Gajic, Ognjen

Objectives: Research indicates that the increasing population of over 25 million people in the United States who have limited English proficiency experience differences in decision-making and subsequent care at end of life in the ICU when compared with the general population. The objective of this study was to assess the perceptions of healthcare team members about the factors that influence discussions and decision-making about end of life for patients and family members with limited English proficiency in the ICU. Design: Qualitative study using semistructured interviews with ICU physicians, nurses, and interpreters. Setting: Three ICUs at Mayo Clinic Rochester. Subjects: Sixteen ICU physicians, 12 ICU nurses, and 12 interpreters. Intervention: None. Measurements and Main Results: We conducted 40 semistructured interviews. We identified six key differences in end-of-life decision-making for patients with limited English proficiency compared with patients without limited English proficiency: 1) clinician communication is modified and less frequent; 2) clinician ability to assess patient and family understanding is impaired; 3) relationship building is impaired; 4) patient and family understanding of decision-making concepts (e.g., palliative care) is impaired; 5) treatment limitations are often perceived to be unacceptable due to faith-based and cultural beliefs; and 6) patient and family decision-making styles are different. Facilitators of high-quality decision-making in patients with limited English proficiency included: 1) premeeting between clinician and interpreter; 2) interpretation that communicates empathy and caring; 3) bidirectional communication of cultural perspectives; 4) interpretation that improves messaging including appropriate word choice; and 5) clinician cultural humility. Conclusions: End-of-life decision-making is significantly different for ICU patients with limited English proficiency. Participants identified several barriers and facilitators to high-quality end-of-life decision-making for ICU patients and families with limited English proficiency. Awareness of these factors can facilitate interventions to improve high-quality, compassionate, and culturally sensitive decision-making for patients and families with limited English proficiency.

For best outcomes, clinicians in the ICU need to attend not only to the immediate clinical needs of the critically ill patient, but also to higher human needs including psychologic, social, and spiritual. Understanding your patient as another human being with her or his fears, desires, preferences, and accomplishments is obviously important in order to provide compassionate care and achieve goal concordant outcomes. In an ever-evolving technological ICU environment, this may not be an easy task. All too often, we focus on monitors, devices, electronic records, and ignore the human being. Patients labeled with a disability are particularly vulnerable. Recently, I had the privilege to participate in the care of a Mayo Clinic patient with a history of cerebral palsy. In the midst of a life-threatening emergency, by paying attention to the human touch, the ICU team learned the story of a truly remarkable person. The essay below summarizes the patient’s and physician’s perspectives.

6596 Background: Several previous systematic reviews and meta-analyses have attempted to summarize toxicity of Immune checkpoint inhibitors (ICIs). However, very soon after each one of these reviews has been published, it became outdated. ICIs are currently used in 14 different cancers and data is rapidly evolving from new clinical trials. A living Systematic review, which is defined as a systematic review that is continually updated to incorporate relevant new evidence as it becomes available, is necessary in this situations. Therefore, we performed an updated systematic review and a meta-analysis which will serve as a foundation of a living Systematic review. Methods: MEDLINE, EMBASE and Cochrane were searched to identify phase 2 and 3 RCTs of PD-1/PD-L1 ICIs. Included studies compared either immunotherapy alone or combination with existing standard of care treatment and reported data for AE’s of interest. DerSimonian-Laird random effects Meta-Analysis was performed to derive pooled odds Ratio (OR) estimates for AE’s of interest. An infrastructure of a living systematic review is being developed and it includes monthly literature searches, cumulative meta-analysis and an online reporting platform. Results: We screened 6746 studies and 31 phase 3 and 2 phase 2 RCTs (n = 21,421) were included in the analysis. 22 RCTs used PD-1/PD-L1 ICIs as a single agent and 11 as a combination therapy. Selected toxicity estimates are summarized in a table. Conclusions: The meta-analysis updates previously published toxicity estimates and provides additional information about the risk of toxicities in single versus combination regimens. We have initiated the first living systematic review in oncology that will be continuously updated, incorporating relevant new evidence as it becomes available, and will provide accurate and up to date toxicity estimates to support clinical decision making. [Table: see text]

Objectives: Midodrine is an α1-agonist approved for orthostatic hypotension. Recently, it has received attention as an oral vasopressor to facilitate ICU discharge. The purpose of this study was to identify the incidence of continuation of newly initiated midodrine upon ICU and hospital discharge and identify risk factors associated with its occurrence. Design: Single-center retrospective study. Setting: ICU patients from January 2011 to October 2016 at Mayo Clinic, Rochester. Patients: Adult patients admitted to any ICU who received new midodrine for hypotension and survived to discharge. Interventions: None. Measurements and Main Results: During the study period, 1,010 patients were newly started on midodrine and survived to ICU discharge. Midodrine was continued in 67% (672/1,010) of patients at ICU discharge. Admission to cardiovascular surgery ICU and mixed medical/surgical ICU was a risk factor for midodrine continuation at ICU discharge (odds ratio, 3.94 [2.50–6.21] and 2.03 [1.29–3.20], respectively). At hospital discharge, 34% (311/909) of patients were continued on midodrine therapy. History of congestive heart failure predicted midodrine continuation at hospital discharge (odds ratio, 1.49 [1.05–2.12]). Hypertension and use of mechanical ventilation were associated with a decreased odds of midodrine prescription at both ICU and hospital discharge. Of those discharged from the ICU or hospital on midodrine, 50% were concomitantly prescribed antihypertensives. Discharge from the ICU on midodrine was associated with a significantly shorter ICU length of stay (7.5 ± 8.9 vs 10.6 ± 13.4 d) and reduced risk of in-hospital mortality (hazard ratio, 0.47 [95% CI, 0.32–0.70]; p < 0.001), despite no difference in baseline severity of illness scores. In contrast, patients discharged from the hospital on midodrine had a higher risk of 1-year mortality (hazard ratio, 1.60 [95% CI, 1.26–2.04]; p < 0.001). Conclusions: This study established a high prevalence of midodrine continuation in transitions of care. The risks and benefits of this practice remain unclear. Future studies should explore the impact of this practice on patient outcomes and resource utilization. These insights could be used to model interventions for proper tapering, discontinuation, or follow-up of new start midodrine.

Introduction: Older adult individuals often have acute illnesses predisposing them to developing acute respiratory distress syndrome (ARDS). We aimed to identify the relationship between age and the development of ARDS in a cohort of hospitalized patients. Methods: This was a secondary analysis of a prospective multicenter observational cohort study of hospitalized patients at risk of developing ARDS admitted to 22 hospitals from March 2009 to August 2009. Patients were classified as older adults if their age was 80 or greater. A multivariable logistic regression was performed, adjusting for severity of illness via Acute Physiology and Chronic Health Evaluation (APACHE II) and risk of ARDS via Lung Injury Prediction Score. Results: Of 5584 patients, 377 (6.8%) developed ARDS. Twenty-four (3.5%) of 694 patients aged 80 or older developed ARDS, compared to 353 (7.2%) of 4890 patients aged less than 80 ( P < .001). After adjusting for severity of illness and the risk of ARDS development, older adult patients had a lower incidence of ARDS compared to younger individuals (odds ratio: 0.28, 95% confidence interval: 0.18-0.42). Conclusion: Older adult patients aged 80 years or older have a reduced incidence of ARDS compared to younger patients, after adjusting for severity of illness and risk of ARDS development.

AbstractAcute respiratory distress syndrome (ARDS) remains an important clinical entity in the intensive care unit with a significant impact on morbidity and mortality. Effective therapeutic interventions are limited; thus current research focus has shifted from treatment to the prevention of this pulmonary syndrome. In recent decades, a decrease in the incidence of ARDS has been observed and this reduction is largely due to preventive strategies including safe lung ventilation practices, avoidance of iatrogenic exposures, and improvement in care of predisposing conditions such as sepsis and pneumonia. Early identification of at-risk patients, prompt treatment of predisposing conditions, and adoption of evidence-based best practice including restrictive transfusion strategies, conservative fluid management, avoidance of large tidal volume ventilation, and aspiration precaution practices are key preventive strategies with demonstrated benefits. There are currently no effective pharmacological preventive strategies for ARDS.

We aimed to assess the role of a short duration multimedia workshop to improve the knowledge and skills in cardiac critical care ultrasonography. Thirty critical care physicians participated in the cardiac critical care ultrasonography workshop. Two weeks prior to hands-on training, a three-hour web-based didactic lecture was provided to learners. Hands-on training consisted of a two-hour examination on models without pathology and a 30-minute debriefing with instructors. Pre- and post-workshop knowledge tests were conducted online using 30 multiple choice questions. Pre- and post-workshop skill tests were video captured for evaluation by two reviewers to whom data were masked. Scores were based on 34 predetermined checklist items including learner performance, instrumentation and adequacy of ultrasound images. Learners’ confidence levels on image acquisition were assessed using a ten-point Likert scale. A short duration multimedia, hands-on workshop improved intensivists’ knowledge, skills and confidence levels on cardiac critical care ultrasonography image acquisition. Further studies are needed to assess the sustainability of observed improvements. This module may be a practical option for the acquisition and maintenance of cardiac critical care ultrasonography knowledge and skills.