Rovati, Lucrezia

IMPORTANCE: Phenobarbital use in ICU alcohol withdrawal syndrome (AWS) may reflect severe or refractory withdrawal and treatment escalation, making multicenter data important to understand its use within ICU practice and its relationship with clinical outcomes. OBJECTIVES: To evaluate phenobarbital use in real-world ICU AWS as a marker of severe or refractory withdrawal and treatment escalation. We also examined its association with time-to-discharge and safety outcomes compared with nonphenobarbital regimens. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study using multiple imputation and propensity score matching. Adults with AWS, defined as Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) score greater than or equal to 10, were included if they received a phenobarbital-based or nonphenobarbital-based regimen in ICUs across a large academic health system from June 30, 2017, to July 1, 2024. Postoperative ICU admissions were excluded. MAIN OUTCOMES AND MEASURES: Primary outcomes were time to ICU and hospital discharge alive from treatment initiation. Safety outcomes were hypotension, new intubation, and aspiration within 48 hours. RESULTS: Of 1216 patients, 345 (28.4%) received phenobarbital. Before matching, phenobarbital-treated patients had higher CIWA-Ar, Acute Physiology and Chronic Health Evaluation III, and pre-ICU benzodiazepine exposure, consistent with more severe or refractory withdrawal. In adjusted time-to-discharge models, phenobarbital use was not significantly associated with time to hospital discharge alive (discharge rate ratio [DRR], 0.91; 95% CI, 0.74–1.12; p = 0.370) or ICU discharge alive (DRR, 0.77; 95% CI, 0.59–1.01; p = 0.057). Hypotension and intubation were similar, and aspiration was less frequent with phenobarbital. CONCLUSIONS: In a contemporary ICU cohort, phenobarbital use reflected treatment escalation in patients with more severe or refractory AWS. After adjustment, time to ICU and hospital discharge alive did not differ significantly, hypotension and intubation were similar, and aspiration was less frequent with phenobarbital. Future studies should define optimal timing, dosing, and patient selection.

OBJECTIVES: The goal of this scoping review was to review some of the challenges hospitals faced in dealing with the shortage of ventilators during the COVID-19 pandemic and the solutions they were able to implement or suggested. By highlighting these problems and solutions, we hope this review can catalyze further discussions about how to better prepare for future pandemics and medical supply shortages. DATA SOURCES: A comprehensive search strategy using identifying key words was applied to several different databases to procure relevant literature. STUDY SELECTION: Four thousand two hundred fifty-nine studies were found in the initial search. Inclusion and exclusion criteria were created and applied to screen studies. Included studies focused on the supply and distribution of ventilators during the COVID-19 pandemic. In the case where reviewers disagreed about whether a study should be included, a third reviewer acted as a tie-breaker. DATA EXTRACTION: Thirty-three studies were included for final data extraction. Two independent reviewers collected various data points from these studies, including the main challenges discussed by the authors, the level of ventilator shortage being addressed, whether ventilator sharing was discussed, and the limitations of the study. DATA SYNTHESIS: A third reviewer compared the collected data and decided on the results. CONCLUSIONS: Some of the common solutions for the ventilator shortage discussed included augmenting overall ventilator supply through increased production, transporting ventilators between hospitals, ventilator sharing, designing new ventilators, and repurposing other resources to help address shortages of supplies.

Objectives There is substantial practice variation in the management strategies for atrial fibrillation (AF) with rapid ventricular rate (RVR) and hemodynamic instability in critically ill patients. This study aimed to evaluate the use and effectiveness of direct current cardioversion (DCCV) for unstable AF RVR in the intensive care unit (ICU). Design Multicenter retrospective cohort study. Setting Non-cardiac/cardiovascular surgery ICUs of the Mayo Clinic Hospitals in Minnesota, Wisconsin, Florida, and Arizona. Patients Adult patients who developed paroxysmal AF RVR with hemodynamic instability (heart rate ≥ 130 beats per minute and a documented SBP ≤ 90 mmHg or the need for vasopressors) during ICU stay. Interventions Emergency DCCV. Measurements and Main Results Primary outcomes were in-hospital mortality, hospital-, ICU-, and organ support-free days. Secondary outcomes were return to sinus rhythm rate before and after discharge. Among 691 patients eligible for inclusion, 47 (6.8%) received emergent DCCV in the ICU. The frequency of DCCV was higher for patients located in surgical ICUs (14.5% vs 6.1%, P = .04). Patients were 1:2 propensity-score matched. The comparative analyses were conducted on 141 patients. Those who underwent DCCV were more likely to restore sinus rhythm (odds ratio [95% confidence interval], 5.2 [1.30 20.8]). However, DCCV was not associated with increased odds of having sinus rhythm at discharge, lower mortality, or higher number of ICU-, or hospital-free days. The number of organ support-free days was significantly lower in the DCCV group (estimate ± standard error, −5.0 ± 2.0, P = .012). Conclusions Emergency DCCV is rarely used to treat unstable AF in non-cardiac ICUs. Despite increased likelihood of immediate sinus rhythm restoration, DCCV was not associated with improvement in patient-centered outcomes. Prospective studies are warranted to evaluate harms and benefits of DCCV in non-cardiac critically ill patients with unstable AF where the driver of hemodynamic instability is often an underlying condition rather than arrhythmia per se.

Abstract Background Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety. Objectives This systematic review assesses the impact of centralized multipatient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes. Methods A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared with the standard practice. We narratively synthesized eligible studies following the SWiM (Synthesis Without Meta-analysis) guidelines. Studies were grouped based on dashboard type and outcomes assessed. Results The search yielded a total of 2,407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association. Conclusion The multipatient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high, and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure, and methodological limitations. Designing and evaluating multipatient tools using robust research methodologies is an important focus for future research.

ABSTRACT Background: Although central venous oxygen saturation (ScvO2) has been used as an endpoint for the treatment of circulatory shock, its role in guiding the evaluation and treatment of patients with severe hypoxemia remains to be assessed. The aim of this study was to assess the incidence of low ScvO2 in a cohort of hypoxemic patients and the association of this finding with differences in clinical management and patient outcomes. Methods: Retrospective review of data from adult intensive care unit patients with hypoxemia who required invasive mechanical ventilation for over 24 h and had at least one ScvO2 measured within 6 h of a PaO2/FiO2 ratio <200. Results: Of 442 mechanically ventilated patients with severe hypoxemia, 249 (56%) had an ScvO2 <70%. When compared with patients with ScvO2 ≥70%, those with low ScvO2 had worse systemic oxygenation and hemodynamic parameters and were more likely to receive red blood cell transfusions (31.7% vs. 18.1%, P = 0.001), epinephrine (27.3% vs. 16.6%, P = 0.007), and inodilators. Outcomes such as median intensive care unit length of stay (7.5 vs. 8.3 days, P = 0.337) and hospital mortality (39.8% vs. 35.7%, P = 0.389) were not different between groups. When stratified by the central venous-to-arterial CO2 difference (∆PCO2), patients with a low ScvO2 and normal ∆PCO2 had lower median PaO2 and hemoglobin levels and received more red blood cell transfusions, whereas those with an increased ∆PCO2 had a lower pulse pressure and cardiac index and were more likely to receive epinephrine and milrinone. Conclusion: Low ScvO2 is frequently observed in mechanically ventilated patients with severe hypoxemia, and these patients receive different interventions. Clinicians often use therapies targeting systemic oxygen delivery to correct low ScvO2. Prospective research is needed to identify patients with severe hypoxemia that might benefit from interventions targeting systemic oxygen delivery.