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Royce-Nagel G, Jarzebowski M, Wongsripuemtet P, Krishnamoorthy V, Fuller M, Ohnuma T, Treggiari M, Yaport M, Cobert J, Garrigan E, Bartz R, Raghunathan K. Use of Early Ketamine Sedation and Association With Clinical and Cost Outcomes Among Mechanically Ventilated Patients With COVID-19: A Retrospective Cohort Study. Crit Care Explor 2024; 6:e1105. [PMID: 38904975 DOI: 10.1097/cce.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVES To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes. DESIGN Retrospective cohort study. SETTING Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021. PATIENTS Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization. INTERVENTION The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day. MEASUREMENTS Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders. MAIN RESULTS Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06-1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08-1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12-1.27]). There were no associations for hospital LOS (17 [10-27] vs. 17 [9-28], MR: 1.05 [0.99-1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95-1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92-1.21]). Total hospital cost was higher (median $72,481 vs. $65,584, MR: 1.11 [1.05-1.19]). CONCLUSIONS In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients.
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Affiliation(s)
- Galen Royce-Nagel
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Mary Jarzebowski
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Pattrapun Wongsripuemtet
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Matthew Fuller
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Miriam Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Miguel Yaport
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Julien Cobert
- Department of Anesthesiology, University of California, San Francisco, CA
| | - Ethan Garrigan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Raquel Bartz
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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Peasah SK, Swart ECS, Huang Y, Kane-Gill SL, Seybert AL, Patel U, Manolis C, Good CB. Disease-Modifying Medications in Patients with Rheumatoid Arthritis in the USA: Trends from 2016 to 2021. Drugs Real World Outcomes 2024; 11:241-249. [PMID: 38368583 PMCID: PMC11176124 DOI: 10.1007/s40801-024-00416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Disease-modifying anti-rheumatic drugs (DMARDs), since their introduction in 1990, have revolutionized the management of rheumatoid arthritis. Newer DMARDs have recently been approved, influencing treatment patterns and clinical guidelines. OBJECTIVE To update the current prescribing patterns of DMARDs in the pharmacotherapy of rheumatoid arthritis (RA) to include the pandemic era. METHODS This was a retrospective cross-sectional multi-year study. Using Optum's Clinformatics® Data Mart Database, we summarized trends in the prevalence of DMARD use in the USA from 2016 to 2021 by year for adult patients ≥ 18 years old with at least one medical RA claim and one pharmacy/medical claim of a DMARD medication. Trends included type of DMARD, class of DMARD (conventional (csDMARDs), biologics [tumor necrosis factor (TNFi) and Non-TNFi), and Janus kinase inhibitors (JAKs)], and triple therapy [methotrexate (MTX), hydroxychloroquine (HCQ), sulfasalazine (SUL)] used. RESULTS The total sample from 2016 to 2021 was 670,679 commercially insured patients. The average age was 63.7 years (SD 13.6), and 76.7% were female and 70% were White. csDMARDs remain the most prescribed (ranging from 77.2 to 79.2%). Although JAKs were the least prescribed DMARD class, their proportion more than doubled from 2016 (1.5%) to 2021 (4%). MTX utilization declined from 40% in 2016 to 34% in 2021. In contrast, HCQ use increased during the pandemic era from < 25% in 2018 to 30% in 2021. Although there is evidence of the therapeutic benefit of triple therapy, its use was very low (~ 1%) compared to biologics only (~ 17%) or biologics+MTX (~ 10%). CONCLUSION About half of patients with RA were on DMARDs. As expected, csDMARDs were highly used consistently. The COVID-19 pandemic might have influenced the use of HCQ and infusion DMARDs. Triple therapy use remains low.
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Affiliation(s)
- Samuel K Peasah
- Value-based Pharmacy Initiatives, Center for High-Value Health Care, UPMC Health Plan, US Steel Tower, 40th Floor. 600 Grant Street, Pittsburgh, PA, 15219, USA.
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Elizabeth C S Swart
- Value-based Pharmacy Initiatives, Center for High-Value Health Care, UPMC Health Plan, US Steel Tower, 40th Floor. 600 Grant Street, Pittsburgh, PA, 15219, USA
| | - Yan Huang
- Value-based Pharmacy Initiatives, Center for High-Value Health Care, UPMC Health Plan, US Steel Tower, 40th Floor. 600 Grant Street, Pittsburgh, PA, 15219, USA
| | | | - Amy L Seybert
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Urvashi Patel
- Evernorth Research Institute, Cigna Health, St. Louis, MO, USA
| | - Chronis Manolis
- Department of Pharmacy, UPMC Health Plan, Pittsburgh, PA, USA
| | - Chester B Good
- Value-based Pharmacy Initiatives, Center for High-Value Health Care, UPMC Health Plan, US Steel Tower, 40th Floor. 600 Grant Street, Pittsburgh, PA, 15219, USA
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Pharmacy, UPMC Health Plan, Pittsburgh, PA, USA
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3
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Rojas-Suarez J, Paruk F. Maternal high-care and intensive care units in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102474. [PMID: 38395025 DOI: 10.1016/j.bpobgyn.2024.102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.
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Affiliation(s)
- José Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Colombia; GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia.
| | - Fathima Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Faculty of Health Science University of Pretoria, South Africa.
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Roche M, Rousseleau D, Danel C, Henry H, Lebuffe G, Odou P, Lannoy D, Simon N. Combination of a propofol emulsion with alpha-2 adrenergic receptor agonists used for multimodal analgesia or sedation in intensive care units: a physicochemical stability study. Eur J Hosp Pharm 2024:ejhpharm-2023-004027. [PMID: 38290833 DOI: 10.1136/ejhpharm-2023-004027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVES To assess the physicochemical stability of the combination of a propofol emulsion with an alpha-2 (α2) adrenergic receptor agonist (α2A; clonidine or dexmedetomidine) under conditions mimicking routine practice in an intensive care unit or in multimodal analgesia procedures. METHODS We developed and validated three stability-indicating methods based on high-performance liquid chromatography with ultraviolet (HPLC-UV) detection. Eight different conditions per combination were evaluated in triplicate, with variations in the simulated, bodyweight-adjusted dose level and the drugs' flow rate. The drugs were mixed in clinically relevant concentrations and proportions and then stored unprotected from light, in clear glass vials at room temperature for 96 hours. At each sampling point, we assessed the chemical stability (the HPLC-UV drug level, pH, and osmolality) and physical compatibility (visual aspect, zeta potential (ZP), mean droplet diameter (MDD, Z-average) and polydispersity index (PDI)). We validated our stability findings in positive and negative control experiments. RESULTS Over the 96-hour test, the concentrations of propofol, clonidine and dexmedetomidine did not fall below 90% of the initial value, and the pH and osmolality were stable. The visual aspect of the mixed propofol emulsions did not change. The MDD remained below 500 nm (range 165-195 nm). The PDI was always below 0.4; 78.7% of the measurements were below 0.1 and 21.3% were between 0.1 and 0.4. The ZP measurements (-31.3 to -42.9 mV) suggested that the emulsion was stable. The MDD and PDI increased slightly at 96 hours under some conditions, which might indicate early destabilisation of the emulsion. Given that the MDD remained below 500 nm, these emulsions are compatible with intravenous administration. CONCLUSIONS Our results demonstrate the chemical and physical compatibility of propofol-α2 agonist mixtures at concentrations and in proportions representative of standard protocols when stored unprotected from light at room temperature for 96 hours.
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Affiliation(s)
- Marine Roche
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Damien Rousseleau
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
- Anaesthesia and Intensive Care Department, Hospital Claude Huriez, Lille University Hospital, Lille, France
| | - Cécile Danel
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Héloïse Henry
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Gilles Lebuffe
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
- Anaesthesia and Intensive Care Department, Hospital Claude Huriez, Lille University Hospital, Lille, France
| | - Pascal Odou
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Damien Lannoy
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | - Nicolas Simon
- Pharmacy, Lille University Hospital, Lille, Nord, France
- ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
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Domingues KZA, Cobre AF, Lazo REL, Amaral LS, Ferreira LM, Tonin FS, Pontarolo R. Systematic review and evidence gap mapping of biomarkers associated with neurological manifestations in patients with COVID-19. J Neurol 2024; 271:1-23. [PMID: 38015300 DOI: 10.1007/s00415-023-12090-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE This study aimed to synthesize the existing evidence on biomarkers related to coronavirus disease 2019 (COVID-19) patients who presented neurological events. METHODS A systematic review of observational studies (any design) following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the Cochrane Collaboration recommendations was performed (PROSPERO: CRD42021266995). Searches were conducted in PubMed and Scopus (updated April 2023). The methodological quality of nonrandomized studies was assessed using the Newcastle‒Ottawa Scale (NOS). An evidence gap map was built considering the reported biomarkers and NOS results. RESULTS Nine specific markers of glial activation and neuronal injury were mapped from 35 studies published between 2020 and 2023. A total of 2,237 adult patients were evaluated in the included studies, especially during the acute phase of COVID-19. Neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) biomarkers were the most frequently assessed (n = 27 studies, 77%, and n = 14 studies, 40%, respectively). Although these biomarkers were found to be correlated with disease severity and worse outcomes in the acute phase in several studies (p < 0.05), they were not necessarily associated with neurological events. Overall, 12 studies (34%) were judged as having low methodological quality, 9 (26%) had moderate quality, and 9 (26%) had high quality. CONCLUSIONS Different neurological biomarkers in neurosymptomatic COVID-19 patients were identified in observational studies. Although the evidence is still scarce and conflicting for some biomarkers, well-designed longitudinal studies should further explore the pathophysiological role of NfL, GFAP, and tau protein and their potential use for COVID-19 diagnosis and management.
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Affiliation(s)
- K Z A Domingues
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Paraná, Curitiba, PR, 80210-170, Brazil
| | - A F Cobre
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Paraná, Curitiba, PR, 80210-170, Brazil
| | - R E L Lazo
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Paraná, Curitiba, PR, 80210-170, Brazil
| | - L S Amaral
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Paraná, Curitiba, PR, 80210-170, Brazil
| | - L M Ferreira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Paraná, Curitiba, PR, 80210-170, Brazil
| | - F S Tonin
- H&TRC- Health & Technology Research Center, ESTeSL, Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096, Lisbon, Portugal
| | - R Pontarolo
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Paraná, Curitiba, PR, 80210-170, Brazil.
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Djeddi WE, Hermi K, Ben Yahia S, Diallo G. Advancing drug-target interaction prediction: a comprehensive graph-based approach integrating knowledge graph embedding and ProtBert pretraining. BMC Bioinformatics 2023; 24:488. [PMID: 38114937 PMCID: PMC10731821 DOI: 10.1186/s12859-023-05593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The pharmaceutical field faces a significant challenge in validating drug target interactions (DTIs) due to the time and cost involved, leading to only a fraction being experimentally verified. To expedite drug discovery, accurate computational methods are essential for predicting potential interactions. Recently, machine learning techniques, particularly graph-based methods, have gained prominence. These methods utilize networks of drugs and targets, employing knowledge graph embedding (KGE) to represent structured information from knowledge graphs in a continuous vector space. This phenomenon highlights the growing inclination to utilize graph topologies as a means to improve the precision of predicting DTIs, hence addressing the pressing requirement for effective computational methodologies in the field of drug discovery. RESULTS The present study presents a novel approach called DTIOG for the prediction of DTIs. The methodology employed in this study involves the utilization of a KGE strategy, together with the incorporation of contextual information obtained from protein sequences. More specifically, the study makes use of Protein Bidirectional Encoder Representations from Transformers (ProtBERT) for this purpose. DTIOG utilizes a two-step process to compute embedding vectors using KGE techniques. Additionally, it employs ProtBERT to determine target-target similarity. Different similarity measures, such as Cosine similarity or Euclidean distance, are utilized in the prediction procedure. In addition to the contextual embedding, the proposed unique approach incorporates local representations obtained from the Simplified Molecular Input Line Entry Specification (SMILES) of drugs and the amino acid sequences of protein targets. CONCLUSIONS The effectiveness of the proposed approach was assessed through extensive experimentation on datasets pertaining to Enzymes, Ion Channels, and G-protein-coupled Receptors. The remarkable efficacy of DTIOG was showcased through the utilization of diverse similarity measures in order to calculate the similarities between drugs and targets. The combination of these factors, along with the incorporation of various classifiers, enabled the model to outperform existing algorithms in its ability to predict DTIs. The consistent observation of this advantage across all datasets underlines the robustness and accuracy of DTIOG in the domain of DTIs. Additionally, our case study suggests that the DTIOG can serve as a valuable tool for discovering new DTIs.
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Affiliation(s)
- Warith Eddine Djeddi
- LR11ES14, Faculty of Sciences of Tunis, University of Tunis El Manar, Campus Universitaire, 2092, Tunis, Tunisia.
- High Institute of Informatics in Kef, University of Jendouba, Saleh Ayech, 8189, Jendouba, Tunisia.
| | - Khalil Hermi
- High Institute of Informatics in Kef, University of Jendouba, Saleh Ayech, 8189, Jendouba, Tunisia
| | - Sadok Ben Yahia
- Department of Software Science, Tallinn University of Technology, Ehitajate tee-5, 12618, Tallinn, Estonia
- The Maersk Mc-Kinney Moller Institute, Southern Syddansk Universitet, Alsion 2, 6400, Sønderborg, Denmark
| | - Gayo Diallo
- Bordeaux Population Health Inserm 1219, University of Bordeaux, rue Léo Saignat, 33000, Bordeaux, France
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Pérez Lucendo A, Piñeiro Otero P, Matía Almudévar P, Alcántara Carmona S, López López E, Ramasco Rueda F. Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:509-535. [PMID: 37742996 DOI: 10.1016/j.redare.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/20/2023] [Indexed: 09/26/2023]
Abstract
This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.
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Affiliation(s)
- A Pérez Lucendo
- Servicio de Medicina Intensiva, Hospital Universitario de La Princesa, Madrid, Spain.
| | - P Piñeiro Otero
- Servicio de Anestesiología y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - P Matía Almudévar
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - S Alcántara Carmona
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - E López López
- Servicio de Anestesiología y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - F Ramasco Rueda
- Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
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Obiedalla M, Patel N, Donyai P. Exploring Drug Shortages in the United Kingdom. PHARMACY 2023; 11:166. [PMID: 37888510 PMCID: PMC10609979 DOI: 10.3390/pharmacy11050166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/28/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Drugs can become short in supply for many reasons including increased demand and reduced production. Drug shortages have the potential to impact patients and pharmacists. This study aimed to highlight the challenges pharmacists face and the constraints of how they manage drug shortages. An online survey was designed with its link distributed electronically to community pharmacists in the UK with the assistance of pharmacy organizations during the period from September to December 2021. Survey data were analysed using descriptive statistics. A total of 83% of the respondents (n= 100) were experiencing drug shortages three or more times per week, and more than 70% of these spent 1-3 h per week dealing with them. A total of 93% of the respondents indicated that the issue of drug shortages was a problem for them, and 61% reported that it has worsened since the start of the pandemic. In addition, 65% of the respondents believed that drug shortages had had an impact on patient care. Drug shortages were shown to impact on the pharmacists' workloads with a potential to affect the quality of patient care. There was a variation between how pharmacists dealt with drug shortages, which needs to be explored further with the reasons behind it.
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Affiliation(s)
- Mohamed Obiedalla
- Reading School of Pharmacy, University of Reading, Reading, Berkshire RG6 6AH, UK;
| | - Nilesh Patel
- Reading School of Pharmacy, University of Reading, Reading, Berkshire RG6 6AH, UK;
| | - Parastou Donyai
- School of Pharmacy, Kings College London, London WC2R 2LS, UK;
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Carvalho RM, de Magalhães-Barbosa MC, Bianchi LM, Rodrigues-Santos G, da Cunha AJLA, Bastos FI, Prata-Barbosa A. Shift in hospital opioid use during the COVID-19 pandemic in Brazil: a time-series analysis of one million prescriptions. Sci Rep 2023; 13:17197. [PMID: 37821638 PMCID: PMC10567754 DOI: 10.1038/s41598-023-44533-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 10/10/2023] [Indexed: 10/13/2023] Open
Abstract
The pronounced change in the profile of hospitalized patients during COVID-19 and the severe respiratory component of this disease, with a great need for mechanical ventilation, led to changes in the consumption pattern of some medicines and supplies. This time-series study analyzed the in-hospital consumption of opioids during the COVID-19 pandemic in 24 Brazilian hospitals compared to the pre-pandemic period. Data included 711,883 adult patients who had opioids prescribed. In 2020, the mean consumption was significantly higher compared to 2019 for parenteral fentanyl, enteral methadone, and parenteral methadone. It was significantly lower for parenteral morphine parenteral sufentanil, and parenteral tramadol. For remifentanil, it did not differ. The number of patients in 2020 was lower but the mean consumption was higher for fentanyl, parenteral methadone, and remifentanil. It was lower for enteral methadone and parenteral sufentanil. The consumption of parenteral morphine and parenteral tramadol was stable. There was a relevant increase in hospital consumption of some potent opioids during the COVID-19 pandemic in Brazil. These results reinforce the concern about epidemiological surveillance of opioid use after periods of increased hospital use since in-hospital consumption can be the gateway to the misuse or other than the prescribed use of opioids after discharge.
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Affiliation(s)
- Romulo Mendonça Carvalho
- Doctoral Program in Medical Sciences, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
- Pharmaceutical Division, Rede D'Or São Luiz, Rio de Janeiro, RJ, 22270-010, Brazil
| | | | - Lucas Monteiro Bianchi
- Doctoral Program in Epidemiology in Public Health, National School of Public Health Sergio Arouca (ENSP), Rio de Janeiro, RJ, 21041-210, Brazil
| | - Gustavo Rodrigues-Santos
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
- Doctoral Program in Collective Health, Institute of Social Medicine (IMS), State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Antônio José Ledo Alves da Cunha
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
- Department of Pediatrics, School of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, 21044-020, Brazil
| | - Francisco Inácio Bastos
- Laboratory of Health Information, Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation (IOC), Rio de Janeiro, RJ, 21040-900, Brazil
| | - Arnaldo Prata-Barbosa
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil.
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10
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Bahk J, Dolan B, Sharma V, Sehmbhi M, Fung JY, Lee YI. Characteristics and Outcomes of Tracheostomized Patients With and Without COVID-19. Crit Care Explor 2023; 5:e0950. [PMID: 37546230 PMCID: PMC10403025 DOI: 10.1097/cce.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Outcomes of tracheostomized patients with COVID-19 are seldomly investigated with conflicting evidence from the existing literature. OBJECTIVES To create a study evaluating the impact of COVID-19 on tracheostomized patients by comparing clinical outcomes and weaning parameters in COVID-19 positive and negative cohorts. DESIGN SETTING AND PARTICIPANTS A retrospective observational cohort study of 604 tracheostomized patients hospitalized in 16 ICUs in New York City between March 9, 2020, and September 8, 2021. MAIN OUTCOMES AND MEASURES Patients were stratified into two cohorts: 398 COVID-19 negative (COVID-ve) and 206 COVID-19 positive (COVID+ve) patients. Clinical characteristics, outcomes, and weaning parameters (first pressure support [PS], tracheostomy collar [TC], speech valve placement, and decannulation) were analyzed. RESULTS COVID+ve had fewer comorbidities including coronary artery disease, congestive heart failure, malignancy, chronic kidney disease, liver disease, and HIV (p < 0.05). Higher Fio2 (53% vs 44%), positive end-expiratory pressure (PEEP) (7.15 vs 5.69), Pco2 (45.8 vs 38.2), and lower pH (7.41 vs 7.43) were observed at the time of tracheostomy in COVID+ve (p < 0.005). There was no statistical difference in post-tracheostomy complication rates. Longer time from intubation to tracheostomy (15.90 vs 13.60 d; p = 0.002), tracheostomy to first PS (2.87 vs 1.80 d; p = 0.005), and TC placement (11.07 vs 4.46 d; p < 0.001) were seen in COVID+ve. However, similar time to speech valve placement, decannulation, and significantly lower 1-year mortality (23.3% vs 36.7%; p = 0.001) with higher number of discharges to long-term acute care hospital (LTACH) (23.8% vs 13.6%; p = 0.015) were seen in COVID+ve. CONCLUSIONS AND RELEVANCE Patients with COVID-19 required higher Fio2 and PEEP ventilatory support at the time of tracheostomy, with no observed change in complication rates. Despite longer initial weaning period with PS or TC, similar time to speech valve placement or decannulation with significantly lower mortality and higher LTACH discharges suggest favorable outcome in COVID-19 positive patients. Higher ventilatory support requirements and prolonged weaning should not be a deterrent to pursuing a tracheostomy.
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Affiliation(s)
- Jeeyune Bahk
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bridget Dolan
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Venus Sharma
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mantej Sehmbhi
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jennifer Y Fung
- Division of Pulmonary and Critical Care, Department of Medicine, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Young Im Lee
- Division of Pulmonary and Critical Care, Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY
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11
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Martínez-Castro S, Monleón B, Puig J, Ferrer Gomez C, Quesada M, Pestaña D, Balvis A, Maseda E, de la Rica AS, Feijoo AM, Badenes R. Sedation with Sevoflurane versus Propofol in COVID-19 Patients with Acute Respiratory Distress Syndrome: Results from a Randomized Clinical Trial. J Pers Med 2023; 13:925. [PMID: 37373914 DOI: 10.3390/jpm13060925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) related to COVID-19 (coronavirus disease 2019) led to intensive care units (ICUs) collapse. Amalgams of sedative agents (including volatile anesthetics) were used due to the clinical shortage of intravenous drugs (mainly propofol and midazolam). METHODS A multicenter, randomized 1:1, controlled clinical trial was designed to compare sedation using propofol and sevoflurane in patients with ARDS associated with COVID-19 infection in terms of oxygenation and mortality. RESULTS Data from a total of 17 patients (10 in the propofol arm and 7 in the sevoflurane arm) showed a trend toward PaO2/FiO2 improvement and the sevoflurane arm's superiority in decreasing the likelihood of death (no statistical significance was found). CONCLUSIONS Intravenous agents are the most-used sedative agents in Spain, even though volatile anesthetics, such as sevoflurane and isoflurane, have shown beneficial effects in many clinical conditions. Growing evidence demonstrates the safety and potential benefits of using volatile anesthetics in critical situations.
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Affiliation(s)
- Sara Martínez-Castro
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Berta Monleón
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Jaume Puig
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Carolina Ferrer Gomez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Marta Quesada
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - David Pestaña
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Alberto Balvis
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Emilio Maseda
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Alejandro Suárez de la Rica
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario De La Princesa, 28006 Madrid, Spain
| | - Ana Monero Feijoo
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
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12
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Rooimans T, Damen M, Markesteijn CMA, Schuurmans CCL, de Zoete NHC, van Hasselt PM, Hennink WE, van Nostrum CF, Hermes M, Besseling R, Vromans H. Development of a compounded propofol nanoemulsion using multiple non-invasive process analytical technologies. Int J Pharm 2023; 640:122960. [PMID: 37061210 PMCID: PMC10101488 DOI: 10.1016/j.ijpharm.2023.122960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/25/2023] [Accepted: 04/11/2023] [Indexed: 04/17/2023]
Abstract
Propofol is the preferred anaesthetic for induction and maintenance of sedation in critically ill mechanically ventilated COVID-19 patients. However, during the outbreak of the COVID-19 pandemic, regular supply chains could not keep up with the sudden increase in global demand, causing drug shortages. Propofol is formulated as an oil-in-water emulsion which is administered intravenously. This study explores the extemporaneous preparation of a propofol emulsion without specialized manufacturing equipment to temporally alleviate such shortages. A commercially available lipid emulsion (IVLE, SMOFlipid 20%), intended for parenteral nutrition, was used to create a propofol loaded nanoemulsion via addition of liquid propofol drug substance and subsequent mixing. Critical quality attributes such as mean droplet size and the volume-weighted percentage of large-diameter (>5µm) droplets were studied. The evolution of droplet size and propofol distribution was monitored in situ and non-destructively, maintaining sterility, using Spatially Resolved Dynamic Light Scattering and Near Infrared Spectroscopy, respectively. Using response surface methodology, an optimum was found for a 4% w/v propofol formulation with a ∼15 minute mixing time in a flask shaker at a 40° shaking angle. This study shows that extemporaneous compounding is a viable option for emergency supply of propofol drug product during global drug shortages.
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Affiliation(s)
- T Rooimans
- Research and Development Department, Tiofarma BV, Oud-Beijerland, the Netherlands; Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.
| | - M Damen
- InProcess-LSP, Oss, the Netherlands
| | - C M A Markesteijn
- Research and Development Department, Tiofarma BV, Oud-Beijerland, the Netherlands
| | | | - N H C de Zoete
- Research and Development Department, Tiofarma BV, Oud-Beijerland, the Netherlands
| | - P M van Hasselt
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - W E Hennink
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - C F van Nostrum
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - M Hermes
- InProcess-LSP, Oss, the Netherlands
| | | | - H Vromans
- Research and Development Department, Tiofarma BV, Oud-Beijerland, the Netherlands; Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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13
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Izutsu KI, Abe Y, Kurita M, Yoshida H. [Shortages of Prescription Drugs Due to Compliance and Quality Issues in Japan]. YAKUGAKU ZASSHI 2023; 143:139-152. [PMID: 36418079 DOI: 10.1248/yakushi.22-00185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Several good manufacturing practice (GMP) compliance issues and their associated quality problems that have been revealed since 2020 have led to large-scale recalls and supply suspensions of drug products in Japan. This paper provides an overview of the causes and countermeasures for supply disruptions of low-molecular-weight chemical pharmaceutical agents, focusing on quality-related issues. A recent increase in the use of generic drugs emphasized the importance of strengthening active pharmaceutical ingredient (API) supply chains and ensuring GMP compliance among drug manufacturers. In addition, increasing recalls in the drug products of certain marketing authorization holders due to storage stability problems strongly suggests the need to improve their development process considerably. Other measures to stabilize the supply of pharmaceuticals, including increasing stockpiles of APIs, were also discussed.
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Affiliation(s)
| | - Yasuhiro Abe
- Division of Drugs, National Institute of Health Sciences
| | - Mari Kurita
- Division of Drugs, National Institute of Health Sciences
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14
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Majeed H, Gangu K, Shekhar R, Sagheer S, Garg I, Shuja H, Bobba A, Chourasia P, Avula SR, Sheikh AB. Impact of COVID-19 on Patients Hospitalized with ST-Segment Elevation Myocardial Infarction in the United States during the Early Pandemic: An Analysis of Outcomes, Care Delivery, and Racial Disparities in Mortality. Infect Dis Rep 2023; 15:55-65. [PMID: 36648860 PMCID: PMC9844427 DOI: 10.3390/idr15010006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/18/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
The COVID-19 pandemic has impacted healthcare delivery to patients with ST-segment elevation myocardial infarction (STEMI). The aim of our retrospective study was to determine the effect of COVID-19 on inpatient STEMI outcomes and to investigate changes in cardiac care delivery during 2020. We utilized the National Inpatient Sample database to examine inpatient mortality and cardiac procedures among STEMI patients with and without COVID-19. In our study, STEMI patients with COVID-19 had higher inpatient mortality (47.4% vs. 11.2%, aOR: 3.8, 95% CI: 3.2−4.6, p < 0.001), increased length of stay (9.0 days vs. 4.3 days, p < 0.001) and higher cost of hospitalization (USD 172,518 vs. USD 131,841, p = 0.004) when compared to STEMI patients without COVID-19. STEMI patients with COVID-19 also received significantly less invasive cardiac procedures (coronary angiograms: 30.4% vs. 50.8%, p < 0.001; PCI: 32.9% vs. 70.1%, p < 0.001; CABG: 0.9% vs. 4.1%, p < 0.001) and were more likely to receive systemic thrombolytic therapy (4.2% vs. 1.1%, p < 0.001) when compared to STEMI patients without COVID-19. Our findings are the result of complications of SARS-CoV2 infection as well as alterations in healthcare delivery due to the burden of the COVID-19 pandemic.
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Affiliation(s)
- Harris Majeed
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Karthik Gangu
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
| | - Rahul Shekhar
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Shazib Sagheer
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Hina Shuja
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Aniesh Bobba
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Prabal Chourasia
- Division of Hospital Medicine, Mary Washington Hospital, Fredericksburg, VA 22401, USA
| | - Sindhu Reddy Avula
- Department of Interventional Cardiology, Division of Cardiology, University of Kansas Health System St. Francis Campus, Kansas City, KS 66606, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
- Correspondence:
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15
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Pancholi P, Wu J, Lessen S, Brogan J, Quinn NJ, Gong MN, Moskowitz A. Triglyceride Concentrations and Their Relationship to Sedation Choice and Outcomes in Mechanically Ventilated Patients Receiving Propofol. Ann Am Thorac Soc 2023; 20:94-101. [PMID: 36053664 PMCID: PMC9819266 DOI: 10.1513/annalsats.202205-403oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/02/2022] [Indexed: 02/05/2023] Open
Abstract
Rationale: Propofol is a first-line sedative agent in the intensive care unit (ICU) but may be associated with hypertriglyceridemia and pancreatitis. To date, the relationship between propofol-induced hypertriglyceridemia and pancreatitis, as well as clinician responses to propofol-induced hypertriglyceridemia, have not been comprehensively studied. Objectives: To assess the incidence of hypertriglyceridemia and pancreatitis in patients receiving continuous propofol infusions in the ICU and to describe the association between hypertriglyceridemia and the use of nonpropofol continuous sedative infusions. Methods: This was a retrospective observational cohort study conducted at three urban academic hospitals within a single health system. Findings were additionally validated using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database containing data from a separate tertiary care hospital. Mechanically ventilated adult patients who received a continuous propofol infusion between 2016 and 2021 were included. The primary exposure was serum triglyceride concentration, and hypertriglyceridemia was defined as a triglyceride concentration greater than 400 mg/dl. Outcomes included new-onset pancreatitis as well as receipt of midazolam, dexmedetomidine, or ketamine after the triglyceride measurement. The incidence of pancreatitis was compared between groups using a Fisher's Exact test. Multivariable logistic regression was used to assess the association between dichotomized triglyceride concentration and alternative sedative use. Results: In the primary cohort of 7,037 patients, 1,724 (24.5%) had one or more triglyceride concentration measured. Of these, 1,365 (79.2%) had a maximum concentration of less than 400 mg/dl, and 359 (20.8%) had a maximum concentration of greater than 400 mg/dl. Compared with patients with low triglyceride concentrations, patients with high triglyceride concentrations were more likely to receive a continuous infusion of midazolam (37.0% vs. 16.4%; adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 2.2-4.4; P < 0.01), ketamine (22.8% vs. 6.9%; aOR, 3.5; 95% CI, 2.3-5.3; P < 0.01), and dexmedetomidine (57.7% vs. 46.6%; aOR, 1.5; 95% CI, 1.1-2.0; P < 0.01). Rates of midazolam infusion increased as triglyceride concentrations exceeded 500 mg/dl. Forty-four (0.6%) patients developed pancreatitis after propofol initiation, of which 4 (9.1%) were considered related to propofol-associated hypertriglyceridemia. Findings were similar in the MIMIC-IV cohort. Conclusions: Propofol-associated hypertriglyceridemia is relatively common in mechanically ventilated ICU patients who have triglycerides measured. Pancreatitis related to propofol-associated hypertriglyceridemia is rare. Patients who develop hypertriglyceridemia while receiving propofol are more likely to receive continuous infusions of other sedatives.
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Affiliation(s)
| | | | | | - James Brogan
- Albert Einstein College of Medicine, The Bronx, New York
| | - Nicholas J. Quinn
- Department of Pharmacy, Montefiore Medical Center, The Bronx, New York
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16
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Heart rate, arterial pressure and propofol-sparing effects of guaifenesin in dogs. Vet Anaesth Analg 2023; 50:50-56. [PMID: 36344374 DOI: 10.1016/j.vaa.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the heart rate (HR) and systemic arterial pressure (sAP) effects, and propofol induction dose requirements in healthy dogs administered propofol with or without guaifenesin for the induction of anesthesia. STUDY DESIGN Prospective blinded crossover experimental study. ANIMALS A total of 10 healthy adult female Beagle dogs. METHODS Dogs were premedicated with intravenous (IV) butorphanol (0.4 mg kg-1) and administered guaifenesin 5% at 50 mg kg-1 (treatment G50), 100 mg kg-1 (treatment G100) or saline (treatment saline) IV prior to anesthetic induction with propofol. HR, invasive sAP and respiratory rate (fR) were recorded after butorphanol administration, after guaifenesin administration and after propofol and endotracheal intubation. Propofol doses for intubation were recorded. Repeated measures analysis of variance (anova) was used to determine differences in propofol dose requirements among treatments, and differences in cardiopulmonary values over time and among treatments with p < 0.05 considered statistically significant. RESULTS Propofol doses (mean ± standard deviation) for treatments saline, G50 and G100 were 3.3 ± 1.0, 2.7 ± 0.7 and 2.1 ± 0.8 mg kg-1, respectively. Propofol administered was significantly lower in treatment G100 than in treatment saline (p = 0.04). In treatments G50 and G100, HR increased following induction of anesthesia and intubation compared with baseline measurements. HR was higher in treatment G100 than in treatments G50 and saline following induction of anesthesia. In all treatments, sAP decreased following intubation compared with baseline values. There were no significant differences in sAP among treatments. fR was lower following intubation than baseline and post co-induction values and did not differ significantly among treatments. CONCLUSIONS AND CLINICAL RELEVANCE When administered as a co-induction agent in dogs, guaifenesin reduced propofol requirements for tracheal intubation. HR increased and sAP and fR decreased, but mean values remained clinically acceptable.
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17
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Blondonnet R, Balde A, Zhai R, Pereira B, Futier E, Bazin JE, Godet T, Constantin JM, Lambert C, Jabaudon M. Use of volatile anesthetics for sedation in the ICU during the COVID-19 pandemic: A national survey in France (VOL'ICU 2 study). PLoS One 2022; 17:e0278090. [PMID: 36580451 PMCID: PMC9799316 DOI: 10.1371/journal.pone.0278090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/09/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has increased the number of patients in ICUs leading to a worldwide shortage of the intravenous sedative agents obligating physicians to find alternatives including inhaled sedation. Inhaled sedation in French ICU has been previously explored in 2019 (VOL'ICU study). This survey was designed to explore the use of inhaled sedation two years after our first survey and to evaluate how the COVID-19 pandemic has impacted the use of inhaled sedation. METHODS We designed a national survey, contacting medical directors of French ICUs between June and October 2021. Over a 50-item questionnaire, the survey covered the characteristics of the ICU, data on inhaled sedation, and practical aspects of inhaled ICU sedation for both COVID-19 and non-COVID-19 patients. Answers were compared with the previous survey, VOL'ICU. RESULTS Among the 405 ICUs contacted, 25% of the questionnaires were recorded. Most ICU directors (87%) knew about the use of inhaled ICU sedation and 63% of them have an inhaled sedation's device in their unit. The COVID-19 pandemic increased the use of inhaled sedation in French ICUs. The main reasons said by the respondent were "need for additional sedative" (62%), "shortage of intravenous sedatives" (38%) and "involved in a clinical trial" (30%). The main reasons for not using inhaled ICU sedation were "device not available" (76%), "lack of familiarity" (60%) and "no training for the teams" (58%). More than 70% of respondents were overall satisfied with the use of inhaled sedation. Almost 80% of respondents stated that inhaled sedation was a seducing alternative to intravenous sedation for management of COVID-19 patients. CONCLUSION The use of inhaled sedation in ICU has increased fastly in the last 2 years, and is frequently associated with a good satisfaction among the users. Even if the COVID-19 pandemic could have impacted the widespread use of inhaled sedation, it represents an alternative to intravenous sedation for more and more physicians.
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Affiliation(s)
- Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- * E-mail:
| | - Aissatou Balde
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ruoyang Zhai
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, GRC 29, AP-HP, DMU DREAM, Sorbonne University, Paris, France
| | - Céline Lambert
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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18
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Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J 2022; 68:1419-1427. [PMID: 35593878 PMCID: PMC9675878 DOI: 10.1097/mat.0000000000001758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly utilized intervention for cardiopulmonary failure. Analgosedation during ECMO support is essential to ensure adequate pain and agitation control and ventilator synchrony, optimize ECMO support, facilitate patient assessment, and minimize adverse events. Although the principles of analgosedation are likely similar for all critically ill patients, ECMO circuitry alters medication pharmacodynamics and pharmacokinetics. The lack of clinical guidelines for analgosedation during ECMO, especially at times of medication shortage, can affect patient management. Here, we review pharmacological considerations, protocols, and special considerations for analgosedation in critically ill adults receiving ECMO support.
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Sim J, Goh WY, Wiryasaputra L, Hum AYM, Neo HY, Poi CH. Use of Phenobarbitone for Palliative Sedation in Dyspneic Crises Due to COVID-19 Pneumonia - A Case Series. J Pain Palliat Care Pharmacother 2022; 36:242-248. [PMID: 36005904 DOI: 10.1080/15360288.2022.2113596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Patients who suffer from dyspnea while dying from COVID-19 are treated with opioids and benzodiazepines. In some instances, patients may experience refractory dyspnea at the end of life. Palliative sedation can be prescribed to alleviate such patients' suffering. We describe two patients being treated for severe COVID-19 pneumonia in a tertiary hospital. Both developed intractable dyspneic crises despite high-dose opioids and benzodiazepines. This led to their requirement of palliative sedation in the general ward using subcutaneous phenobarbitone (phenobarbital). We outline clinical considerations for the use of palliative sedation in COVID-19 related dyspnea. In particular, we discuss the evidence for, benefits and limitations of using phenobarbitone for palliative sedation in COVID-19 patients.
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Affiliation(s)
- Jingwei Sim
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wen Yang Goh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Lynn Wiryasaputra
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Yin-Mei Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Han Yee Neo
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Choo Hwee Poi
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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20
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Majeed H, Gangu K, Sagheer S, Garg I, Khan U, Shuja H, Bobba A, Chourasia P, Shekhar R, Avula SR, Sheikh AB. COVID-19 and NSTEMI Outcomes among Hospitalized Patients in the United States and Racial Disparities in Mortality: Insight from National Inpatient Sample Database. Vaccines (Basel) 2022; 10:vaccines10122024. [PMID: 36560434 PMCID: PMC9780864 DOI: 10.3390/vaccines10122024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
The COVID-19 pandemic has impacted healthcare delivery to patients with non-ST-segment elevation myocardial infraction (NSTEMI). The aim of our retrospective study is to determine the effect of COVID-19 on inpatient NSTEMI outcomes and to investigate whether changes in cardiac care contributed to the observed outcomes. After multivariate adjustment, we found that NSTEMI patients with COVID-19 had a higher rate of inpatient mortality (37.3% vs. 7.3%, adjusted odds ratio: 4.96, 95% CI: 4.6−5.4, p < 0.001), increased length of stay (9.9 days vs. 5.4 days, adjusted LOS: 3.6 days longer, p < 0.001), and a higher cost of hospitalization (150,000 USD vs. 110,000 USD, inflation-adjusted cost of hospitalization: 36,000 USD higher, p < 0.001) in comparison to NSTEMI patients without COVID-19, despite a lower burden of pre-existing cardiac comorbidity. NSTEMI patients with COVID-19 also received less invasive cardiac procedures (coronary angiography: 8.7% vs. 50.3%, p < 0.001; PCI: 4.8% vs. 29%, p < 0.001; and CABG: 0.7% vs. 6.2%, p < 0.001). In our study, we observed increased mortality and in-hospital complications to be a combined effect of COVID-19 infection and myocardial inflammation as a result of cytokine storm, prothrombic state, oxygen supply/demand imbalance and alterations in healthcare delivery from January to December 2020.
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Affiliation(s)
- Harris Majeed
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Karthik Gangu
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
| | - Shazib Sagheer
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Umair Khan
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Hina Shuja
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Aniesh Bobba
- Department of Medicine, John H. Stronger Hospital, Cook County, Chicago, IL 60612, USA
| | - Prabal Chourasia
- Division of Hospital Medicine, Mary Washington Hospital, Fredericksburg, VA 22401, USA
| | - Rahul Shekhar
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Sindhu Reddy Avula
- Department of Interventional Cardiology, Division of Cardiology, University of Kansas, St. Francis Campus, Kansas City, KS 66606, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
- Correspondence: ; Tel.: +1-505-272-4661
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Tobar E, Farías JI, Rojas V, Penna A, Egaña JI, Ponce D, Bravo D, Maldonado F, Gajardo A, Gutiérrez R. Electroencephalography spectral edge frequency and suppression rate-guided sedation in patients with COVID-19: A randomized controlled trial. Front Med (Lausanne) 2022; 9:1013430. [DOI: 10.3389/fmed.2022.1013430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
BackgroundSedation in coronavirus disease 2019 (COVID-19) patients has been identified as a major challenge. We aimed to investigate whether the use of a multiparameter electroencephalogram (EEG) protocol to guide sedation in COVID-19 patients would increase the 30-day mechanical ventilation-free days (VFD).MethodsWe conducted a double-blind randomized clinical trial. We included patients with severe pneumonia due to COVID-19 who required mechanical ventilation (MV) and deep sedation. We randomized to the control (n = 25) or multiparameter group (n = 25). Sedation in the intervention group was administered following the standard institutional protocols together with a flow chart designed to reduce the propofol administration dose if the EEG suppression rate was over 2% or the spectral edge frequency 95 (SEF95) was below 10 Hz. We performed an intention-to-treat analysis to evaluate our primary outcome (30-day VFD).ResultsThere was no difference in VFD at day 30 (median: 11 [IQR 0–20] days in the control group vs. 0 [IQR 0–21] days in the BIS multiparameter group, p = 0.87). Among secondary outcomes, we documented a 17% reduction in the total adjusted propofol administered during the first 5 days of the protocol [median: 2.3 (IQR 1.9–2.8) mg/k/h in the control group vs. 1.9(IQR 1.5–2.2) mg/k/h in the MP group, p = 0.005]. This was accompanied by a higher average BIS value in the intervention group throughout the treatment period.ConclusionA sedation protocol guided by multivariate EEG-derived parameters did not increase the 30-day VFD. However, the intervention led to a reduction in total propofol administration.
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Machado-Duque ME, Gaviria-Mendoza A, Valladales-Restrepo LF, Albanés-Beltrán JP, Machado-Alba JE. Trends in the Use of Sedative-Hypnotics, Opioids, and Neuromuscular Blockers in Hospitalized Patients During the COVID-19 Pandemic: Observational Retrospective Study. Drugs Real World Outcomes 2022; 9:629-638. [PMID: 36329371 PMCID: PMC9633019 DOI: 10.1007/s40801-022-00337-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has increased the use of drugs administered for mechanical ventilation, leading to shortages in some countries. Objective The aim was to identify trends in the consumption of sedatives, hypnotics, neuromuscular blockers, and opioids used for anesthetic induction and deep sedation in hospitals in Colombia. Method This was a descriptive, longitudinal, and retrospective study with monthly follow-up of sedative, hypnotic, opioid, and neuromuscular blocker dispensing in 20 clinics and hospitals from January to November 2020. The frequencies of use of each drug and variations in the institutions and intensive care units (ICUs) were identified. Results A total of 1,252,576 units of the analyzed drugs were delivered to 79,094 treated patients, 55.0% of whom were women (n = 43,521). The drugs with the greatest increase in consumption were rocuronium (1058% variation in March–November) and propofol (511%). The consumption of midazolam and vecuronium initially increased, but by the end of the study period, it decreased. Among drugs dispensed only in ICUs, 920,170 units were delivered (73.5% of the drugs dispensed during the study), and the most often dispensed drugs were fentanyl (n = 251,519; 27.3% of the drugs used in the ICU) and midazolam (5 mg/5 mL) solution (n = 188,568; 20.5%). Specifically in the ICU, the drugs with the greatest increase in use were rocuronium (19,709%), propofol (2622%), and ketamine (2591%). Conclusion Rapid changes in the use of drugs were evident, which demonstrates the need for closer cooperation among treating physicians, service providers, pharmaceutical managers, and state institutions to maintain a sufficient and timely supply of critical drugs in this type of contingency. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-022-00337-z.
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Affiliation(s)
- Manuel E. Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A. Pereira, Calle 105 No. 14-140, Pereira, 660003 Risaralda, Colombia ,Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A. Pereira, Calle 105 No. 14-140, Pereira, 660003 Risaralda, Colombia ,Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A. Pereira, Calle 105 No. 14-140, Pereira, 660003 Risaralda, Colombia ,Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Juan Pablo Albanés-Beltrán
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A. Pereira, Calle 105 No. 14-140, Pereira, 660003 Risaralda, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A. Pereira, Calle 105 No. 14-140, Pereira, 660003 Risaralda, Colombia
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Bose S, Kelly L, Shahn Z, Novack L, Banner‐Goodspeed V, Subramaniam B. Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID-19 patients: A retrospective cohort study. Acta Anaesthesiol Scand 2022; 66:1099-1106. [PMID: 35900078 PMCID: PMC9353360 DOI: 10.1111/aas.14119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/01/2022] [Accepted: 07/05/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Polypharmacy of sedatives (PP) is a potentially modifiable, iatrogenic risk factor for ICU delirium. The extent to which sedative PP influenced development of high rates of delirium among critically ill COVID-19 patients is unknown. We tested the hypothesis that PP, defined as the use of four or more classes of intravenous agents, is a mediator in the causal pathway of mechanical ventilation and delirium. METHODS Retrospective cohort study of adults admitted with a primary diagnosis of RT-PCR+ for SARS-CoV2 to ICUs of a tertiary-level academic medical center between February 2020 and April 2021. Mediation analysis was conducted with bootstrap estimation to assess whether an association between mechanical ventilation and delirium was mediated by PP. Analyses were adjusted for potential confounders related to mechanical ventilation, mediator, and outcome, including age, gender, vasopressor use, median RASS scores, SOFA score within 24 h of admission, and maximum CRP levels. RESULTS A total of 212 patients were included in the analysis. Of total patients, 72.6%(154/212) of patients had delirium (CAM-ICU+) during ICU stay. 54.7%(116/212) patients received PP. Mechanical ventilation (OR 3.81 [1.16-12.52]) and PP (OR 7.38 [2.4-22.68]) were identified as risk factors for development of ICU delirium after adjusting for prespecified confounders. PP acts as a mediator in the causal pathway between mechanical ventilation and delirium. 39% (95% CI: 17%-94%) of the effect of mechanical ventilation on delirium was mediated through PP. CONCLUSION PP mediates approximately 39% of the effect of mechanical ventilation on delirium, which is clinically and statistically significant. Studies should assess whether mitigating PP could lead to reduction in ICU delirium. IMPLICATION STATEMENT PP of sedatives (defined as use of four or more intravenous agents) mediates approximately 39% of the effect of mechanical ventilation on development of ICU delirium. Avoidance of sedative PP may represent a viable strategy for reduction of ICU delirium.
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Affiliation(s)
- Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
- Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Lauren Kelly
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
- Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Zachary Shahn
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health and Public PolicyNew YorkNew YorkUSA
| | - Lena Novack
- Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Soroka University Medical CenterBeer‐ShevaIsrael
| | - Valerie Banner‐Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
- Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
- Sadhguru Center for a Conscious Planet‐Enhancing ConsciousnessCognition, and CompassionBostonMassachusettsUSA
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Jung H, Lee J, Ahn HY, Yang JH, Suh GY, Ko RE, Chung CR. Safety and feasibility of continuous ketamine infusion for analgosedation in medical and cardiac ICU patients who received mechanical ventilation support: A retrospective cohort study. PLoS One 2022; 17:e0274865. [PMID: 36137164 PMCID: PMC9499237 DOI: 10.1371/journal.pone.0274865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/07/2022] [Indexed: 12/16/2022] Open
Abstract
Purpose To assess the effect of continuous ketamine administration in patients admitted to medical and cardiac intensive care units (ICUs) and received mechanical ventilation support. Methods We conducted a retrospective cohort study between March 2012 and June 2020 at an academy-affiliated tertiary hospital. Adult patients who received mechanical ventilation support for over 24 h and continuous ketamine infusion for at least 8 h were included. The primary outcome was immediate hemodynamic safety after continuous ketamine infusion. The secondary outcomes included immediate delirium, pain, and use of sedation. Results Of all 12,534 medical and cardiac ICU patients, 564 were eligible for the analysis. Ketamine was used for 33.3 (19.0–67.5) h and the median continuous infusion dose was 0.11 (0.06–0.23) mcg/kg/h. Of all patients, 469 (83.2%) received continuous ketamine infusion concomitant with analgosedation. Blood pressure and vasopressor inotropic scores did not change after continuous ketamine infusion. Heart rate decreased significantly from 106.9 (91.4–120.9) at 8 h before ketamine initiation to 99.8% (83.9–114.4) at 24 h after ketamine initiation. In addition, the respiratory rate decreased from 21.7 (18.6–25.4) at 8 h before ketamine initiation to 20.1 (17.0–23.0) at 24 h after ketamine initiation. Overall opioid usage was significantly reduced: 3.0 (0.0–6.0) mcg/kg/h as fentanyl equivalent dose at 8 h before ketamine initiation to 1.0 (0.0–4.1) mcg/kg/h as fentanyl equivalent dose at 24 h post-ketamine initiation. However, the use of sedatives and antipsychotic medications did not decrease. In addition, ketamine did not increase the incidence of delirium within 24 h after ketamine infusion. Conclusion Ketamine may be a safe and feasible analgesic for medical and cardiac ICU patients who received mechanical ventilation support as an opioid-sparing agent without adverse hemodynamic effects.
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Affiliation(s)
- Hohyung Jung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jihye Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Young Ahn
- Department of Pharmaceutical Services, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail: (REK); (CRC)
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
- * E-mail: (REK); (CRC)
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Implementation of supply management strategies by the pharmacy service in a general hospital during the COVID-19 pandemic. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 7:100161. [PMID: 35910488 PMCID: PMC9316629 DOI: 10.1016/j.rcsop.2022.100161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Given the global uncertainty faced due to the Covid-19 pandemic, health services were forced to adjust inventory management and purchase projections. This publication aims to describe the strategies taken and their impact on the supply chain indicators by the pharmacy service in the management of drug purchases during the pandemic to expose the importance of pharmacist in charge of the supply chain. Methods This observational study describes the drug purchasing system in a general hospital and the strategies used to manage drug supply. The actions proposed by the pharmacy department are listed chronologically related to inventory issues and purchasing decisions. The accuracy of the purchase forecast was evaluated by calculating indicators such as the mean absolute standard deviation (MAD) and the variance of the forecast error (MSE). Inventory days and inventory turnover indicators were also compared in pre-pandemic and pre-pandemic periods. Findings In general, the forecast error given by MAD and MSE tended to decrease. Specifically, from the 82 drug categories, during the pandemic period, this indicator decreased in 72 (88%), increased in 9 (11%), and remained the same in only 1 (1%) of the categories. In financial terms, comparing the 2018–2019 and 2020–2021 periods, a favorable result was obtained when evaluating the inventory turnover indicators, which decreased by 0.01 points and the days of inventory increased on average by two days. Conclusions The implementation and use of these indicators prevented drug shortages, reducing inventory forecast errors. A pharmacist with knowledge in inventory management allows managing a process of continuous improvement and tactics for efficient inventory management without neglecting the benefit to patients or the economic profitability of the service. There were limitations since digital operating systems do not generate centralized or organized data for this type of analysis.
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Rodríguez-Blanco J, Rodríguez-Yanez T, Rodríguez-Blanco JD, Almanza-Hurtado AJ, Martínez-Ávila MC, Borré-Naranjo D, Acuña Caballero MC, Dueñas-Castell C. Neuromuscular blocking agents in the intensive care unit. J Int Med Res 2022; 50:3000605221128148. [PMID: 36173012 PMCID: PMC9528036 DOI: 10.1177/03000605221128148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.
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Affiliation(s)
- Jonathan Rodríguez-Blanco
- Divission of Pain Medicine, Department of Anesthesiology, University of Antioquia, Medellin, Colombia
| | - Tomás Rodríguez-Yanez
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | | | | | - Diana Borré-Naranjo
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | - Carmelo Dueñas-Castell
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
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Silent Hypoxemia in the Emergency Department: A Retrospective Cohort of Two Clinical Phenotypes in Critical COVID-19. J Clin Med 2022; 11:jcm11175034. [PMID: 36078970 PMCID: PMC9457247 DOI: 10.3390/jcm11175034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Understanding hypoxemia, with and without the clinical signs of acute respiratory failure (ARF) in COVID-19, is key for management. Hence, from a population of critical patients admitted to the emergency department (ED), we aimed to study silent hypoxemia (Phenotype I) in comparison to symptomatic hypoxemia with clinical signs of ARF (Phenotype II). Methods: This multicenter study was conducted between 1 March and 30 April 2020. Adult patients who were presented to the EDs of nine Great-Eastern French hospitals for confirmed severe or critical COVID-19, who were then directly admitted to the intensive care unit (ICU), were retrospectively included. Results: A total of 423 critical COVID-19 patients were included, out of whom 56.1% presented symptomatic hypoxemia with clinical signs of ARF, whereas 43.9% presented silent hypoxemia. Patients with clinical phenotype II were primarily intubated, initially, in the ED (46%, p < 0.001), whereas those with silent hypoxemia (56.5%, p < 0.001) were primarily intubated in the ICU. Initial univariate analysis revealed higher ICU mortality (29.2% versus 18.8%, p < 0.014) and in-hospital mortality (32.5% versus 18.8%, p < 0.002) in phenotype II. However, multivariate analysis showed no significant differences between the two phenotypes regarding mortality and hospital or ICU length of stay. Conclusions: Silent hypoxemia is explained by various mechanisms, most physiological and unspecific to COVID-19. Survival was found to be comparable in both phenotypes, with decreased survival in favor of Phenotype II. However, the spectrum of silent to symptomatic hypoxemia appears to include a continuum of disease progression, which can brutally evolve into fatal ARF.
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Shang Y, Wu J, Liu J, Long Y, Xie J, Zhang D, Hu B, Zong Y, Liao X, Shang X, Ding R, Kang K, Liu J, Pan A, Xu Y, Wang C, Xu Q, Zhang X, Zhang J, Liu L, Zhang J, Yang Y, Yu K, Guan X, Chen D. Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019 (COVID-19). JOURNAL OF INTENSIVE MEDICINE 2022; 2:199-222. [PMID: 36785648 PMCID: PMC9411033 DOI: 10.1016/j.jointm.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/24/2022] [Indexed: 12/16/2022]
Affiliation(s)
- You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Jianfeng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510010, China
| | - Jinglun Liu
- Department of Emergency and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, China
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Yuan Zong
- Department of Critical Care Medicine, Shaanxi Provincial Hospital, Xi'an, Shannxi 710068, China
| | - Xuelian Liao
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiuling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fuzhou, Fujian 350001, China
| | - Renyu Ding
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning 110001, China
| | - Kai Kang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Yonghao Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Changsong Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang 150001, China
| | - Qianghong Xu
- Department of Critical Care Medicine, Zhejiang Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, Zhejiang 310013, China
| | - Xijing Zhang
- Department of Critical Care Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shannxi 710032, China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, China
| | - Jiancheng Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Yi Yang
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China
- Corresponding authors: Dechang Chen, Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China. Xiangdong Guan, Department of Critical Care Medicine, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China. Kaijiang Yu, Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China.
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510010, China
- Corresponding authors: Dechang Chen, Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China. Xiangdong Guan, Department of Critical Care Medicine, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China. Kaijiang Yu, Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China.
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Corresponding authors: Dechang Chen, Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China. Xiangdong Guan, Department of Critical Care Medicine, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China. Kaijiang Yu, Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China.
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Lele AV, Wahlster S, Alunpipachathai B, Awraris Gebrewold M, Chou SHY, Crabtree G, English S, Der-Nigoghossian C, Gagnon DJ, Kim-Tenser M, Karanjia N, Kirkman MA, Lamperti M, Livesay SL, Mejia-Mantilla J, Melmed K, Prabhakar H, Tumino L, Venkatasubba Rao CP, Udy AA, Videtta W, Moheet AM. Perceptions Regarding the SARS-CoV-2 Pandemic's Impact on Neurocritical Care Delivery: Results From a Global Survey. J Neurosurg Anesthesiol 2022; 34:209-220. [PMID: 34882104 PMCID: PMC8900891 DOI: 10.1097/ana.0000000000000825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The SARS-CoV-2 (COVID-19) pandemic has impacted many facets of critical care delivery. METHODS An electronic survey was distributed to explore the pandemic's perceived impact on neurocritical care delivery between June 2020 and March 2021. Variables were stratified by World Bank country income level, presence of a dedicated neurocritical care unit (NCCU) and experiencing a COVID-19 patient surge. RESULTS Respondents from 253 hospitals (78.3% response rate) from 47 countries (45.5% low/middle income countries; 54.5% with a dedicated NCCU; 78.6% experienced a first surge) participated in the study. Independent of country income level, NCCU and surge status, participants reported reductions in NCCU admissions (67%), critical care drug shortages (69%), reduction in ancillary services (43%) and routine diagnostic testing (61%), and temporary cancellation of didactic teaching (44%) and clinical/basic science research (70%). Respondents from low/middle income countries were more likely to report lack of surge preparedness (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.8-5.8) and struggling to return to prepandemic standards of care (OR, 12.2; 95% CI, 4.4-34) compared with respondents from high-income countries. Respondents experiencing a surge were more likely to report conversion of NCCUs and general-mixed intensive care units (ICUs) to a COVID-ICU (OR 3.7; 95% CI, 1.9-7.3), conversion of non-ICU beds to ICU beds (OR, 3.4; 95% CI, 1.8-6.5), and deviations in critical care and pharmaceutical practices (OR, 4.2; 95% CI 2.1-8.2). Respondents from hospitals with a dedicated NCCU were less likely to report conversion to a COVID-ICU (OR, 0.5; 95% CI, 0.3-0.9) or conversion of non-ICU to ICU beds (OR, 0.5; 95% CI, 0.3-0.9). CONCLUSION This study reports the perceived impact of the COVID-19 pandemic on global neurocritical care delivery, and highlights shortcomings of health care infrastructures and the importance of pandemic preparedness.
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Affiliation(s)
- Abhijit V. Lele
- Departments of Anesthesiology and Pain Medicine, and Neurological Surgery
| | - Sarah Wahlster
- Neurology, Anesthesiology and Pain Medicine, and Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Meron Awraris Gebrewold
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sherry H.-Y. Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - Gretchen Crabtree
- Neurocritical Care, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - Shane English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York City, NY
| | - David J. Gagnon
- Maine Medical Center, Tufts University School of Medicine, Maine Medical Center Research Institute, Portland, ME
| | - May Kim-Tenser
- University of Southern California/Keck School of Medicine, Los Angeles
| | | | - Matthew A. Kirkman
- Atkinson Morley Regional Neurosciences Centre, St George’s Hospital, London, UK
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | | | - Kara Melmed
- Department of Neurology and Neurosurgery at NYU Grossman School of Medicine, Langone Health, New York City, NY
| | - Hemanshu Prabhakar
- Departments of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Leandro Tumino
- HIGA San Martín de La Plata y Clinica San Camilo, Argentina
| | - Chethan P. Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and St. Luke’s Medical Center, Houston, TX
| | - Andrew A. Udy
- Department of Intensive Care & Hyperbaric Medicine, The Alfred Hospital, and Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Vic., Australia
| | | | - Asma M. Moheet
- Neurocritical Care, OhioHealth Riverside Methodist Hospital, Columbus, OH
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Traxler BD, Rucker BM, Greenough MC, Sajjadi NB, Hartwell M. The Influence of COVID-19 on Clinical Trial Discontinuation in Anesthesiology: Cross-Sectional Analysis. JMIR Perioper Med 2022; 5:e34936. [PMID: 35358057 PMCID: PMC8985690 DOI: 10.2196/34936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic dramatically altered perioperative medical practice due to safety concerns, postponing elective or non-emergent procedures, supply chain shortages, and reallocating perioperative staff to care for patients with COVID-19. However, the impact of the pandemic on the conduct on Anesthesiology clinical research is unknown. OBJECTIVE The primary objective was to quantify the magnitude of the COVID-19 pandemic's impact on anesthesiology clinical research. METHODS We performed a systematic search using ClinicalTrials.gov to identify clinical trials related to the practice of anesthesiology. We searched through trials with status updates between January 1, 2020 through October 1, 2021 to capture trials potentially affected by the COVID-19 pandemic by the time of our search. Investigators screened for relevant studies and extracted trial characteristics along with the reason for discontinuation reported on the clinical trial registry. RESULTS A total of 823 clinical trials met inclusion criteria, and 146 clinical trials were discontinued within the designated date range. Twenty-four (16.4%) of the 146 clinical trials were halted explicitly due to the COVID-19 pandemic. A significant association existed between trial enrollment numbers and the likelihood of discontinuation due to COVID-19, as larger trials were more likely to be disrupted (z= -2.914, P=.0036). CONCLUSIONS The COVID-19 pandemic has been reportedly associated with the discontinuation of anesthesiology-related clinical trials. With the uncertain course of the COVID-19 pandemic, developing anesthesia trial protocols to help minimize social interaction and prevent premature trial disruption are imperative.
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Affiliation(s)
- Brett D Traxler
- Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Office of Medical Student Research, 1111 W 17th Street, Tulsa, US
| | - Brayden M Rucker
- Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Office of Medical Student Research, 1111 W 17th Street, Tulsa, US
| | - Mary C Greenough
- University of Oklahoma, School of Community Medicine, Office for Research Development and Scholarly Activity, Tulsa, US
| | - Nicholas B Sajjadi
- Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Office of Medical Student Research, 1111 W 17th Street, Tulsa, US
| | - Micah Hartwell
- Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Office of Medical Student Research, 1111 W 17th Street, Tulsa, US.,Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Department of Psychiatry and Behavioral Sciences, Tulsa, US
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31
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Luz M, Brandão Barreto B, de Castro REV, Salluh J, Dal-Pizzol F, Araujo C, De Jong A, Chanques G, Myatra SN, Tobar E, Gimenez-Esparza Vich C, Carini F, Ely EW, Stollings JL, Drumright K, Kress J, Povoa P, Shehabi Y, Mphandi W, Gusmao-Flores D. Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic. Ann Intensive Care 2022; 12:9. [PMID: 35122204 PMCID: PMC8815719 DOI: 10.1186/s13613-022-00985-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/16/2022] [Indexed: 12/16/2022] Open
Abstract
Background Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. Methods This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. Results We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. Conclusions Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00985-y.
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Affiliation(s)
- Mariana Luz
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil. .,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil. .,Intensive Care Unit, Hospital Universitário Professor Edgard Santos, Salvador, Brazil.
| | - Bruna Brandão Barreto
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil.,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Roberta Esteves Vieira de Castro
- Departamento de Pediatria, Hospital Universitário Pedro Ernesto, Universidade Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Caio Araujo
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Gérald Chanques
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Eduardo Tobar
- Internal Medicine Department, Critical Care Unit, Hospital Clínico Universidad de Chile, Santiago, Chile
| | | | - Federico Carini
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eugene Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly Drumright
- Tennessee Valley Healthcare System VA Medical Center, Nashville, TN, USA
| | - John Kress
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal.,CHRC, CEDOC, NOVA Medical School, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Yahya Shehabi
- Department of Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Wilson Mphandi
- Intensive Care Unit, Hospital Américo Boavida, Luanda, Angola
| | - Dimitri Gusmao-Flores
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil.,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
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Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:jcm11030588. [PMID: 35160040 PMCID: PMC8837042 DOI: 10.3390/jcm11030588] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.
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Palamim CVC, Boschiero MN, Faria AG, Valencise FE, Marson FAL. Opioids in COVID-19: Two Sides of a Coin. Front Pharmacol 2022; 12:758637. [PMID: 35069193 PMCID: PMC8770909 DOI: 10.3389/fphar.2021.758637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/29/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics-possibly in higher doses than usual-which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: "Opioids", "COVID-19," "COVID-19 pandemic," "SARS-CoV-2," "Opioid use disorder," "Opioid dependence" and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic. Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug. Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.
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Affiliation(s)
- Camila Vantini Capasso Palamim
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Matheus Negri Boschiero
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Aléthea Guimarães Faria
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Felipe Eduardo Valencise
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Fernando Augusto Lima Marson
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
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de Castro REV, Rodríguez-Rubio M, de Magalhães-Barbosa MC, Prata-Barbosa A, Holbrook J, Kamat P, Stormorken A. A review of key strategies to address the shortage of analgesics and sedatives in pediatric intensive care. Front Pediatr 2022; 10:895541. [PMID: 36110118 PMCID: PMC9468272 DOI: 10.3389/fped.2022.895541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Targeted analgosedation is a challenge in critically ill children, and this challenge becomes even more significant with drug shortages. OBSERVATIONS Published guidelines inform the provision of analgosedation in critically ill children. This review provides insights into general approaches using these guidelines during drug shortages in Pediatric Intensive Care Units as well as strategies to optimize both pharmacological and non-pharmacological approaches in these situations. CONCLUSIONS AND RELEVANCE Considering that drug shortages are a recurrent worldwide problem, this review may guide managing these drugs in critically ill children in situations of scarcity, such as in pandemics or disasters.
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Affiliation(s)
- Roberta Esteves Vieira de Castro
- Pediatric Intensive Care Unit, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil.,Department of Pediatrics, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil.,Department of Pediatrics, Souza Marques School of Medicine, Rio de Janeiro, RJ, Brazil
| | - Miguel Rodríguez-Rubio
- Pediatric Intensive Care Department, Hospital Universitario La Paz, Madrid, Spain.,Department of Pediatrics, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Arnaldo Prata-Barbosa
- Department of Pediatrics, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - Jaimee Holbrook
- Department of Pediatrics, University of Chicago Medicine, Chicago, IL, United States
| | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Anne Stormorken
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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35
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Long SM, Feit NZ, Chern A, Cooley V, Hill SS, Rajwani K, Schenck EJ, Stiles B, Tassler AB. Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City. Laryngoscope 2021; 131:E2849-E2856. [PMID: 34037983 PMCID: PMC8242792 DOI: 10.1002/lary.29669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/09/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN Review of prospectively collected data. METHODS Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2849-E2856, 2021.
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Affiliation(s)
- Sallie M. Long
- Department of Otolaryngology—Head and Neck SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Noah Z. Feit
- Weill Cornell Medical CollegeNew YorkNew YorkU.S.A.
| | - Alexander Chern
- Department of Otolaryngology—Head and Neck SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Victoria Cooley
- Division of Biostatistics and EpidemiologyWeill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Shanna S. Hill
- Department of AnesthesiologyNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Kapil Rajwani
- Division of Pulmonary and Critical Care MedicineNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Edward J. Schenck
- Division of Pulmonary and Critical Care MedicineNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Brendon Stiles
- Department of Cardiothoracic SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Andrew B. Tassler
- Department of Otolaryngology—Head and Neck SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
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36
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Bellgardt M, Özcelik D, Breuer-Kaiser AFC, Steinfort C, Breuer TGK, Weber TP, Herzog-Niescery J. Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome. World J Crit Care Med 2021; 10:323-333. [PMID: 34888158 PMCID: PMC8613718 DOI: 10.5492/wjccm.v10.i6.323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/24/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is a severe complication of infection with severe acute respiratory syndrome coronavirus 2, and the primary cause of death in the current pandemic. Critically ill patients often undergo extracorporeal membrane oxygenation (ECMO) therapy as the last resort over an extended period. ECMO therapy requires sedation of the patient, which is usually achieved by intravenous administration of sedatives. The shortage of intravenous sedative drugs due to the ongoing pandemic, and attempts to improve treatment outcome for COVID-19 patients, drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy. Administration of volatile anesthetics requires an appropriate delivery. Commercially available ones are the anesthetic gas reflection systems AnaConDa® and MIRUSTM, and each should be combined with a gas scavenging system. In this review, we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS. We focus particularly on the technical details of administration of volatile anesthetics. Furthermore, we describe the advantages of inhaled sedation and volatile anesthetics, and we discuss the limitations as well as the requirements for safe application in the clinical setting.
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Affiliation(s)
- Martin Bellgardt
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Dennis Özcelik
- Chemistry | Biology | Pharmacy Information Center, ETH Zürich, Zürich 8093, Switzerland
| | | | - Claudia Steinfort
- General and Visceral Surgery, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Thomas Georg Karl Breuer
- Internal Medicine/Intensive Care, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Thomas Peter Weber
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
| | - Jennifer Herzog-Niescery
- Anesthesia and Intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Bochum 44791, Germany
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Ren AL, Digby RJ, Needham EJ. Neurological update: COVID-19. J Neurol 2021; 268:4379-4387. [PMID: 33929617 PMCID: PMC8085652 DOI: 10.1007/s00415-021-10581-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus Disease 2019 is predominantly a disorder of the respiratory system, but neurological complications have been recognised since early in the pandemic. The major pathophysiological processes leading to neurological damage in COVID-19 are cerebrovascular disease, immunologically mediated neurological disorders and the detrimental effects of critical illness on the nervous system. It is still unclear whether direct invasion of the nervous system by the Severe Acute Respiratory Syndrome Coronavirus 2 occurs; given the vast numbers of people infected at this point, this uncertainty suggests that nervous system infection is unlikely to represent a significant issue if it occurs at all. In this review, we explore what has been learnt about the neurological complications of COVID-19 over the course of the pandemic, and by which mechanisms these complications most commonly occur.
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Affiliation(s)
- A L Ren
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - R J Digby
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - E J Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
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Taylor SP, Hammer JM, Taylor BT. Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation. J Intensive Care Med 2021; 37:998-1004. [PMID: 34632845 DOI: 10.1177/08850666211048779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.
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Kang N, Alrashed MA, Place EM, Nguyen PT, Perona SJ, Erstad BL. Clinical outcomes of concomitant use of enteral and intravenous sedatives and analgesics in mechanically ventilated patients with COVID-19. Am J Health Syst Pharm 2021; 79:S21-S26. [PMID: 34597357 DOI: 10.1093/ajhp/zxab385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To evaluate potential differences in days on mechanical ventilation for patients with coronavirus disease 2019 (COVID-19) based on route of administration of analgesic and sedative medications: intravenous (IV) alone vs IV + enteral (EN). SUMMARY This institutional review board-approved study evaluated ventilation time and fentanyl or midazolam requirements with or without concurrent EN hydromorphone and lorazepam. Patients were included in the study if they were 18 to 89 years old and were admitted to the intensive care unit with a positive severe acute respiratory syndrome coronavirus 2 reverse transcription and polymerase chain reaction or antigen test and respiratory failure requiring invasive mechanical ventilation for more than 72 hours. In total, 100 patients were evaluated, 60 in the IV-only group and 40 in the IV + EN group. There was not a significant difference in ventilation time between the groups (mean [SD], 19.6 [12.8] days for IV + EN vs 15.6 [11.2] days for IV only; P = 0.104). However, fentanyl (2,064 [847] μg vs 2,443 [779] μg; P < 0.001) and midazolam (137 [72] mg vs 158 [70] mg; P = 0.004) requirements on day 3 were significantly higher in the IV-only group, and the increase in fentanyl requirements from day 1 to day 3 was greater in the IV-only group than in the IV + EN group (378 [625] μg vs 34 [971] μg; P = 0.033). CONCLUSION Addition of EN analgesic and sedative medications to those administered by the IV route did not change the duration of mechanical ventilation in patients with COVID-19, but the combination may reduce IV opioid requirements, decreasing the impact of IV medication shortages.
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Affiliation(s)
- Nayoung Kang
- Department of Pharmacy, Northwest Medical Center, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Mohammed A Alrashed
- Department of Pharmacy, Northwest Medical Center, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Eric M Place
- Department of Pharmacy, Northwest Medical Center, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Phuongthao T Nguyen
- Department of Pharmacy, Northwest Medical Center, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Stephen J Perona
- Department of Pharmacy, Northwest Medical Center, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
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Pata R, Sandeep P, Aung HM, Patel MJ, Dolkar T, Nway N, Bhanu K, Ahmady A, Kiani R, Swaroop R, Schmidt F, Enriquez D. Ketamine infusion as a sedative-analgesic in severe ARDS (KISS). J Community Hosp Intern Med Perspect 2021; 11:619-623. [PMID: 34567451 PMCID: PMC8462878 DOI: 10.1080/20009666.2021.1948669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Rationale Ketamine has been used as a sedative analgesic in trauma setting, but data regarding its efficacy and safety is lacking in severe ARDS. This retrospective study aims to determine if Ketamine is safer as a sedative agent in mechanically ventilated patients. During the COVID pandemic, as there was a shortage of sedative agents, Ketamine was used. Objectives The primary objective was to compare the safety of ketamine to other sedatives. The secondary objective was to compare the effect of ketamine to other sedatives regarding the need for vasopressor, incidence of delirium, infectious complications, acute kidney injury, hospital length of stay, and length of ventilator days. Methods A retrospective, observational cohort study was conducted. Measurements and Main Results
One hundred and twenty-four patients (63 men and 61 women) were included. Thirty-four patients received ketamine, while 90 patients received other traditionally used sedatives such as propofol and midazolam. The patients’ median age was 64 years in the ketamine group and 68 years in the non-ketamine group. Seventeen patients in the ketamine group (50%) and 65 patients (72%) in the non-ketamine group had mortality (p < 0.02). The hospital length of stay was 22.85 days (± 16.36) in the ketamine group and 15.62 days (± 14.63) in the non-ketamine group (p < 0.02). There was no statistically significant difference among the outcomes of the need for vasopressor, the incidence of delirium, infectious complications, and acute kidney injury. Conclusions Ketamine as a sedative-analgesic agent in COVID-19 patients with severe acute respiratory distress syndrome demonstrated safety with reduced mortality. The ketamine group had a higher hospital length of stay, but a similar complication profile compared to the non-ketamine group. Further prospective randomized controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Ramakanth Pata
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | | | - Htun Min Aung
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Meet J Patel
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Tsering Dolkar
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Nway Nway
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | | | - Abolfazl Ahmady
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Roudabeh Kiani
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Ramaiah Swaroop
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Frances Schmidt
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Danilo Enriquez
- Department of Pulmonary and Critical Care Medicine, Interfaith Medical Center, Brooklyn, NY, USA
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Bai T, Zhu X, Zhou X, Grathwohl D, Yang P, Zha Y, Jin Y, Chong H, Yu Q, Isberner N, Wang D, Zhang L, Kortüm KM, Song J, Rasche L, Einsele H, Ning K, Hou X. Reliable and Interpretable Mortality Prediction With Strong Foresight in COVID-19 Patients: An International Study From China and Germany. Front Artif Intell 2021; 4:672050. [PMID: 34541519 PMCID: PMC8446629 DOI: 10.3389/frai.2021.672050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/26/2021] [Indexed: 12/20/2022] Open
Abstract
Cohort-independent robust mortality prediction model in patients with COVID-19 infection is not yet established. To build up a reliable, interpretable mortality prediction model with strong foresight, we have performed an international, bi-institutional study from China (Wuhan cohort, collected from January to March) and Germany (Würzburg cohort, collected from March to September). A Random Forest-based machine learning approach was applied to 1,352 patients from the Wuhan cohort, generating a mortality prediction model based on their clinical features. The results showed that five clinical features at admission, including lymphocyte (%), neutrophil count, C-reactive protein, lactate dehydrogenase, and α-hydroxybutyrate dehydrogenase, could be used for mortality prediction of COVID-19 patients with more than 91% accuracy and 99% AUC. Additionally, the time-series analysis revealed that the predictive model based on these clinical features is very robust over time when patients are in the hospital, indicating the strong association of these five clinical features with the progression of treatment as well. Moreover, for different preexisting diseases, this model also demonstrated high predictive power. Finally, the mortality prediction model has been applied to the independent Würzburg cohort, resulting in high prediction accuracy (with above 90% accuracy and 85% AUC) as well, indicating the robustness of the model in different cohorts. In summary, this study has established the mortality prediction model that allowed early classification of COVID-19 patients, not only at admission but also along the treatment timeline, not only cohort-independent but also highly interpretable. This model represents a valuable tool for triaging and optimizing the resources in COVID-19 patients.
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Affiliation(s)
- Tao Bai
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xue Zhu
- Key Laboratory of Molecular Biophysics of the Ministry of Education, Hubei Key Laboratory of Bioinformatics and Molecular-imaging, Department of Bioinformatics and Systems Biology, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Zhou
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Denise Grathwohl
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Pengshuo Yang
- Key Laboratory of Molecular Biophysics of the Ministry of Education, Hubei Key Laboratory of Bioinformatics and Molecular-imaging, Department of Bioinformatics and Systems Biology, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Yuguo Zha
- Key Laboratory of Molecular Biophysics of the Ministry of Education, Hubei Key Laboratory of Bioinformatics and Molecular-imaging, Department of Bioinformatics and Systems Biology, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Jin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Chong
- Key Laboratory of Molecular Biophysics of the Ministry of Education, Hubei Key Laboratory of Bioinformatics and Molecular-imaging, Department of Bioinformatics and Systems Biology, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Qingyang Yu
- Key Laboratory of Molecular Biophysics of the Ministry of Education, Hubei Key Laboratory of Bioinformatics and Molecular-imaging, Department of Bioinformatics and Systems Biology, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Nora Isberner
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Dongke Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - K Martin Kortüm
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Jun Song
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Leo Rasche
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Kang Ning
- Key Laboratory of Molecular Biophysics of the Ministry of Education, Hubei Key Laboratory of Bioinformatics and Molecular-imaging, Department of Bioinformatics and Systems Biology, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Beng TS, Kim CLC, Shee CC, Ching DNL, Liang TJ, Kumar MKN, Guan NC, Khuen LP, Loong LC, Chin LE, Zainuddin SI, Capelle DP, Munn AC, Yen LK, Isahak NNHN. COVID-19, Suffering and Palliative Care: A Review. Am J Hosp Palliat Care 2021; 39:986-995. [PMID: 34525862 PMCID: PMC9294437 DOI: 10.1177/10499091211046233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
According to the WHO guideline, palliative care is an integral component of COVID-19 management. The relief of physical symptoms and the provision of psychosocial support should be practiced by all healthcare workers caring for COVID-19 patients. In this review, we aim to provide a simple outline on COVID-19, suffering in COVID-19, and the role of palliative care in COVID-19. We also introduce 3 principles of palliative care that can serve as a guide for all healthcare workers caring for COVID-19 patients, which are (1) good symptom control, (2) open and sensitive communication, and (3) caring for the whole team. The pandemic has brought immense suffering, fear and death to people everywhere. The knowledge, skills and experiences from palliative care could be used to relieve the suffering of COVID-19 patients.
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Affiliation(s)
- Tan Seng Beng
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Carol Lai Cheng Kim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chai Chee Shee
- Department of Medicine, Faculty of Medicine and Health Science, University Sarawak Malaysia, Sarawak, Malaysia
| | - Diana Ng Leh Ching
- Department of Medicine, Faculty of Medicine and Health Science, University Sarawak Malaysia, Sarawak, Malaysia
| | - Tan Jiunn Liang
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Ng Chong Guan
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lim Poh Khuen
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lam Chee Loong
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Loh Ee Chin
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sheriza Izwa Zainuddin
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - David Paul Capelle
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ang Chui Munn
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lim Kah Yen
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Nakayama J, Ogihara T, Yajima R, Innami Y, Ouchi T. Anesthetic management of super-elderly patients with remimazolam: a report of two cases. JA Clin Rep 2021; 7:71. [PMID: 34528145 PMCID: PMC8442815 DOI: 10.1186/s40981-021-00474-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
Background Remimazolam is a newly developed benzodiazepine with more rapid onset and offset of sedation effects than midazolam. We report elderly patients in whom a small dose of remimazolam was successfully used for general anesthesia. Case presentation Two elderly women (patients 1 and 2, aged 95 and 103 years, respectively) underwent hip fracture surgery under general anesthesia guided by bispectral index (BIS). Anesthesia was induced with 1.2 and 1.0 mg/kg/h and maintained with 0.2 and 0.1 mg/kg/h remimazolam, combined with fentanyl and remifentanil in patients 1 and 2, respectively. Their hemodynamics were stable with a small dose of vasopressor, and they awoke soon after the discontinuation of remimazolam without flumazenil reversal. Their postoperative courses were uneventful without any complications. Conversely, the remimazolam dose required to achieve adequate sedation were much lower than expected. Conclusion Remimazolam could be useful in general anesthesia, particularly for super-elderly patients. However, the appropriate dose for induction and maintenance of anesthesia should be carefully considered based on BIS or vital signs.
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Affiliation(s)
- Junko Nakayama
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa City, Chiba, 272-8513, Japan.
| | - Tomomi Ogihara
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa City, Chiba, 272-8513, Japan
| | - Rui Yajima
- Department of Anesthesiology, Itakura Hospital, Chiba, Japan
| | - Yasushi Innami
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa City, Chiba, 272-8513, Japan
| | - Takashi Ouchi
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa City, Chiba, 272-8513, Japan
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Battaglini D, Robba C, Ball L, Silva PL, Cruz FF, Pelosi P, Rocco PRM. Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: a narrative review. Br J Anaesth 2021; 127:353-364. [PMID: 34217468 PMCID: PMC8173496 DOI: 10.1016/j.bja.2021.05.024] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/17/2021] [Accepted: 05/16/2021] [Indexed: 12/20/2022] Open
Abstract
COVID-19 pneumonia is associated with hypoxaemic respiratory failure, ranging from mild to severe. Because of the worldwide shortage of ICU beds, a relatively high number of patients with respiratory failure are receiving prolonged noninvasive respiratory support, even when their clinical status would have required invasive mechanical ventilation. There are few experimental and clinical data reporting that vigorous breathing effort during spontaneous ventilation can worsen lung injury and cause a phenomenon that has been termed patient self-inflicted lung injury (P-SILI). The aim of this narrative review is to provide an overview of P-SILI pathophysiology and the role of noninvasive respiratory support in COVID-19 pneumonia. Respiratory mechanics, vascular compromise, viscoelastic properties, lung inhomogeneity, work of breathing, and oesophageal pressure swings are discussed. The concept of P-SILI has been widely investigated in recent years, but controversies persist regarding its mechanisms. To minimise the risk of P-SILI, intensivists should better understand its underlying pathophysiology to optimise the type of noninvasive respiratory support provided to patients with COVID-19 pneumonia, and decide on the optimal timing of intubation for these patients.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil.
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Amer M, Maghrabi K, Bawazeer M, Alshaikh K, Shaban M, Rizwan M, Amin R, De Vol E, Baali M, Altewerki M, Bano M, Alkhaldi F, Alenazi S, Hijazi M. Adjunctive ketamine for sedation in critically ill mechanically ventilated patients: an active-controlled, pilot, feasibility clinical trial. J Intensive Care 2021; 9:54. [PMID: 34462007 PMCID: PMC8404029 DOI: 10.1186/s40560-021-00569-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Ketamine has been shown to decrease sedative requirements in intensive care unit (ICU). Randomized trials are limited on patient-centered outcomes. We designed this pilot trial to evaluate the feasibility of a large randomized controlled trial (RCT) testing the effect of ketamine as an adjunct analgosedative compared with standard of care alone as a control group (CG) in critically ill patients with mechanical ventilation (MV). We also provided preliminary evidence on clinically relevant outcomes to plan a larger trial. MATERIAL AND METHODS Pilot, active-controlled, open-label RCT was conducted at medical, surgical, and transplant ICUs at a large tertiary and quaternary care medical institution (King Faisal Specialist Hospital and Research Center, Saudi Arabia). The study included adult patients who were intubated within 24 h, expected to require MV for the next calendar day, and had institutional pain and sedation protocol initiated. Patients were randomized in a 1:1 ratio to adjunct ketamine infusion 1-2 μg/kg/min for 48 h or CG alone. RESULTS Of 437 patients screened from September 2019 through November 2020, 83 (18.9%) patients were included (43 in CG and 40 in ketamine) and 352 (80.5%) were excluded. Average enrollment rate was 3-4 patients/month. Consent and protocol adherence rates were adequate (89.24% and 76%, respectively). Demographics were balanced between groups. Median MV duration was 7 (interquartile range [IQR] 3-9.25 days) in ketamine and 5 (IQR 2-8 days) in CG. Median VFDs was 19 (IQR 0-24.75 days) in ketamine and 19 (IQR 0-24 days) in the CG (p = 0.70). More patients attained goal Richmond Agitation-Sedation Scale at 24 and 48 h in ketamine (67.5% and 73.5%, respectively) compared with CG (52.4% and 66.7%, respectively). Sedatives and vasopressors cumulative use, and hemodynamic changes were similar. ICU length-of-stay was 12.5 (IQR 6-21.2 days) in ketamine, compared with 12 (IQR 5.5-23 days) in CG. No serious adverse events were observed in either group. CONCLUSIONS Ketamine as an adjunct analgosedative agent appeared to be feasible and safe with no negative impact on outcomes, including hemodynamics. This pilot RCT identified areas of improvement in study protocol before conducting a large, adequately powered, multicenter RCT which is likely justified to investigate ketamine association with patient-centered outcomes further. Trial registration ClinicalTrials.gov: NCT04075006. Registered on 30 August 2019. Current controlled trials: ISRCTN14730035. Registered on 3 February 2020.
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Affiliation(s)
- Marwa Amer
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Kingdom of Saudi Arabia. .,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Khalid Maghrabi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Bawazeer
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Kamel Alshaikh
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammad Shaban
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Muhammad Rizwan
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rashid Amin
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Kingdom of Saudi Arabia
| | - Edward De Vol
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mawadah Baali
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Malak Altewerki
- Department of Neurosciences, Residency Training Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mehreen Bano
- Departments of Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fawziah Alkhaldi
- Departments of Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sanaa Alenazi
- Departments of Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Hijazi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Kim KC, Tadrous M, Kane-Gill SL, Barbash IJ, Rothenberger S, Suda KJ. Changes in Purchases for Intensive Care Medicines During the COVID-19 Pandemic: A Global Time Series Study. Chest 2021; 160:2123-2134. [PMID: 34389295 PMCID: PMC8421073 DOI: 10.1016/j.chest.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Drug supply disruptions have increased during the COVID-19 pandemic, especially for medicines used in the intensive care unit (ICU). Despite reported shortages in wealthy countries, global analyses of ICU drug purchasing during COVID-19 are limited. RESEARCH QUESTION Has COVID-19 impacted global drug purchases of first, second- and third-choice agents used in intensive care? STUDY DESIGN AND METHODS We conducted a cross-sectional time series study in a global pharmacy sales dataset comprising approximately 60% of the world's population. We analyzed pandemic-related changes in units purchased per 1,000 population for 69 ICU agents. Interventional autoregressive integrated moving average (ARIMA) models tested for significant changes when the pandemic was declared (March 2020) and during its first stage from April to August 2020, globally and by development status. RESULTS Relative to 2019, ICU drug purchases increased by 23.6% (95% CI: 7.9-37.9%) in March 2020 (P-value<0.001), and then decreased by 10.3% (95% CI:-16.9 to -3.5%) from April to August (P-value=0.006). Purchases for second-choice medicines changed the most, especially in developing countries (e.g.: 45.8% increase in March 2020). Despite similar relative changes (P-value=0.88), absolute purchasing rates in developing nations remained low. The observed decrease from April to August 2020 was only significant in developed countries (-13.1%; 95% CI: -17.4 to -4.4%; P-value< 0.001). Country-level variation appeared unrelated to expected demand and healthcare infrastructure. INTERPRETATION Purchases for intensive care medicines increased globally in the month of the COVID-19 pandemic declaration, but prior to peak infection rates. These changes were most pronounced for second-choice agents, suggesting that inexpensive, generic medicines may be more easily purchased in anticipation of pandemic-related ICU surges. Nevertheless, disparities in access persisted. Trends appeared unrelated to expected demand, and decreased purchasing from April to August 2020 may suggest over-buying. National and international policies are needed to ensure equitable drug purchasing during future pandemics.
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Affiliation(s)
- Katherine Callaway Kim
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA; University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management Pittsburgh, PA, USA.
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto Toronto, ON, Canada; Women's College Research Institute Toronto, ON, Canada
| | | | - Ian J Barbash
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA; CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
| | - Scott Rothenberger
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA
| | - Katie J Suda
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA; Center of Health Equity Research and Promotion, VA Pittsburgh Healthcare System Pittsburgh, PA, USA
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Mefford B, Donaldson JC, Bissell BD. The immunomodulatory effects of opioids and implications for intensive care unit populations. Pharmacotherapy 2021; 41:668-675. [PMID: 34129683 DOI: 10.1002/phar.2602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/05/2022]
Abstract
Analgesia within the intensive care unit (ICU) is often achieved via the utilization of opioids in alignment with current guidelines. Recent evidence has not only demonstrated the potential impact of opioids in suppression of immune function, but also the potential harm of immunosuppression of patients within the ICU. Despite the potential immunosuppression seen with opioids in this at-risk population, their use remains frequent. In this review, we highlight the potential immunomodulatory impact of opioids within the critically ill and considerations for their use.
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Kermad A, Speltz J, Danziger G, Mertke T, Bals R, Volk T, Lepper PM, Meiser A. Comparison of isoflurane and propofol sedation in critically ill COVID-19 patients-a retrospective chart review. J Anesth 2021; 35:625-632. [PMID: 34169362 PMCID: PMC8225486 DOI: 10.1007/s00540-021-02960-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/06/2021] [Indexed: 02/07/2023]
Abstract
Purpose In this retrospective study, we compared inhaled sedation with isoflurane to intravenous propofol in invasively ventilated COVID-19 patients with ARDS (Acute Respiratory Distress Syndrome). Methods Charts of all 20 patients with COVID-19 ARDS admitted to the ICU of a German University Hospital during the first wave of the pandemic between 22/03/2020 and 21/04/2020 were reviewed. Among screened 333 days, isoflurane was used in 97 days, while in 187 days, propofol was used for 12 h or more. The effect and dose of these two sedatives were compared. Mixed sedation days were excluded. Results Patients’ age (median [interquartile range]) was 64 (60–68) years. They were invasively ventilated for 36 [21–50] days. End-tidal isoflurane concentrations were high (0.96 ± 0.41 Vol %); multiple linear regression yielded the ratio (isoflurane infusion rate)/(minute ventilation) as the single best predictor. Infusion rates were decreased under ECMO (3.5 ± 1.4 versus 7.1 ± 3.2 ml∙h−1; p < 0.001). In five patients, the maximum recommended dose of propofol of 4 mg∙hour−1∙kg−1ABW was exceeded on several days. On isoflurane compared to propofol days, neuro-muscular blocking agents (NMBAs) were used less frequently (11% versus 21%; p < 0.05), as were co-sedatives (7% versus 31%, p < 0.001); daily opioid doses were lower (720 [720–960] versus 1080 [720–1620] mg morphine equivalents, p < 0.001); and RASS scores indicated deeper levels of sedation (− 4.0 [− 4.0 to − 3.0] versus − 3.0 [− 3.6 to − 2.5]; p < 0.01). Conclusion Isoflurane provided sufficient sedation with less NMBAs, less polypharmacy and lower opioid doses compared to propofol. High doses of both drugs were needed in severely ill COVID-19 patients.
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Affiliation(s)
- Azzeddine Kermad
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany.
| | - Jacques Speltz
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Guy Danziger
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Thilo Mertke
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Robert Bals
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
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Tapaskar N, Colon Hidalgo D, Koo G, Shingada K, Rao S, Rodriguez R, Alcantar D, Espinoza Barrera D, Lee R, Rameshkumar N, Amine M, Rodrigues S, Giron F, Chaugule A, Rech MA. Sedation Usage in COVID-19 Acute Respiratory Distress Syndrome: A Multicenter Study. Ann Pharmacother 2021; 56:117-123. [PMID: 34075807 DOI: 10.1177/10600280211021925] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Patients with COVID-19 acute respiratory distress syndrome (ARDS) have been shown to have high sedation requirements. OBJECTIVE The purpose of this study was to compare sedative use between patients with COVID-19 ARDS and non-COVID-19 ARDS. METHODS This was a retrospective study of patients with COVID-19 ARDS compared with historical controls of non-COVID-19 ARDS who were admitted to 2 hospitals from March 1, 2020, to April 30, 2020, and April 1, 2018, to December 31, 2019, respectively. The primary outcome was median cumulative dose of propofol (µg/kg) at 24 hours after intubation. RESULTS There were 92 patients with COVID-19 ARDS and 37 patients with non-COVID-19 ARDS included. Within the first 24 hours of intubation, patients with COVID-19 ARDS required higher total median doses of propofol: 51 045 µg/kg (interquartile range, 26 150-62 365 µg/kg) versus 33 350 µg/kg (9632-51 455 µg/kg; P = 0.004). COVID-19 patients were more likely receive intravenous lorazepam (37% vs 14%; P = 0.02) and higher cumulative median doses of midazolam by days 5 (14 vs 4 mg; P = 0.04) and 7 of intubation (89 vs 4 mg; P = 0.03) to achieve the same median Richmond Analgesia-Sedation Scale scores. COVID-19 ARDS patients required more ventilator days (10 vs 6 days; P = 0.02). There was no difference in 30-day mortality. CONCLUSION AND RELEVANCE Patients with COVID-19 ARDS required higher doses of propofol and benzodiazepines than patients with non-COVID-19 ARDS to achieve the same median levels of sedation.
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Affiliation(s)
| | | | - Grace Koo
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Krupa Shingada
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | - Swathi Rao
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | - Raul Rodriguez
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | - Daniel Alcantar
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | | | - Raymond Lee
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | | | - Mukarram Amine
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | | | - Fanny Giron
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | - Akshata Chaugule
- Loyola University Medical Center MacNeal Hospital, Berwyn, IL, USA
| | - Megan A Rech
- Loyola University Chicago, Maywood, IL, USA.,Loyola University Medical Center, Maywood, IL, USA
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Keswani M, Mehta N, Mazer-Amirshahi M, Tran QK, Pourmand A. Sedation in mechanically ventilated covid-19 patients: A narrative review for emergency medicine providers. Am J Emerg Med 2021; 54:309-311. [PMID: 34020844 PMCID: PMC8118705 DOI: 10.1016/j.ajem.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
- Meghana Keswani
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, United States
| | - Nikita Mehta
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, United States
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington DC, United States
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, United States.
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