Gajic, Ognjen

Introduction Sepsis is a global health priority with nearly 50 million cases annually. Cardiovascular dysfunction is common, frequently manifesting as hypotension that persists despite fluid resuscitation. Most affected patients require the use of intravenous (IV) vasoactive agents, typically necessitating intensive care unit (ICU)-level monitoring, invasive interventions and contributing substantially to healthcare costs. Midodrine, an oral alpha-1 agonist approved for orthostatic hypotension, has increasingly been used off-label as a vasopressor-sparing (reducing IV vasopressor use) strategy in sepsis, despite limited and inconsistent evidence. This pragmatic, randomised, open-label trial evaluates the efficacy and safety of midodrine in patients with sepsis-associated hypotension. We hypothesise that, compared with standard care, midodrine administration will reduce the duration of IV vasopressor use. Methods and analysis A total of 308 adult patients with sepsis-associated hypotension will be enrolled (154 per arm). The intervention group will, in addition to standard of care, receive enteral midodrine 10 mg three times daily. Outcomes will be ascertained pragmatically via electronic health record-based data retrieval and adjudicated by research coordinators blinded to treatment assignment. The primary outcome is time alive and off IV vasopressors in the first 28 days (in hours) after randomisation. Secondary outcomes include cumulative vasopressor exposure; use and duration of central venous access; cumulative fluid balance over the first 48 hours and up to 7 days of ICU stay; ICU and hospital length of stay; and ICU-, hospital-, and organ support-free days through day 28. Safety outcomes include adverse events potentially attributable to midodrine during hospitalisation including acute kidney injury. Primary analyses will follow an intention-to-treat framework, including all randomised participants according to their assigned treatment groups. Primary and secondary outcomes will be compared using a van Elteren test stratified by randomisation factors. A predefined secondary Bayesian analysis of the primary outcome will provide complementary estimates of treatment effect. Safety outcomes will be summarised descriptively without formal between-arm hypothesis testing. Ethics and dissemination The Mayo Clinic Institutional Review Board approved this protocol and required written informed consent from all participants (IRB# 24–0 00 121). Findings will be disseminated through peer-reviewed publications and international conference presentations. Trial registration number NCT06319248 .

Introduction Patient dehumanization when caring for critically ill patients in the intensive care unit (ICU) is commonplace. The Get to Know Me board (GTKMB) has been identified as a valuable tool for promoting humanized care and communication in the ICU; however, its implementation is highly variable. This study aimed to identify the barriers and facilitators influencing consistent implementation of the GTKMB in the ICU. Materials and methods We conducted multidisciplinary focus groups via teleconference with ICU clinicians at a large quaternary care academic medical center. A thematic content analysis was performed to identify key themes and concepts related to GTKMB implementation. Results Thirty-eight clinicians participated across six focus groups, including 10 nurses, 7 physicians, 6 advanced practice providers, 5 rehabilitation therapists (allied health clinicians), 1 respiratory therapist and 1 social worker. Major themes related to barriers and facilitators of GTKMB implementation included, (1) identifying appropriate patients and optimal timing for completing the GTKMB, (2) logistical challenges such as access to the board, visibility and unclear responsibility for completion, (3) the importance of clinician role modeling supporting the board completion, and (4) opportunities to improve the design and functionality of the board itself. Conclusion Although clinicians recognize the GTKMB as a meaningful tool to support humanized care in the ICU, inconsistent implementation limits its potential impact. This study highlights several key barriers and facilitators to its use. Future efforts should focus on targeted quality improvement initiatives to enhance consistent completion and integration of the GTKMB into ICU practice.

The intensive care unit (ICU) is a highly disease-focused environment where patients are often perceived primarily through their diagnoses rather than as individuals. The Get-To-Know-Me Board (GTKMB) was introduced as a humanizing tool to highlight patients’ personal attributes and foster person-centered care. Despite being found valuable in supporting humanized caring and fostering communication, completion rates at our institution remained low. Through a stakeholder-driven quality improvement initiative, we tested sequential interventions including reminders and checklists, visual magnets, and educational pamphlets to improve and increase the use of the GTKMB. These measures produced modest gains, with reminders and checklists yielding the most notable improvement. Barriers to using the GKTMB included unclear ownership, timing, and inconsistent integration into workflow. Our experience underscores both the promise and limitations of humanizing interventions in critical care. Sustainable implementation requires multidisciplinary buy-in and integration into daily routines. Whereas humanizing tools such as the GTKMB should be evaluated for their impact on meaningful patient outcomes, such outcomes are not clearly established; therefore, we embark on the necessary first step of a method of implementation.

Background Adherence to evidence-based care processes and patient outcomes in intensive care units (ICUs) can be influenced by staffing and resource availability. We aimed to evaluate if there is a weekend effect on adherence to evidence-based care processes, and hospitalization outcomes and whether a checklist implementation could mitigate potential differences. Methods Post hoc analysis of the Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) study dataset collected before and after checklist implementation in 34 ICUs across 15 countries (2013-2017). Admission days were classified as ‘weekend/holidays’ or ‘weekdays’ according to local work schedules and public holidays. The primary outcome was the omission of 10 evidence-based care processes addressed in the checklist. Mortality and length of stay differences between weekend/holiday and weekday admissions were evaluated as secondary outcomes. Results 4256 patients contributed 1141 weekend versus 3501 weekday observation days pre-intervention, and 2014 versus 6507 post-intervention. Pre-intervention, peptic ulcer prophylaxis was omitted more frequently on weekends/holidays than weekdays (adjusted rate ratio [aRR], 0.58 [95%–confidence interval [CI] 0.38-0.88), whereas head-of-bed elevation was omitted more often on weekdays than on weekends/holidays (aRR, 3.17 [1.14-8.86]). Post-intervention, peptic ulcer prophylaxis omission rates became similar (aRR, 1.03 [0.68-1.56], but head-of-bed elevation became omitted more often on weekends than on weekdays (aRR, 0.63 [0.45-0.88]). Post-intervention, oral care was omitted more frequently on weekends/holidays than in weekdays (aRR, 0.63 [0.45-0.9]), and central catheter removal was more frequent on weekdays than in weekends/holidays (aRR, 1.11 [1.02-1.21]). No significant differences in mortality or length of stay were found. Conclusion A weekend effect influenced adherence to some care processes. While checklist implementation improved overall adherence, some disparities diminished, while new ones emerged. Organizational, cultural, and temporal factors should be further studied to optimize care delivery across all times and settings. Clinical Trial Registration Number NCT01973829

Background: Propofol is a first-line sedative for critically ill adults receiving invasive mechanical ventilation (IMV). However, it can contribute to hemodynamic instability, especially in the setting of intubation. The magnitude, timing, risk factors, and variability of sedation-associated mean arterial pressure (MAP) changes remain poorly characterized in ICU settings. Objectives: To quantify MAP changes following propofol sedation, identify risk factors for hemodynamic instability, and characterize associated interventions. Methods: We included adults (≥18 years old) across 11 ICUs in the Mayo Clinic Enterprise who required IMV and received ≥6 consecutive hours of propofol infusion between 05/05/2018 and 07/31/2024. The primary outcome was MAP change within 2-hours following sedation. Secondary outcomes included vasopressor use and hypotension (MAP ≤60 mmHg). Mixed-effects modeling was utilized to account for individual patient differences. The main model used a “neutral” adjustment, estimating a 5 mmHg MAP increase per 0.05 mcg/kg/min of norepinephrine equivalents, reduced to 3 mmHg per 0.05 mcg/kg/min after reaching a dose of 0.20 mcg/kg/min. Those on any vasopressors prior to propofol sedation initiation were analyzed separately. Results: Across 16,418 patients, 25.2% were on vasopressors before sedation initiation. Among the remaining 12,281 patients, 40.3% required vasopressors and 7.7% experienced hypotension within 2 hours of sedation ( Image 1 ). Post-intubation sedation was associated with a MAP reduction within the first 30 minutes (-6.58 mmHg; 95% CI: -6.85 to -6.32; P<0.001; Images 2 and 3 ). There was substantial inter-patient variability in both baseline MAP (9.5% variation attributable to between-patient differences) and MAP decline after sedation (40.9% between-patient differences). Higher SOFA scores (-0.31 mmHg per point), older age (-0.04 mmHg per year), and male sex (-0.47 mmHg) were associated with lower MAP. Patients with higher illness severity experienced progressively greater MAP changes over time (-0.20 mmHg per hour per increasing SOFA point; P<0.001). Conclusions: Propofol sedation is associated with clinically significant hemodynamic effects requiring intervention in the early post-intubation period. The marked inter-patient variability in hemodynamic responses highlights the importance of personalized management approaches. Risk stratification may help identify patients who could benefit from preemptive hemodynamic optimization.