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INTRODUCTION: Increased sedation and analgesia requirements have been described in patients with acute respiratory distress syndrome (ARDS) on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. The primary objective of this study was to compare analgesia and sedation requirements in adult patients with SARS-CoV-2 ARDS versus other etiologies of ARDS requiring VV-ECMO support. METHOD(S): This was a retrospective cohort study of adult patients requiring VV-ECMO for ARDS between May 2016 and July 2021. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days. The primary outcome of the study was the daily median dose for continuous infusion analgosedation for 7 days following ECMO cannulation. Secondary outcomes included the daily median analgosedation requirements utilizing the highest daily rate, ICU length of stay and mortality, and incidence of adjunct sedation, analgesia, and anxiolytic use while on VVECMO. RESULT(S): Of 108 patients evaluated on VV-ECMO support, 44 had non-SARS-CoV-2 ARDS and 64 had SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs. 13.4 mcg/kg/day, p=0.03), while the median propofol daily requirements were significantly higher in the non- SARS-CoV-2 cohort (40.3 vs. 53.5 mg/kg/day, p < 0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Patients in the SARS-CoV-2 cohort remained on greater than 2 continuous infusion agents significantly longer than the non-SARS-CoV-2 cohort (3.0 vs. 2.0 days, p=0.04). Use of non-parenteral adjunct agents was significantly higher in the SARS-CoV-2 cohort (78.1% vs. 43.2%, p< 0.01). CONCLUSION(S): Patients with ARDS on VV-ECMO support require multiple analgesic and sedative agents with higher utilization of non-parenteral adjunct agents in the SARSCoV- 2 ARDS cohort. To circumvent these challenges, ECMO centers should consider implementation of ECMO-specific analgosedation protocols to optimize patient outcomes.
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Introduction: There are limited options for the treatment of malignant mesothelioma (MM) following progression with pemetrexed-platinum chemotherapy. Recently, nivolumab showed a survival benefit over placebo in this setting. In the UK, since April 2020, nivolumab has been funded through the interim national COVID-19 cancer plan. We assessed the real-world efficacy and toxicity outcomes in MM patients treated with nivolumab at Guy’s Cancer Centre.Methods: We identified all chemotherapy-pre-treated patients administered single-agent nivolumab for MM. Baseline characteristics, treatment, response, survival and treatment-related adverse events (TRAEs) were assessed. Best responses – disease control or progression – were derived from radiologic and clinical documentation. Results: Twenty patients were identified. Median age was 72 years (range 45 – 85), 80% male and 95% had epithelioid (5% sarcomatoid) disease. Programmed death-ligand 1 (PD-L1) measurements were unavailable. Nineteen (95%) had pleural and one peritoneal MM. ECOG PS was 0, 1 or 2 in 1 (5%), 16 (80%) and 3 (15%) patients respectively. All were previously exposed to pemetrexed-platinum chemotherapy, and 4 (20%) had received rechallenge. Median time from prior treatment to commencement of nivolumab was 6 months. Median follow-up was 10.8 months. Median number of two-weekly 240mg equivalent cycles administered was twelve. Best response was disease control in 17 (85%) patients and progressive disease in 3 (15%). Median progression-free survival was 5.0 months (95% CI 3.7 – 6.2). Six patients (30%) had died by time of analysis, with median overall survival not reached. Twenty TRAEs were seen among 14 patients (70%), all except one graded 1/2 (Table 1). Conclusions: Nivolumab proved a safe and effective way to deliver non-myelosuppressive anticancer therapy at a favourable dosing schedule to a vulnerable population during the COVID-19 pandemic. These real-world outcomes corroborate findings from the CONFIRM trial, although limited by small sample size and retrospective nature.
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Introduction - The ideal timing of tracheostomy for intubated COVID-19 patients is highly debated. The duration of intubation varies greatly but is frequently prolonged and data suggests that sedation requirements are high in these patients. Tracheostomy, rather than ongoing oral intubation, may be beneficial by decreasing the amount of sedation needed. We hypothesize that tracheostomy placement in patients requiring prolonged intubation secondary to COVID-19 significantly reduces the amount of sedation required post-procedure.Methods - We retrospectively evaluated 32 COVID-19 patients that underwent tracheostomy for prolonged intubation at a single tertiary care center. Bedside tracheostomy was performed by two experienced operators from March- June 2020. We captured total daily amounts of sedation 7 days prior to and following tracheostomy. Benzodiazepines, opiates, antipsychotics and other hypnotics (e.g. propofol, ketamine, etc) were recorded. Individual medications were compared in addition to total amounts of benzodiazepines and opiates after converting to equivalent dosing. Paired t-tests were used to determine whether there were significant changes in the average daily dose of each medication or group of medications pre vs. post tracheostomyResults - The average age of our patients was 57 (SD=11.13), 26 (83.9%) were male and 20 (62.5%) were Hispanic. The average time to tracheostomy was 28 days (SD=8.5) after intubation. There was a significant decrease in both benzodiazepine and opiate use after tracheostomy. The average daily use of benzodiazepines decreased by 17.5 mg lorazepam equivalents (SD=34.2, p=.01) and opiates by 157.5 mg morphine equivalents (sd=339.3, p=.01) . There was no significant difference in antipsychotic or other hypnotic drug doses. 23 patients (71.9%) were liberated from the ventilator (average of 24 days post-tracheostomy) and 16 were decannulated (average 42 days post-tracheostomy) at 6-month follow-up. Five (15.6%) of the 32 patients died, and all deaths were prior to hospital discharge. Discussion - Tracheostomy significantly decreased both benzodiazepine and opiate dosing for COVID-19 patients at our institution. COVID patients with severe respiratory failure should be considered for tracheostomy to help prevent over-sedation and facilitate ventilator liberation and decannulation. Limiting sedation in these patients has the potential to lower the incidence of delirium, improve mobility and shorten the duration of ventilation. These improvements may translate into shorter ICU stays and improved survival. References:Chao, Tiffany N et al. “Tracheotomy in Ventilated Patients With COVID-19.” Annals of surgery vol. 272,1 (2020): e30-e32.Cagino, Leigh M., et al. ' Annals of the American Thoracic Society ja (2020). .
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Background -Patients intubated due to COVID-19 can experience prolonged intubation and have a significant risk of hospital-acquired delirium. Consequences of delirium include longer hospitals stays, increased risk of death and persistent cognitive impairment. We hypothesize that tracheostomy facilitates ventilator liberation, may decrease ICU LOS and allows for improved patient communication and early mobility, all which may help improve delirium. This can help inform timing of tracheostomy for future outbreaks of COVID-19 or similar illnesses . Methods - We retrospectively evaluated 32 COVID-19 patients that underwent tracheostomy for prolonged intubation at a single tertiary care center. Bedside tracheostomy was performed by 2 experienced operators. We captured daily CAM-ICU and RASS for 7 days prior to and following tracheostomy. We defined patients as having coma or delirium if their RASS was -4 or -5 or they had a positive CAM-ICU score. Patients were considered not comatose or delirious if their RASS was -3 or higher and they had a negative CAM-ICU. We computed the average proportion of delirium days for each patient both pre-and post-tracheostomy and used a paired t-test to determine if there was a significant change in this outcome Results - The average age of our patients was 57 (SD=11.13), 26 (83.9%) were male and 20 (62.5%) were Hispanic. The average ICU length of stay was 53 days (SD=16.8). The average length of time until tracheostomy after intubation was 28 days (SD=8.51). Greater than 90% of the patient data days had recorded RASS scores and CAM-ICU assessments. There was a significant decrease in the proportion of days of coma or delirium (mean decrease in proportion 0.16, sd=.32, p-value = 0.008) post-tracheostomy. The mean RASS before tracheostomy was -2.12 (SD=1.59) and the mean RASS after tracheostomy was -1.30 (SD=1.50). Discussion - At our institution, COVID-19 patients had significantly fewer days of delirium in the 7 days after tracheostomy than 7 days prior to the procedure. These patients also had a higher (less negative) RASS. The reason for this difference is likely multifactorial and includes differences in sedation before and after tracheostomy, improved ability to communicate and ability to be discharged from the ICU. References:Salluh, Jorge IF, et al. 'Outcome of delirium in critically ill patients: systematic review and meta-analysis.' bmj 350 (2015). Van Rompaey, Bart, et al. 'Risk factors for delirium in intensive care patients: a prospective cohort study.' Critical care 13.3 (2009): R77. .
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The COVID-19 pandemic has changed the way we deliver healthcare. During 'lockdown' all but the most urgent face-toface (F2F) consultations stopped. There will be a continuing need for innovation to maintain services, and teledermatology offers the potential to help meet demand, while continuing to maintain social distancing. We report the use of a store-andforward teledermatology platform to facilitate virtual asynchronous consultations. The platform was developed and piloted across two health boards, with initial use focused on return consultations. The restrictions imposed during the pandemic prompted its use on a larger scale, with the addition of a specific proforma for new consultations. Patients are invited to register using a web-based app, and then have a 5-day window to submit information and pictures to an assigned clinician. The clinician then responds within an agreed timeframe, and a PDF of the consultation is sent to the general practitioner automatically. The system can integrate with patientmanagement systems, although at the time of this audit it was only integrated in one of two health boards. During an 11-week period from late March 2020, 405 consultations (new 297;return 108) were completed. In total, 292 consultations involved the assessment of lesions, most referred as suspected cancers. Patients of all ages participated successfully, with 31% over the age of 60 years. Parents of 12 children also successfully participated. Responses to 219 consultations were completed from home by a clinician, highlighting the potential for the system to facilitate remote working. Outcomes from the virtual consultations included further virtual review (16%), F2F review (47%), direct surgery (12%), discharge (22%) and other treatment/investigations (3%). The majority of those needing F2F review were scheduled for routine follow-up, although 29% were booked as urgent to confirm diagnosis, typically where image quality was not sufficient for diagnostic certainty. The average time taken by the clinician was 10 min per consultation vs. 13 min for equivalent F2F. However, these timings were taken without the benefit of full system integration. Patient satisfaction was good, with 82% of respondents reporting ease of use. Forty-two per cent reported that they would normally have had to miss work to attend the clinic. The system also confers environmental benefits with a total of 5758 km of patient travel saved. This pandemic has resulted in a paradigm shift in the way we deliver outpatient care. Virtual asynchronous consultations, within an integrated dermatology service, provide an efficient alternative to some F2F consultations.