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ICU admissions raise chronic condition risk
SAN DIEGO – The research showed rising likelihood of conditions such as depression, diabetes, and heart disease.
By merging two existing databases, the researchers were able to capture a more comprehensive picture of post-ICU patients. “We were able to include almost the entire country,” Ilse van Beusekom, a PhD candidate in health sciences at the University of Amsterdam and data manager at the National Intensive Care Evaluation (NICE) foundation, said in an interview.
Ms. van Beusekom presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. The study was simultaneously published in Critical Care Medicine.
The work compared 56,760 ICU survivors from 81 facilities across the Netherlands to 75,232 age-, sex-, and socioeconomic status–matched controls. The mean age was 65 years and 60% of the population was male. “The types of chronic conditions are the same, only the prevalences are different,” said Ms. van Beusekom.
The researchers compared chronic conditions in the year before ICU admission and the year after, based on data pulled from the NICE national quality database, which includes data describing the first 24 hours of ICU admission, and the Vektis insurance claims database, which includes information on medical treatment. Before ICU admission, 45% of the ICU population was free of chronic conditions, as were 62% of controls. One chronic condition was present in 36% of ICU patients, versus 29% of controls, and two or more conditions were present in 19% versus 9% of controls.
The ICU population was more likely to have high cholesterol (16% vs. 14%), heart disease (14% vs. 6%), chronic obstructive pulmonary disease (8% vs. 3%), type II diabetes (8% vs. 6%), type I diabetes (6% vs. 3%), and depression (6% vs. 4%).
The ICU population also was at greater risk of developing one or more new chronic conditions during the year following their stay. The risk was three- to fourfold higher throughout age ranges.
The study suggests the need for greater follow-up after an ICU admission in order to help patients cope with lingering problems. Ms. van Beusekom noted that there are follow-up programs in the Netherlands for several patient groups, but none for ICU survivors. One possibility would be to have the patient return to the ICU 3 months or so after release to discuss their diagnosis, treatment, and any lingering concerns. “A lot of people don’t know that their complaints are linked with the ICU visit,” said Ms. van Beusekom.
Timothy G. Buchman, MD, professor of surgery at Emory University, Atlanta, who moderated the session, wondered why the ICU seems to be an inflection point for developing new chronic conditions. Could it simply be because patients are sicker to begin with and have reached an inflection point of their illness, or could the treatments in ICU be contributing to or exposing those conditions? Ms. van Beusekom believed it was likely a combination of factors, and she referred to data she had not presented showing that even control patients who had been to the hospital (though not the ICU) during the study period were at lower risk of new chronic conditions than ICU patients.
Ms. van Beusekom’s group plans to investigate ICU-related variables that might be associated with risk of chronic conditions.
The study was not funded. Ms. van Beusekom had no relevant disclosures.
SOURCE: van Beusekom I et al. CCC48, Abstract Crit Care Med. 2019;47:324-30.
SAN DIEGO – The research showed rising likelihood of conditions such as depression, diabetes, and heart disease.
By merging two existing databases, the researchers were able to capture a more comprehensive picture of post-ICU patients. “We were able to include almost the entire country,” Ilse van Beusekom, a PhD candidate in health sciences at the University of Amsterdam and data manager at the National Intensive Care Evaluation (NICE) foundation, said in an interview.
Ms. van Beusekom presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. The study was simultaneously published in Critical Care Medicine.
The work compared 56,760 ICU survivors from 81 facilities across the Netherlands to 75,232 age-, sex-, and socioeconomic status–matched controls. The mean age was 65 years and 60% of the population was male. “The types of chronic conditions are the same, only the prevalences are different,” said Ms. van Beusekom.
The researchers compared chronic conditions in the year before ICU admission and the year after, based on data pulled from the NICE national quality database, which includes data describing the first 24 hours of ICU admission, and the Vektis insurance claims database, which includes information on medical treatment. Before ICU admission, 45% of the ICU population was free of chronic conditions, as were 62% of controls. One chronic condition was present in 36% of ICU patients, versus 29% of controls, and two or more conditions were present in 19% versus 9% of controls.
The ICU population was more likely to have high cholesterol (16% vs. 14%), heart disease (14% vs. 6%), chronic obstructive pulmonary disease (8% vs. 3%), type II diabetes (8% vs. 6%), type I diabetes (6% vs. 3%), and depression (6% vs. 4%).
The ICU population also was at greater risk of developing one or more new chronic conditions during the year following their stay. The risk was three- to fourfold higher throughout age ranges.
The study suggests the need for greater follow-up after an ICU admission in order to help patients cope with lingering problems. Ms. van Beusekom noted that there are follow-up programs in the Netherlands for several patient groups, but none for ICU survivors. One possibility would be to have the patient return to the ICU 3 months or so after release to discuss their diagnosis, treatment, and any lingering concerns. “A lot of people don’t know that their complaints are linked with the ICU visit,” said Ms. van Beusekom.
Timothy G. Buchman, MD, professor of surgery at Emory University, Atlanta, who moderated the session, wondered why the ICU seems to be an inflection point for developing new chronic conditions. Could it simply be because patients are sicker to begin with and have reached an inflection point of their illness, or could the treatments in ICU be contributing to or exposing those conditions? Ms. van Beusekom believed it was likely a combination of factors, and she referred to data she had not presented showing that even control patients who had been to the hospital (though not the ICU) during the study period were at lower risk of new chronic conditions than ICU patients.
Ms. van Beusekom’s group plans to investigate ICU-related variables that might be associated with risk of chronic conditions.
The study was not funded. Ms. van Beusekom had no relevant disclosures.
SOURCE: van Beusekom I et al. CCC48, Abstract Crit Care Med. 2019;47:324-30.
SAN DIEGO – The research showed rising likelihood of conditions such as depression, diabetes, and heart disease.
By merging two existing databases, the researchers were able to capture a more comprehensive picture of post-ICU patients. “We were able to include almost the entire country,” Ilse van Beusekom, a PhD candidate in health sciences at the University of Amsterdam and data manager at the National Intensive Care Evaluation (NICE) foundation, said in an interview.
Ms. van Beusekom presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. The study was simultaneously published in Critical Care Medicine.
The work compared 56,760 ICU survivors from 81 facilities across the Netherlands to 75,232 age-, sex-, and socioeconomic status–matched controls. The mean age was 65 years and 60% of the population was male. “The types of chronic conditions are the same, only the prevalences are different,” said Ms. van Beusekom.
The researchers compared chronic conditions in the year before ICU admission and the year after, based on data pulled from the NICE national quality database, which includes data describing the first 24 hours of ICU admission, and the Vektis insurance claims database, which includes information on medical treatment. Before ICU admission, 45% of the ICU population was free of chronic conditions, as were 62% of controls. One chronic condition was present in 36% of ICU patients, versus 29% of controls, and two or more conditions were present in 19% versus 9% of controls.
The ICU population was more likely to have high cholesterol (16% vs. 14%), heart disease (14% vs. 6%), chronic obstructive pulmonary disease (8% vs. 3%), type II diabetes (8% vs. 6%), type I diabetes (6% vs. 3%), and depression (6% vs. 4%).
The ICU population also was at greater risk of developing one or more new chronic conditions during the year following their stay. The risk was three- to fourfold higher throughout age ranges.
The study suggests the need for greater follow-up after an ICU admission in order to help patients cope with lingering problems. Ms. van Beusekom noted that there are follow-up programs in the Netherlands for several patient groups, but none for ICU survivors. One possibility would be to have the patient return to the ICU 3 months or so after release to discuss their diagnosis, treatment, and any lingering concerns. “A lot of people don’t know that their complaints are linked with the ICU visit,” said Ms. van Beusekom.
Timothy G. Buchman, MD, professor of surgery at Emory University, Atlanta, who moderated the session, wondered why the ICU seems to be an inflection point for developing new chronic conditions. Could it simply be because patients are sicker to begin with and have reached an inflection point of their illness, or could the treatments in ICU be contributing to or exposing those conditions? Ms. van Beusekom believed it was likely a combination of factors, and she referred to data she had not presented showing that even control patients who had been to the hospital (though not the ICU) during the study period were at lower risk of new chronic conditions than ICU patients.
Ms. van Beusekom’s group plans to investigate ICU-related variables that might be associated with risk of chronic conditions.
The study was not funded. Ms. van Beusekom had no relevant disclosures.
SOURCE: van Beusekom I et al. CCC48, Abstract Crit Care Med. 2019;47:324-30.
REPORTING FROM CCC48
Opportunities missed for advance care planning for elderly ICU patients
SAN DIEGO – A nationally representative survey of the problem is more pronounced among some blacks and Hispanics and those with lower net worth. The study also found that these patients see physicians an average of 20 times in the year preceding the ICU visit, which suggests that there are plenty of opportunities to put ACP in place.
“Over two-thirds were seen by a doctor in the last 2 weeks. So they’re seeing doctors, but they’re still not doing advance care planning,” said Brian Block, MD, during a presentation of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. Dr. Block is with the University of California, San Francisco.
Lack of advance planning can put major road blocks in front of patient care in the ICU, as well as complicate communication between physicians and family members. The findings underscore the need to encourage conversations about end-of-life care between physicians and their patients – before the patients wind up in intensive care.
One audience member believes these conversations are already happening. Paul Yodice, MD, chairman of medicine at Saint Barnabas Medical Center in Livingston, N.J., suggested that physicians are attempting to engage older patients and family members in ACP, but many are unready to make decisions. “In my experience, it is happening much more frequently than is captured either in the medical record or in the research that we’ve been publishing. I’ve been a part of those conversations. Those individuals who are faced with those toughest of choices choose to delay making the decision or speaking about it further because it’s just too painful to consider, and they hold out hope of being the one to beat the odds, to have one more day,” said Dr. Yodice.
He called for further research to document whether ACP conversations are happening and to identify barriers to decisions and the means to overcome them. “A next good study would be to send out a respectful survey to the families of those who have lost people they love and ask: Has someone in the past year spoken with you or offered to have a discussion about end-of-life issues? We could get a better handle on [how often] the discussion is being had, and then find a solution,” said Dr. Yodice.
ACP can also be difficult for the provider, he added. Family members and patients, desperate for another treatment option, will often ask if there’s anything else that can be done. “In medicine, the answer almost always is ‘Well, we can try something else even though I know it’s not going to work.’ And people hold on to that, including us,” said Dr. Yodice.
The study analyzed data from a Medicare cohort of 1,109 patients who died during 2000-2013 and had an ICU admission within the last 30 days of their life. Ages were fairly evenly distributed, with 29% aged 65-74 years, 39% aged 75-84, and 32% aged 85 and over. Fifty-four percent were women, 26% were nonwhite, 42% had not completed high school, and 11% were in skilled nursing facilities.
About 35% had no ACP in 2000-2001, and that percentage gradually declined, to about 20% in 2012-2013 (slope, –1.6%/year; P = .009).
Seventeen percent of white participants had no ACP, compared with 51% of blacks and 49% of Hispanics. Net worth was also strongly associated with having ACP: The top quartile had 13% lacking ACP, compared with 43% of the bottom quartile.
The study found that 94% of patients who had no ACP had visited a health care provider in the past year. The average number of visits in the past year was 20, and 83% had seen a provider within the past 30 days.
Dr. Block did not declare a source of funding or potential conflicts. Dr. Yodice had no disclosures.
SOURCE: Block B et al. CCC48, Abstract 401.
SAN DIEGO – A nationally representative survey of the problem is more pronounced among some blacks and Hispanics and those with lower net worth. The study also found that these patients see physicians an average of 20 times in the year preceding the ICU visit, which suggests that there are plenty of opportunities to put ACP in place.
“Over two-thirds were seen by a doctor in the last 2 weeks. So they’re seeing doctors, but they’re still not doing advance care planning,” said Brian Block, MD, during a presentation of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. Dr. Block is with the University of California, San Francisco.
Lack of advance planning can put major road blocks in front of patient care in the ICU, as well as complicate communication between physicians and family members. The findings underscore the need to encourage conversations about end-of-life care between physicians and their patients – before the patients wind up in intensive care.
One audience member believes these conversations are already happening. Paul Yodice, MD, chairman of medicine at Saint Barnabas Medical Center in Livingston, N.J., suggested that physicians are attempting to engage older patients and family members in ACP, but many are unready to make decisions. “In my experience, it is happening much more frequently than is captured either in the medical record or in the research that we’ve been publishing. I’ve been a part of those conversations. Those individuals who are faced with those toughest of choices choose to delay making the decision or speaking about it further because it’s just too painful to consider, and they hold out hope of being the one to beat the odds, to have one more day,” said Dr. Yodice.
He called for further research to document whether ACP conversations are happening and to identify barriers to decisions and the means to overcome them. “A next good study would be to send out a respectful survey to the families of those who have lost people they love and ask: Has someone in the past year spoken with you or offered to have a discussion about end-of-life issues? We could get a better handle on [how often] the discussion is being had, and then find a solution,” said Dr. Yodice.
ACP can also be difficult for the provider, he added. Family members and patients, desperate for another treatment option, will often ask if there’s anything else that can be done. “In medicine, the answer almost always is ‘Well, we can try something else even though I know it’s not going to work.’ And people hold on to that, including us,” said Dr. Yodice.
The study analyzed data from a Medicare cohort of 1,109 patients who died during 2000-2013 and had an ICU admission within the last 30 days of their life. Ages were fairly evenly distributed, with 29% aged 65-74 years, 39% aged 75-84, and 32% aged 85 and over. Fifty-four percent were women, 26% were nonwhite, 42% had not completed high school, and 11% were in skilled nursing facilities.
About 35% had no ACP in 2000-2001, and that percentage gradually declined, to about 20% in 2012-2013 (slope, –1.6%/year; P = .009).
Seventeen percent of white participants had no ACP, compared with 51% of blacks and 49% of Hispanics. Net worth was also strongly associated with having ACP: The top quartile had 13% lacking ACP, compared with 43% of the bottom quartile.
The study found that 94% of patients who had no ACP had visited a health care provider in the past year. The average number of visits in the past year was 20, and 83% had seen a provider within the past 30 days.
Dr. Block did not declare a source of funding or potential conflicts. Dr. Yodice had no disclosures.
SOURCE: Block B et al. CCC48, Abstract 401.
SAN DIEGO – A nationally representative survey of the problem is more pronounced among some blacks and Hispanics and those with lower net worth. The study also found that these patients see physicians an average of 20 times in the year preceding the ICU visit, which suggests that there are plenty of opportunities to put ACP in place.
“Over two-thirds were seen by a doctor in the last 2 weeks. So they’re seeing doctors, but they’re still not doing advance care planning,” said Brian Block, MD, during a presentation of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. Dr. Block is with the University of California, San Francisco.
Lack of advance planning can put major road blocks in front of patient care in the ICU, as well as complicate communication between physicians and family members. The findings underscore the need to encourage conversations about end-of-life care between physicians and their patients – before the patients wind up in intensive care.
One audience member believes these conversations are already happening. Paul Yodice, MD, chairman of medicine at Saint Barnabas Medical Center in Livingston, N.J., suggested that physicians are attempting to engage older patients and family members in ACP, but many are unready to make decisions. “In my experience, it is happening much more frequently than is captured either in the medical record or in the research that we’ve been publishing. I’ve been a part of those conversations. Those individuals who are faced with those toughest of choices choose to delay making the decision or speaking about it further because it’s just too painful to consider, and they hold out hope of being the one to beat the odds, to have one more day,” said Dr. Yodice.
He called for further research to document whether ACP conversations are happening and to identify barriers to decisions and the means to overcome them. “A next good study would be to send out a respectful survey to the families of those who have lost people they love and ask: Has someone in the past year spoken with you or offered to have a discussion about end-of-life issues? We could get a better handle on [how often] the discussion is being had, and then find a solution,” said Dr. Yodice.
ACP can also be difficult for the provider, he added. Family members and patients, desperate for another treatment option, will often ask if there’s anything else that can be done. “In medicine, the answer almost always is ‘Well, we can try something else even though I know it’s not going to work.’ And people hold on to that, including us,” said Dr. Yodice.
The study analyzed data from a Medicare cohort of 1,109 patients who died during 2000-2013 and had an ICU admission within the last 30 days of their life. Ages were fairly evenly distributed, with 29% aged 65-74 years, 39% aged 75-84, and 32% aged 85 and over. Fifty-four percent were women, 26% were nonwhite, 42% had not completed high school, and 11% were in skilled nursing facilities.
About 35% had no ACP in 2000-2001, and that percentage gradually declined, to about 20% in 2012-2013 (slope, –1.6%/year; P = .009).
Seventeen percent of white participants had no ACP, compared with 51% of blacks and 49% of Hispanics. Net worth was also strongly associated with having ACP: The top quartile had 13% lacking ACP, compared with 43% of the bottom quartile.
The study found that 94% of patients who had no ACP had visited a health care provider in the past year. The average number of visits in the past year was 20, and 83% had seen a provider within the past 30 days.
Dr. Block did not declare a source of funding or potential conflicts. Dr. Yodice had no disclosures.
SOURCE: Block B et al. CCC48, Abstract 401.
REPORTING FROM CCC48
Peripheral perfusion fails septic shock test, but optimism remains
SAN DIEGO – During resuscitation of patients but missed statistical significance.
Although the paper, published online in JAMA, concludes that normalization of capillary refill time cannot be recommended over targeting serum lactate levels, Glenn Hernández, MD, PhD, sounded more optimistic after presenting the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. “I think it’s good news to develop techniques that, even though they have this integrated variability, they can provide a signal that is also very close to the [underlying] physiology,” Dr. Hernández, who is a professor of intensive medicine at Pontifical Catholic University in Santiago, Chile. The Peripheral perfusion was also associated with lower mean Sequential Organ Failure Assessment (SOFA) Score at 72 hours.
The technique involves pressing a glass microscope slide to the ventral surface of the right index finger distal phalanx, increasing pressure and maintaining pressure for 10 seconds. After release, a chronometer assessed return of normal skin color, with refill times over 3 seconds considered abnormal. Clinicians applied the technique every 30 minutes during until normalization (every hour after that), compared with every 2 hours for the lactate arm of the study.
The ANDROMEDA-SHOCK randomized clinical trial was conducted at 28 hospitals in five countries (Argentina, Chile, Colombia, Ecuador, Uruguay). The trial did not demonstrate superiority of capillary refill, and it was not designed for noninferiority. It nevertheless seems unlikely that assessment of capillary refill is inferior to lactate levels, according an accompanying editorial by JAMA-associated editor Derek Angus, MD, who also is a professor of critical care medicine at the University of Pittsburgh. The simplicity of using a capillary refill could be particularly useful in resource-limited settings, since it can be accomplished visually.
It also a natural marker for resuscitation. The body slows fluid flow to peripheral tissues until vital organs are well perfused. Normal capillary refill time “is an indirect signal of reperfusion,” said Dr. Hernández.
The researchers are not calling for this technique to replace lactate measurements, noting that in many ways the techniques can be complementary, since lactate levels are a good indicator of the patient’s overall improvement. In any case, it would take more research to prove superiority of the capillary refill, and that’s not something Dr. Hernández is planning to undertake. The current study had no external funding and required about half of his time over a 2-year period. Getting the work done at all “was sort of a miracle. We would not repeat this,” he said.
The researchers randomized 416 patients with septic shock (mean age, 63 years; 53% of whom were women) to be managed by peripheral perfusion or lactate measurement. By day 28, 43.4% in the lactate group had died, compared with 34.9% in the peripheral perfusion group (hazard ratio, 0.75; P = .06). At 72 hours, the peripheral perfusion group had less organ dysfunction as measured by SOFA (mean, 5.6 vs. 6.6; P = .045). Six other secondary outcomes revealed no between-group differences.
The peripheral perfusion group received an average of 408 fewer mL of resuscitation fluids during the first 8 hours (P = .01).
That result fits with the greater responsiveness of peripheral perfusion measurements, and it’s relevant because some septic shock patients who are unresponsive to fluids often receive fluids anyway. “The general knowledge, though not correct, is that you treat lactate or blood pressure with fluids,” said coauthor Jan Bakker, MD, PhD, who is a professor at New York-Presbyterian Hospital Columbia University, and Erasmus University Rotterdam, the Netherlands.
After a series of observational studies suggested that warm, well-perfused patients were doing well, the idea was tested in a small interventional trial in which physicians were forbidden from giving fluids once patients were warm and well perfused. Patients did better than did those on standard of care. “We have said, if the patient is warm and well perfused, even if they are hypotensive, don’t give fluids, it won’t benefit them anymore. Give vasopressors or whatever, but don’t give fluids,” said Dr. Bakker.
The latest research also reinforced a signal from the earlier, smaller trial. “You get less organ failure if you use [fewer] fluids,” Dr. Bakker added.
The study received no external funding. Dr. Hernández and Dr. Bakker had no relevant financial disclosures. Dr. Angus received consulting fees from Ferring Pharmaceutical, Bristol-Myers Squibb, Bayer AG, and others outside the submitted work; he also has patents pending for compounds, compositions, and methods for treating sepsis and for proteomic biomarkers.
SOURCE: Hernández G et al. JAMA 2019 Feb 17. doi: 10.1001/jama.2019.0071.
SAN DIEGO – During resuscitation of patients but missed statistical significance.
Although the paper, published online in JAMA, concludes that normalization of capillary refill time cannot be recommended over targeting serum lactate levels, Glenn Hernández, MD, PhD, sounded more optimistic after presenting the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. “I think it’s good news to develop techniques that, even though they have this integrated variability, they can provide a signal that is also very close to the [underlying] physiology,” Dr. Hernández, who is a professor of intensive medicine at Pontifical Catholic University in Santiago, Chile. The Peripheral perfusion was also associated with lower mean Sequential Organ Failure Assessment (SOFA) Score at 72 hours.
The technique involves pressing a glass microscope slide to the ventral surface of the right index finger distal phalanx, increasing pressure and maintaining pressure for 10 seconds. After release, a chronometer assessed return of normal skin color, with refill times over 3 seconds considered abnormal. Clinicians applied the technique every 30 minutes during until normalization (every hour after that), compared with every 2 hours for the lactate arm of the study.
The ANDROMEDA-SHOCK randomized clinical trial was conducted at 28 hospitals in five countries (Argentina, Chile, Colombia, Ecuador, Uruguay). The trial did not demonstrate superiority of capillary refill, and it was not designed for noninferiority. It nevertheless seems unlikely that assessment of capillary refill is inferior to lactate levels, according an accompanying editorial by JAMA-associated editor Derek Angus, MD, who also is a professor of critical care medicine at the University of Pittsburgh. The simplicity of using a capillary refill could be particularly useful in resource-limited settings, since it can be accomplished visually.
It also a natural marker for resuscitation. The body slows fluid flow to peripheral tissues until vital organs are well perfused. Normal capillary refill time “is an indirect signal of reperfusion,” said Dr. Hernández.
The researchers are not calling for this technique to replace lactate measurements, noting that in many ways the techniques can be complementary, since lactate levels are a good indicator of the patient’s overall improvement. In any case, it would take more research to prove superiority of the capillary refill, and that’s not something Dr. Hernández is planning to undertake. The current study had no external funding and required about half of his time over a 2-year period. Getting the work done at all “was sort of a miracle. We would not repeat this,” he said.
The researchers randomized 416 patients with septic shock (mean age, 63 years; 53% of whom were women) to be managed by peripheral perfusion or lactate measurement. By day 28, 43.4% in the lactate group had died, compared with 34.9% in the peripheral perfusion group (hazard ratio, 0.75; P = .06). At 72 hours, the peripheral perfusion group had less organ dysfunction as measured by SOFA (mean, 5.6 vs. 6.6; P = .045). Six other secondary outcomes revealed no between-group differences.
The peripheral perfusion group received an average of 408 fewer mL of resuscitation fluids during the first 8 hours (P = .01).
That result fits with the greater responsiveness of peripheral perfusion measurements, and it’s relevant because some septic shock patients who are unresponsive to fluids often receive fluids anyway. “The general knowledge, though not correct, is that you treat lactate or blood pressure with fluids,” said coauthor Jan Bakker, MD, PhD, who is a professor at New York-Presbyterian Hospital Columbia University, and Erasmus University Rotterdam, the Netherlands.
After a series of observational studies suggested that warm, well-perfused patients were doing well, the idea was tested in a small interventional trial in which physicians were forbidden from giving fluids once patients were warm and well perfused. Patients did better than did those on standard of care. “We have said, if the patient is warm and well perfused, even if they are hypotensive, don’t give fluids, it won’t benefit them anymore. Give vasopressors or whatever, but don’t give fluids,” said Dr. Bakker.
The latest research also reinforced a signal from the earlier, smaller trial. “You get less organ failure if you use [fewer] fluids,” Dr. Bakker added.
The study received no external funding. Dr. Hernández and Dr. Bakker had no relevant financial disclosures. Dr. Angus received consulting fees from Ferring Pharmaceutical, Bristol-Myers Squibb, Bayer AG, and others outside the submitted work; he also has patents pending for compounds, compositions, and methods for treating sepsis and for proteomic biomarkers.
SOURCE: Hernández G et al. JAMA 2019 Feb 17. doi: 10.1001/jama.2019.0071.
SAN DIEGO – During resuscitation of patients but missed statistical significance.
Although the paper, published online in JAMA, concludes that normalization of capillary refill time cannot be recommended over targeting serum lactate levels, Glenn Hernández, MD, PhD, sounded more optimistic after presenting the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. “I think it’s good news to develop techniques that, even though they have this integrated variability, they can provide a signal that is also very close to the [underlying] physiology,” Dr. Hernández, who is a professor of intensive medicine at Pontifical Catholic University in Santiago, Chile. The Peripheral perfusion was also associated with lower mean Sequential Organ Failure Assessment (SOFA) Score at 72 hours.
The technique involves pressing a glass microscope slide to the ventral surface of the right index finger distal phalanx, increasing pressure and maintaining pressure for 10 seconds. After release, a chronometer assessed return of normal skin color, with refill times over 3 seconds considered abnormal. Clinicians applied the technique every 30 minutes during until normalization (every hour after that), compared with every 2 hours for the lactate arm of the study.
The ANDROMEDA-SHOCK randomized clinical trial was conducted at 28 hospitals in five countries (Argentina, Chile, Colombia, Ecuador, Uruguay). The trial did not demonstrate superiority of capillary refill, and it was not designed for noninferiority. It nevertheless seems unlikely that assessment of capillary refill is inferior to lactate levels, according an accompanying editorial by JAMA-associated editor Derek Angus, MD, who also is a professor of critical care medicine at the University of Pittsburgh. The simplicity of using a capillary refill could be particularly useful in resource-limited settings, since it can be accomplished visually.
It also a natural marker for resuscitation. The body slows fluid flow to peripheral tissues until vital organs are well perfused. Normal capillary refill time “is an indirect signal of reperfusion,” said Dr. Hernández.
The researchers are not calling for this technique to replace lactate measurements, noting that in many ways the techniques can be complementary, since lactate levels are a good indicator of the patient’s overall improvement. In any case, it would take more research to prove superiority of the capillary refill, and that’s not something Dr. Hernández is planning to undertake. The current study had no external funding and required about half of his time over a 2-year period. Getting the work done at all “was sort of a miracle. We would not repeat this,” he said.
The researchers randomized 416 patients with septic shock (mean age, 63 years; 53% of whom were women) to be managed by peripheral perfusion or lactate measurement. By day 28, 43.4% in the lactate group had died, compared with 34.9% in the peripheral perfusion group (hazard ratio, 0.75; P = .06). At 72 hours, the peripheral perfusion group had less organ dysfunction as measured by SOFA (mean, 5.6 vs. 6.6; P = .045). Six other secondary outcomes revealed no between-group differences.
The peripheral perfusion group received an average of 408 fewer mL of resuscitation fluids during the first 8 hours (P = .01).
That result fits with the greater responsiveness of peripheral perfusion measurements, and it’s relevant because some septic shock patients who are unresponsive to fluids often receive fluids anyway. “The general knowledge, though not correct, is that you treat lactate or blood pressure with fluids,” said coauthor Jan Bakker, MD, PhD, who is a professor at New York-Presbyterian Hospital Columbia University, and Erasmus University Rotterdam, the Netherlands.
After a series of observational studies suggested that warm, well-perfused patients were doing well, the idea was tested in a small interventional trial in which physicians were forbidden from giving fluids once patients were warm and well perfused. Patients did better than did those on standard of care. “We have said, if the patient is warm and well perfused, even if they are hypotensive, don’t give fluids, it won’t benefit them anymore. Give vasopressors or whatever, but don’t give fluids,” said Dr. Bakker.
The latest research also reinforced a signal from the earlier, smaller trial. “You get less organ failure if you use [fewer] fluids,” Dr. Bakker added.
The study received no external funding. Dr. Hernández and Dr. Bakker had no relevant financial disclosures. Dr. Angus received consulting fees from Ferring Pharmaceutical, Bristol-Myers Squibb, Bayer AG, and others outside the submitted work; he also has patents pending for compounds, compositions, and methods for treating sepsis and for proteomic biomarkers.
SOURCE: Hernández G et al. JAMA 2019 Feb 17. doi: 10.1001/jama.2019.0071.
REPORTING FROM CCC48
Palliative care has improved for critically ill children, but challenges remain
SAN DIEGO – and is more common among older children, female children, and those with government insurance or at a high risk of mortality. The findings come from a retrospective analysis of data from 52 hospitals, which included ICU admissions (except neonatal ICU) during 2007-2018.
The good news is that palliative care consultations have increased, with consultations in less than 1% of cases at the start of the study and rising quickly to more than 7% in 2018.
“In the adult world, palliative care has expanded in recent decades, and I think now that it’s coming to the pediatric world, it’ll just continue to go up,” said Siobhan O’Keefe, MD, in an interview. Dr. O’Keefe is with Children’s Hospital Colorado, Aurora. She presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
More work needs to be done, she said. “We are not uniformly using palliative care for critically ill children in the U.S., and it varies across institutions. That’s probably not the ideal situation,” said Dr. O’Keefe. The study did not track palliative care versus the presence of board-certified palliative care physicians or palliative care fellowships, but she suspects they would correlate.
Dr. O’Keefe called for physicians to think beyond the patient, to family members and caregivers. “We need to focus on family outcomes, how they are taking care of children with moderate disability, and incorporate that into our outcomes,” she said. Previous research has shown family members to be at risk of anxiety, depression, unemployment, and financial distress.
The researchers analyzed data from 740,890 patients with 1,024,666 hospitalizations (82% had one hospitalization). They divided subjects into three cohorts, one of which was a category of patients with criteria for palliative care based on previous research (PC-ICU). The PC-ICU cohort included patients with an expected length of stay more than 2 weeks, patients receiving extracorporeal membrane oxygenation (ECMO), severe brain injuries, acute respiratory failure with serious comorbidity, hematologic or oncologic disease, metabolic disease, renal failure that required continuous renal replacement therapy, hepatic failure, or serious chromosomal abnormality. A second cohort included chronic complex conditions not found in the PC-ICU cohort (additional criteria), and a third cohort had no criteria for palliative care.
Thirty percent of hospitalizations met the PC-ICU cohort criteria, 40% met the additional cohort criteria, and 30% fell in the no criteria cohort. The PC-ICU group had the highest mortality, at 8.03%, compared with 1.08% in the additional criteria group and 0.34% in the no criteria group (P less than .00001).
Palliative care consultations occurred more frequently in 5-12 year olds (odds ratio 1.06; 95% confidence interval, 1.01-1.13) and in those aged 13 years or older (OR, 1.38; 95% CI, 1.3-1.46), in females (OR, 1.13; 95% CI, 1.06-1.15), and in patients with government insurance (OR, 1.23; 95% CI, 1.17-1.29). Compared with those in the no criteria cohort, PC-ICU patients were more likely to receive a palliative care consult (OR, 75.5; 95% CI, 60.4-94.3), as were those in the additional criteria group (OR, 19.1; 95% CI, 15.3-23.9).
Cross-institutional palliative care frequency varied widely among patients in the PC-ICU group, ranging from 0% to 44%. The frequency ranged from 0% to 12% across institutions for patients in the additional criteria group.
SOURCE: O’Keefe S et al. Critical Care Congress 2019, Abstract 418.
SAN DIEGO – and is more common among older children, female children, and those with government insurance or at a high risk of mortality. The findings come from a retrospective analysis of data from 52 hospitals, which included ICU admissions (except neonatal ICU) during 2007-2018.
The good news is that palliative care consultations have increased, with consultations in less than 1% of cases at the start of the study and rising quickly to more than 7% in 2018.
“In the adult world, palliative care has expanded in recent decades, and I think now that it’s coming to the pediatric world, it’ll just continue to go up,” said Siobhan O’Keefe, MD, in an interview. Dr. O’Keefe is with Children’s Hospital Colorado, Aurora. She presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
More work needs to be done, she said. “We are not uniformly using palliative care for critically ill children in the U.S., and it varies across institutions. That’s probably not the ideal situation,” said Dr. O’Keefe. The study did not track palliative care versus the presence of board-certified palliative care physicians or palliative care fellowships, but she suspects they would correlate.
Dr. O’Keefe called for physicians to think beyond the patient, to family members and caregivers. “We need to focus on family outcomes, how they are taking care of children with moderate disability, and incorporate that into our outcomes,” she said. Previous research has shown family members to be at risk of anxiety, depression, unemployment, and financial distress.
The researchers analyzed data from 740,890 patients with 1,024,666 hospitalizations (82% had one hospitalization). They divided subjects into three cohorts, one of which was a category of patients with criteria for palliative care based on previous research (PC-ICU). The PC-ICU cohort included patients with an expected length of stay more than 2 weeks, patients receiving extracorporeal membrane oxygenation (ECMO), severe brain injuries, acute respiratory failure with serious comorbidity, hematologic or oncologic disease, metabolic disease, renal failure that required continuous renal replacement therapy, hepatic failure, or serious chromosomal abnormality. A second cohort included chronic complex conditions not found in the PC-ICU cohort (additional criteria), and a third cohort had no criteria for palliative care.
Thirty percent of hospitalizations met the PC-ICU cohort criteria, 40% met the additional cohort criteria, and 30% fell in the no criteria cohort. The PC-ICU group had the highest mortality, at 8.03%, compared with 1.08% in the additional criteria group and 0.34% in the no criteria group (P less than .00001).
Palliative care consultations occurred more frequently in 5-12 year olds (odds ratio 1.06; 95% confidence interval, 1.01-1.13) and in those aged 13 years or older (OR, 1.38; 95% CI, 1.3-1.46), in females (OR, 1.13; 95% CI, 1.06-1.15), and in patients with government insurance (OR, 1.23; 95% CI, 1.17-1.29). Compared with those in the no criteria cohort, PC-ICU patients were more likely to receive a palliative care consult (OR, 75.5; 95% CI, 60.4-94.3), as were those in the additional criteria group (OR, 19.1; 95% CI, 15.3-23.9).
Cross-institutional palliative care frequency varied widely among patients in the PC-ICU group, ranging from 0% to 44%. The frequency ranged from 0% to 12% across institutions for patients in the additional criteria group.
SOURCE: O’Keefe S et al. Critical Care Congress 2019, Abstract 418.
SAN DIEGO – and is more common among older children, female children, and those with government insurance or at a high risk of mortality. The findings come from a retrospective analysis of data from 52 hospitals, which included ICU admissions (except neonatal ICU) during 2007-2018.
The good news is that palliative care consultations have increased, with consultations in less than 1% of cases at the start of the study and rising quickly to more than 7% in 2018.
“In the adult world, palliative care has expanded in recent decades, and I think now that it’s coming to the pediatric world, it’ll just continue to go up,” said Siobhan O’Keefe, MD, in an interview. Dr. O’Keefe is with Children’s Hospital Colorado, Aurora. She presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
More work needs to be done, she said. “We are not uniformly using palliative care for critically ill children in the U.S., and it varies across institutions. That’s probably not the ideal situation,” said Dr. O’Keefe. The study did not track palliative care versus the presence of board-certified palliative care physicians or palliative care fellowships, but she suspects they would correlate.
Dr. O’Keefe called for physicians to think beyond the patient, to family members and caregivers. “We need to focus on family outcomes, how they are taking care of children with moderate disability, and incorporate that into our outcomes,” she said. Previous research has shown family members to be at risk of anxiety, depression, unemployment, and financial distress.
The researchers analyzed data from 740,890 patients with 1,024,666 hospitalizations (82% had one hospitalization). They divided subjects into three cohorts, one of which was a category of patients with criteria for palliative care based on previous research (PC-ICU). The PC-ICU cohort included patients with an expected length of stay more than 2 weeks, patients receiving extracorporeal membrane oxygenation (ECMO), severe brain injuries, acute respiratory failure with serious comorbidity, hematologic or oncologic disease, metabolic disease, renal failure that required continuous renal replacement therapy, hepatic failure, or serious chromosomal abnormality. A second cohort included chronic complex conditions not found in the PC-ICU cohort (additional criteria), and a third cohort had no criteria for palliative care.
Thirty percent of hospitalizations met the PC-ICU cohort criteria, 40% met the additional cohort criteria, and 30% fell in the no criteria cohort. The PC-ICU group had the highest mortality, at 8.03%, compared with 1.08% in the additional criteria group and 0.34% in the no criteria group (P less than .00001).
Palliative care consultations occurred more frequently in 5-12 year olds (odds ratio 1.06; 95% confidence interval, 1.01-1.13) and in those aged 13 years or older (OR, 1.38; 95% CI, 1.3-1.46), in females (OR, 1.13; 95% CI, 1.06-1.15), and in patients with government insurance (OR, 1.23; 95% CI, 1.17-1.29). Compared with those in the no criteria cohort, PC-ICU patients were more likely to receive a palliative care consult (OR, 75.5; 95% CI, 60.4-94.3), as were those in the additional criteria group (OR, 19.1; 95% CI, 15.3-23.9).
Cross-institutional palliative care frequency varied widely among patients in the PC-ICU group, ranging from 0% to 44%. The frequency ranged from 0% to 12% across institutions for patients in the additional criteria group.
SOURCE: O’Keefe S et al. Critical Care Congress 2019, Abstract 418.
REPORTING FROM CCC48
Supplementary compression doesn’t improve DVT odds in critically ill
SAN DIEGO – In critically ill patients receiving pharmacologic thromboprophylaxis, (DVT), according to a new trial.
“I was surprised. My hypothesis was that it would work,” said lead author Yaseen M. Arabi, MD, chairman of the intensive care department at King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
Many physicians routinely carry out the practice on the assumption that IPC should lead to better blood flow and further cut DVT risk. The procedure carries few risks, aside from patient discomfort. “The main issue is that it’s not needed. It might be useful in patients who are not receiving heparin or low-molecular-weight heparin,” said Dr. Arabi, who presented the results of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. The study was simultaneously published online in the New England Journal of Medicine.
Unfractionated or low-molecular-weight heparin reduces the risk of DVT by about 50%, but about 5%-20% of critically ill patients will develop DVT in spite of treatment, and mechanical thromboprophylaxis reduces DVT risk, compared with no prophylaxis. Some researchers have attempted to address whether adjunct intermittent pneumatic compression could further reduce DVT risk, but their studies were marked by a lack of controls, unoptimized pharmacologic regimens, and other limitations.
The trial included 2,003 adults from 20 sites in Saudi Arabia, Canada, Australia, and India, who were expected to have an intensive care unit stay of at least 72 hours. They were randomized to receive IPC combined with pharmacologic thromboprophylaxis (pneumatic compression group) or pharmacologic thromboprophylaxis alone (control).
The proportion of patients receiving unfractionated heparin versus low-molecular-weight heparin was similar between the two groups, with about 58% treated with unfractionated heparin.
A total of 3.9% of patients in the pneumatic compression group experienced incident proximal DVT, compared with 4.2% of controls (relative risk, 0.93; P =.74). A total of 3.4% experienced prevalent proximal DVT, compared with 2.7% of controls (RR, 1.29; 95% confidence interval, 0.78-2.12). There was no significant difference in the incidence of any lower-limb DVT (9.6% vs. 8.4%; RR, 1.14; 95% CI, 0.86-1.51).
There was no difference between the two groups in a composite outcome that included pulmonary embolism or all prevalent and incident lower-limb DVT (RR, 1.11; 95% CI, 0.85-1.44), and there were no between-group differences with respect to lower-limb skin injury or ischemia.
The results should change practice among those who still provide adjunct intermittent pneumatic compression, however surprising physicians may find these new results to be, according to Dr. Arabi: “People believed strongly that (adjunct IPC) should work, but you need to be evidence based, and here it showed no difference. But that’s why we do studies, right?”
The study was funded by King Abdulaziz City for Science and Technology and King Abdullah International Medical Research Center. Dr. Arabi has no relevant financial conflicts.
SOURCE: Arabi Y et al. CCC48, Abstract 142. N Engl J Med Feb 18. doi: 10.1056/NEJMoa1816150.
SAN DIEGO – In critically ill patients receiving pharmacologic thromboprophylaxis, (DVT), according to a new trial.
“I was surprised. My hypothesis was that it would work,” said lead author Yaseen M. Arabi, MD, chairman of the intensive care department at King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
Many physicians routinely carry out the practice on the assumption that IPC should lead to better blood flow and further cut DVT risk. The procedure carries few risks, aside from patient discomfort. “The main issue is that it’s not needed. It might be useful in patients who are not receiving heparin or low-molecular-weight heparin,” said Dr. Arabi, who presented the results of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. The study was simultaneously published online in the New England Journal of Medicine.
Unfractionated or low-molecular-weight heparin reduces the risk of DVT by about 50%, but about 5%-20% of critically ill patients will develop DVT in spite of treatment, and mechanical thromboprophylaxis reduces DVT risk, compared with no prophylaxis. Some researchers have attempted to address whether adjunct intermittent pneumatic compression could further reduce DVT risk, but their studies were marked by a lack of controls, unoptimized pharmacologic regimens, and other limitations.
The trial included 2,003 adults from 20 sites in Saudi Arabia, Canada, Australia, and India, who were expected to have an intensive care unit stay of at least 72 hours. They were randomized to receive IPC combined with pharmacologic thromboprophylaxis (pneumatic compression group) or pharmacologic thromboprophylaxis alone (control).
The proportion of patients receiving unfractionated heparin versus low-molecular-weight heparin was similar between the two groups, with about 58% treated with unfractionated heparin.
A total of 3.9% of patients in the pneumatic compression group experienced incident proximal DVT, compared with 4.2% of controls (relative risk, 0.93; P =.74). A total of 3.4% experienced prevalent proximal DVT, compared with 2.7% of controls (RR, 1.29; 95% confidence interval, 0.78-2.12). There was no significant difference in the incidence of any lower-limb DVT (9.6% vs. 8.4%; RR, 1.14; 95% CI, 0.86-1.51).
There was no difference between the two groups in a composite outcome that included pulmonary embolism or all prevalent and incident lower-limb DVT (RR, 1.11; 95% CI, 0.85-1.44), and there were no between-group differences with respect to lower-limb skin injury or ischemia.
The results should change practice among those who still provide adjunct intermittent pneumatic compression, however surprising physicians may find these new results to be, according to Dr. Arabi: “People believed strongly that (adjunct IPC) should work, but you need to be evidence based, and here it showed no difference. But that’s why we do studies, right?”
The study was funded by King Abdulaziz City for Science and Technology and King Abdullah International Medical Research Center. Dr. Arabi has no relevant financial conflicts.
SOURCE: Arabi Y et al. CCC48, Abstract 142. N Engl J Med Feb 18. doi: 10.1056/NEJMoa1816150.
SAN DIEGO – In critically ill patients receiving pharmacologic thromboprophylaxis, (DVT), according to a new trial.
“I was surprised. My hypothesis was that it would work,” said lead author Yaseen M. Arabi, MD, chairman of the intensive care department at King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
Many physicians routinely carry out the practice on the assumption that IPC should lead to better blood flow and further cut DVT risk. The procedure carries few risks, aside from patient discomfort. “The main issue is that it’s not needed. It might be useful in patients who are not receiving heparin or low-molecular-weight heparin,” said Dr. Arabi, who presented the results of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. The study was simultaneously published online in the New England Journal of Medicine.
Unfractionated or low-molecular-weight heparin reduces the risk of DVT by about 50%, but about 5%-20% of critically ill patients will develop DVT in spite of treatment, and mechanical thromboprophylaxis reduces DVT risk, compared with no prophylaxis. Some researchers have attempted to address whether adjunct intermittent pneumatic compression could further reduce DVT risk, but their studies were marked by a lack of controls, unoptimized pharmacologic regimens, and other limitations.
The trial included 2,003 adults from 20 sites in Saudi Arabia, Canada, Australia, and India, who were expected to have an intensive care unit stay of at least 72 hours. They were randomized to receive IPC combined with pharmacologic thromboprophylaxis (pneumatic compression group) or pharmacologic thromboprophylaxis alone (control).
The proportion of patients receiving unfractionated heparin versus low-molecular-weight heparin was similar between the two groups, with about 58% treated with unfractionated heparin.
A total of 3.9% of patients in the pneumatic compression group experienced incident proximal DVT, compared with 4.2% of controls (relative risk, 0.93; P =.74). A total of 3.4% experienced prevalent proximal DVT, compared with 2.7% of controls (RR, 1.29; 95% confidence interval, 0.78-2.12). There was no significant difference in the incidence of any lower-limb DVT (9.6% vs. 8.4%; RR, 1.14; 95% CI, 0.86-1.51).
There was no difference between the two groups in a composite outcome that included pulmonary embolism or all prevalent and incident lower-limb DVT (RR, 1.11; 95% CI, 0.85-1.44), and there were no between-group differences with respect to lower-limb skin injury or ischemia.
The results should change practice among those who still provide adjunct intermittent pneumatic compression, however surprising physicians may find these new results to be, according to Dr. Arabi: “People believed strongly that (adjunct IPC) should work, but you need to be evidence based, and here it showed no difference. But that’s why we do studies, right?”
The study was funded by King Abdulaziz City for Science and Technology and King Abdullah International Medical Research Center. Dr. Arabi has no relevant financial conflicts.
SOURCE: Arabi Y et al. CCC48, Abstract 142. N Engl J Med Feb 18. doi: 10.1056/NEJMoa1816150.
REPORTING FROM CCC48
PERT alerts improve pulmonary embolism outcomes
SAN DIEGO – One year after implementation, a at the Christiana Medical Center in Delaware. An analysis of data collected showed reductions in ICU stays, early death, and overall hospital length of stay.
Such patients pose a challenge to clinicians because some will go on to develop more serious pulmonary embolism (PE), yet aggressive treatment options carry their own risk. Existing guidelines, such as those by the European Society of Cardiology, recommend conservative treatment of these patients, with more aggressive measures if conditions don’t quickly improve.
However, about 12% of patients on conservative therapy die, or about 100,000 per year. Those patients who go on to have bad outcomes “are obviously intermediate high risk or high risk. This is the patient population that we’re interested in [addressing through PERT]. These aren’t really sick patients. The blood pressure is normal, but they have the risk based on comorbidities or the clot burden to do poorly over the next day or two,” said Michael Benninghoff, DO, section chief of medical critical care and director of respiratory therapy at Christiana Medical Center, Wilmington, Del. Dr. Benninghoff presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The PERT concept was developed by physicians at Massachusetts General Hospital. It establishes clinical criteria that, if met, prompt a PERT alert, which in turn triggers a meeting between the initiating provider, a pulmonary intensivist, and a vascular and interventional radiology physician within 15 minutes to review the case and make rapid clinical decisions.
A PERT alert requires either a CT diagnosis of PE or a VQ scan showing a high probability of PE, combined with one of three additional criteria: elevated B-type (brain) natriuretic peptide (BNP) and troponin; echocardiographic evidence of right ventricular dysfunction; or clinical instability as indicated by heart rate over 110 beats per minute, systolic blood pressure below 100 mm Hg, or oxygen saturation lower than 90%.
The PERT program caught Dr. Benninghoff’s attention because of institutional experience with patients deteriorating on conservative treatment, but also because the treatment of submassive PE with RV dysfunction is quite scattered. “We were seeing really conservative to really aggressive treatment. I don’t think we’ve had the data to support treating a patient whose blood pressure is normal but they have signs of right ventricular dysfunction, whether it’s echocardiographic, radiographic, or laboratory evidence of myocardial necrosis. I don’t think we have a group conscience as providers as far as how aggressive to be with those patients,” said Dr. Benninghoff.
To examine the efficacy of the PERT program after 1 year, Dr. Benninghoff’s team reviewed all PE cases from 2016 (pre-PERT, n = 717) and 2017 (post-PERT, n = 752). The mortality index declined 30%, from 1.13 to 0.79, while the percentage of early death declined 52%, from 2.51 to 1.20. The mean number of ICU days fell from 5.01 to 4.40.
When the team restricted the analysis to PE lysis patients (n = 27 in 2016; n = 33 in 2017), the mean length of ICU stay dropped from 66.1 hours to 58.8 hours, and fewer patients were transferred from a lower level of care to the ICU (6 vs. 3).
“We think we have shown that just by talking in real time, forcing physicians to communicate – it certainly doesn’t hurt, that it probably helps with ICU utilization and perhaps even mortality,” said Dr. Benninghoff.
The results are far from definitive, and much more work needs to be done to determine how best to manage patients with submassive PEs and RV dysfunction. Dr. Benninghoff doesn’t have the answers, but he’s hopeful that the PERT program can eventually provide some. “Probably the most important thing is we’re giving back to the medical community by enrolling in the consortium, putting our data in the hands of the Boston research institute, and seeing what comes of it. Hopefully in 5 years we will have a standard of care based on the work we’re doing now,” he said.
The study was funded internally. Dr. Benninghoff declared no conflicts of interest.
SOURCE: Benninghoff M. Critical Care Congress 2019, Abstract 490.
SAN DIEGO – One year after implementation, a at the Christiana Medical Center in Delaware. An analysis of data collected showed reductions in ICU stays, early death, and overall hospital length of stay.
Such patients pose a challenge to clinicians because some will go on to develop more serious pulmonary embolism (PE), yet aggressive treatment options carry their own risk. Existing guidelines, such as those by the European Society of Cardiology, recommend conservative treatment of these patients, with more aggressive measures if conditions don’t quickly improve.
However, about 12% of patients on conservative therapy die, or about 100,000 per year. Those patients who go on to have bad outcomes “are obviously intermediate high risk or high risk. This is the patient population that we’re interested in [addressing through PERT]. These aren’t really sick patients. The blood pressure is normal, but they have the risk based on comorbidities or the clot burden to do poorly over the next day or two,” said Michael Benninghoff, DO, section chief of medical critical care and director of respiratory therapy at Christiana Medical Center, Wilmington, Del. Dr. Benninghoff presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The PERT concept was developed by physicians at Massachusetts General Hospital. It establishes clinical criteria that, if met, prompt a PERT alert, which in turn triggers a meeting between the initiating provider, a pulmonary intensivist, and a vascular and interventional radiology physician within 15 minutes to review the case and make rapid clinical decisions.
A PERT alert requires either a CT diagnosis of PE or a VQ scan showing a high probability of PE, combined with one of three additional criteria: elevated B-type (brain) natriuretic peptide (BNP) and troponin; echocardiographic evidence of right ventricular dysfunction; or clinical instability as indicated by heart rate over 110 beats per minute, systolic blood pressure below 100 mm Hg, or oxygen saturation lower than 90%.
The PERT program caught Dr. Benninghoff’s attention because of institutional experience with patients deteriorating on conservative treatment, but also because the treatment of submassive PE with RV dysfunction is quite scattered. “We were seeing really conservative to really aggressive treatment. I don’t think we’ve had the data to support treating a patient whose blood pressure is normal but they have signs of right ventricular dysfunction, whether it’s echocardiographic, radiographic, or laboratory evidence of myocardial necrosis. I don’t think we have a group conscience as providers as far as how aggressive to be with those patients,” said Dr. Benninghoff.
To examine the efficacy of the PERT program after 1 year, Dr. Benninghoff’s team reviewed all PE cases from 2016 (pre-PERT, n = 717) and 2017 (post-PERT, n = 752). The mortality index declined 30%, from 1.13 to 0.79, while the percentage of early death declined 52%, from 2.51 to 1.20. The mean number of ICU days fell from 5.01 to 4.40.
When the team restricted the analysis to PE lysis patients (n = 27 in 2016; n = 33 in 2017), the mean length of ICU stay dropped from 66.1 hours to 58.8 hours, and fewer patients were transferred from a lower level of care to the ICU (6 vs. 3).
“We think we have shown that just by talking in real time, forcing physicians to communicate – it certainly doesn’t hurt, that it probably helps with ICU utilization and perhaps even mortality,” said Dr. Benninghoff.
The results are far from definitive, and much more work needs to be done to determine how best to manage patients with submassive PEs and RV dysfunction. Dr. Benninghoff doesn’t have the answers, but he’s hopeful that the PERT program can eventually provide some. “Probably the most important thing is we’re giving back to the medical community by enrolling in the consortium, putting our data in the hands of the Boston research institute, and seeing what comes of it. Hopefully in 5 years we will have a standard of care based on the work we’re doing now,” he said.
The study was funded internally. Dr. Benninghoff declared no conflicts of interest.
SOURCE: Benninghoff M. Critical Care Congress 2019, Abstract 490.
SAN DIEGO – One year after implementation, a at the Christiana Medical Center in Delaware. An analysis of data collected showed reductions in ICU stays, early death, and overall hospital length of stay.
Such patients pose a challenge to clinicians because some will go on to develop more serious pulmonary embolism (PE), yet aggressive treatment options carry their own risk. Existing guidelines, such as those by the European Society of Cardiology, recommend conservative treatment of these patients, with more aggressive measures if conditions don’t quickly improve.
However, about 12% of patients on conservative therapy die, or about 100,000 per year. Those patients who go on to have bad outcomes “are obviously intermediate high risk or high risk. This is the patient population that we’re interested in [addressing through PERT]. These aren’t really sick patients. The blood pressure is normal, but they have the risk based on comorbidities or the clot burden to do poorly over the next day or two,” said Michael Benninghoff, DO, section chief of medical critical care and director of respiratory therapy at Christiana Medical Center, Wilmington, Del. Dr. Benninghoff presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The PERT concept was developed by physicians at Massachusetts General Hospital. It establishes clinical criteria that, if met, prompt a PERT alert, which in turn triggers a meeting between the initiating provider, a pulmonary intensivist, and a vascular and interventional radiology physician within 15 minutes to review the case and make rapid clinical decisions.
A PERT alert requires either a CT diagnosis of PE or a VQ scan showing a high probability of PE, combined with one of three additional criteria: elevated B-type (brain) natriuretic peptide (BNP) and troponin; echocardiographic evidence of right ventricular dysfunction; or clinical instability as indicated by heart rate over 110 beats per minute, systolic blood pressure below 100 mm Hg, or oxygen saturation lower than 90%.
The PERT program caught Dr. Benninghoff’s attention because of institutional experience with patients deteriorating on conservative treatment, but also because the treatment of submassive PE with RV dysfunction is quite scattered. “We were seeing really conservative to really aggressive treatment. I don’t think we’ve had the data to support treating a patient whose blood pressure is normal but they have signs of right ventricular dysfunction, whether it’s echocardiographic, radiographic, or laboratory evidence of myocardial necrosis. I don’t think we have a group conscience as providers as far as how aggressive to be with those patients,” said Dr. Benninghoff.
To examine the efficacy of the PERT program after 1 year, Dr. Benninghoff’s team reviewed all PE cases from 2016 (pre-PERT, n = 717) and 2017 (post-PERT, n = 752). The mortality index declined 30%, from 1.13 to 0.79, while the percentage of early death declined 52%, from 2.51 to 1.20. The mean number of ICU days fell from 5.01 to 4.40.
When the team restricted the analysis to PE lysis patients (n = 27 in 2016; n = 33 in 2017), the mean length of ICU stay dropped from 66.1 hours to 58.8 hours, and fewer patients were transferred from a lower level of care to the ICU (6 vs. 3).
“We think we have shown that just by talking in real time, forcing physicians to communicate – it certainly doesn’t hurt, that it probably helps with ICU utilization and perhaps even mortality,” said Dr. Benninghoff.
The results are far from definitive, and much more work needs to be done to determine how best to manage patients with submassive PEs and RV dysfunction. Dr. Benninghoff doesn’t have the answers, but he’s hopeful that the PERT program can eventually provide some. “Probably the most important thing is we’re giving back to the medical community by enrolling in the consortium, putting our data in the hands of the Boston research institute, and seeing what comes of it. Hopefully in 5 years we will have a standard of care based on the work we’re doing now,” he said.
The study was funded internally. Dr. Benninghoff declared no conflicts of interest.
SOURCE: Benninghoff M. Critical Care Congress 2019, Abstract 490.
REPORTING FROM CCC48
Disruptive behavior on the job linked to depression, burnout
SAN DIEGO – Hospitals pay a price for bad behavior by staff in the workplace, results of a large multicenter study suggest.
A work culture in which disruptive behavior is tolerated can have consequences. Research on this topic has linked disruptive behavior by staff in the health care setting to increased frequency of medical errors and lower quality of care (Am J Med Qual. 2011 Sep-Oct;26(5):372-9; J Caring Sci. 2016 Sep 1;5(3):241-9). This new study, based on a workplace culture survey of 7,923 health care workers and 325 work settings at 16 hospitals in a large West Coast health care system, found , researchers found. The paper was presented by study lead Allison Hadley, MD, of Duke Children’s Hospital, Durham, N.C., at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The investigators developed a novel survey scale for evaluating disruptive behaviors in the health care setting. The objective was to look at the associations between disruptive behavior, teamwork, safety culture, burnout, and depression. Disruptive behaviors included turning backs or hanging up the phone before a conversation is over, bullying or trying to publicly humiliate other staff, making inappropriate comments (with sexual, racial, religious, or ethnic slurs), and physical aggression (such as throwing, hitting, and pushing).
San Francisco internist Alan H. Rosenstein, MD, who studies disruptive behavior in medicine, said in an interview that the findings confirm anecdotal experience of medical staff. “One of the downsides of disruptive behavior is very unsatisfied and unhappy people,” he said
The investigators used a t-test analysis to study the strength of the association between disruptive behavior and work culture in health care work settings. They found a statistically significant association between less disruptive behavior and lower levels of burnout and depression among staff (t = 6.4 and t = 4.1, respectively, P less than .001) and higher levels of teamwork, safety culture, and work-life balance (t = 10.2, t = 9.5 and t = 5.8, respectively, P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001).
Bullying was reported at about 40% of workplaces with low teamwork levels, compared with nearly 20% in those with high teamwork levels.
Physical aggression was reported in nearly 20% of those workplaces with low teamwork levels, compared with 5% in workplaces with high teamwork levels (P less than .001).
Researchers also found that disruptive behaviors were least common during day shifts and more common among health care workers who care for both adults and children than among those who care for only adults. “Teamwork, safety culture, and work-life balance were highest in those [hospital] units with the least disruptive behaviors,” said Dr. Hadley.
Overall, the highest positive correlation was found between higher levels of teamwork and lower levels of disruptive behavior, Dr. Hadley said. If a hospital department is trying to address one issue to improve disruptive behavior, she’d suggest it “focus on teamwork first. I hope that would have the greatest impact.”
Dr. Rosenstein, who has conducted several studies on disruptive behavior, said the key to improving the workplace is to “build a culture based on the mission of providing patient care. It’s not to save a dollar, to make a dollar. The mission is patient care.”
What’s next? Dr. Hadley said her team is continuing to work on developing a scale to measure disruptive behavior in the workplace.
No study funding was reported. Dr. Hadley and Dr. Rosenstein reported no relevant disclosures.
SOURCE: Hadley A et al. CCC48, Abstract 114.
SAN DIEGO – Hospitals pay a price for bad behavior by staff in the workplace, results of a large multicenter study suggest.
A work culture in which disruptive behavior is tolerated can have consequences. Research on this topic has linked disruptive behavior by staff in the health care setting to increased frequency of medical errors and lower quality of care (Am J Med Qual. 2011 Sep-Oct;26(5):372-9; J Caring Sci. 2016 Sep 1;5(3):241-9). This new study, based on a workplace culture survey of 7,923 health care workers and 325 work settings at 16 hospitals in a large West Coast health care system, found , researchers found. The paper was presented by study lead Allison Hadley, MD, of Duke Children’s Hospital, Durham, N.C., at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The investigators developed a novel survey scale for evaluating disruptive behaviors in the health care setting. The objective was to look at the associations between disruptive behavior, teamwork, safety culture, burnout, and depression. Disruptive behaviors included turning backs or hanging up the phone before a conversation is over, bullying or trying to publicly humiliate other staff, making inappropriate comments (with sexual, racial, religious, or ethnic slurs), and physical aggression (such as throwing, hitting, and pushing).
San Francisco internist Alan H. Rosenstein, MD, who studies disruptive behavior in medicine, said in an interview that the findings confirm anecdotal experience of medical staff. “One of the downsides of disruptive behavior is very unsatisfied and unhappy people,” he said
The investigators used a t-test analysis to study the strength of the association between disruptive behavior and work culture in health care work settings. They found a statistically significant association between less disruptive behavior and lower levels of burnout and depression among staff (t = 6.4 and t = 4.1, respectively, P less than .001) and higher levels of teamwork, safety culture, and work-life balance (t = 10.2, t = 9.5 and t = 5.8, respectively, P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001).
Bullying was reported at about 40% of workplaces with low teamwork levels, compared with nearly 20% in those with high teamwork levels.
Physical aggression was reported in nearly 20% of those workplaces with low teamwork levels, compared with 5% in workplaces with high teamwork levels (P less than .001).
Researchers also found that disruptive behaviors were least common during day shifts and more common among health care workers who care for both adults and children than among those who care for only adults. “Teamwork, safety culture, and work-life balance were highest in those [hospital] units with the least disruptive behaviors,” said Dr. Hadley.
Overall, the highest positive correlation was found between higher levels of teamwork and lower levels of disruptive behavior, Dr. Hadley said. If a hospital department is trying to address one issue to improve disruptive behavior, she’d suggest it “focus on teamwork first. I hope that would have the greatest impact.”
Dr. Rosenstein, who has conducted several studies on disruptive behavior, said the key to improving the workplace is to “build a culture based on the mission of providing patient care. It’s not to save a dollar, to make a dollar. The mission is patient care.”
What’s next? Dr. Hadley said her team is continuing to work on developing a scale to measure disruptive behavior in the workplace.
No study funding was reported. Dr. Hadley and Dr. Rosenstein reported no relevant disclosures.
SOURCE: Hadley A et al. CCC48, Abstract 114.
SAN DIEGO – Hospitals pay a price for bad behavior by staff in the workplace, results of a large multicenter study suggest.
A work culture in which disruptive behavior is tolerated can have consequences. Research on this topic has linked disruptive behavior by staff in the health care setting to increased frequency of medical errors and lower quality of care (Am J Med Qual. 2011 Sep-Oct;26(5):372-9; J Caring Sci. 2016 Sep 1;5(3):241-9). This new study, based on a workplace culture survey of 7,923 health care workers and 325 work settings at 16 hospitals in a large West Coast health care system, found , researchers found. The paper was presented by study lead Allison Hadley, MD, of Duke Children’s Hospital, Durham, N.C., at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The investigators developed a novel survey scale for evaluating disruptive behaviors in the health care setting. The objective was to look at the associations between disruptive behavior, teamwork, safety culture, burnout, and depression. Disruptive behaviors included turning backs or hanging up the phone before a conversation is over, bullying or trying to publicly humiliate other staff, making inappropriate comments (with sexual, racial, religious, or ethnic slurs), and physical aggression (such as throwing, hitting, and pushing).
San Francisco internist Alan H. Rosenstein, MD, who studies disruptive behavior in medicine, said in an interview that the findings confirm anecdotal experience of medical staff. “One of the downsides of disruptive behavior is very unsatisfied and unhappy people,” he said
The investigators used a t-test analysis to study the strength of the association between disruptive behavior and work culture in health care work settings. They found a statistically significant association between less disruptive behavior and lower levels of burnout and depression among staff (t = 6.4 and t = 4.1, respectively, P less than .001) and higher levels of teamwork, safety culture, and work-life balance (t = 10.2, t = 9.5 and t = 5.8, respectively, P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001).
Bullying was reported at about 40% of workplaces with low teamwork levels, compared with nearly 20% in those with high teamwork levels.
Physical aggression was reported in nearly 20% of those workplaces with low teamwork levels, compared with 5% in workplaces with high teamwork levels (P less than .001).
Researchers also found that disruptive behaviors were least common during day shifts and more common among health care workers who care for both adults and children than among those who care for only adults. “Teamwork, safety culture, and work-life balance were highest in those [hospital] units with the least disruptive behaviors,” said Dr. Hadley.
Overall, the highest positive correlation was found between higher levels of teamwork and lower levels of disruptive behavior, Dr. Hadley said. If a hospital department is trying to address one issue to improve disruptive behavior, she’d suggest it “focus on teamwork first. I hope that would have the greatest impact.”
Dr. Rosenstein, who has conducted several studies on disruptive behavior, said the key to improving the workplace is to “build a culture based on the mission of providing patient care. It’s not to save a dollar, to make a dollar. The mission is patient care.”
What’s next? Dr. Hadley said her team is continuing to work on developing a scale to measure disruptive behavior in the workplace.
No study funding was reported. Dr. Hadley and Dr. Rosenstein reported no relevant disclosures.
SOURCE: Hadley A et al. CCC48, Abstract 114.
REPORTING FROM CCC48
Bag-mask ventilation during intubation reduces severe hypoxemia
, according to data presented at the Critical Care Congress, sponsored by the Society of Critical Care Medicine.
A multicenter study, published simultaneously in the Feb. 18 issue of the New England Journal of Medicine, randomized 401 critically-ill patients in the ICU who were undergoing tracheal intubation to receive either ventilation with a bag-mask device during induction for intubation or no ventilation.
The median lowest oxygen saturation between induction and 2 minutes after intubation was 96% in the bag-mask ventilated patients and 93% in the no-ventilation group, representing a 4.7% difference after adjusting for prespecified covariates (P = .01).
In a post-hoc analysis that adjusted for other factors such as the provision of preoxygenation, the preoxygenation device, pneumonia, and gastrointestinal bleeding, there was a 5.2% difference between the two groups in median lowest oxygen saturation, favoring the bag-mask group.
Bag-mask ventilation was also associated with almost a halving in the incidence of severe hypoxemia – defined as an oxygen saturation below 80% – compared with no-ventilation (10.9% vs. 22.8%; relative risk = 0.48). There was also a lower incidence of patients with an oxygen saturation below 90% and below 70% in the bag-mask ventilation group, compared with the no-ventilation group.
Overall, the median decrease in oxygen saturation from induction to the lowest point was 1% in the bag-mask group, and 5% in the no-ventilation group.
The study saw no effects of factors such as body-mass index, operator experience, or Acute Physiology and Chronic Health Evaluation (APACHE II) score. The patients had a median age of 60 years, about half had sepsis or septic shock, and close to 60% had hypoxemic respiratory failure as an indication for tracheal intubation.
Jonathan D. Casey, MD, of Vanderbilt University, Nashville, Tenn., and his coauthors wrote that their results suggested for every nine critically ill patients undergoing tracheal intubation, bag-mask ventilation would prevent severe hypoxemia in one patient.
“These findings are important because oxygen saturation is an established endpoint in airway management trials and is a contributing factor to periprocedural cardiac arrest and death,” they wrote.
They noted that there are conflicting guidelines on the use of bag-mask ventilation during tracheal intubation, with some recommending its use for all patients – even those who are not hypoxemic – and others advising their use only for patients with hypoxemia. This study excluded patients who were identified as hypoxemic or in whom bag-mask ventilation was contraindicated.
Despite concerns about bag-mask ventilation increasing the risk the aspiration, the study showed no significant difference between the two groups in the incidence of operator-reported aspiration or the presence of a new opacity on chest radiograph in the 48 hours after intubation.
The authors acknowledged that, given the low incidence of operator-reported aspiration during tracheal intubation, a much larger study would be needed to show whether bag-mask ventilation did increase the risk of aspiration.
“However, our trial provides some reassurance, since the incidence of operator-reported aspiration was numerically lower in the bag-mask ventilation group than in the no-ventilation group,” they wrote.
There were also no significant differences between the two groups in oxygen saturation, fraction of inspired oxygen or positive end-expiratory pressure in the 24 hours after intubation. Bag-mask ventilation was also associated with similar rates of in-hospital mortality, number of ventilator-free days, and days out of the ICU as no-ventilation.
The authors noted that their trial focused on critically-ill patients in the ICU, so the results may not be generalizable to patients in the emergency department or in a prehospital setting.
The study and some authors were supported by the National Institutes of Health. Two authors declared personal fees from the pharmaceutical industry unrelated to the study, and no other conflicts of interest were declared.
SOURCE: Casey J et al. N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1812405
Debate around the question of whether to use bag-mask ventilation in critically-ill patients has been limited by the lack of high-quality evidence on the risk of aspiration or on the benefits of this approach. This study found no evidence of an increase in the incidence of aspiration, despite using multiple measures to detect it, which provide some reassurance that manual ventilation during tracheal intubation is not likely to cause significant harm.
One significant limitation of this trial, however, is that it did not standardize the preoxygenation strategy across the two groups, so significantly more patients in the bag-mask group received bag-mask ventilation before induction. Median oxygen saturation before induction was the same in the two groups, but this does not rule out the possibility of differences in the arterial pressure of oxygen.
This study may not settle the question of whether to use bag-mask ventilation during tracheal intubation, but it provides strong suggestion that the practice is not harmful.
Patricia A. Kritek, MD, and Andrew M. Luks, MD, are with the division of pulmonary, critical care, and sleep medicine at the University of Washington in Seattle. These comments are adapted from their editorial accompanying the paper by Casey et al. (N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMe1900708). Dr. Luks declared personal fees from private industry outside the submitted work. Dr. Kritek reported having nothing to disclose.
Debate around the question of whether to use bag-mask ventilation in critically-ill patients has been limited by the lack of high-quality evidence on the risk of aspiration or on the benefits of this approach. This study found no evidence of an increase in the incidence of aspiration, despite using multiple measures to detect it, which provide some reassurance that manual ventilation during tracheal intubation is not likely to cause significant harm.
One significant limitation of this trial, however, is that it did not standardize the preoxygenation strategy across the two groups, so significantly more patients in the bag-mask group received bag-mask ventilation before induction. Median oxygen saturation before induction was the same in the two groups, but this does not rule out the possibility of differences in the arterial pressure of oxygen.
This study may not settle the question of whether to use bag-mask ventilation during tracheal intubation, but it provides strong suggestion that the practice is not harmful.
Patricia A. Kritek, MD, and Andrew M. Luks, MD, are with the division of pulmonary, critical care, and sleep medicine at the University of Washington in Seattle. These comments are adapted from their editorial accompanying the paper by Casey et al. (N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMe1900708). Dr. Luks declared personal fees from private industry outside the submitted work. Dr. Kritek reported having nothing to disclose.
Debate around the question of whether to use bag-mask ventilation in critically-ill patients has been limited by the lack of high-quality evidence on the risk of aspiration or on the benefits of this approach. This study found no evidence of an increase in the incidence of aspiration, despite using multiple measures to detect it, which provide some reassurance that manual ventilation during tracheal intubation is not likely to cause significant harm.
One significant limitation of this trial, however, is that it did not standardize the preoxygenation strategy across the two groups, so significantly more patients in the bag-mask group received bag-mask ventilation before induction. Median oxygen saturation before induction was the same in the two groups, but this does not rule out the possibility of differences in the arterial pressure of oxygen.
This study may not settle the question of whether to use bag-mask ventilation during tracheal intubation, but it provides strong suggestion that the practice is not harmful.
Patricia A. Kritek, MD, and Andrew M. Luks, MD, are with the division of pulmonary, critical care, and sleep medicine at the University of Washington in Seattle. These comments are adapted from their editorial accompanying the paper by Casey et al. (N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMe1900708). Dr. Luks declared personal fees from private industry outside the submitted work. Dr. Kritek reported having nothing to disclose.
, according to data presented at the Critical Care Congress, sponsored by the Society of Critical Care Medicine.
A multicenter study, published simultaneously in the Feb. 18 issue of the New England Journal of Medicine, randomized 401 critically-ill patients in the ICU who were undergoing tracheal intubation to receive either ventilation with a bag-mask device during induction for intubation or no ventilation.
The median lowest oxygen saturation between induction and 2 minutes after intubation was 96% in the bag-mask ventilated patients and 93% in the no-ventilation group, representing a 4.7% difference after adjusting for prespecified covariates (P = .01).
In a post-hoc analysis that adjusted for other factors such as the provision of preoxygenation, the preoxygenation device, pneumonia, and gastrointestinal bleeding, there was a 5.2% difference between the two groups in median lowest oxygen saturation, favoring the bag-mask group.
Bag-mask ventilation was also associated with almost a halving in the incidence of severe hypoxemia – defined as an oxygen saturation below 80% – compared with no-ventilation (10.9% vs. 22.8%; relative risk = 0.48). There was also a lower incidence of patients with an oxygen saturation below 90% and below 70% in the bag-mask ventilation group, compared with the no-ventilation group.
Overall, the median decrease in oxygen saturation from induction to the lowest point was 1% in the bag-mask group, and 5% in the no-ventilation group.
The study saw no effects of factors such as body-mass index, operator experience, or Acute Physiology and Chronic Health Evaluation (APACHE II) score. The patients had a median age of 60 years, about half had sepsis or septic shock, and close to 60% had hypoxemic respiratory failure as an indication for tracheal intubation.
Jonathan D. Casey, MD, of Vanderbilt University, Nashville, Tenn., and his coauthors wrote that their results suggested for every nine critically ill patients undergoing tracheal intubation, bag-mask ventilation would prevent severe hypoxemia in one patient.
“These findings are important because oxygen saturation is an established endpoint in airway management trials and is a contributing factor to periprocedural cardiac arrest and death,” they wrote.
They noted that there are conflicting guidelines on the use of bag-mask ventilation during tracheal intubation, with some recommending its use for all patients – even those who are not hypoxemic – and others advising their use only for patients with hypoxemia. This study excluded patients who were identified as hypoxemic or in whom bag-mask ventilation was contraindicated.
Despite concerns about bag-mask ventilation increasing the risk the aspiration, the study showed no significant difference between the two groups in the incidence of operator-reported aspiration or the presence of a new opacity on chest radiograph in the 48 hours after intubation.
The authors acknowledged that, given the low incidence of operator-reported aspiration during tracheal intubation, a much larger study would be needed to show whether bag-mask ventilation did increase the risk of aspiration.
“However, our trial provides some reassurance, since the incidence of operator-reported aspiration was numerically lower in the bag-mask ventilation group than in the no-ventilation group,” they wrote.
There were also no significant differences between the two groups in oxygen saturation, fraction of inspired oxygen or positive end-expiratory pressure in the 24 hours after intubation. Bag-mask ventilation was also associated with similar rates of in-hospital mortality, number of ventilator-free days, and days out of the ICU as no-ventilation.
The authors noted that their trial focused on critically-ill patients in the ICU, so the results may not be generalizable to patients in the emergency department or in a prehospital setting.
The study and some authors were supported by the National Institutes of Health. Two authors declared personal fees from the pharmaceutical industry unrelated to the study, and no other conflicts of interest were declared.
SOURCE: Casey J et al. N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1812405
, according to data presented at the Critical Care Congress, sponsored by the Society of Critical Care Medicine.
A multicenter study, published simultaneously in the Feb. 18 issue of the New England Journal of Medicine, randomized 401 critically-ill patients in the ICU who were undergoing tracheal intubation to receive either ventilation with a bag-mask device during induction for intubation or no ventilation.
The median lowest oxygen saturation between induction and 2 minutes after intubation was 96% in the bag-mask ventilated patients and 93% in the no-ventilation group, representing a 4.7% difference after adjusting for prespecified covariates (P = .01).
In a post-hoc analysis that adjusted for other factors such as the provision of preoxygenation, the preoxygenation device, pneumonia, and gastrointestinal bleeding, there was a 5.2% difference between the two groups in median lowest oxygen saturation, favoring the bag-mask group.
Bag-mask ventilation was also associated with almost a halving in the incidence of severe hypoxemia – defined as an oxygen saturation below 80% – compared with no-ventilation (10.9% vs. 22.8%; relative risk = 0.48). There was also a lower incidence of patients with an oxygen saturation below 90% and below 70% in the bag-mask ventilation group, compared with the no-ventilation group.
Overall, the median decrease in oxygen saturation from induction to the lowest point was 1% in the bag-mask group, and 5% in the no-ventilation group.
The study saw no effects of factors such as body-mass index, operator experience, or Acute Physiology and Chronic Health Evaluation (APACHE II) score. The patients had a median age of 60 years, about half had sepsis or septic shock, and close to 60% had hypoxemic respiratory failure as an indication for tracheal intubation.
Jonathan D. Casey, MD, of Vanderbilt University, Nashville, Tenn., and his coauthors wrote that their results suggested for every nine critically ill patients undergoing tracheal intubation, bag-mask ventilation would prevent severe hypoxemia in one patient.
“These findings are important because oxygen saturation is an established endpoint in airway management trials and is a contributing factor to periprocedural cardiac arrest and death,” they wrote.
They noted that there are conflicting guidelines on the use of bag-mask ventilation during tracheal intubation, with some recommending its use for all patients – even those who are not hypoxemic – and others advising their use only for patients with hypoxemia. This study excluded patients who were identified as hypoxemic or in whom bag-mask ventilation was contraindicated.
Despite concerns about bag-mask ventilation increasing the risk the aspiration, the study showed no significant difference between the two groups in the incidence of operator-reported aspiration or the presence of a new opacity on chest radiograph in the 48 hours after intubation.
The authors acknowledged that, given the low incidence of operator-reported aspiration during tracheal intubation, a much larger study would be needed to show whether bag-mask ventilation did increase the risk of aspiration.
“However, our trial provides some reassurance, since the incidence of operator-reported aspiration was numerically lower in the bag-mask ventilation group than in the no-ventilation group,” they wrote.
There were also no significant differences between the two groups in oxygen saturation, fraction of inspired oxygen or positive end-expiratory pressure in the 24 hours after intubation. Bag-mask ventilation was also associated with similar rates of in-hospital mortality, number of ventilator-free days, and days out of the ICU as no-ventilation.
The authors noted that their trial focused on critically-ill patients in the ICU, so the results may not be generalizable to patients in the emergency department or in a prehospital setting.
The study and some authors were supported by the National Institutes of Health. Two authors declared personal fees from the pharmaceutical industry unrelated to the study, and no other conflicts of interest were declared.
SOURCE: Casey J et al. N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1812405
FROM CCC48
Key clinical point: Bag-mask ventilation during tracheal intubation reduces the risk of severe hypoxemia.
Major finding: For every nine patients who receive bag-mask ventilation during tracheal intubation, one case of severe hypoxemia is avoided.
Study details: Randomized, controlled trial in 401 critically-ill patients undergoing tracheal intubation.
Disclosures: The study and some authors were supported by the National Institutes of Health. Two authors declared personal fees from the pharmaceutical industry unrelated to the study.
Source: Casey J et al. N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1812405