Vasopressor Discontinuation Order in Septic Shock With Reduced Left Ventricular Function

Background: The optimal vasopressor management for septic patients with left ventricular (LV) dysfunction has not been well established, and current evidence is conflicting regarding the optimal vasopressor discontinuation order. Objective: The objective was to evaluate the impact of LV dysfunction on the hemodynamic management of septic shock by assessing the incidence of clinically significant hypotension after vasopressor discontinuation. Methods: In this single-center, retrospective cohort study, adult patients were included if they met the Sepsis-3 definition of septic shock, had LV dysfunction (defined as an ejection fraction ≤40%), and received norepinephrine and vasopressin as the last vasopressors discontinued. The primary outcome was the incidence of clinically significant hypotension following discontinuation of vasopressin or norepinephrine. Clinically significant hypotension was defined as a MAP less than 60 mmHg and the need for either: 1) the reinstitution of the previously discontinued agent at any dosage, 2) the receipt of at least 500 mL of a crystalloid at a rate of at least 500 mL/hour, 3) or the receipt of at least 25 grams of albumin 5% at a rate of at least 25 gram/hour. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and ICU and hospital mortality. Results: A total of 78 patients met inclusion criteria, with 37 patients having vasopressin discontinued first and 41 having norepinephrine discontinued first. Clinically significant hypotension occurred in 28 patients (76%) following the discontinuation of vasopressin, compared to 28 patients (81%) following the discontinuation of norepinephrine (p = 0.61). ICU length of stay was 9 days in the vasopressin discontinued first cohort, compared to 15 days in the norepinephrine discontinued first cohort (p = 0.01). There was no statistically significant difference in mortality observed. Conclusion: The discontinuation order of norepinephrine and vasopressin did not impact the incidence of clinically significant hypotension in patients with septic shock and LV dysfunction, but may influence ICU length of stay, although other factors may have impacted this finding.

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Impact of the Sequence of Norepinephrine and Vasopressin Discontinuation in Patients Recovering From Septic Shock

Hospital Pharmacy ◽

10.1177/0018578718817469 ◽

2018 ◽

Vol 55 (1) ◽

pp. 26-31

Author(s):

Benjamin E. Bredhold ◽

Shauna D. Winters ◽

John C. Callison ◽

Robert E. Heidel ◽

Lauren M. Allen ◽

...

Keyword(s):

Septic Shock ◽

Length Of Stay ◽

Medical Condition ◽

Medical Center ◽

Secondary Outcome ◽

University Of Tennessee ◽

Icu Length Of Stay ◽

Significant Difference ◽

The University ◽

The Impact

Background: Septic shock is a serious medical condition affecting millions of people each year and guidelines direct vasopressor use in these patients. However, there is little information as to which vasopressor should be discontinued first. Objective: The objective of this study was to assess the impact of the sequence of norepinephrine and vasopressin discontinuation on intensive care unit (ICU) length of stay. Methods: This was a single-center retrospective cohort study conducted at The University of Tennessee Medical Center in Knoxville, Tennessee. Patients included in this study were adults 18 years of age and older with a diagnosis of septic shock who received norepinephrine in combination with vasopressin. Patients were excluded if norepinephrine or vasopressin were not the last 2 vasoactive agents used or if the patient expired or care was withdrawn. Measurements and Main Results: A total of 86 patients were included in this study, with 34 patients in the norepinephrine discontinued first group (NDF) and 52 in the vasopressin discontinued first group (VDF). For the primary outcome of ICU length of stay, no statistically significant difference was found between the NDF and the VDF groups (9.38 days vs 11.07 days, P = .313). The secondary outcome of the dose of norepinephrine at which vasopressin was initiated was also found to not be significant between the NDF and VDF groups (22 µg/min vs 31.1 µg/min, P = .11). The rates of hypotension within 24 hours of discontinuation of the first agent were also not significant between the NDF and VDF groups (17% vs 31%, P = .38). Conclusions: Based on the results of this study, there was significant no difference in ICU length of stay based on the sequence of discontinuation between norepinephrine and vasopressin in patients recovering from septic shock.

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Vitamin C, Thiamine, and Hydrocortisone in the Treatment of Sepsis: A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

Journal of Intensive Care Medicine ◽

10.1177/0885066620987809 ◽

2021 ◽

pp. 088506662098780

Author(s):

Yazan Zayed ◽

Bashar N. Alzghoul ◽

Momen Banifadel ◽

Hima Venigandla ◽

Ryan Hyde ◽

...

Keyword(s):

Septic Shock ◽

Length Of Stay ◽

Vitamin C ◽

Sofa Score ◽

Sequential Analysis ◽

Trial Sequential Analysis ◽

Controlled Trials ◽

Randomized Controlled ◽

Icu Length Of Stay ◽

Significant Difference

Background: There is a conflicting body of evidence regarding the benefit of vitamin C, thiamine, and hydrocortisone in combination as an adjunctive therapy for sepsis with or without septic shock. We aimed to assess the efficacy of this treatment among predefined populations. Methods: A literature review of major electronic databases was performed to include randomized controlled trials (RCTs) evaluating vitamin C, thiamine, and hydrocortisone in the treatment of patients with sepsis with or without septic shock in comparison to the control group. Results: Seven studies met our inclusion criteria, and 6 studies were included in the final analysis totaling 839 patients (mean age 64.2 ± 18; SOFA score 8.7 ± 3.3; 46.6% female). There was no significant difference between both groups in long term mortality (Risk Ratio (RR) 1.05; 95% CI 0.85-1.30; P = 0.64), ICU mortality (RR 1.03; 95% CI 0.73-1.44; P = 0.87), or incidence of acute kidney injury (RR 1.05; 95% CI 0.80-1.37; P = 0.75). Furthermore, there was no significant difference in hospital length of stay, ICU length of stay, and ICU free days on day 28 between the intervention and control groups. There was, however, a significant difference in the reduction of SOFA score on day 3 from baseline (MD −0.92; 95% CI −1.43 to −.41; P < 0.05). In a trial sequential analysis for mortality outcomes, our results are inconclusive for excluding lack of benefit of this therapy. Conclusion: Among patients with sepsis with or without septic shock, treatment with vitamin C, thiamine, and hydrocortisone was not associated with a significant reduction in mortality, incidence of AKI, hospital and ICU length of stay, or ICU free days on day 28. There was a significant reduction of SOFA score on day 3 post-randomization. Further studies with a larger number of patients are needed to provide further evidence on the efficacy or lack of efficacy of this treatment.

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Diagnostic accuracy of handheld cardiac ultrasound device for assessment of left ventricular structure and function: systematic review and meta-analysis

Heart ◽

10.1136/heartjnl-2021-319561 ◽

2021 ◽

pp. heartjnl-2021-319561

Author(s):

Sam Jenkins ◽

Samer Alabed ◽

Andrew Swift ◽

Gabriel Marques ◽

Alisdair Ryding ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Meta Analysis ◽

Left Ventricular ◽

Test Accuracy ◽

Diagnostic Ability ◽

Operator Experience ◽

Lv Dysfunction ◽

Significant Difference ◽

And Function ◽

The Impact

ObjectiveHandheld ultrasound devices (HUD) has diagnostic value in the assessment of patients with suspected left ventricular (LV) dysfunction. This meta-analysis evaluates the diagnostic ability of HUD compared with transthoracic echocardiography (TTE) and assesses the importance of operator experience.MethodsMEDLINE and EMBASE databases were searched in October 2020. Diagnostic studies using HUD and TTE imaging to determine LV dysfunction were included. Pooled sensitivities and specificities, and summary receiver operating characteristic curves were used to determine the diagnostic ability of HUD and evaluate the impact of operator experience on test accuracy.ResultsThirty-three studies with 6062 participants were included in the meta-analysis. Experienced operators could predict reduced LV ejection fraction (LVEF), wall motion abnormality (WMA), LV dilatation and LV hypertrophy with pooled sensitivities of 88%, 85%, 89% and 85%, respectively, and pooled specificities of 96%, 95%, 98% and 91%, respectively. Non-experienced operators are able to detect cardiac abnormalities with reasonable sensitivity and specificity. There was a significant difference in the diagnostic accuracy between experienced and inexperienced users in LV dilatation, LVEF (moderate/severe) and WMA. The diagnostic OR for LVEF (moderate/severe), LV dilatation and WMA in an experienced hand was 276 (95% CI 58 to 1320), 225 (95% CI 87 to 578) and 90 (95% CI 31 to 265), respectively, compared with 41 (95% CI 18 to 94), 45 (95% CI 16 to 123) and 28 (95% CI 20 to 41), respectively, for inexperienced users.ConclusionThis meta-analysis is the first to establish HUD as a powerful modality for predicting LV size and function. Experienced operators are able to accurately diagnose cardiac disease using HUD. A cautious, supervised approach should be implemented when imaging is performed by inexperienced users. This study provides a strong rationale for considering HUD as an auxiliary tool to physical examination in secondary care, to aid clinical decision making when considering referral for TTE.Trial registration numberCRD42020182429.

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668 Early Enteral Nutrition in Geriatric Burn Patients: Is There a Benefit?

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.284 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S179-S179

Author(s):

Lourdes Castanon ◽

Kamil Hanna ◽

Samer Asmar ◽

Michael F Ditillo ◽

Lynn Gries ◽

...

Keyword(s):

Length Of Stay ◽

Enteral Nutrition ◽

Hospital Length Of Stay ◽

Early Enteral Nutrition ◽

Trauma Patients ◽

Burn Patients ◽

Burn Care ◽

Icu Length Of Stay ◽

Significant Difference ◽

The Impact

Abstract Introduction Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition (EN) in geriatric burn patients. The aim of our study was to assess the impact of early EN on outcomes in geriatric burn patients. We hypothesized that early EN is associated with improved outcomes. Methods We performed a 2-year (2015–2016) analysis of the ACS-TQIP and included all older adult (age ≥65years) burn patients who received EN. Patients were stratified into two groups based on timing of initiation of EN: Early-EN (< 24 hrs) vs. Late-EN (≥ 24 hrs). We performed propensity score matching (1:2 ratio) to control for possible confounding variables including demographics, comorbidities, injury parameters, height and body weight. Outcome measures were in-hospital; complications, hospital and ICU length of stay, and mortality. Results A total of 593,818 trauma patients were analyzed, of which 447 patients were matched (Early-EN: 159 vs Late-EN: 318). Mean age was 44±22, 75% were males, and median ISS was 29 [26–36] and mean total body burn surface area (TBSA) was 15±5%. There was no significant difference between the two groups in terms of age (p=0.99), gender (p=0.60), race (p=0.91), ISS (p=0.43), GCS (p=0.85), TBSA (p=0.51), height (p=0.71), and weight (p=0.61). Overall, the complications rate was 40%, median hospital LOS was 25 [15–36] days, median ICU LOS was 15 [8–26] days and mortality rate was 16%. Patients in the early ED group had significantly lower rate of complications and mortality Table 1. At the same time, patients in the early group had lower hospital length of stay (23[12–36] vs. 26[16–38], p=0.013) and ICU length of stay (12[8–24] vs. 16[8–26], p=0.025). Conclusions In our propensity matched cohort of geriatric burn patients, early EN was associated with improvement in outcomes. The cumulative benefits observed may warrant incorporating early EN as part of intensive care protocols. Applicability of Research to Practice Geriatric patients are a special subset of the population that require additional considerations. Our research highlights the impact of early enteral nutrition on different in hospital outcomes. This is an area of constant debate, our study shows that early enteral nutrition in geriatric burn patients is associated with improved outcome. We found this applicable in most of our patients and thus it might warrant further incorporation in ICU burn protocols.

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Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic

Wiener klinische Wochenschrift ◽

10.1007/s00508-021-01857-4 ◽

2021 ◽

Author(s):

Răzvan Bologheanu ◽

Mathias Maleczek ◽

Daniel Laxar ◽

Oliver Kimberger

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Medical Specialty ◽

Routine Care ◽

Treatment Pathways ◽

Icu Length Of Stay ◽

Matched Study ◽

The Impact

Summary Background Coronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed. Methods The objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching. Results A total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344. Conclusion In this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

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The Impact of Using Echinacea as a Complementary Modality on ICU Length of Stay and Mortality in Intubated and Ventillated Patient

The Medical Journal of Cairo University ◽

10.21608/mjcu.2020.93981 ◽

2020 ◽

Vol 88 (3) ◽

pp. 217-224

Author(s):

JEHAN A. EL-KHOLY, M.D.; IMAN A. FOUAD, M.D. ◽

AKRAM S. EL-ADAWY, M.D.; HEBA F. SHAFEI, M.D. ◽

MONA S. ALLAM, M.Sc.*

Keyword(s):

Length Of Stay ◽

Icu Length Of Stay ◽

The Impact

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The Impact of Selenium Supplementation on Trauma Patients—Systematic Review and Meta-Analysis

Nutrients ◽

10.3390/nu14020342 ◽

2022 ◽

Vol 14 (2) ◽

pp. 342

Author(s):

Jen-Fu Huang ◽

Chih-Po Hsu ◽

Chun-Hsiang Ouyang ◽

Chi-Tung Cheng ◽

Chia-Cheng Wang ◽

...

Keyword(s):

Length Of Stay ◽

Meta Analysis ◽

Infectious Complications ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Current Evidence ◽

Trauma Patients ◽

Positive Effects ◽

Standard Difference ◽

The Impact

This study aimed to assess current evidence regarding the effect of selenium (Se) supplementation on the prognosis in patients sustaining trauma. MEDLINE, Embase, and Web of Science databases were searched with the following terms: “trace element”, “selenium”, “copper”, “zinc”, “injury”, and “trauma”. Seven studies were included in the meta-analysis. The pooled results showed that Se supplementation was associated with a lower mortality rate (OR 0.733, 95% CI: 0.586, 0.918, p = 0.007; heterogeneity, I2 = 0%). Regarding the incidence of infectious complications, there was no statistically significant benefit after analyzing the four studies (OR 0.942, 95% CI: 0.695, 1.277, p = 0.702; heterogeneity, I2 = 14.343%). The patients with Se supplementation had a reduced ICU length of stay (standard difference in means (SMD): −0.324, 95% CI: −0.382, −0.265, p < 0.001; heterogeneity, I2 = 0%) and lesser hospital length of stay (SMD: −0.243, 95% CI: −0.474, −0.012, p < 0.001; heterogeneity, I2 = 45.496%). Se supplementation after trauma confers positive effects in decreasing the mortality and length of ICU and hospital stay.

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Evaluation of the Effect of Prehospital Application of Continuous Positive Airway Pressure Therapy in Acute Respiratory Distress

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00007731 ◽

2010 ◽

Vol 25 (1) ◽

pp. 87-91 ◽

Cited By ~ 19

Author(s):

G. Scott Warner

Keyword(s):

Continuous Positive Airway Pressure ◽

Data Collection ◽

Length Of Stay ◽

Respiratory Distress ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Prehospital Setting ◽

Rural Setting ◽

Icu Length Of Stay ◽

The Impact

AbstractObjective:The impact of the use of mask continuous positive airway pressure (CPAP) on patients with acute respiratory distress in the prehospital, rural setting has not been defined. The goal was to test the use of CPAP using the Respironics® WhisperFlow® CPAP in patients presenting with acute respiratory distress. This was a collaborative evaluation of CPAP involving a rural EMS agency and the regional medical center. Patient outcomes including the overall rate of intubation-both in the field and in the emergency department (ED), and length of stay in the hospital and Intensive Care Unit (ICU) were tracked.Methods:The study was an eight-month, crossover, observational, non-blinded study.Results:During the four months of baseline data collection, 7.9% of patients presenting with respiratory distress were intubated within the first 48 hours of care. Their average ICU length of stay was 8.0 days. During the four months of data collection when CPAP was available in the prehospital setting, intubation was not required for any patients in the field or in the ED. Admissions to the ICU decreased. Those patients admitted to the ICU, the average ICU length of stay deceased to 4.3 days.Conclusions:The use of the CPAP in the prehospital setting is beneficial for patients in acute respiratory distress.

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Impact of Valve Surgery on Serum Osteopontin Levels in Patients with Mitral Regurgitation

Cardiology ◽

10.1159/000368299 ◽

2015 ◽

Vol 130 (2) ◽

pp. 82-86

Author(s):

H.M. Gunes ◽

G.B. Guler ◽

E. Guler ◽

G.G. Demir ◽

S. Hatipoglu ◽

...

Keyword(s):

Mitral Regurgitation ◽

Left Ventricular ◽

Valve Surgery ◽

Lv Function ◽

Vena Contracta ◽

Atherosclerotic Lesions ◽

Lv Dysfunction ◽

Echocardiographic Parameters ◽

Artery Disease ◽

The Impact

Objective: Osteopontin (OPN), a sialoprotein present within atherosclerotic lesions, especially in calcified plaques, is linked to the progression of coronary artery disease and heart failure. We assessed the impact of valve surgery on serum OPN and left ventricular (LV) function in patients with mitral regurgitation (MR). Methods: Thirty-two patients with severe MR scheduled for surgery were included in the study. Echocardiography markers were assessed preoperatively and at 3 months following the surgery and matched with the serum OPN levels. Results: Valve surgery was associated with a reduction of the ejection fraction (EF) from 55.2 ± 6.3 to 48.8 ± 7.1% after surgery, p < 0.001. Following surgery, the OPN level was significantly higher than preoperatively (mean 245, range 36-2,284 ng/ml vs. 76, 6-486 ng/ml, p = 0.007). Preoperative OPN exhibited a slight negative correlation with the EF (r = -0.35, p = 0.04), and a moderate correlation with vena contracta (r = -0.38, p = 0.02). There were no other meaningful correlations between conventional echocardiographic parameters and OPN. Conclusion: Following valve surgery due to severe MR, patients exhibited a decrease in EF and an increase in OPN levels. The assessment of preoperative OPN failed to strongly predict probable LV dysfunction.

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P5280The impact of background phase offset errors in cardiovascular magnetic resonance phase contrast imaging: a multi-scanner study

European Heart Journal ◽

10.1093/eurheartj/ehz746.0251 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S C S Minderhoud ◽

N Van Der Velde ◽

J J Wentzel ◽

M Attrach ◽

P A Wielopolski ◽

...

Keyword(s):

Phase Contrast ◽

Main Pulmonary Artery ◽

Flow Quantification ◽

Flow Measurements ◽

Total N ◽

Phase Offset ◽

Wide Range ◽

Significant Difference ◽

Clinically Significant ◽

The Impact

Abstract Background Phase contrast (PC) CMR flow measurements (FM) are widely used for blood flow assessment, but they suffer from phase offset errors (POE). Stationary phantom correction limits these inaccuracies, however, this adds scan time. Stationary tissue (ST) correction is an alternative method that does not require additional scanning. The aim of this study was to evaluate the impact of POE, to assess interscanner variation, and to evaluate the ST correction usage. Methods We included 166 patients in which both aorta and main pulmonary artery FM were acquired including static gelatin phantom data. Subjects were scanned on three types of 1.5T scanners from the one vendor. Uncorrected and ST corrected FM were compared with phantom corrected FM, our reference value, and corrected for BSA. A difference of >10% in net flow was defined as clinically relevant. Regurgitation fraction was calculated and POE influences were assessed. Regurgitation severity was graded and POE influence on severity grading was assessed. Results Of the 166 cases included, the median age was 27 (5–74) years. Overall, the median difference between no corrected and phantom corrected FM was ≤6%, however, with a wide range of over- and underestimation (−155%–78% change) (figure). ST correction resulted in larger differences compared to no correction (p<0.01). Clinically significant differences were seen in 19% of all FM with no correction and in 30% of with ST correction (p<0.01). Furthermore, there were significant differences between scanners (no correction 10%, p<0.01; ST correction, p<0.01). Regurgitation severity indexing changed in 38 (11%) cases with no correction and in 48 (48%) with ST correction. Magnitude of flow change with and without offset corrections (n=332) Flow (ml/m2) Δ no correction and phantom correction (%) Δ ST correction and phantom correction (%) Clinically significant difference (>10%) Mean ± SD Median IQR Range Median IQR Range No correction, N (%) ST correction , N (%) MRI 1 (n=126) 50±12 3 0 to 6 −8 to 30 5 −3 to 9 −26 to 28 13 (10%) 34 (27%) MRI 2 (n=102) 48±13 −2 −15 to 6 −155 to 78 5 −3 to 11 −74 to 52 50 (49%) 50 (49%) MRI 3 (n=104) 48±12 −1 −1 to 0 −7 to 14 2 −2 to 5 −39 to 29 1 (1%) 16 (15%) Total (n=332) 49±12 0 −2 to 4 −155 to 78 3 −2 to 8 −74 to 52 64 (19%) 100 (30%) Conclusion Background POE have a significant impact on flow quantification and regurgitation severity. Unexpectedly, background correction using ST correction worsens accuracy compared to no correction. POE vary greatly between scanners. Therefore, careful assessment of FM at each scanner is essential to determine if routine phantom scanning is necessary.

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