy, hormonal or biologic therapy directed at a malignancy and were characterized as initiation (initial administration) or continuation (part of an ongoing regimen).

RESULTS

84 unique patients (6.8% of total ICU admissions) received oncologic therapies in the ICU; 43 (51%) had hematologic malignancies and 41 (49%) had solid tumors. The intent of oncologic therapy was palliative in 63% and curative in 27%. Twenty-two (26%) patients received initiation and 62 (74%) received continuation oncologic therapies. The intent of oncologic therapy was significantly different by regimen type (initiation vs. continuation, p = <0.0001). Initiation therapy was more commonly prescribed with curative intent and continuation therapy was more commonly administered with palliative intent (p = <0.0001). Oncologic therapies were given in the ICU mainly for an oncologic emergency (56%) and because the patients happened to be in the ICU for a non-oncologic critical illness when their oncologic therapy was due (34.5%).

CONCLUSION

Our study provides intensivists with a better understanding of the context and intent of oncologic therapies and why these therapies are administered in the ICU.

Discharge prescribing of enteral opioids in opioid naïve patients following non-surgical intensive care: A retrospective cohort study

PURPOSE

To estimate the incidence of new prescription of enteral opioids on hospital discharge in opioid naïve, non-surgical, critically ill patients and evaluate the risk factors associated with such occurrence.

METHODS

Using hospital-wide and ICU databases, we retrospectively identified all patients (≥ 18 years old) who were admitted to the 20-bed adult ICU of Memorial Sloan Kettering Cancer Center (MSKCC) between July 1, 2015 and April 20, 2020. Patients' electronic medical records (EMR) were retrieved and patient demographics, peri-ICU admission data were captured and analyzed.

RESULTS

During the study period, a total of 3755 opioid naïve patients were admitted to the ICU and 848 patients met the inclusion criteria. Among these, 346 (40.8%) patients were discharged with a new opioid prescription. Age at ICU admission, preadmission use of benzodiazepine, and antidepressants, a diagnosis of sepsis, and use of mechanical ventilation, antidepressants or, opioid infusion for greater than 4 h during the ICU stay, hospital length of stay (LOS), and days between ICU discharge and hospital discharge were independently associated with increased odds of a new opioid prescription.

CONCLUSIONS

A significant proportion of opioid naïve non-surgical ICU survivors receive a new opioid prescription on hospital discharge.

Clinical Characteristics, Management, and Outcomes of Cancer Patients With Coronavirus Disease 2019 Admitted to the ICU

Adult patients with cancer have a greater likelihood of developing severe illness and death from coronavirus disease 2019 compared with patients without cancer. We sought to characterize the clinical characteristics and outcomes of cancer patients who tested positive for severe acute respiratory syndrome coronavirus 2 and were admitted to the ICU at the peak of the first wave of the pandemic in the United States.

DESIGN

A single-center retrospective cohort study.

SETTING

Two medical-surgical ICUs of a tertiary-care cancer center.

PATIENTS/SUBJECTS

All consecutive adult patients (≥ 18 yr) with current or past (< 2 yr) diagnosis of cancer who were admitted to the ICU with coronavirus disease 2019 between March 1, and June 30, 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, and laboratory data of 89 critically ill cancer patients were extracted from electronic medical records. Median age was 65 years (interquartile range, 57-70 yr), 66% were White, and 58% male. Approximately a third of patients had three or more comorbidities. Fifty-one patients (57%) had solid tumors, and 38 (42%) had hematologic malignancies. Sixty-one patients (69%) received cancer-directed therapy within the previous 90 days. Sixty patients (67%) required mechanical ventilation, 56% required prone positioning, 28% underwent tracheostomy, and 71% required vasopressors. Hospital mortality was 45% (40/89). Among those who required mechanical ventilation, mortality was 53% (32/60). Hospital mortality was significantly higher among patients with hematologic malignancies, higher severity of illness and organ failure scores, need for invasive mechanical ventilation and vasopressor therapy, lower hemoglobin and platelet count, and higher d-dimer levels at ICU admission. ICU and hospital length of stay were 10 and 26 days, respectively. At 9-month follow-up, the mortality rate was 54% (48/89).

CONCLUSIONS

We report the largest case series and intermediate-term follow-up of cancer patients with coronavirus disease 2019 who were admitted to the ICU. Hospital mortality was 45%. Intermediate-term outcome after hospital discharge was favorable.

Toxic 'Toxo' in the heart: Cardiac toxoplasmosis following a hematopoietic stem cell transplant- a case report

Toxoplasmosis is a rare but potentially severe complication after allogeneic hematopoietic cell transplantation. Toxoplasma gondii-associated cardiac involvement can cause myocarditis, pericarditis, arrhythmias, and congestive heart failure. Most cases with cardiac toxoplasmosis following BMT have been fatal and diagnosed at autopsy. We present an unfortunate case of sudden onset congestive heart failure symptoms and delayed post-transplant Toxoplasma PCR testing that ultimately led to the diagnosis of cardiac toxoplasmosis on autopsy in our patient.

Critically ill patients with severe immune checkpoint inhibitor related neurotoxicity: A multi-center case series

PURPOSE

Serious immune checkpoint inhibitor (ICI)-related neurotoxicity is rare. There is limited data on the specifics of care and outcomes of patients with severe neurological immune related adverse events (NirAEs) admitted to the Intensive Care Unit (ICU).

MATERIALS AND METHODS

Retrospective study of patients with severe NirAEs admitted to the ICU at 3 academic centers between January 2016 and December 2018. Clinical data collected included ICI exposure, type of NirAE (central [CNS] or peripheral nervous system [PNS) disorders), and patient outcomes including neurological recovery and mortality.

RESULTS

Seventeen patients developed severe NirAEs. Eight patients presented with PNS disorders; 6 with myasthenia gravis (MG), 1 had a combination of MG and polyneuropathy and 1 had Guillain-Barre syndrome. Nine patients had CNS disorders (6 seizures and 5 had concomitant encephalopathy. During ICU admission, 65% of patients required mechanical ventilation, 35% vasopressors, and 18% renal replacement therapy. The median ICU and hospital length of stay were 7 (2-36) and 18 (4-80) days, respectively. Hospital mortality was 29%. At hospital discharge, 18% of patients made a full neurologic recovery, 41% partial recovery, and 12% did not recover.

CONCLUSION

Severe NirAEs while uncommon, can be serious or even life-threatening if not diagnosed and treated early.

Corticosteroids in COVID-19 and non-COVID-19 ARDS: a systematic review and meta-analysis

Purpose

Corticosteroids are now recommended for patients with severe COVID-19 including those with COVID-related ARDS. This has generated renewed interest regarding whether corticosteroids should be used in non-COVID ARDS as well. The objective of this study was to summarize all RCTs examining the use of corticosteroids in ARDS.

Methods

The protocol of this study was pre-registered on PROSPERO (CRD42020200659). We searched online databases including MEDLINE, EMBASE, CDC library of COVID research, CINAHL, and COCHRANE. We included RCTs that compared the effect of corticosteroids to placebo or usual care in adult patients with ARDS, including patients with COVID-19. Three reviewers abstracted data independently and in duplicate using a pre-specified standardized form. We assessed individual study risk of bias using the revised Cochrane ROB-2 tool and rated certainty in outcomes using GRADE methodology. We pooled data using a random effects model. The main outcome for this review was 28-day-mortality.

Results

We included 18 RCTs enrolling 2826 patients. The use of corticosteroids probably reduced mortality in patients with ARDS of any etiology (2740 patients in 16 trials, RR 0.82, 95% CI 0.72–0.95, ARR 8.0%, 95% CI 2.2–12.5%, moderate certainty). Patients who received a longer course of corticosteroids (over 7 days) had higher rates of survival compared to a shorter course.

Conclusion

The use of corticosteroids probably reduces mortality in patients with ARDS. This effect was consistent between patients with COVID-19 and non-COVID-19 ARDS, corticosteroid types, and dosage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06394-2.

Oncologic immunomodulatory agents in patients with cancer and COVID-19

Corticosteroids, anti-CD20 agents, immunotherapies, and cytotoxic chemotherapy are commonly used in the treatment of patients with cancer. It is unclear how these agents affect patients with cancer who are infected with SARS-CoV-2. We retrospectively investigated associations between SARS-CoV-2-associated respiratory failure or death with receipt of the aforementioned medications and with pre-COVID-19 neutropenia. The study included all cancer patients diagnosed with SARS-CoV-2 at Memorial Sloan Kettering Cancer Center until June 2, 2020 (N = 820). We controlled for cancer-related characteristics known to predispose to worse COVID-19 as well as level of respiratory support during corticosteroid administration. Corticosteroid administration was associated with worse outcomes prior to use of supplemental oxygen; no statistically significant difference was observed in sicker cohorts. In patients with metastatic thoracic cancer, 9 of 25 (36%) and 10 of 31 (32%) had respiratory failure or death among those who did and did not receive immunotherapy, respectively. Seven of 23 (30%) and 52 of 187 (28%) patients with hematologic cancer had respiratory failure or death among those who did and did not receive anti-CD20 therapy, respectively. Chemotherapy itself was not associated with worse outcomes, but pre-COVID-19 neutropenia was associated with worse COVID-19 course. Relative prevalence of chemotherapy-associated neutropenia in previous studies may account for different conclusions regarding the risks of chemotherapy in patients with COVID-19. In the absence of prospective studies and evidence-based guidelines, our data may aid providers looking to assess the risks and benefits of these agents in caring for cancer patients in the COVID-19 era.

Toxicities Associated with Immunotherapy and Approach to Cardiotoxicity with Novel Cancer Therapies

In recent years, major advances in oncology especially the advent of targeted agents and immunotherapies (immune checkpoint inhibitors [ICIs] and chimeric antigen receptor [CAR] T-cell therapy) have led to improved quality of life and survival rates in patients with cancer. This article focuses on the clinical features, and grading and management of toxicities associated with ICIs and CAR T-cell therapy. In addition, because cardiotoxicity is one of the most harmful effects of anticancer therapeutics, we describe the risk factors and mechanisms of cardiovascular injury associated with newer agents, screening technologies for at-risk patients, and preventive and treatment strategies.

Utility of procalcitonin as a predictor of bloodstream infections and supportive modality requirements in critically ill cancer patients

BACKGROUND

We evaluated the diagnostic utility of procalcitonin (PCT) in predicting bacterial bloodstream infections (BSI) in critically ill cancer patients with and without neutropenia. We also investigated the role of PCT as a prognostic marker of supportive modalities (vasopressors, invasive mechanical ventilation, and renal replacement therapy (RRT)) in the intensive care unit (ICU).

METHODS

We retrospectively analyzed 2200 PCT and blood cultures from adult cancer patients with suspected sepsis. Primary outcome was BSI, defined by positive blood culture, collected within 72 h of PCT collection.

RESULTS

Median PCT values were higher in encounters with BSI (3.2 vs 0.5 ng/ml, p < 0.001). The area under the ROC curve (AUC) was 0.726 (95%CI 0.698, 0.754). PCT > 2.0 ng/ml was significantly associated with greater likelihood of BSI and this effect was significantly stronger for neutropenic (OR 9.09, 95%CI: 4.39, 18.79) compared with non-neutropenic patients (OR 4.00 (95% CI: 3.13, 5.10), interaction p = 0.036). PCT > 2.0 was associated with vasopressor requirement on ICU admission (OR 1.82 (95% CI 1.31, 2.53), p < 0.001) and RRT (OR 2.20 (95% CI 1.24, 3.91), p = 0.007).

CONCLUSIONS

Procalcitonin is a fair discriminator of BSI in critically ill cancer patients with and without neutropenia and a PCT > 2.0 ng/ml was significantly more likely to require vasopressors and RRT in the ICU.

The chimeric antigen receptor-intensive care unit (CAR-ICU) initiative: Surveying intensive care unit practices in the management of CAR T-cell associated toxicities

PURPOSE

A task force of experts from 11 United States (US) centers, sought to describe practices for managing chimeric antigen receptor (CAR) T-cell toxicity in the intensive care unit (ICU).

MATERIALS AND METHODS

Between June-July 2019, a survey was electronically distributed to 11 centers. The survey addressed: CAR products, toxicities, targeted treatments, management practices and interventions in the ICU.

RESULTS

Most centers (82%) had experience with commercial and non-FDA approved CAR products. Criteria for ICU admission varied between centers for patients with Cytokine Release Syndrome (CRS) but were similar for Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS). Practices for vasopressor support, neurotoxicity and electroencephalogram monitoring, use of prophylactic anti-epileptic drugs and tocilizumab were comparable. In contrast, fluid resuscitation, respiratory support, methods of surveillance and management of cerebral edema, use of corticosteroid and other anti-cytokine therapies varied between centers.

CONCLUSIONS

This survey identified areas of investigation that could improve outcomes in CAR T-cell recipients such as fluid and vasopressor selection in CRS, management of respiratory failure, and less common complications such as hemophagocytic lymphohistiocytosis, infections and stroke. The variability in specific treatments for CAR T-cell toxicities, needs to be considered when designing future outcome studies of critically ill CAR T-cell patients.

Treating sepsis with vitamin C, thiamine, and hydrocortisone: Exploring the quest for the magic elixir

The administration of ascorbic acid (vitamin C) alone or in combination with thiamine (vitamin B1) and corticosteroids (VCTS) has recently been hypothesized to improve hemodynamics, end-organ function, and may even increase survival in critically ill patients. There are several clinical studies that have investigated the use of vitamin C alone or VCTS in patients with sepsis and septic shock or are ongoing. Some of these studies have demonstrated its safety and potential benefit in septic patients. However, many questions remain regarding the optimal dosing regimens and plasma concentrations, timing of administration, and adverse effects of vitamin C and thiamine. These questions exist because the bulk of research regarding the efficacy of vitamin C alone or in combination with thiamine and corticosteroids in sepsis is limited to a few randomized controlled trials, retrospective before-and-after studies, and case reports. Thus, although the underlying rationale and mechanistic pathways of vitamin C and thiamine in sepsis have been well described, the clinical impact of the VCTS regimen is complex and remains to be determined. This review aims to explore the current evidence and potential benefits and adverse effects of the VCTS regimen for the treatment of sepsis.

Characteristics and outcomes of patients with solid tumors receiving chemotherapy in the intensive care unit

PURPOSE

The objective of this study was to evaluate the short- and long-term outcomes of adult patients with solid tumors receiving chemotherapy in the intensive care unit (ICU).

METHODS

This was a retrospective single-center study comparing the outcomes of patients with solid tumors who received chemotherapy in the ICU with a matched cohort of ICU patients (by age, sex, and tumor type) who did not receive chemotherapy. Conditional logistic regression and shared frailty Cox regression were used to assess short-term (ICU and hospital) mortality and death by 12-month post-hospital discharge, respectively.

RESULTS

Seventy-three patients with solid tumors who received chemotherapy in the ICU were successfully matched. The most common solid tumors included thoracic (30%), genitourinary (26%), and breast (16%). The ICU, hospital, and 12-month (post discharge)  mortality rates of patients who recieved chomtherapy in the ICU were 23%, 36%, and 43%, respectively. When compared to the matched cohort of patients who did not receive chemotherapy, patients who received chemotherapy had a significantly longer length of stay in the ICU (median 7 vs. 4 days, p < 0.001) and hospital (median 15 vs. 11 days, p = 0.011) but similar short-term ICU and hospital mortality rates (23% vs. 18% and 36% vs. 38%, respectively). Patients who received chemotherapy in the ICU were at a lower risk of death by 12 months (HR 0.31, p < 0.001) compared to the matched cohort on multivariable analysis.

CONCLUSIONS

Patients with solid tumors who received chemotherapy had increased ICU and hospital length of stay compared to patients who did not. Although short-term mortality did not differ, patients who received chemotherapy in the ICU had improved long-term survival. Our data can inform critical care triage decisions to include patients who are to receive chemotherapy in the ICU.

A pilot survey of ventilated cancer patients' perspectives and recollections of early mobility in the intensive care unit

Purpose

To determine the level of recall, satisfaction, and perceived benefits of early mobility (EM) among ventilated cancer patients after extubation in the intensive care unit (ICU).

Methods

A survey of patients’ perceptions and recollections of EM was administered within 72 h of extubation. Data on recall of EM participation, activities achieved, adequacy of staffing and rest periods, strength to participate, activity level of difficulty, satisfaction with staff instructions, breathing management, and overall rating of the experience were analyzed. The Confusion Assessment Method for ICU (CAM-ICU) was used for delirium screening.

Results

Fifty-four patients comprised the study group. Nearly 90% reported satisfaction with instructions, staffing, rest periods, and breathing management during EM. Participants indicated that EM maintained their strength (67%) and gave them control over their recovery (61%); a minority felt optimistic (37%) and safe (22%). Patients who achieved more sessions and “out-of-bed” exercises had better recall of actual activities compared with those who exercised in bed. Overall, patients with CAM-ICU-positive results (33%) performed less physical and occupational therapy exercises.

Conclusions

Ventilated cancer patients reported an overall positive EM experience, but factual memory impairment of EM activities was common. These findings highlight the needs and the importance of shaping strategies to deliver a more patient focused EM experience.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-04867-1) contains supplementary material, which is available to authorized users.

Characteristics and outcomes of patients with hematologic malignancies receiving chemotherapy in the intensive care unit

BACKGROUND

The objective of this study was to evaluate the short-term and long-term outcomes of adult patients with hematologic malignancies who received chemotherapy in the intensive care unit (ICU).

METHODS

This was a retrospective, single-center study comparing the outcomes of patients with hematologic malignancies who received chemotherapy in the ICU with a matched cohort of ICU patients who did not receive chemotherapy. Conditional logistic regression and shared-frailty Cox regression were used to assess short-term (ICU and hospital) mortality and death by 12 months after hospital discharge, respectively.

RESULTS

One hundred eighty-one patients with hematologic malignancies received chemotherapy in the ICU. The ICU and hospital mortality rates were 25% and 42% for chemotherapy patients and 22% and 33% for non-chemotherapy patients, respectively. Higher severity of illness scores on ICU admission were significantly associated with higher ICU mortality (odds ratio, 1.07; P < .001) and hospital mortality (odds ratio, 1.05; P ≤ .001). Six-month and 12-month survival estimates posthospital discharge were 58% and 50%, respectively. Compared with the matched cohort of patients who did not receive chemotherapy, those who did receive chemotherapy had a significantly longer length of stay in the ICU (median, 6 vs 3 days; P < .001) and in the hospital (median, 22 vs 14 days; P = .024). In multivariable analysis, the patients who received chemotherapy in the ICU had a trend toward a higher risk of dying by 12 months (hazard ratio, 1.45; P = .08).

CONCLUSIONS

Short-term mortality was similar among patients with hematologic malignancies who did and did not receive chemotherapy in the ICU, although patients who received chemotherapy had increased resource utilization. These results may inform ICU triage and goals-of-care discussions with patients and their families regarding outcomes after receiving chemotherapy in the ICU. Cancer 2018;124:3025-36. © 2018 American Cancer Society.

Reducing Unnecessary Testing in the Intensive Care Unit by Choosing Wisely

Overuse of laboratory and X-ray testing is common in the intensive care unit (ICU). This review highlights focused strategies for critical care clinicians as outlined by the Critical Care Societies Collaborative (CCSC) as part of the American Board of Internal Medicine Foundation’s Choosing Wisely^® campaign. The campaign aims to promote the use of judicious testing and decrease unnecessary treatment measures in the ICU. The CCSC outlines five specific recommendations for reducing unnecessary testing in the ICU. First, reduce the use of daily or regular interval diagnostic testing. Second, do not transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dl. Third, do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of ICU stay. Fourth, do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Finally, do not continue life support for patients at high risk of death without offering patients and their families the alternative of comfort focused care. A number of strategies can be used to reduce unnecessary testing in the ICU, including educational campaigns, audit and feedback, and implementing prompts in the electronic ordering system to allow only acceptable indications when ordering routine testing. Greater awareness of the lack of outcome benefit and associated costs can prompt clinicians to be more mindful of ordering tests and procedures in order to reduce unnecessary testing in the ICU.

Correction to: Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.

Acute Respiratory Failure After Hematopoietic Stem Cell Transplantation

Infectious and noninfectious pulmonary complications are common among HSCT recipients and are the leading cause for respiratory failure requiring mechanical ventilation and ICU admission. Unique pulmonary syndromes include peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, and idiopathic pneumonia syndrome. Respiratory failure requiring mechanical ventilation after HSCT continues to be associated with a poor prognosis.

A Basic Therapy Gone Awry

Baking soda (sodium bicarbonate) is a common household item that has gained popularity as an alternative cancer treatment. Some have speculated that alkali therapy neutralizes the extracellular acidity of tumor cells that promotes metastases. Internet blogs have touted alkali as a safe and natural alternative to chemotherapy that targets cancer cells without systemic effects. Sodium bicarbonate overdose is uncommon, with few reports of toxic effects in humans. The case described here is the first reported case of severe metabolic alkalosis related to topical use of sodium bicarbonate as a treatment for cancer. This case highlights how a seemingly benign and readily available product can have potentially lethal consequences.

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

OBJECTIVE

To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.

PARTICIPANTS

A multispecialty task force of 16 international experts in Critical Care Medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.

DESIGN/METHODS

The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.

RESULTS

The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of <9 µg/dl) after cosyntropin (250 µg) administration and a random plasma cortisol of <10 µg/dl may be used by clinicians. We suggest against using plasma free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using intravenous (IV) hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO₂/FiO₂ < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).

CONCLUSIONS

Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.

The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code status or for time-limited trials, increased survival and quality of life in ICU survivors, changing prognostic factors, early ICU admission for optimal monitoring, and use of noninvasive diagnostic and therapeutic strategies. In this review, experts in the management of critically ill cancer patients highlight recent changes in the use and the results of intensive care in patients with malignancies. They seek to put forward a standard of care for the management of these patients and highlight important updates that are required to care for them. The research agenda they suggest includes important studies to be conducted in the next few years to increase our understanding of organ dysfunction in this population and to improve our ability to appropriately use life-saving therapies or select new therapeutic approaches that are likely to improve outcomes. This review aims to provide more guidance for the daily management of patients with cancer, in whom outcomes are constantly improving, as is our global ability to fight against what is becoming the leading cause of mortality in industrialized and non-industrialized countries.

Monitoring sound and light continuously in an intensive care unit patient room: A pilot study

PURPOSE

To determine the feasibility of continuous recording of sound and light in the intensive care unit (ICU).

MATERIALS AND METHODS

Four 1-hour baseline scenarios in an empty ICU patient room by day and night (doors open or closed and maximal or minimal lighting) and two daytime scenarios simulating a stable and unstable patient (quiet or loud devices and staff) were conducted. Sound and light levels were continuously recorded using a commercially available multisensor monitor and transmitted via the hospital's network to a cloud-based data storage and management system.

RESULTS

The empty ICU room was loud with similar mean sound levels of 45 to 46 dBA for the day and night simulations. Mean levels for maximal lighting during day and night ranged from 1306 to 1812 lux and mean levels for minimum lighting were 1 to 3 lux. The mean sound levels for the stable and unstable patient simulations were 61 and 81 dBA, respectively. The mean light levels were 349 lux for the stable patient and 1947 lux for the unstable patient.

CONCLUSIONS

Combined sound and light can be continuously and easily monitored in the ICU setting. Incorporating sound and light monitors in ICU rooms may promote an enhanced patient- and staff-centered healing environment.

Management of Acute Respiratory Failure in Patients With Hematological Malignancy

Acute respiratory failure (ARF) is the leading cause of intensive care unit admission in patients with hematologic malignancies and is associated with a high mortality. The main causes of ARF are bacterial and opportunistic pulmonary infections and noninfectious lung disorders. Management consists of a systematic clinical evaluation aimed at identifying the most likely cause, which in turn determines the best first-line empirical treatments. The need for mechanical ventilation is a major determinant of prognosis. Beneficial outcomes have been demonstrated with early use of noninvasive ventilation (NIV) in selected patients with hematologic malignancies. However, most of these studies did not control the time between onset of ARF to NIV implementation nor accounted for the etiology of ARF or the presence of associated organ dysfunction at the time of NIV initiation. Moreover, the benefits demonstrated with NIV in these patients were derived from studies with high mortality rates of intubated patients. Additional studies are therefore warranted to determine the appropriate patients with hematologic malignancy and ARF who may benefit from prophylactic or curative NIV.

Short- and long-term outcomes of adult allogeneic hematopoietic stem cell transplant patients admitted to the intensive care unit in the peritransplant period

Survival of allogeneic hematopoietic stem cell transplant (aHSCT) recipients in the intensive care unit (ICU) has been poor. We retrospectively analyzed the short- and long-term outcomes of aHSCT patients admitted to the ICU over a 12-year period. Of 1235 adult patients who had aHSCT between 2002 and 2013, 161 (13%) were admitted to the ICU. The impact of clinical parameters was assessed and outcomes were compared for the periods 2002-2007 and 2008-2013. The ICU, in-hospital, 1- and 5-year survival rates were 64.6%, 46%, 33% and 20%, respectively. Mechanical ventilation and vasopressor use predicted for worse hospital- and overall survival (OS). After 2008, the requirement for mechanical ventilation and vasopressors, and the diagnosis of sepsis were reduced. While hospital mortality decreased from 69% to 44%, long-term survival (LTS) remained unchanged. Late deaths, due to causes not associated with the ICU such as relapse and graft-versus-host disease, increased. As thresholds for transplant are lowered, improvements in ICU outcomes for aHSCT recipients may be limited.

An analysis of patients transferred to a tertiary oncological intensive care unit for defined procedures

BACKGROUND

Up to 50 000 intensive care unit interhospital transfers occur annually in the United States.

OBJECTIVE

To determine the prevalence, characteristics, and outcomes of cancer patients transferred from an intensive care unit in one hospital to another intensive care unit at an oncological center and to evaluate whether interventions planned before transfer were performed.

METHODS

Data on transfers for planned interventions from January 2008 through December 2012 were identified retrospectively. Demographic and clinical variables, receipt of planned interventions, and outcome data were analyzed.

RESULTS

Of 4625 admissions to an intensive care unit at the oncological center, 143 (3%) were transfers from intensive care units of other hospitals. Of these, 47 (33%) were transfers for planned interventions. Patients' mean age was 57 years, and 68% were men. At the time of intensive care unit transfer, 20 (43%) were receiving mechanical ventilation. Interventions included management of airway (n = 19) or gastrointestinal (n = 2) obstruction, treatment of tumor bleeding (n = 12), chemotherapy (n = 10), and other (n = 4). A total of 37 patients (79%) received the planned interventions within 48 hours of intensive care unit arrival; 10 (21%) did not because their signs and symptoms abated. Median intensive care unit and hospital lengths of stay at the oncological center were 4 and 13 days, respectively. Intensive care unit and hospital mortality rates were 11% and 19%, respectively. Deaths occurred only in patients who received interventions.

CONCLUSIONS

Interhospital transfers of cancer patients to an intensive care unit at an oncological center are infrequent but are most commonly done for direct interventional care. Most patients received planned interventions soon after transfer.