Oseltamivir-Associated Bradycardia in Critically Ill Patients

Background: Oseltamivir is frequently administered to critically ill patients with presumed influenza. It may modulate Na+, K+, and Ca2+ channels to produce bradycardia. Objective: To evaluate the association between oseltamivir and bradycardia in critically ill patients and assess parameters associated with bradycardia. Methods: This was a retrospective audit of 203 critically ill adults with presumed influenza receiving at least 2 doses of oseltamivir. The primary outcome was the occurrence of bradycardia, defined as a heart rate (HR) ≤59 beats per minute (BPM) while receiving oseltamivir or a decrease of ≥20 BPM compared with the lowest HR before initiating oseltamivir. Results: A total of 88 (43.4%) patients manifested bradycardia, 59 with HR ≤59 BPM, 19 with HR decrease of ≥20 BPM, and 10 with both. The time from first dose to bradycardia was 51.4 ± 43 hours. In all, 48 (54.6%) patients received therapies for bradycardia, including increased inotropic/vasopressor dose, electrolyte replacement, electrocardiogram, discontinuation of other medications, cardiology consult, discontinuation of oseltamivir, and pacer placement. There were no significant differences between groups with bradycardia versus without in terms of demographics, laboratory values, hospital characteristics, or oseltamivir dosing. Multivariate logistic regression showed that bradycardia was associated with baseline HR, age, past medical history of neurological issues, and positive influenza status. Between hours 6 through 126, significant differences existed between groups in actual and lowest HR. Conclusion and Relevance: Oseltamivir was associated with clinically relevant bradycardia in critically ill patients. Clinicians should closely monitor HR in critically ill patients receiving oseltamivir.

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Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults

SAGE Open Medicine ◽

10.1177/2050312120930898 ◽

2020 ◽

Vol 8 ◽

pp. 205031212093089

Author(s):

Kathryn A Connor ◽

Kelly M Conn

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Low Dose ◽

Secondary Prophylaxis ◽

Infection Prophylaxis ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Critically Ill Adults ◽

Ill Adults ◽

Infection Recurrence

Introduction: Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non- Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. Objectives: To determine whether critically ill adults receiving low-dose per os vancomycin for secondary Clostridioides difficile infection prophylaxis have fewer recurrences of Clostridioides difficile infection in 90 days compared with patients receiving metronidazole for secondary Clostridioides difficile infection prophylaxis or control (no secondary prophylaxis). Methods: This was a retrospective, two-center, observational study in a large academic medical center and affiliated community hospital. Included patients had a history of Clostridioides difficile infection within 1 year of receiving antibiotics for clinical care. We compared patients receiving secondary prophylaxis with vancomycin or metronidazole and control patients; in addition, an unplanned fourth group (vancomycin/metronidazole combination) was identified and analyzed. The primary outcome was Clostridioides difficile infection recurrence within 90 days of a course of broad-spectrum antibiotic therapy. Fisher’s exact, analysis of variance, and Kruskal–Wallis tests were used to compare Clostridioides difficile infection recurrence with prophylaxis group and additional contributing factors. Results: Eighty-two patients were included: 38 control (46.3%), 20 metronidazole (24.4%), 17 vancomycin (20.7%), and 7 combination (8.5%). Ten of 82 patients (12.2%) had at least one Clostridioides difficile infection recurrence; 8/38 patients in the control group (21.1%), 1/7 patients in the combination group (14.3%), 1/17 patients in the per os vancomycin group (5.9%), and 0/20 in the metronidazole group (0%; p = 0.073). As a post hoc secondary analysis, the three prophylaxis groups were coalesced into one group and compared with control (4.5% vs 21%; p = 0.039). Additional factors (e.g. age, obesity, immunosuppression, acid suppression) were not significantly associated with Clostridioides difficile infection recurrence or with prophylaxis group. Conclusion: There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.

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Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis

BMC Gastroenterology ◽

10.1186/s12876-019-1105-y ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Xiaoyang Zhou ◽

Hanyuan Fang ◽

Jianfei Xu ◽

Peifu Chen ◽

Xujun Hu ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Sequential Analysis ◽

Stress Ulcer ◽

Meta Analysis ◽

Trial Sequential Analysis ◽

Gi Bleeding ◽

Ulcer Prophylaxis ◽

Critically Ill Adults ◽

Ill Adults

Abstract Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.

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Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review

Critical Care Nurse ◽

10.4037/ccn2018633 ◽

2018 ◽

Vol 38 (1) ◽

pp. 38-49 ◽

Cited By ~ 24

Author(s):

Céline Gélinas ◽

Mélanie Bérubé ◽

Annie Chevrier ◽

Brenda T. Pun ◽

E. Wesley Ely ◽

...

Keyword(s):

Psychometric Properties ◽

Critically Ill ◽

Critically Ill Patients ◽

Assessment Tools ◽

Cognitive Test ◽

Delirium Assessment ◽

Nursing Delirium Screening Scale ◽

Detection Score ◽

Critically Ill Adults ◽

Ill Adults

BACKGROUNDDelirium is highly prevalent in critically ill patients. Its detection with valid tools is crucial.OBJECTIVETo analyze the development and psychometric properties of delirium assessment tools for critically ill adults.METHODSDatabases were searched to identify relevant studies. Inclusion criteria were English language, publication before January 2015, 30 or more patients, and patient population of critically ill adults (>18 years old). Search terms were delirium, scales, critically ill patients, adult, validity, and reliability. Thirty-six manuscripts were identified, encompassing 5 delirium assessment tools (Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Cognitive Test for Delirium, Delirium Detection Score, Intensive Care Delirium Screening Checklist (ICDSC), and Nursing Delirium Screening Scale). Two independent reviewers analyzed the psychometric properties of these tools by using a standardized scoring system (range, 0–20) to assess the tool development process, reliability, validity, feasibility, and implementation of each tool.RESULTSPsychometric properties were very good for the CAM-ICU (19.6) and the ICDSC (19.2), moderate for the Nursing Delirium Screening Scale (13.6), low for the Delirium Detection Score (11.2), and very low for the Cognitive Test for Delirium (8.2).CONCLUSIONSThe results indicate that the CAM-ICU and the ICDSC are the most valid and reliable delirium assessment tools for critically ill adults. Additional studies are needed to further validate these tools in critically ill patients with neurological disorders and those at various levels of sedation or consciousness.

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Association of multiple glycemic parameters at intensive care unit admission with mortality and clinical outcomes in critically ill patients

Scientific Reports ◽

10.1038/s41598-019-55080-3 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 6

Author(s):

Priscila Bellaver ◽

Ariell F. Schaeffer ◽

Diego P. Dullius ◽

Marina V. Viana ◽

Cristiane B. Leitão ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Renal Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Glycemic Variability ◽

Stress Hyperglycemia ◽

Critically Ill Adults ◽

Ill Adults

AbstractThe aim of the present study was to investigate the association of multiple glycemic parameters at intensive care unit (ICU) admission with outcomes in critically ill patients. Critically ill adults admitted to ICU were included prospectively in the study and followed for 180 days until hospital discharge or death. Patients were assessed for glycemic gap, hypoglycemia, hyperglycemia, glycemic variability, and stress hyperglycemia ratio (SHR). A total of 542 patients were enrolled (30% with preexisting diabetes). Patients with glycemic gap >80 mg/dL had increased need for renal replacement therapy (RRT; 37.7% vs. 23.7%, p = 0.025) and shock incidence (54.7% vs. 37.4%, p = 0.014). Hypoglycemia was associated with increased mortality (54.8% vs. 35.8%, p = 0.004), need for RRT (45.1% vs. 22.3%, p < 0.001), mechanical ventilation (MV; 72.6% vs. 57.5%, p = 0.024), and shock incidence (62.9% vs. 35.8%, p < 0.001). Hyperglycemia increased mortality (44.3% vs. 34.9%, p = 0.031). Glycemic variability >40 mg/dL was associated with increased need for RRT (28.3% vs. 14.4%, p = 0.002) and shock incidence (41.4% vs.31.2%, p = 0.039). In this mixed sample of critically ill subjects, including patients with and without preexisting diabetes, glycemic gap, glycemic variability, and SHR were associated with worse outcomes, but not with mortality. Hypoglycemia and hyperglycemia were independently associated with increased mortality.

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112. Physiological Signature of Bloodstream Infection in Critically Ill Patients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.187 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S87-S88

Author(s):

Alex Zimmet ◽

Matthew Clark ◽

Shrirang M Gadrey ◽

Taison Bell ◽

J Randall Moorman ◽

...

Keyword(s):

Blood Culture ◽

Bloodstream Infection ◽

Critically Ill ◽

Positive Blood Culture ◽

Critically Ill Patients ◽

Vital Sign ◽

Physiological Data ◽

Surgical Trauma ◽

Critically Ill Adults ◽

Ill Adults

Abstract Background Bloodstream infection (BSI) is associated with high mortality rates in critically ill patients but is difficult to identify clinically. This uncertainty results in frequent blood culture testing, which exposes patients to additional costs and the potential harms of unnecessary antibiotics. Accordingly, we aimed to identify signatures in physiological data from critically ill adults that characterize BSI. Methods We reviewed all blood culture, vital sign, laboratory, and cardiorespiratory monitoring (CRM) data from patients admitted to the medical and surgical/trauma ICUs at the University of Virginia Medical Center from February 2011 to June 2015. Blood culture results were categorized as positive, negative, or contaminant. For the BSI population, we included data obtained within 12 hours before or 24 hours after the acquisition of a positive blood culture. The control population included data greater than 12 hours before or 24 hours after the acquisition of a positive blood culture, and all data from patients without BSI. We used multivariable logistic regression to identify the physiological characteristics of BSI. Results We analyzed 9,955 ICU admissions with 144 patient-years of vital sign and CRM data (1.3M hourly measurements). The average age was 59 years; the population was mostly Caucasian (81%) and male (56%). There were 5,671 (57%) admissions with ≥1 blood culture, and 744 (7%) had a BSI. The in-hospital mortality rate for patients with BSI was 28% vs. 12% for all others. The physiological signature of BSI was characterized by abnormalities in 12 parameters (Figure 1)—e.g., BSI was more likely in patients with a higher pulse and lower platelets. Several associations were nonlinear—e.g., temperature and WBC had U-shaped relationships with BSI. The internally validated C-statistic was 0.77. Conclusion Statistical modeling revealed a clinically sensible physiological signature of BSI that could assist with bedside decisions regarding the utility of blood culture testing in critically ill adults. Disclosures All authors: No reported disclosures.

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Automated Fluid Management for Treatment of Rhabdomyolysis

International Journal of Nephrology ◽

10.1155/2016/2932593 ◽

2016 ◽

Vol 2016 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Christian M. Beilstein ◽

John R. Prowle ◽

Christopher J. Kirwan

Keyword(s):

Critically Ill ◽

Urine Output ◽

Primary Outcome ◽

Fluid Management ◽

Kidney Injury ◽

Service Evaluation ◽

Standard Group ◽

Convenience Sample ◽

Critically Ill Adults ◽

Ill Adults

Purpose. Fluid therapy aimed at increasing urine output is a commonly employed strategy to prevent acute kidney injury (AKI) in critically ill patients with rhabdomyolysis. Automated fluid management has the potential to optimise urine output while avoiding fluid accumulation in rhabdomyolysis patients. Methods. In a single centre clinical service evaluation we compared a convenience sample of critically ill adults with rhabdomyolysis treated with automated fluid management using the RenalGuard® device to patients managed with manual fluid adjustment following our standard rhabdomyolysis protocol. Primary outcome was number of hours with urine output >2 mL/kg during first 48 h of therapy. Results. Eight patients treated with RenalGuard were compared to 28 patients treated with manual fluid management. Number of hours of target urine output was greater in the RenalGuard versus the Standard group (176/312 (56.4%) versus 534/1305 (40.9%); p<0.01). Urine output was significantly higher in the first 24 h in the RenalGuard group (median (IQR) 4033 mL (3682–7363) versus 2913 mL (2263–4188 mL); p<0.01). Fluid balance, electrolyte, diuretics, and bicarbonate use were comparable between groups. Conclusions. Automated fluid management resulted in a higher urine output more quickly in the treatment of rhabdomyolysis. Further research is needed to analyse the effect of diuresis-matched hydration for the prevention of AKI in rhabdomyolysis.

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Penetration of echinocandins into wound secretion of critically ill patients

Infection ◽

10.1007/s15010-021-01604-x ◽

2021 ◽

Author(s):

Tiziana Gasperetti ◽

René Welte ◽

Herbert Oberacher ◽

Jana Marx ◽

Ingo Lorenz ◽

...

Keyword(s):

Clinical Outcome ◽

Critically Ill ◽

Critically Ill Patients ◽

Plasma Concentrations ◽

Individual Variability ◽

Wound Infections ◽

Concentration Data ◽

Life Threatening ◽

Critically Ill Adults ◽

Ill Adults

Abstract Purpose Wound infections caused by Candida are life-threatening and difficult to treat. Echinocandins are highly effective against Candida species and recommended for treatment of invasive candidiasis. As penetration of echinocandins into wounds is largely unknown, we measured the concentrations of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) in wound secretion (WS) and in plasma of critically ill patients. Methods We included critically ill adults with an indwelling wound drainage or undergoing vacuum-assisted closure therapy, who were treated with an echinocandin for suspected or proven invasive fungal infection. Concentrations were measured by liquid chromatography with UV (AFG and MFG) or tandem mass spectrometry detection (CAS). Results Twenty-one patients were enrolled. From eight patients, serial WS samples and simultaneous plasma samples were obtained within a dosage interval. AFG concentrations in WS amounted to < 0.025–2.25 mg/L, MFG concentrations were 0.025–2.53 mg/L, and CAS achieved concentrations of 0.18–4.04 mg/L. Concentrations in WS were significantly lower than the simultaneous plasma concentrations and below the MIC values of some relevant pathogens. Conclusion Echinocandin penetration into WS displays a high inter-individual variability. In WS of some of the patients, concentrations may be sub-therapeutic. However, the relevance of sub-therapeutic concentrations is unknown as no correlation has been established between concentration data and clinical outcome. Nevertheless, in the absence of clinical outcome studies, our data do not support the use of echinocandins at standard doses for the treatment of fungal wound infections, but underline the pivotal role of surgical debridement.

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Optimal Nutritional Factors Influencing the Duration of Mechanical Ventilation among Critically ill Adults in the Intensive Care Unit

10.20944/preprints202104.0330.v1 ◽

2021 ◽

Author(s):

Apinya Koontalay ◽

Wanich Suksatan ◽

Kantapong Prabsangob

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Severity Of Illness ◽

Nutrition Status ◽

Nutritional Factors ◽

Duration Of Hospitalization ◽

Critically Ill Adults ◽

Ill Adults ◽

Dyspnea Assessment

Background: Malnutrition is associated with a complication problem affecting critically ill patients throughout the trajectory of their illness and which may increase the duration of hospitalization and mechanical ventilation and mortality. To explore nutritional factors impact on the duration of mechanical ventilation in critically ill patients. Methods: In this single-center, prospective observational study in a critical care unit. The sample of the study consisting of a total of 100 critically ill patients who were included in the regression analyzed by purposive sampling, performed to address the research objectives. The data were collected for each patient who participated in the study for 2 consecutive days with SGA, Dyspnea assessment form, APACHE II, and time to initial EN on the 24 hours of hospital admitted and the daily calories target requirement on the seven days. Results: At the end of monitoring, the nutrition status, time to initial EN, and calories, target requirements were moderate positive statistically significant related to the duration of mechanical ventilation (R = 0.54, R = 0.30, R= 0.40, p < 0.05). However, age, the severity of illness, and dyspnea scales were not related to the duration of mechanical ventilation (p> 0.05). Therefore, nutrition status and calory target requirements could be a predictor of the duration of mechanical ventilation. The predictive power was 28.0 percent of variance (R2 = 0.28, p< 0.01). Conclusion: The finding supports which assessment of the nutritional status and calory target requirement within 7 days revealed with reducing the duration of mechanical ventilation in critically ill patients.

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In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study

BMJ ◽

10.1136/bmj.m3513 ◽

2020 ◽

pp. m3513 ◽

Cited By ~ 3

Author(s):

Salim S Hayek ◽

Samantha K Brenner ◽

Tariq U Azam ◽

Husam R Shadid ◽

Elizabeth Anderson ◽

...

Keyword(s):

Cardiac Arrest ◽

Intensive Care ◽

Cardiopulmonary Resuscitation ◽

Hospital Discharge ◽

Critically Ill ◽

Critically Ill Patients ◽

Multicenter Cohort Study ◽

Critically Ill Adults ◽

Ill Adults ◽

Hospital Cardiac Arrest

Abstract Objectives To estimate the incidence, risk factors, and outcomes associated with in-hospital cardiac arrest and cardiopulmonary resuscitation in critically ill adults with coronavirus disease 2019 (covid-19). Design Multicenter cohort study. Setting Intensive care units at 68 geographically diverse hospitals across the United States. Participants Critically ill adults (age ≥18 years) with laboratory confirmed covid-19. Main outcome measures In-hospital cardiac arrest within 14 days of admission to an intensive care unit and in-hospital mortality. Results Among 5019 critically ill patients with covid-19, 14.0% (701/5019) had in-hospital cardiac arrest, 57.1% (400/701) of whom received cardiopulmonary resuscitation. Patients who had in-hospital cardiac arrest were older (mean age 63 (standard deviation 14) v 60 (15) years), had more comorbidities, and were more likely to be admitted to a hospital with a smaller number of intensive care unit beds compared with those who did not have in-hospital cardiac arrest. Patients who received cardiopulmonary resuscitation were younger than those who did not (mean age 61 (standard deviation 14) v 67 (14) years). The most common rhythms at the time of cardiopulmonary resuscitation were pulseless electrical activity (49.8%, 199/400) and asystole (23.8%, 95/400). 48 of the 400 patients (12.0%) who received cardiopulmonary resuscitation survived to hospital discharge, and only 7.0% (28/400) survived to hospital discharge with normal or mildly impaired neurological status. Survival to hospital discharge differed by age, with 21.2% (11/52) of patients younger than 45 years surviving compared with 2.9% (1/34) of those aged 80 or older. Conclusions Cardiac arrest is common in critically ill patients with covid-19 and is associated with poor survival, particularly among older patients.

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A Retrospective Characterization of Dexmedetomidine-Suspected Fever and Its Consequences in Adult Critically Ill Patients

Annals of Pharmacotherapy ◽

10.1177/10600280211060082 ◽

2022 ◽

pp. 106002802110600

Author(s):

Emily Schranz ◽

Stephen Rappaport ◽

Christine Groth ◽

Paritosh Prasad ◽

Kevin Cooper ◽

...

Keyword(s):

Cardiac Surgery ◽

Critically Ill ◽

Critically Ill Patients ◽

Multidrug Resistant ◽

Culture Collection ◽

Primary Objective ◽

Current Evidence ◽

Resistant Organism ◽

Critically Ill Adults ◽

Ill Adults

Background: Current evidence for dexmedetomidine-suspected fever (DSF) is limited. Lack of recognition may lead to costly or potentially harmful interventions for critically ill patients. Objective: The primary objective was to characterize escalations of care related to DSF. Secondary objectives were to describe the incidence, severity, and consequences associated with DSF. Methods: A retrospective review was conducted in critically ill adults who developed fever ≥39°C within 12 h from initiation of dexmedetomidine, with resolution of fever to <39°C within 12 h after discontinuation. The primary outcome was percentage of patients who received an escalation of care due to fever. Secondary outcomes included the percentage of patients who developed a multidrug-resistant organism or Clostridium difficile infection. Results: Eighteen of 3943 patients screened in 4099 encounters met criteria for DSF (0.4%). The majority were white (83.3%), male (66.7%), and underwent cardiac surgery (61.1%). Median (interquartile range [IQR]) time to fever onset and resolution were 5.5 (3.6-7.6) and 1.3 (1.0-2.9) h. Nine patients (50%) underwent infectious workup including antimicrobial initiation (n = 1, 5.6%), broadening of antimicrobials (n = 4, 22.2%), or culture collection (n = 9, 50%). Eleven patients (61.1%) underwent attempted temperature reduction. Twelve patients (66.7%) underwent diagnostic imaging. Incidence of multidrug-resistant organism and C. difficile infection were low (11.1 and 16.7% of fever patients, respectively). Conclusion and Relevance: Incidence of DSF was low and more common in cardiac surgery patients. Unrecognized DSF led to an escalation of care in most patients. Dexmedetomidine exposure should be considered as a potential cause of fever in critically ill adults.

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