469: CIRRHOTIC PATIENTS WITH GREATER BASELINE SEVERITY OF ILLNESS EXPERIENCE HIGHER USE OF TIMELY ALBUMIN

AbstractCOVID-19-associated respiratory failure offers the unprecedented opportunity to evaluate the differential host response to a uniform pathogenic insult. Understanding whether there are distinct subphenotypes of severe COVID-19 may offer insight into its pathophysiology. Sequential Organ Failure Assessment (SOFA) score is an objective and comprehensive measurement that measures dysfunction severity of six organ systems, i.e., cardiovascular, central nervous system, coagulation, liver, renal, and respiration. Our aim was to identify and characterize distinct subphenotypes of COVID-19 critical illness defined by the post-intubation trajectory of SOFA score. Intubated COVID-19 patients at two hospitals in New York city were leveraged as development and validation cohorts. Patients were grouped into mild, intermediate, and severe strata by their baseline post-intubation SOFA. Hierarchical agglomerative clustering was performed within each stratum to detect subphenotypes based on similarities amongst SOFA score trajectories evaluated by Dynamic Time Warping. Distinct worsening and recovering subphenotypes were identified within each stratum, which had distinct 7-day post-intubation SOFA progression trends. Patients in the worsening suphenotypes had a higher mortality than those in the recovering subphenotypes within each stratum (mild stratum, 29.7% vs. 10.3%, p = 0.033; intermediate stratum, 29.3% vs. 8.0%, p = 0.002; severe stratum, 53.7% vs. 22.2%, p < 0.001). Pathophysiologic biomarkers associated with progression were distinct at each stratum, including findings suggestive of inflammation in low baseline severity of illness versus hemophagocytic lymphohistiocytosis in higher baseline severity of illness. The findings suggest that there are clear worsening and recovering subphenotypes of COVID-19 respiratory failure after intubation, which are more predictive of outcomes than baseline severity of illness. Distinct progression biomarkers at differential baseline severity of illness suggests a heterogeneous pathobiology in the progression of COVID-19 respiratory failure.

Download Full-text

Evaluation of a Phenobarbital-Based Protocol for Severe Alcohol Withdrawal in Critically Ill Patients

Hospital Pharmacy ◽

10.1177/0018578720931464 ◽

2020 ◽

pp. 001857872093146

Author(s):

Melanie Goodberlet ◽

Kevin Dube ◽

Mary Kovacevic ◽

Paul Szumita ◽

Jeremy DeGrado

Keyword(s):

Alcohol Withdrawal ◽

Primary Outcome ◽

Guideline Implementation ◽

Severity Of Illness ◽

Future Research ◽

Apache Ii Score ◽

Efficacy And Safety ◽

Safety And Efficacy ◽

Baseline Severity ◽

Icu Length Of Stay

Background: Phenobarbital offers several possible advantages to benzodiazepines including a longer half-life and anti-glutamate activity, and is an alternative for the treatment of alcohol withdrawal. The objective of this analysis was to evaluate the safety and efficacy of a phenobarbital protocol for alcohol withdrawal newly implemented at our institution. Methods: This was a single-center, retrospective analysis of adult patients admitted to the medical/surgical/burn/trauma intensive care unit (ICU) with or at risk of severe alcohol withdrawal. Patients who were admitted prior to guideline implementation and received scheduled benzodiazepines (PRE) were compared to those who received phenobarbital post guideline update (POST). The primary outcome was ICU length of stay (LOS). Results: Upon analysis, 68 patients in the PRE and 64 patients in the POST were identified for inclusion. The median APACHE II score was significantly higher in the POST (4.5 [3:9] vs 10 [5:13], P < 0.001). ICU (2 [1:2] vs 2 [2:5], P = 0.002) and hospital (4.5 [3:6] vs 8 [6:12], P < 0.001) LOS were significantly longer in the POST. There was no difference in mortality or duration of mechanical ventilation. More patients required propofol or dexmedetomidine on day one in the POST ( P < 0.001). Conclusion: Patients in the POST had significantly longer ICU and hospital LOS, and had a higher baseline severity of illness. Future research is needed to evaluate the efficacy and safety of phenobarbital compared to benzodiazepines for severe alcohol withdrawal.

Download Full-text

Metaraminol and Noradrenaline in Septic Shock: A Retrospective Comparison

10.21203/rs.3.rs-934176/v1 ◽

2021 ◽

Author(s):

Anirudh Krishnamohan ◽

Anthony Delaney ◽

Mark Gillett

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Severity Of Illness ◽

Standard Drug ◽

Baseline Severity ◽

Drug Of Choice ◽

Apache Iii ◽

The Mean

Abstract IntroductionVasopressor use is an important facet of septic shock management, in order to maintain hemodynamic targets and end organ perfusion. Traditionally, Noradrenaline has been the ‘gold standard’ drug of choice for septic shock. Metaraminol is an alternative vasopressor that has been used for septic shock. However, there has been minimal research in comparing the two drugs in septic patients, particularly with regards to total time spent on infusion. ObjectivesTo compare total time spent on either Metaraminol or Noradrenaline infusion by septic shock patients, whilst adjusting for baseline severity of illness. Secondary outcomes included incidence of mechanical ventilation and new requirement of renal replacement therapy, and mortality. MethodsA retrospective medical records review was undertaken, looking at all septic shock patients admitted to ICU in 2019, who received either Metaraminol or Noradrenaline. Data extracted from eRIC (the ICU database) included total time spent on infusion, APACHE III scores, incidence of mechanical ventilation, incidence of renal replacement therapy, and mortality. ResultsOur review yielded 174 patients who were eligible for further statistical analysis (63 in Metaraminol group, and 111 in the Noradrenaline group). The mean duration of infusion in the Metaraminol group was 1655 minutes, and 2663 minutes in the Noradrenaline group. The mean APACHE III Scores were 62 in the Metaraminol group and 77 in the Noradrenaline group. A one-way ANCOVA test found that there was a statistically significant [F(1, 171)=4.511, p=0.035] reduction in time spent on Metaraminol infusion, compared with Noradrenaline, after adjusting for baseline severity of illness by way of APACHE III Score. ConclusionOur study found a statistically significant reduction in time spent on a Metaraminol infusion compared with Noradrenaline by septic shock patients, after controlling for severity of illness. However, due to its retrospective study design, we were unable to account for bias and confounders, such as antibiotic and fluid administration, or clinician preference for one drug over the other. Nevertheless, our study adds to the paucity of literature comparing Metaraminol to Noradrenaline, and paves the way for future randomized trials comparing the two drugs in septic shock.

Download Full-text