970: EVALUATION OF THE USE OF MODAFINIL IN CRITICALLY ILL PATIENTS: A RETROSPECTIVE CHART REVIEW

Objectives: To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy. Methods: Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy. Results: Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent ( P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS ( P = .015) and SOFA ( P = .019) scores and death within 90 days of tracheotomy. Conclusions: The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

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Documentation of Crucial Information Relating to Critically Ill Patients

Journal of Palliative Care ◽

10.1177/0825859717746273 ◽

2017 ◽

Vol 33 (1) ◽

pp. 5-8 ◽

Cited By ~ 1

Author(s):

Alexandria Bear ◽

Elizabeth Thiel

Keyword(s):

Decision Making ◽

Palliative Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Chart Review ◽

Retrospective Chart Review ◽

Medical Decision ◽

Care Providers ◽

Significant Difference ◽

Review Study

Background: Medical decision-making has evolved to the modern model of shared decision-making among patients, surrogate decision-makers, and medical providers. As such, informed consent discussions with critically ill patients often should include larger discussions relating to values and goals of care. Documentation of care options and prognosis serves as an important component of electronic communication relating to patient preferences among care providers. Objective: This retrospective chart review study sought to evaluate the prevalence of documentation of critical data, care options, prognosis, and medical plan, within primary team and palliative care consult team documentation. Results: Three hundred two electronic medical records were reviewed. There was a significant difference in documentation between palliative care and primary teams for prognosis (83% vs 32%, P < .001), care options (82% vs 50%, P < .001), and care plan (82% vs 46%, P < .001). Conclusions: Our retrospective chart review study demonstrated a significant difference in documentation between primary and palliative care teams. We acknowledge that review of documentation cannot be extrapolated to the presence or absence of conversations between providers and patients and/or surrogates. Additional studies to evaluate this connection would be advantageous.

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Impact of an Extended Infusion Β-lactam Strategy on Outcomes in Critically Ill Patients with Pseudomonas Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.689 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S299-S299

Author(s):

Kenneth Klinker ◽

Veena Venugopalan ◽

Andrea Carnley ◽

Stacy Voils ◽

Jessica Cope ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Clinical Cure ◽

Chart Review ◽

Additional Data ◽

Retrospective Chart Review ◽

Patient Characteristics ◽

Drug Concentrations ◽

Secondary Endpoints ◽

Extended Infusion

Abstract Background Pseudomonas aeruginosa (PSA) is frequently associated with nosocomial infections resulting in significant morbidity and mortality. High MICs in MDR strains highlights the need to maximize antibiotic exposure with the goal of improving patient outcomes. For β-lactams, optimal efficacy is achieved when free drug concentrations are above the MIC for ~ 40–60% of the dosing interval. Unfortunately, due to significant pharmacokinetic variability in the critically ill, achieving this target with standard intermittent infusions (II) is challenging, resulting in preference for extended (EI) or continuous infusion strategies. Additional data in patients with PSA infections are needed to understand the association between infusion strategy and clinical outcome. Methods A single-center, retrospective chart review. Adult patients with positive respiratory or blood cultures for PSA treated with cefepime or piperacillin/tazobactam managed in an ICU from January 2012 to May 2016 were included. Primary endpoint was clinical cure (CC) at end of therapy (EOT) between patients receiving EI or II. Secondary endpoints included microbiologic eradication (ME), 28-day mortality, length of ICU and hospital stay, and effect of baseline kidney function on clinical cure. Results Eighty-three patients were included in the analysis. Patient characteristics were well matched except for a higher frequency of malignancy in the EI arm (P = 0.02). CC was achieved in an overwhelming majority of EI patients compared with II (89.2% vs. 69.6%, P = 0.031). Further, patients with normal renal function (CrCL ≥ 60; P = 0.02) or APACHE II ≥ 17 (P = 0.04) receiving II experienced higher failure rates. In multivariate analysis, use of II associated with 4-fold higher incidence of clinical failure (OR 4.5 [1.3–16.3]). For other secondary endpoints, ME was observed in 73% of EI vs. 65% of II (P = 0.44) and 28-day mortality was observed in 13% of patients in both arms (P = 0.94). No significant differences were observed with other secondary variables. Conclusion Use of an EI strategy in critically ill patients with PSA infections improves CC. Further, EI benefitted those patients with normal to augmented renal clearance suggesting that improved exposure may play a role in clinical outcomes. Disclosures K. Klinker, The Medicines Company: Scientific Advisor, Consulting fee.

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Whether Early Steroid Dose Is Associated with Lower Mortality in COVID-19 Critically Ill Patients- An Exploratory Chart Review

SSRN Electronic Journal ◽

10.2139/ssrn.3688878 ◽

2020 ◽

Author(s):

Abhishek Goyal ◽

Saurabh Saigal ◽

Ankur Joshi ◽

Dodda Brahmam ◽

Yogesh Niwariya ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Chart Review ◽

Lower Mortality

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Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon

Current Diabetes Reviews ◽

10.2174/1573399814666180119142254 ◽

2019 ◽

Vol 15 (2) ◽

pp. 133-140 ◽

Cited By ~ 1

Author(s):

Ghada El Khoury ◽

Hanine Mansour ◽

Wissam K. Kabbara ◽

Nibal Chamoun ◽

Nadim Atallah ◽

...

Keyword(s):

Hospital Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Care Center ◽

Descriptive Analysis ◽

Tertiary Care ◽

Multivariable Analysis ◽

Length Of Hospital Stay ◽

Retrospective Chart Review ◽

Diabetic Patients

Background: Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. Objective: The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. Methods: The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. Results: A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). Conclusion: Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.

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Whether Early Pulse Steroid dose is associated with lower mortality in COVID-19 critically ill Patients- An exploratory retrospective Chart Review

10.1101/2020.08.19.20171868 ◽

2020 ◽

Author(s):

Abhishek Goyal ◽

Saurabh Saigal ◽

Ankur Joshi ◽

Dodda Brahmam ◽

Yogesh Niwariya ◽

...

Keyword(s):

Regression Analysis ◽

Protective Effect ◽

Critically Ill ◽

Steroid Therapy ◽

Critically Ill Patients ◽

Chart Review ◽

Cox Regression ◽

Exploratory Analysis ◽

Model Diagnostics ◽

Cox Regression Analysis

Introduction: Steroids have shown its usefulness in critically ill COVID19 patients. However time of starting steroid and dose tailored to severity remains a matter of inquiry due to still emerging evidences and wide-ranging concerns of benefits and harms. We did a retrospective record analysis in an apex teaching hospital ICU setting to explore optimal doses and duration of steroid therapy which minimizes the hazard of death. Methodology: 114 adults with COVID19-ARDS admitted to ICU between 20thMarch-15thAugust2020 were included in chart review. We did preliminary exploratory analysis(rooted in steroid therapy matrix categorized by dose and duration) to understand the effect of several covariates on survival. This was followed by univariate and multivariate Cox proportion hazard regression analysis and model diagnostics. Results: Exploratory analysis and visualization indicated age, optimal steroid, severity (measured in P/F) of disease and infection status as potential covariates for survival. Univariate cox regression analysis showed significant positive association of age>60 years{2.6 (1.5-4.7)} and protective effect of optimum steroid{0.38(0.2-0.72)} on death (hazard) in critically ill patients. Multivariate cox regression analysis after adjusting effect of age showed protective effect of optimum steroid on hazard defined as death {0.46(0.23-0.87),LR=17.04,(p=2e-04)}.The concordance was 0.70 and model diagnostics fulfilled the assumption criteria for proportional hazard model. Conclusion: Optimal dose steroid as per defined optimum(<24 hours and doses tailored to P/F at presentation) criteria can offer protective effect from mortality which persists after adjusting for age. This protective effect was not found to be negatively influenced by the risk of infection.

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Transesophageal Echocardiography Performed by Intensivist and Emergency Physicians—A 5-Year, Single-Center Experience

Journal of Intensive Care Medicine ◽

10.1177/08850666211042522 ◽

2021 ◽

pp. 088506662110425

Author(s):

Trenton C. Wray ◽

Molly Johnson ◽

Shelby Cluff ◽

Fiona T. Nguyen ◽

Isaac Tawil ◽

...

Keyword(s):

Critical Care ◽

Transesophageal Echocardiography ◽

Critically Ill ◽

Critically Ill Patients ◽

Retrospective Chart Review ◽

The United States ◽

Left Ventricular ◽

Emergency Physicians ◽

Single Center ◽

Common Diagnosis

Purpose: Data on the use of transesophageal echocardiography (TEE) by intensivist physicians (IP) and emergency physicians (EP) are limited. This study aims to characterize the use of TEE by IPs and EPs in critically ill patients at a single center in the United States. Materials and Methods: Retrospective chart review of all critical care TEEs performed from January 1, 2016 to January 31, 2021. The personnel performing the exams, location of the exams, characteristics of exams, complications, and outcome of the patients were reviewed. Results: A total of 396 examinations was reviewed. TEE was performed by IPs (92%) and EPs (9%). The location of TEE included: intensive care unit (87%), emergency department (11%), and prehospital (2%) settings. The most common indications for TEE were: hemodynamic instability/shock (44%), cardiac arrest (23%), and extracorporeal membrane oxygenation (ECMO) facilitation, adjustment, or weaning (21%). The most common diagnosis based on TEE were: normal TEE (25%), left ventricular dysfunction (19%), and vasodilatory shock (15%). A management change resulted from 89% of exams performed. Complications occurred in 2% of critical care TEEs. Conclusion: TEE can be successfully performed by IPs and EPs on critically ill patients in multiple clinical settings. TEE frequently informed management changes with few complications.

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Tocilizumab as a Therapeutic Agent for Critically Ill Patients Infected with SARS-CoV-2

10.1101/2020.06.05.20122622 ◽

2020 ◽

Cited By ~ 3

Author(s):

Russell M. Petrak ◽

Nathan C. Skorodin ◽

Nicholas W. Van Hise ◽

Robert M. Fliegelman ◽

Jonathan Pinsky ◽

...

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Inflammatory Markers ◽

Chart Review ◽

Therapeutic Agent ◽

P Value ◽

Cytokine Storm ◽

Multi Center Study ◽

Center Study

AbstractBackgroundTocilizumab is an IL-6 receptor antagonist with the ability to suppress the cytokine storm in critically ill patients infected with SARS-CoV-2.MethodsWe evaluated patients treated with tocilizumab for a SARS-CoV-2 infection who were admitted between 3/13/20 and 4/16/20. This was a multi-center study with data collected by chart review both retrospectively and concurrently. Parameters evaluated included age, sex, race, use of mechanical ventilation (MV), usage of steroids and vasopressors, inflammatory markers, and comorbidities. Early dosing was defined as a tocilizumab dose administered prior to or within one (1) day of intubation. Late dosing was defined as a dose administered greater than one (1) day after intubation. In the absence of mechanical ventilation, the timing of the dose was related to the patient’s date of admission only.ResultsWe evaluated 145 patients. The average age was 58.1 years, 64% were male, 68.3% had comorbidities, and 60% received steroid therapy. Disposition of patients was 48.3% discharged and 29.3% expired, of which 43.9% were African American. Mechanical ventilation was required in 55.9%, of which 34.5% expired. Avoidance of MV (p value = 0.002) and increased survival (p value < 0.001) was statistically associated with early dosing.ConclusionsTocilizumab therapy was effective at decreasing mortality and should be instituted early in the management of critically ill COVID-19 patients.SummaryUtilizing tocilizumab early in the treatment course of critically ill patients with COVID-19 resulted in significant decreases in mortality and the avoidance of mechanical ventilation.

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