ABSTRACT
INTRODUCTION: Sedative medications are frequently utilized to relieve stress and anxiety, control agitation, and/or improve ventilator synchrony in patients requiring mechanical ventilation. However, many sedative agents have the potential to cause short- and long-term harm. Observational data have described associations between race and negative outcomes in patients with sepsis. It is unclear if race is associated with sedation administration practices. The purpose of this study was to investigate whether Black race is associated with differences in exposure to continuous infusion sedatives compared to White race. METHOD(S): A single-center, retrospective, cohort study was performed in adult patients admitted to the medical or surgical intensive care unit (ICU) with community-onset sepsis between June 1, 2018 and June 1, 2021. Data were collected from the electronic health record. The primary outcome was the cumulative dose of fentanyl received by continuous infusion between day 1-14 of ICU admission. The cumulative doses of other continuous infusion sedatives were described as secondary outcomes. A linear regression model assessed the association of race and the primary outcome while controlling for relevant confounding variables. RESULT(S): 772 patients were included. Black patients had a higher median modified APACHE II score (18 vs. 17, p< 0.001), Charlson Comorbidity Index (4 vs. 3, p=0.003), COVID-19 diagnosis incidence (18.5% vs. 7.1%, p< 0.001), and renal disease incidence (44.9% vs. 27.8%, p< 0.001) at baseline. No difference was observed in the amount of fentanyl received by continuous infusion between day 1-14 of ICU admission between Black and White patients (7085 mcg vs. 6426 mcg, p=0.37). Similarly, no association between Black race and the total amount of propofol (p=0.65), dexmedetomidine (p=0.67), or midazolam (p=0.08) via continuous infusion was observed. A linear regression model observed no significant association between race and the primary outcome. CONCLUSION(S): Black race was not associated with increased exposure to continuous infusion sedatives compared to White race. This is the first known study to investigate racial disparities in sedation strategies in mechanically ventilated adults in the ICU with sepsis.
ABSTRACT
Rationale: COVID-19 infection is well known to cause Acute Respiratory Distress Syndrome (ARDS). Patients with COVID ARDS have been found to have higher mortality than those with ARDS from other causes. Patients with increased oxygenation and ventilation requirements are being placed on inhaled vasodilators in hopes of increasing oxygenation and decreasing mortality of this disease, however, no large study in COVID-related ARDS has been done in patients requiring noninvasive positive pressure ventilation and/or mechanical ventilation evaluating effects of pulmonary vasodilators. Here we evaluated whether inhaled epoprostenol does improve P/F ratios in patients with COVID-ARDS and whether that is associated with a mortality benefit. Methods: Eligible patients aged ≥18 years of age with a positive COVID-19 PCR/antigen test within 14 days or 7 days after hospital admission admitted to one of eleven hospitals in a large integrated healthcare system who received inhaled epoprostenol between 3/2020 and 9/2021 were added for evaluation. P/F ratios were calculated before and up to 4 hours after starting epoprostenol. In patients with only SpO2, nonlinear imputation of PaO2/FiO2 from SpO2/Fio2 was used to determine P/F ratios. Patients were stratified as responders to epoprostenol (defined as improvement in P/F ratio by 10%) or non responders. Results: In total, 209 patients met inclusion criteria. Of those, 116 were male, 93 female. Age ranged between 35-90 (Median age 63, (IQR:55- 75)) 142 patients were mechanically ventilated, 23 were on NPPV, 43 were on high flow oxygen. Baseline P/F in survivors and nonsurvivors was not significantly different (82 versus 71 P = 0.47). Similarly, the change in P/F between survivors and nonsurvivors after epoprostenol was not significantly different (24.1% versus 23.8%;P = 0.902). Conclusions: Although there was an improvement in P/F ratio in this patient population, overall, there was no mortality benefit seen. Further evaluation of patients in smaller sub-groups may demonstrate a patient population that could see mortality benefit with the addition of inhaled epoprostenol.