Dugar, Siddharth

Objectives: Consensus clinical criteria for refractory septic shock were recently developed, but the incidence and outcomes with these criteria are unknown. There were two aims: 1) to describe the incidence of refractory septic shock and 2) to assess outcomes of patients with septic shock meeting refractory septic shock criteria compared with those who did not. Design: Multicohort, retrospective study. For aim 1, a descriptive epidemiologic study was designed to ascertain the cumulative incidence of refractory septic shock in patients with septic shock. For aim 2, a cohort study was conducted to compare hospital mortality between patients meeting refractory septic shock clinical criteria compared with those who did not. Setting: Large U.S. health system from 2012 to 2024. Patients: Adults (age ≥ 18 yr) meeting both Centers for Disease Control and Prevention Adult Sepsis Event and Sepsis-3 clinical criteria for septic shock. Patients with missing hospital discharge disposition and incomplete vasopressor dosage information were excluded. Interventions: None. Measurements and Main Results: Clinical criteria for refractory septic shock were operationalized as concomitant occurrence of norepinephrine (base) equivalent greater than 0.5 µg/kg/min and lactate greater than 2 mmol/L. Risk-adjusted hospital mortality was assessed with a generalized linear mixed-effects model with a random effect for hospital and fixed effects for age, sex, Elixhauser Comorbidity Index, and Sequential Organ Failure Assessment (original description, without cardiovascular component). Of 35,914 patients assessed, 15,732 patients with septic shock were included. Refractory septic shock occurred in 3423 patients (21.8%), with a cumulative incidence of 218 cases (95% CI, 211–224) per 1000 patients with septic shock. Hospital mortality with refractory septic shock was 64.4%, and risk-adjusted hospital mortality odds were 4.87-fold higher (95% CI, 4.46–5.31) compared with patients without refractory septic shock. Conclusions: Clinical criteria for refractory septic shock were fulfilled in about one in five patients with septic shock and associated with substantially higher mortality.

OBJECTIVE: A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN: Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING: Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS: A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS: A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS: A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.

Objective: The specialty of critical care in the United States currently lacks a single, broad, unified database. We conducted a scoping review of existing established national ICU databases, describing national and international patterns of critical care delivery. Data Sources: A systematic literature search was undertaken using MEDLINE, Embase, and Web of Science search engines. Study Selection: Projects describing national critical care delivery (including any subspecialty) published in any language were included. Titles, abstracts, and full-text manuscripts were reviewed in duplicate for inclusion. Data Extraction: National database characteristics were collected, including the number and subspecialty of ICUs, the inaugural year, data entry methodology, the number of episodes of care included, and captured clinical data elements. Data Synthesis: Of 24,003 abstracts screened, 185 manuscripts were eligible for inclusion. Thirty countries were identified as having established national ICU registries: Argentina, Australia/New Zealand, Austria, Belgium, Brazil, Canada, Denmark, Ecuador, Finland, Germany, Iceland, India, Ireland, Italy, Japan, Kenya, Malaysia, Mexico, Nepal, Netherlands, Norway, Pakistan, Paraguay, Spain, Sri Lanka, Sweden, Switzerland, United Kingdom, United States and Uruguay. Data entry commonly incorporates a combination of automated data abstraction from electronic healthcare systems and manual data entry, followed by independent validation. Frequently recorded variables include patient demographics; admission vital signs and laboratory data; comorbidities; admission source and diagnoses; ICU diagnoses, treatments, and complications; illness severity scores; and clinically relevant outcomes including discharge disposition, functional status, lengths of stay, and mortality. Conclusions: Insights and experience gained from the study of mature national ICU registries may be used to guide an equivalent U.S. multidisciplinary program aimed at benchmarking, needs assessment, quality improvement, and research facilitation

OBJECTIVES: To provide guidance on the reporting of norepinephrine formulation labeling, reporting in publications, and use in clinical practice. DESIGN: Review and task force position statements with necessary guidance. SETTING: A series of group conference calls were conducted from August 2023 to October 2023, along with a review of the available evidence and scope of the problem. SUBJECTS: A task force of multinational and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. INTERVENTIONS: The implications of a variation in norepinephrine labeled as conjugated salt (i.e., bitartrate or tartrate) or base drug in terms of effective concentration of norepinephrine were examined, and guidance was provided. MEASUREMENTS AND MAIN RESULTS: There were significant implications for clinical care, dose calculations for enrollment in clinical trials, and results of datasets reporting maximal norepinephrine equivalents. These differences were especially important in the setting of collaborative efforts across countries with reported differences. CONCLUSIONS: A joint task force position statement was created outlining the scope of norepinephrine-dose formulation variations, and implications for research, patient safety, and clinical care. The task force advocated for a uniform norepinephrine-base formulation for global use, and offered advice aimed at appropriate stakeholders.

The study’s objective was to assess facilitators and barriers of Tele-Critical Care (TCC) perceived by SCCM members. By utilizing a survey distributed to SCCM members, a cross-sectional study was developed to analyze survey results from December 2019 and July 2020. SCCM members responded to the survey (n = 15,502) with a 1.9% response rate for the first distribution and a 2.54% response rate for the second survey (n = 9985). Participants (n = 286 and n = 254) were almost equally distributed between non-users, providers, users, and potential users of TCC services. The care delivery models for TCC were similar across most participants. Some consumers of TCC services preferred algorithmic coverage and scheduled rounds, while reactive and on-demand models were less utilized. The surveys revealed that outcome-driven measures were the principal form of TCC performance evaluation. A 1:100 (provider: patients) ratio was reported to be optimal. Factors related to costs, perceived lack of need for services, and workflow challenges were described by those who terminated TCC services. Barriers to implementation revolved around lack of reimbursement and adequate training. Interpersonal communication was identified as an essential TCC provider skill. The second survey introduced after the onset pandemic demonstrated more frequent use of advanced practice providers and focus on performance measures. Priorities for effective TCC deployment include communication, knowledge, optimal operationalization, and outcomes measurement at the organizational level. The potential effect of COVID-19 during the early stages of the pandemic on survey responses was limited and focused on the need to demonstrate TCC value.

Abstract Background: Previous studies have found various incidences of right ventricular dysfunction (RVD) and its association with clinical outcome. In this systematic review and meta-analysis, we aimed to investigate the impact of the presence of RVD on mortality in patients with ARDS.Method: We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies investigating the association between RVD and mortality. Two authors independently evaluated whether studies meet eligibility criteria and extracted the selected patients’ and studies’ characteristics and outcomes. The primary outcome was the association between mortality and the presence of RVD in patients with ARDS. Results: We included 9 studies (N = 1,861 patients) in this meta-analysis. RVD was present in 21.0% (391/1,861). In the pooled meta-analysis, the presence of RVD in patients with ARDS was associated with significantly higher overall mortality (OR: 1.45, 95%CI: 1.13-1.86, p-value = 0.003, I2 = 0%), as well as short-term mortality (OR: 1.48, 95%CI: 1.14-1.93, p-value = 0.003, I2 = 0%).Conclusion: In this systematic review and meta-analysis including 1,861 patients with ARDS, the presence of RVD was significantly associated with increased overall and short-term mortality.Trial registration: The protocol was registered at PROSPERO (CRD42020206521).