Effects From Continuous Infusions of Dexmedetomidine and Propofol on Hemodynamic Stability in Critically Ill Adult Patients With Septic Shock

2018 ◽  
Vol 35 (9) ◽  
pp. 875-880 ◽  
Author(s):  
Kristen M. Nelson ◽  
Gourang P. Patel ◽  
Drayton A. Hammond
Keyword(s):  
Intensive Care Unit ◽  
Septic Shock ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hemodynamic Stability ◽  
Lengths Of Stay ◽  
Academic Medical ◽  
Clinically Significant

Purpose: To compare the development of clinically significant hemodynamic event (ie, hypotension or bradycardia) in adults with septic shock receiving either propofol or dexmedetomidine. Materials and Methods: A retrospective cohort study of adults with septic shock admitted to an intensive care unit (ICU) at an academic medical center between July 2013 and July 2017. Results: Patients in the propofol (n = 35) and dexmedetomidine (n = 37) groups developed a clinically significant hemodynamic event at similar frequencies (31.4 vs 29.7%, P = .99). All patients with an event experienced hypotension, whereas 2 (5.4%) patients in the dexmedetomidine group also experienced bradycardia. Most patients in both groups (70% vs 90%) received an escalating sedative dose, and almost half (42.9%) in the dexmedetomidine group had the sedative dosage increased more frequently than every 30 minutes. Patients in both groups had similar ICU (24.1 vs 24.3 days, P = .98) and hospital (37.9 vs 29.7 days, P = .29) lengths of stay. There was no difference in median time to hemodynamic event between the groups (propofol 1 hour [interquartile range, IQR: 0.5-9.9] vs dexmedetomidine 2 hours [IQR: 1.5-11.1 hours], P = .85). Conclusion: Patients with septic shock receiving propofol or dexmedetomidine experienced similar rates of clinically significant hemodynamic events. Most patients did not experience an event and those who did most frequently did so in the first couple of hours of therapy.

scholarly journals Telehealth Use by Age and Race at a Single Academic Medical Center During the COVID-19 Pandemic: Retrospective Cohort Study (Preprint)

2020 ◽  
Author(s):  
Jennifer P Stevens ◽  
Oren Mechanic ◽  
Lawrence Markson ◽  
Ashley O'Donoghue ◽  
Alexa B Kimball
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Health Care Disparities ◽  
Medical Center ◽  
Cohort Analysis ◽  
Academic Medical Center ◽  
Race And Gender ◽  
Asian Patients ◽  
Academic Medical

BACKGROUND During the COVID-19 pandemic, many ambulatory clinics transitioned to telehealth, but it remains unknown how this may have exacerbated inequitable access to care. OBJECTIVE Given the potential barriers faced by different populations, we investigated whether telehealth use is consistent and equitable across age, race, and gender. METHODS Our retrospective cohort study of outpatient visits was conducted between March 2 and June 10, 2020, compared with the same time period in 2019, at a single academic health center in Boston, Massachusetts. Visits were divided into in-person visits and telehealth visits and then compared by racial designation, gender, and age. RESULTS At our academic medical center, using a retrospective cohort analysis of ambulatory care delivered between March 2 and June 10, 2020, we found that over half (57.6%) of all visits were telehealth visits, and both Black and White patients accessed telehealth more than Asian patients. CONCLUSIONS Our findings indicate that the rapid implementation of telehealth does not follow prior patterns of health care disparities.

Hemodynamic Effects of Ketamine Compared With Propofol or Dexmedetomidine as Continuous ICU Sedation

2021 ◽  
pp. 106002802110510
Author(s):  
Evan Atchley ◽  
Eljim Tesoro ◽  
Robert Meyer ◽  
Alexia Bauer ◽  
Mark Pulver ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical ◽  
Clinically Significant ◽  
Critically Ill Adults ◽  
Icu Sedation ◽  
Ill Adults ◽  
Positive Effect

Background Ketamine has seen increased use for sedation in the intensive care unit. In contrast to propofol or dexmedetomidine, ketamine may provide a positive effect on hemodynamics. Objective The objective of this study was to compare the development of clinically significant hypotension or bradycardia (ie, negative hemodynamic event) between critically ill adults receiving sedation with ketamine and either propofol or dexmedetomidine. Methods This was a retrospective cohort study of adults admitted to an intensive care unit at an academic medical center between January 2016 and January 2021. Results Patients in the ketamine group (n = 78) had significantly less clinically significant hypotension or bradycardia compared with those receiving propofol or dexmedetomidine (n = 156) (34.6% vs 63.5%; P < 0.001). Patients receiving ketamine also experienced smaller degree of hypotension observed by percent decrease in mean arterial pressure (25.3% [17.4] vs 33.8% [14.5]; P < 0.001) and absolute reduction in systolic blood pressure (26.5 [23.8] vs 42.0 [37.8] mm Hg; P < 0.001) and bradycardia (15.5 [24.3] vs 32.0 [23.0] reduction in beats per minute; P < 0.001). In multivariate logistic regression modeling, receipt of propofol or dexmedetomidine was the only independent predictor of a negative hemodynamic event (odds ratio [OR]: 3.3, 95% confidence interval [CI], 1.7 to 6.1; P < 0.001). Conclusion and Relevance Ketamine was associated with less clinically relevant hypotension or bradycardia when compared with propofol or dexmedetomidine, in addition to a smaller absolute decrease in hemodynamic parameters. The clinical significance of these findings requires further investigation.

Impact of Telemedicine Use on Blood Pressure Control During the Covid-19 Pandemic: A Cohort Study (Preprint)

2021 ◽  
Author(s):  
Siqin Ye ◽  
D. Edmund Anstey ◽  
Anne Grauer ◽  
Gil Metser ◽  
Nathalie Moise ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Medical Center ◽  
Academic Medical Center ◽  
Pressure Control ◽  
Care Quality ◽  
Academic Medical ◽  
Cardiovascular Care

BACKGROUND Telemedicine use vastly expanded during the Covid-19 pandemic, with uncertain impact on cardiovascular care quality. OBJECTIVE We sought to examine the association between telemedicine use and blood pressure (BP) control. METHODS This is a retrospective cohort study of 32,727 adult patients with hypertension (HTN) seen in primary care and cardiology clinics at an urban, academic medical center from February to December, 2020. The primary outcome was poor BP control, defined as having no BP recorded OR if the last recorded BP was ≥140/90 mmHg. Multivariable logistic regression was used to assess the association between telemedicine use during the study period (none, 1 telemedicine visit, 2+ telemedicine visits) and poor BP control, adjusting for demographic and clinical characteristics. RESULTS During the study period, no BP was recorded for 486/20,745 (2.3%) patients with in-person visits only, for 1,863/6,878 (27.1%) patients with 1 telemedicine visit, and for 1,277/5,104 (25.0%) patients with 2+ telemedicine visits. After adjustment, telemedicine use was associated with poor BP control (odds ratio [OR], 2.06, 95% confidence interval [CI] 1.94 to 2.18, p<.001 for 1 telemedicine visit, and OR 2.49, 95% CI 2.31 to 2.68, p<.001 for 2+ telemedicine visits; reference, in-person visit only). This effect disappears when analysis was restricted to patients with at least one recorded BP (OR 0.89, 95% CI 0.83 to 0.95, p=.001 for 1 telemedicine visit, and OR 0.91, 95% CI 0.83 to 0.99, p=.03 for 2+ telemedicine visits). CONCLUSIONS BP is less likely to be recorded during telemedicine visits, but telemedicine use does not negatively impact BP control when BP is recorded. CLINICALTRIAL NA

A Retrospective Comparison of the Effectiveness and Safety of Intravenous Olanzapine Versus Intravenous Haloperidol for Agitation in Adult Intensive Care Unit Patients

2021 ◽  
pp. 088506662098445
Author(s):  
Michelle Wang ◽  
Tuyen T. Yankama ◽  
George T. Abdallah ◽  
Ijeoma Julie Eche ◽  
Kristen N. Knoph ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cohort Study ◽  
Intensive Care ◽  
Length Of Stay ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Medical Center ◽  
Academic Medical Center ◽  
Icu Length Of Stay ◽  
Haloperidol Group

Objective: Intravenous (IV) olanzapine could be an alternative to first-generation antipsychotics for the management of agitation in intensive care unit (ICU) patients. We compared the effectiveness and safety of IV olanzapine to IV haloperidol for agitation management in adult patients in the ICU at a tertiary academic medical center. Methods: A retrospective cohort study was conducted. The primary outcome was the proportion of patients who achieved a Richmond Agitation Sedation Scale (RASS) score of < +1 within 4 hours of IV olanzapine or IV haloperidol administration. Secondary outcomes included the proportion of patients who required rescue medications for agitation within 4 hours of initial IV olanzapine or IV haloperidol administration, incidence of adverse events and ICU length of stay. Results: In the 192 patient analytic cohort, there was no difference in the proportion of patients who achieved a RASS score of < +1 within 4 hours of receiving IV olanzapine or IV haloperidol (49% vs. 42%, p = 0.31). Patients in the IV haloperidol group were more likely to receive rescue medications (28% vs 55%, p < 0.01). There was no difference in the incidence of respiratory events or hypotension between IV olanzapine and IV haloperidol. Patients in the IV olanzapine group experienced more bradycardia (11% vs. 3%, p = 0.04) and somnolence (9% vs. 1%, p = 0.02) compared to the IV haloperidol group. Patients in the IV olanzapine group had a longer median ICU length of stay (7.5 days vs. 5 days, p = 0.04). Conclusion: In this retrospective cohort study, there was no difference in the effectiveness of IV olanzapine compared to IV haloperidol for the management of agitation. IV olanzapine was associated with an increased incidence of bradycardia and somnolence.

Discontinuation of Vasopressin Before Norepinephrine in the Recovery Phase of Septic Shock

2017 ◽  
Vol 34 (10) ◽  
pp. 805-810 ◽  
Author(s):  
Drayton A. Hammond ◽  
Kelsey McCain ◽  
Jacob T. Painter ◽  
Oktawia A. Clem ◽  
Julia Cullen ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Septic Shock ◽  
Cohort Study ◽  
Odds Ratio ◽  
Retrospective Cohort ◽  
Recovery Phase ◽  
Assessment Scores ◽  
Failure Assessment ◽  
Clinically Significant ◽  
Unadjusted Analysis

Background: Guidance for the discontinuation of vasopressors in the recovery phase of septic shock is limited. Norepinephrine is more easily titrated; however, septic shock is a vasopressin deficient state, which exogenous vasopressin endeavors to resolve. Discontinuation of vasopressin before norepinephrine may result in clinically significant hypotension. Methods: This retrospective, cohort study compared discontinuation of norepinephrine and vasopressin in medically, critically ill patients in the recovery phase of septic shock from May 2014 to June 2016. Difference in clinically significant hypotension after norepinephrine or vasopressin discontinuation was evaluated with χ2 test. Linear regression was performed, examining the effect of agent discontinuation on clinically significant hypotension. Baseline variables were examined for a bivariate relationship with clinically significant hypotension; those with P < .2 were included in the model. Results: Vasopressin was discontinued first or last in 62 and 92 patients, respectively. Sequential Organ Failure Assessment scores at 72 hours (7.9 vs 7.6, P = .679) were similar. In unadjusted analysis, when vasopressin was discontinued first, more clinically significant hypotension developed (10.9% vs 67.8%, P < .001). There was no difference in intensive care unit (174 vs 216 hours, P = .178) or hospital duration (470 vs 473 hours, P = .977). In adjusted analyses, discontinuing vasopressin first was associated with increased clinically significant hypotension (odds ratio [OR]: 13.837, 95% confidence interval [CI]: 3.403-56.250, P < .001) but not in-hospital (OR: 0.659, 95% CI: 0.204-2.137, P = .488) or 28-day mortality (OR: 0.215, 95% CI: 0.037-1.246, P = .086). Conclusion: Adult patients receiving norepinephrine and vasopressin in the resolving phase of septic shock may be less likely to develop clinically significant hypotension if vasopressin is the final vasopressor discontinued.

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