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Introduction: Automatic drug dispensers are now widely used in critical care.1-2 They can provide information about dispensed drugs. Good practice in sedation restricts the use of sedatives and titrates doses to defined responses.3-4 Objectives: To extract drug dispenser issuing records for sedatives and link these to patient records to evaluate sedative use. Method(s): in October 2019, we introduced two Omnicell XT automated dispensing cabinets (Omnicell inc. CA, USA) into a 42 bedded general/neurological unit. ICNARC (Intensive care national audit and research centre) and CCMDS (Critical care minimum data set) data was collected using the Ward Watcher program. Dispenser issuing records for alfentanil, propofol and midazolam were obtained as Excel files for 13 months from January 2020. Output time stamps were converted to dates and times. Outputs were linked to outputs of the ICNARC and CCMDS records for the patients that the drugs were issued to. All the outputs had patients identified by their unique hospital numbers. These were used in Excel "power queries" to produce a spread sheet with a single row per patient. Multiple admissions used the first diagnosis, the final outcome and the total length of stay. The total dose of sedatives was calculated from ampoule dose and number. The duration of treatment was calculated from the first and last issues of the drug. ICNARC codes were used to identify the primary system in the admission diagnostic code and those patients admitted for COVID-19. Variables were compared using Chi Squared, Mann-Whitney U and Kruskal Wallis Tests. The significance of associations was established using Spearman's Rho. Linear regression was used to define relationships more clearly. Result(s): Table one summarises the patient characteristics with respect to all admissions during the study period and for patients who had had the studied drugs issued to them. Midazolam was used in fewer patients, they were more likely to be male, heavier (p>0001) and to die than patients receiving Propofol or Alfentanil (p>0.001). With respect to diagnostic groups, all the sedatives, particularly Midazolam (p<0.001), were more likely to be used in patients with COVID-19. The relationship between the dose of sedative drugs and patient age and weight was explored using the dose per advanced respiratory day. All three drugs had a significant but weak negative relationship with age, lower doses being given to older people (Propofol r2 = 0.02, p=0.01. Alfentanil r2 = 0.04, p=0.00. Midazolam r2 = 0.07, p=0.00.). There was also a weak but significant relationship between increasing dose of Propofol with patient weight (r2 = 0.02, p=0.01), but there was no relation between weight and doses of the other drugs. Conclusion(s): Information from automatic drug dispensers can be interpreted and combined with other datasets to produce clinically relevant information. The limited weak relationships between drug dose and age and weight suggests that sedative drugs could have been better titrated to response.
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Aim: To determine the intraoperative Ramsay sedation score after dexmedetomidine infusion in patients undergoing perineal surgery. Study design: Descriptive study. Place and duration of study: Department of Anaesthesia, JPMC, Karachi from 13th February 2021 to 13th August 2021. Methodology: One hundred and seventy four patients who met the diagnostic criteria were enrolled. Result(s): The mean age was 46.51 years with the standard deviation of +/-10.87. 66 (37.9%) were male and 108 (62.1%) were female. Whereas, mean duration of surgery, Ramsay sedation score at 5 minutes, 15 minutes, 30 minutes, height, weight and BMI in our study was 1.41+/-0.40 hours, 1.72+/-0.44, 3.51+/-0.60, 4.57+/-0.62, 165.62+/-8.23 cm, 68.34+/-8.23 kg and 24.85+/-3.34 kg/m2 respectively. Conclusion(s): Intraoperative dexmedetomidine proved beneficial in perineal surgeries and could be served as a potent sedative drug.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.
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Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).
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The prevalence of psychiatric disorders namely depression, anxiety, and sleep disturbances has been increased worldwide, particularly during the COVID-19 pandemic. In this regard, the interest of recent investigations is moved toward phytomedicines and bioactive substances derived from natural sources. Although Tilia platyphyllos Scop. contains high amounts of phenolic compounds such as quercetin, kaempferol, and catechin, there is no study on the possible effects of its extract on psychological disorders. The present study was carried out to determine the antidepressant-like, anxiolytic, and sedative-hypnotic effects of the hydroethanolic extract of T. platyphyllos leaves using forced swimming test (FST), tail suspension test (TST), elevated plus maze test (EPMT), pentobarbital-induced loss of righting reflex test and open field test (OFT). Following the ethanolic extraction of T. platyphyllos leaves, the extraction yield was 14% and the total phenolic and total flavonoid contents were found to be 135.23 +/- 0.14 mg gallic acid equivalent/g dry extract and 19.02 +/- 0.03 mg rutin equivalent/g dry extract, respectively. Both FTS and TST revealed a significant antidepressant-like activity for the tested extract at 400 mg/kg compared to the control group. In addition, the anxiolytic activity of the extract was proven through OFT and EPMT in the same dose. Finally, T. platyphyllos extract at 200 mg/kg and 400 mg/kg significantly increased the sleeping time when compared to the control group reflecting its potential hypnotic activity. Co-administration of T. platyphyllos extract at 400 mg/kg and flumazenil as the GABA-A receptor antagonist decreased the sleeping time but the observed effect was not statistically significant. Therefore, we cannot completely rule out the GABA-A receptor's involvement in the hypnotic activity of the extract. The biological results presented here led us to conclude that T. platyphyllos extract can be a prominent source of antidepressant, anxiolytic and hypnotic agents. Probably, the main phenolic compounds of T. platyphyllos such as quercetin, kaempferol, and catechin are involved in the observed effects. However, there is still a great need for additional investigations on the exact mechanisms.Copyright © 2022, Iranian Association of Pharmaceutical Scientists. All rights reserved.
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Objectives: To examine temporal trends of FDA-approved and off-label second-generation antipsychotic (SGA) prescribing for adolescents over time through the Covid-19 pandemic. Method(s): This is a new-user, retrospective longitudinal panel study using electronic health record data from a large, integrated health care system. Outpatient prescription orders for a new SGA (index date) for adolescents (age 10-17 years) during 2013-2021 were analyzed. Prescription orders were linked to diagnoses at time of encounter to examine prescribing behavior. A one-year lookback period was used for baseline inclusion and exclusion criteria, including one-year "washout" of SGAs and continuous insurance enrollment. FDA-approved use was determined by two outpatient diagnoses (one baseline diagnosis and the prescription order diagnosis) for autism, psychotic disorders, bipolar disorders, or Tourette's;the remaining proportion was considered potentially off-label. We report crude annual prescribing rates per 1,000 youths. Result(s): There were 8,145 unique patients with new SGA prescription orders, of which 5,828 (71.6%) had linked diagnoses available. Calendar year 2013 had the highest prescribing rate prior to Covid-19 onset (2.1 per 1,000) but then declined through 2016 (1.7 per 1,000). Prescribing rates in 2020 (2.0 per 1,000) and 2021 (2.2 per 1,000) were higher than those between 2017-2019. Across all study years, SGA prescriptions were mostly off-label and ordered for aripiprazole, quetiapine, or risperidone. The proportion of off-label indications was highest in 2013 (80.1%) and lowest (69.1%) in 2019. Off-label proportions increased again in 2020 (76.1%) and in 2021 (74.1%). At baseline, patients frequently had other psychotropic prescriptions (e.g., antidepressants 63.3%, stimulants 22.9%, and sedatives/hypnotics 20.7%). Conclusion(s): A general decline in SGA prescribing rates among adolescents was observed from 2013 to 2019, but then increased following Covid-19 onset. Despite known safety risks, off-label use of SGAs remains prominent. Future studies are needed to better understand prescribing outside of pediatric professional society guidelines.Copyright © 2023
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Background: Renewed interest in regional anaesthesia during the recent COVID-19 pandemic has inspired application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by the bispectral index (BIS). In contrast, no published study has investigated the possible sedative effects of non-neuraxial regional anaesthesia. This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of, performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Method(s): Forty participants presenting for forearm surgery were randomly allocated to two treatment groups (supraclavicular block and control). Their level of sedation was monitored with BIS prior to surgery for 60 minutes. Specific feasibility outcomes were planned and data were collected according to CONSORT 2010 recommendations. Result(s): Out of 48 patients screened, 41 (85.42%) were invited to participate. Forty patients (97.56%) consented and 100% of these completed the study. In four participants (10%), BIS electrodes needed replacement, while inadequate contact was shown in three participants (7.50%). Data collection and form completion were deemed "easy" and block success rate was 100%. Differences in mean BIS between groups were < 5 and a difference of 10% between groups in incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion(s): We propose that progression to formal RCT is feasible only with specific modifications to the study design. The decrease in BIS value from baseline should be measured per patient and a clinically significant decrease should be estimated;emergency patients should be excluded;the sample size should be 500 patients;and multiple trial sites should be used. Further consideration should be given to whether such a trial would provide clinically useful information, and would justify the risks, patient discomfort and the considerable financial cost.Copyright © 2023, Medpharm Publications. All rights reserved.
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Introduction: The aim of our study is to evaluate the relationship between dexmedetomidine (DEX) use as a sedative agent in mechanical ventilated ICU patients and 28-day mortality. DEX, a selective alfa-2 adrenergic receptor agonist, widely used for its sedative and analgesic properties, has been linked to increasing parasympathetic tone, reducing the inflammatory response and oxidative stress [1]. Since severe COVID-19 is associated with an hyperinflammatory state, it is hypothesized that DEX might improve outcomes in these patients. Method(s): This is a retrospective observational study of mechanically ventilated patients admitted with COVID-19 pneumonia in the ICU of a tertiary center in Portugal, between March 2020 and December 2021. Logistic regression analysis was performed to evaluate the association of DEX use and 28-day mortality from time of intubation. Result(s): A total of 277 patients were analyzed, 151 in the DEX group and 126 in the no DEX group. Patients in the DEX group were younger (53.3 vs. 63.3 years, p < 0.001), had less comorbidities (2.8 vs. 3.5, p = 0.01), lower SOFA at admission (6.2 vs. 7.1, p = 0.01) but had a prolonged ICU stay (21.4 vs. 15.9, p < 0.001). Male gender (65.6 vs. 69.0, p = 0.54), incidence of obesity (56.3 vs. 46.8, p = 0.12), coronary artery disease (4.0 vs. 7.9, p = 0.16) and atrial fibrillation (4.0 vs. 7.1, p = 0.25) were similar between groups. PaO2/ FiO2 ratio at admission (111.1 vs. 108.1, p = 0.61), days spent in RASS < 3 (13.7 vs. 12.4, p = 0.31) and opioid use (14.8 vs. 13.1, p = 0.16) were also similar. From time of intubation, 28-day mortality in the cohort receiving DEX was 14.7% compared to 59.5% in the no DEX group (OR 0.12;95% CI 0.07-0.21;p = 0.01). Conclusion(s): Use of DEX was associated with lower 28-day mortality in COVID-19 critically ill patients requiring invasive mechanical ventilation in our study analysis. Considering the limitations of a retrospective observational study, RCTs are needed to confirm the results.
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Background: The large proportion of coronavirus disease 2019 (COVID-19) patients has been associated with a large number of neu-ropsychiatric manifestations. Despite the high prevalence of COVID-19, few studies have examined such manifestations, especially in children and adolescents. Objective(s): This study investigated neuropsychiatric manifestations in hospitalized children and adolescents admitted for COVID-19 infection in Iran. Method(s): This prospective observational study included admitted children and adolescents (4-18 years old) diagnosed with COVID-19 infection, pediatric neurologists, child and adolescent psychiatrists, and infectious disease specialists, and assessed 375 infected patients during August and December 2021. Result(s): Of the 375 patients, 176 (47%) were female, with a mean age of 9.0 +/- 3.39 years. Psychiatric and neurological manifestations were reported in 58 (15.5%) and 58 (15.5%) patients, respectively. The most prevalent psychiatric disorders were separation anxiety disorder (SAD) (5.1%), major depressive disorder (MDD) (3.5%), generalized anxiety disorder (GAD) (2.7%), insomnia (2.4%), and op-positional defiant disorder (ODD) (2.4%). Regarding neurological complications, seizures were the most prevalent (13.1%), followed by encephalitis (1.9%), transverse myelitis (0.3%), acute ischemic stroke (0.3%), and Guillain-Barre syndrome (0.3%). There was no significant relationship between the duration of COVID-19 infection (P = 0.54) and ICU admission (P = 0.44) with the emergence of psychiatric symptoms. Conclusion(s): The most prevalent neurologic and psychiatric complications among children and adolescents with COVID-19 infection were seizures and the symptoms of anxiety/mood disorders, respectively.Copyright © 2023, Author(s).
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Objective To analyze the mental health status of medical staff in the Fourth Branch of National Convention and Exhibition Center Makeshift Hospital during the COVID-19 epidemic in Shanghai to lay a theoretical foundation for the mental health and psychological intervention of medical staff in COVID-19 and other public health emergencies. Methods An online questionnaire survey was conducted with the generalized anxiety disorder scale (GAD-7), patient health questionnaire (PHQ-9), and Athens insomnia scale (AIS) before medical staff entering the makeshift hospital and one month later. Results The detection rates of anxiety, depression and insomnia were 18.4%, 22.1% and 27.0% respectively before entering the makeshift hospital, and 28.8%, 59.3% and 64.2% respectively during the follow-up period one month later. The GAD-7, PHQ-9 and AIS scores of medical staff after working in the makeshift hospital for one month increased significantly compared with those at the baseline period (P<0.01). Female and previous history of using sedative and hypnotic drugs were risk factors for increased depression level among medical staff in the makeshift hospital. Conclusions The anxiety, depression and insomnia levels of the medical staff in Shanghai increased after working in the makeshift hospital for one month. It is of great significance for the front-line support work to identify the medical staff with serious psychological problems and carry out psychological intervention in the early stage.Copyright © 2022 Authors. All rights reserved.
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Introduction: Patients with COVID-19 who require CPAP as ceiling of care have a high mortality. Evidence is lacking for appropriate end of life care for these patients and withdrawal from high CPAP pressures can be distressing for patients and their families. Method(s): We retrospectively reviewed case notes for 36 patients with COVID-19 pneumonitis who were not suitable for intubation and required withdrawal of CPAP at Colchester Hospital, UK from 29th April, 2020 to 13th February, 2021. Result(s): Mean age was 74.14 (SD 9.48) years, 14 patients were female. Decision to withdraw was discussed with family in 91.7% of cases and with the patient in 50% of cases. A family member was present during withdrawal in 38.9% of cases. All patients after CPAP withdrawal died. Mean time to death since withdrawal (known in 30 patients) was 26.06 (SD 43.84) hours. Reasons for withdrawal included patient deterioration (55.6%), patient discomfort (36.1%) and patient wish (8.3%). Sedative drugs were often needed to achieve comfort, high doses were required in some cases. Comfort was achieved with midazolam, morphine and levomepromazine in the majority, however in one case, phenobarbitone was also required. Total doses used from time of decision to withdraw CPAP to death, are summarised in table 1. Conclusion(s): Optimum palliative care is vital for looking after these patients. In our experience, some patients required higher than usual doses of sedation whilst CPAP was withdrawn. (Table Presented).
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Aim To assess the use of sedative pharmacological agents (SPA) among students in Croatia during the coronavirus disease 2019 pandemic. Methods An online questionnaire, specially developed for the research purposes, was completed by 1403 students. The questionnaire inquired about general characteristics, the effect of the pandemic and earthquakes on students' lives, and SPA use (method of purchasing, modes, and frequency). Results In the total sample, the SPA use before the pandemic significantly correlated with that after the beginning of the pandemic (P < 0.001). After the beginning of the pandemic, medical students used significantly more SPA than other biomedical students (P = 0.017). When compared with non-biomedical students, biomedical students did not differ significantly in SPA use after the beginning of the pandemic (P = 0.365). Conclusion Medical students used more SPA than other biomedical students. Biomedical students did not differ in SPA use from non-biomedical students.Copyright © 2022 Medicinska Naklada Zagreb. All rights reserved.
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Objectives: The number of pharmaceutical supply chain disruptions is increasing these last years in France. To prevent the consequences of shortages, our university hospital structure establishes substitution procurement agreements (SPA) with an alternate supplier. The defaulting holder pays the overcost. However if this one is regarded as not responsible for the shortage, the overcost is borne by the hospital. The aim is to analyze retrospectively the SPA contracted in our hospital between 2019 and 2021. Method(s): Each SPA is analyzed: type of drugs, disruption delays, amount used, defaulting and suppliant holder's prices, and financial impact. Result(s): Between 2019 and 2021, 221 SPA have been established, with a constant average around 70 SPA per year and an average period of 155 days [1 - 934]. The SPA included 75% of generics and affected mainly oral solid forms except in 2020. This rise in 2020 provides primarily from injectable medications (45%) used in intensive care units as drugs of nervous system. Indeed, sedative and anesthesic drugs represent 70% of the overcost. The substitute drug price rose on average by 270%. The SPA contracted in 2019 represent an overcost of 1 406 585 exclusively paid by defaulting holders. This cost has been twofold increase in 2020 (hospital: 3 007 000 and defaulting holders: 793 000) and reduced to less than 1 million euros in 2021 (hospital: 432 000 and defaulting holders: 388 000), for an annual drug budget of around 1,1 billion euros. Conclusion(s): The covid-19 led to an increase of injectable drug shortages and an important financial impact for the hospital. However, a stabilization of the number of SPA is observed these last years. This can be explained partly by French legislation. Indeed, since 2021, pharmaceutical companies are required to maintain a safety stock for all medicines of major therapeutic interest. Copyright © 2022
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Introduction: Patients undergoing Deep brain stimulator (DBS) insertion require a high-resolution MRI for treatment planning prior to DBS surgery. This group of patients has movement disorders therefore traditionally the planning MRI is done under General anaesthesia to ensure patient immobility and to obtain good quality MRI images. Providing sedation/anaesthesia for MRI procedure during COVID-19 pandemic was challenging. When we restarted elective surgery during Covid-19 pandemic we were worried about aerosol generating procedures, therefore we looked at the feasibility of using Dexmedetomidine-Propofol sedation for treatment planning MRI as an alternative to General anaesthesia to prevent aerosol generating procedure. Method(s): We conducted retrospective review of anaesthetic records of all patients who underwent MRI under sedation for DBS planning from August 2020 to July 2021. We collected the data on patient demographics, Indication & target site for DBS, duration of sedation, complications during the scan, cardiovascular side effects like hypotension and bradycardia during scan, quality of image, duration of PACU stay and post scan complications. The quality of MRI imaging was assessed by the neurosurgeon who did the treatment planning. Sedation protocol: sedation was commenced with Propofol target controlled infusion (TCI) using Schneider model with effector site concentration (Cet) of 2 to 3 and Dexmedetomidine bolus dose of 1 microgram per kilogram was infused over 10 minutes. All the patients were induced to a Ramsay Sedation Scale of at least 5 or 6. Sedation was maintained with Dexmedetomidine infusion at 0.5 mcg/kg/hr and Propofol TCI (Schneider model Cet of 2 mcg/mL). Result(s): During our study period 15 patients underwent MRI under sedation with Propofol-Dexmedetomidine for DBS treatment planning. Of this 7 were males and 8 were females. Age range was from 39 to 75 years. The target site was Subthalamic nucleus in 9 patients, Thalamic nuclei in 4 patients and Globus pallidus internus in 2 patients. Duration of sedation ranged from 40 minutes to 100 minutes with a median of 45 minutes. 2 patients developed movement artefacts during scanning and were converted to GA, 3 patients developed hypotension (20% reduction from pre-induction blood pressure) requiring treatment with ephedrine. Five patients had sinus bradycardia (20% reduction from pre-induction heart rate) but did not require treatment. The qualities of images were classified as good in 11 patients and acceptable in 2 patients by the neurosurgeon involved in treatment planning. None of the patients needed repeat MRI scanning. Patient's stay in PACU ranged from 20-50 minutes with a mean of 26.5 minutes. Discussion(s): Dexmedetomidine-Propofol sedation has been widely used for sedation to perform MRI scans in paediatric patients, its use in adult patients is not well documented in the literature. Propofol enables smooth induction of sedation and rapid recovery however it may cause hypotension, decreased respiratory drive and upper airway obstruction. Dexmedetomidine has been used as a single sedative agent for MRI however its onset of action is slow and when used as a sole sedative agent large dose of dexmedetomidine is required and this may contribute to delayed recovery after sedation. Propofol-Dexmedetomidine combination has synergistic effects and is advantageous. Propofol can induce sedation smoothly, Dexmedetomidine can reduce dose required for sedation and suppression of motor response in healthy subjects (1). Combination of Dexmedetomidine- Propofol infusion reduced total Propofol dose and decreased the incidence of airway complications in a paediatric study (2). During our study period 2 patients sedation were converted to General anaesthesia, both patients had raised BMI and had laboured breathing under sedation causing transmitted head movement, therefore patient selection is important for successful scan under sedation. Propofol-Dexmedetomidine sedation can be used safely for treatment planning MRI in selective movement disorder patients.
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Background: Drug shortages represent a longstanding challenge for healthcare providers, including toxicologists, who continue to confront scarcities of antidotes and other agents used to treat poisonings. Prior research examining availability of drugs with toxicologic applications from 2001 to 2013 demonstrated broad shortages including anticholinergic, cholinergic, and cyanide antidotes, anti-hypoglycemics, chelators, antivenom, naloxone, sedative- hypnotics, and decontamination products, many of which were unresolved and involved xenobiotics without therapeutic alternative. Reports of vital agents being scarce or unobtainable have continued since 2013, and new pressures on global and US (United States) supply chains have emerged, most notably the COVID-19 pandemic. Given this, up-to-date analysis of shortages of agents used to treat poisonings is needed. Method(s): US drug shortage data from January 2012 to December 2021 were obtained from the University of Utah Drug Information Service. Shortage data for agents used to treat poisonings were analyzed. Information on drug type, formulation, shortage reason, shortage duration, number of manufacturing sources, substitute availability, and substitute agent shortage during the study period were investigated. Result(s): 1570 drug shortages were reported during the study period;230 (14.6%) involved agents used to treat poisonings. Of the 230 shortages, 21.3% were unresolved as of December 2021. Mean shortage duration was 13.6 months. The longest shortage involved intravenous calcium gluconate and lasted 78 months. Intravenous dextrose products were the agent most frequently affected by shortage, with 20 shortages in total. 58 agents had multiple shortages. Total shortages peaked in 2017 with 33 shortages reported. 20 shortages were reported in 2020 and 24 in 2021 during the COVID-19 pandemic. 10.9% of shortages involved single-source products;however, this number is limited by incomplete reporting. 80.9% of shortages involved parenteral products. Agent classes with the most shortages reported were: Sedative-hypnotics (12.2% of shortages), anti-hypoglycemics (9.6%), anticoagulant reversal (7.8%), vitamins/electrolytes (7.4%), blood pressure support (7%), antihypertensives (6.5%), antimuscarinic delirium (4.8%), and chelators (4.3%). Three naloxone shortages were reported, one of which is ongoing due to increased demand. Buprenorphine and methadone shortages were reported but are resolved as of December 2021. New shortages of multiple pressors and flumazenil were reported. The most common reason for shortage was a manufacturing issue, occurring in 36.1% of shortages. Shortage reason was not reported 37.8% of the time. For 77% of shortages an alternative therapeutic agent was available, however 97% of alternatives were also affected by shortage at some point during the study period. Conclusion(s): Shortages of agents used to treat poisonings remain problematic. For the time period 2011-2021 previously reported shortages of many products persist and new shortages have emerged. The ongoing naloxone shortage is particularly concerning given the continued rise in drug overdose deaths in the US in 2021, as are shortages of buprenorphine and methadone used to treat opioid use disorder. Despite supply chain stressors, total shortages did not peak during the COVID-19 pandemic.
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SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Discontinuing mechanical ventilation is a difficult process and takes time. Some patients succeed while others fail and remain on full ventilator support for a longer period. Extubation failure can result in many complications for the patient and a prolonged stay in the ICU. It's a common practice to have an SAT and SBT protocol in the majority of ICUs. Spontaneous awakening trial (SAT) is a nurse-driven protocol for discontinuation of sedation hypnotic drug to facilitate recovery to her baseline level of consciousness/responsiveness and assessment of intrinsic respiratory drive in the critical care setting. In general SAT protocol is followed and most ICUs are in the morning hours. If the patient needs the initial safety screening for SAT the sedative infusion is interrupted with a goal to awaken the patient or SAS 3-4. If the patient is showing signs of SAT failure with either tachypnea or desaturation or cardiac dysrhythmia or unacceptable ventilator asynchrony that the patient is resumed sedation/analgesia at 50% of the previous dose and bolus as needed dose of sedation is also utilized to achieve stability. A spontaneous breathing trial (SBT) is a protocol for systematic weaning of a patient from a mechanical ventilator in preparation for extubation. Before SBT protocol again safety screening is done and if the patient meets the criteria for SBT protocol, the patient is placed on spontaneous breathing mode that his CPAP of 5 to 8 cm of water for 30 to 120 minutes at the same FiO2. Various tools are utilized to analyze the success of the SBT trials including the RSBI index. Each institution has its own assessment of the average length of ventilator stay and the average length of ICU stay. The majority of hospital does SAT/SBT trials once a day for evaluation and successful liberation from ventilator. This project was done with the assumption that if compliance of SAT/SBT huddle is improved and if it is done twice in a day rather than only once the outcome in terms of length of ventilator stay, length of ICU stay, and rate of successful extubation improves METHODS: This is a prospective quality improvement study done at Einstein Medical Center Philadelphia. This is a 16-bed MICU unit and we implemented twice daily hurdle from August 2021 to April 2022. ( Study Period) This project was happening during the COVID pandemic during which the average length of ICU stay and the average length of ventilator stay was already high due to the natural course of COVID ARDS. The SAT/SBT Huddle involved interaction between our respiratory therapist, ICU fellow, and the nurse involved in the patient care. It had a checklist of SAT SBT protocol which needed a signature (electronic or manual) to consider it completed. This was done twice a day from the period of August 2021 to April 2022 (STUDY PERIOD). This study period was compared to the control period (August 2020 to April 2021). The reason for selecting this control period was to remove outlier and increased length of stay due to the COVID pandemic itself with the assumption that the COVID pandemic was present throughout the study and control period. RESULTS: In the control period- ie August 2020 to April 2021 the average ventilator length of stay is 6.85 days. In the study period from August 2021 to April 2022, the average length of a ventilator was 6.21. There is a clear decrease in ventilator length of stay with the intervention and no other change in the sample size. It should be noted that the COVID pandemic with the third surge was happening in both the control and study period. This is approximately a 10% decrease in length of stay. This is a Pilot study and with better compliance with a huddle, the length of stay will decrease further is our assumption. Here the huddle compliance ranged from 60-65% and out estimate is for better power we need at least 70% or more compliance with huddle CONCLUSIONS: Conclusion- This q ality improvement project aims to improve communication amongst healthcare providers with the ultimate goal of patient safety and decreased length of ventilator stay for every patient in MICU. Clearly, the minimal intervention of documenting each huddle and doing it twice a day had a decrease in ventilator length of stay. The greatest challenge for this compliance project is to have documentation of having a twice-daily hurdle. During this period to improve her compliance we have done various methods that included paper signatures electronic signatures and also QR code signatures. Of this, the maximum Complan success rate was achieved with a QR code signature for the huddle members. CLINICAL IMPLICATIONS: Limitation to the study–due to the COVID pandemic the average length of ventilator stay has increased in all hospitals which are affected by the COVID pandemic. Though the reflection of decreased length of ventilator stay is small this gives a glimpse of how her daily communication between a respiratory therapist, nursing staff, and the physician taking care of the patient makes a difference in the patient's overall length of stay and mortality. DISCLOSURES: No relevant relationships by Raminder Cheema No relevant relationships by Megan Dondarski No relevant relationships by Yasmeen Hassan No relevant relationships by Mahwish Hussain No relevant relationships by Myriam Poindijour No relevant relationships by Arnaldo Rodriguez No relevant relationships by Kumar Sarvottam No relevant relationships by Bhavna Sharma No relevant relationships by Teresa Vizak
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SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Drug-induced hepatotoxicity is a well-known occurrence from a variety of different medications. However, phenobarbital (PHB) induced hepatotoxicity has not been well studied, and acute liver injury from PHB even less so. In this case, although our patient had many reasons to develop acute liver failure, including alcohol and toluene exposure, timing and investigations seem to point to PHB being responsible. CASE PRESENTATION: Patient is a 39 y.o male with past medical history significant for hepatitis A and B, hyperlipidemia and alcohol abuse who was found unresponsive by EMS after friends reported witnessing patient drinking alcohol and sniffing paint thinner. Patient remained unresponsive on arrival and was intubated and transferred to the MICU. Patient was afebrile with BP 100/55 and otherwise normal vital signs. Significant labs on presentation included a WBC of 8.15, CO2 of 16, lactic acid of 3.6 and mildly elevated transaminases (ALT: 59, AST: 48). Urine toxicology was positive for marijuana. EKG, chest x-ray and CT Head without contrast unremarkable. COVID negative. Video EEG was negative except for generalized slowing. On hospital day 3, patient was increasingly agitated, at which point phenobarbital was started due to concerns for alcohol withdrawal. Hepatic function panel the following mornings showed significant increases in transaminases (ALT: 972 and 5,746, AST: 790 and 4,805) and total bilirubin (6.8 and 11.4), and mild increase in alkaline phosphatase (112 and 125), respectively. Hepatitis panel, acetaminophen level and salicylate level were unremarkable. RUQ ultrasound was also negative for pathology. Gastroenterology was consulted, who recommended starting NAC protocol. Phenobarbital was discontinued. Hepatic function panel the following morning showed significant improvement. Liver transplant was considered, however LFTs continued to downtrend and remainder of hospital course was unremarkable. DISCUSSION: PHB is an anticonvulsant developed primarily for seizure management. However its use has expanded to alcohol withdrawal and even sedative withdrawal. Studies have demonstrated in vitro liver toxicity as well as idiosyncratic reactions and acute liver failure in children (1) (2), with minimal documentation in adults. And while there has even been histological analysis with linkage of chronic phenobarbital use to hepatic necrosis and granulomatous formation (3), there has been minimal documentation regarding acute liver failure in an adults taking phenobarbital. CONCLUSIONS: In conclusion, it is clear that phenobarbital played a significant role in this patient's liver injury and may need to be considered in future episodes of acute liver injury with unclear etiology. Reference #1: Li AM, Nelson EA, Hon EK, Cheng FW, Chan DF, Sin NC, Ma KC, Cheung KL, Fok TF. Hepatic failure in a child with anti-epileptic hypersensitivity syndrome. J Paediatr Child Health. 2005 Apr;41(4):218-20. doi: 10.1111/j.1440-1754.2005.00591.x. PMID: 15813878;PMCID: PMC7166358. Reference #2: Roberts EA, Spielberg SP, Goldbach M, Phillips MJ. Phenobarbital hepatotoxicity in an 8-month-old infant. J Hepatol. 1990 Mar;10(2):235-9. doi: 10.1016/0168-8278(90)90058-y. PMID: 2332596. Reference #3: Di Mizio Di Mizio, G., Gambardella, A., Labate, A., Perna, A., Ricci, P., & Quattrone, (2007). Hepatonecrosis and cholangitis related to long-term phenobarbital therapy: An autopsy report of two patients. Seizure, 16(7), 653–656. https://doi.org/10.1016/j.seizure.2007.05.008 DISCLOSURES: No relevant relationships by Zachary Banbury No relevant relationships by Michael Basir No relevant relationships by Inessa Bronshteyn No relevant relationships by Kyle Foster No relevant relationships by Anna-Belle Robertson
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SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Acute respiratory distress syndrome (ARDS), due to Coronavirus disease 2019 (COVID-19) Is associated with a significant rate of mortality. The ideal sedative(s) of choice in mechanically ventilated COVID-19 patients is still unclear. Here we report the clinical outcomes of using propofol for more than 48 hours vs any other sedative in such patients. METHODS: This was a retrospective study of patients admitted to an intensive care unit (ICU) at Trumbull Regional Medical Centre and Sharon Regional Medical Centre between February 2020 and January 2022 with COVID-19 viral pneumonia. Our study consisted of 176 patients with moderate to severe ARDS as per Berlin’s criteria who were mechanically ventilated for atleast 48 hours. The primary outcome was mortality at 28 days from the date of intubation. Secondary outcomes included ventilator free days during the first 28 days after intubation (defined as being alive and free from mechanical ventilation), mortality at the end of hospitalization, length of stay, and readmission rate. RESULTS: Out of 176 patients, 100 patients received sedation with propofol for more than 48 hours (test group) and 76 patients received other sedative agents or received propofol for less than 48 hours (control group). We compared the outcomes of the two different groups using paired t-test. The average age of the study population (63 vs 67 p=0.061), gender((0.44 vs 0.49 females p=0.54), BMI (34.93 vs 34.08 p=0.54), and oxygen requirement on admission (0.73 vs 0.64 p= 0.227) were not statistically different between the test and control groups respectively. Prevalence of comorbidities including diabetes, hypertension, chronic kidney disease, active cancer, and COPD were not significantly different between the two groups. There was a significant difference in the primary outcome of mortality at day 28 from intubation between the test and control group (0.62 vs 0.84 p=0.001). A significant difference in the secondary outcome of mortality at the end of hospitalization between the test group and control group (0.67 vs 0.84 p =0.009) was also observed. There were no statistically significant differences in the rest of secondary outcomes. CONCLUSIONS: In this retrospective study, using propofol for more than 48 hours was associated with decreased mortality at day 28 (22%) as well as at end of hospitalization (17%) in mechanically ventilated COVID-19 patients. Propofol is known to have antiviral effects as well as immunosuppressive effects on biosynthesis of inflammatory cytokines by macrophages which is likely responsible for the mortality benefits that we encountered in this study. CLINICAL IMPLICATIONS: Even though we found mortality benefits with using propofol in our study population, further investigations using prospective studies with a larger study population are required and clinicians need to be cautious with the complications associated with long term use of propofol. DISCLOSURES: No relevant relationships by Arooj Ahmed no disclosure submitted for Manuel Bautista;No relevant relationships by Apeksha Gupta No relevant relationships by Anirudh Jaglan no disclosure on file for Saman Karki;no disclosure submitted for Ritha Kartan;No relevant relationships by Tamandeep Kaur No relevant relationships by Sanjay Mahat No relevant relationships by Krutarth Pandya No relevant relationships by Stuti Patel No relevant relationships by Janki Patel no disclosure on file for Kim Porter;No relevant relationships by Aayush Pradhan No relevant relationships by Arun Pyakuryal No relevant relationships by Pratik Saha No relevant relationships by Parth Shah
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Introduction: Patients in the intensive care (ICU) commonly receive analgesics and sedatives to facilitate mechanical ventilation. Recommendations suggest patients are kept as lightly sedated as feasible. Studies report an inconsistent association between deep sedation, prolonged ventilation and ICU stay.1 Opinions around patients 'wakefulness' include discomfort and the potential increased prevalence of psychological morbidity.2 Alpha-2-agonists (clonidine and dexmedetomidine) are agents used in ASD management and reported to produce lighter sedation. The aim of this project was to explore ICU pharmacist's perspective on ASD practice over UK. Objectives: • Explore ICU pharmacist's views on: ASD practices, sedation research priority, importance of A2B clinical trial and the impact of Covid19. • Determine the prevalence of clonidine and dexmedetomidine prescribing. Methods: An online survey was devised on SurveyMonkey. The survey was designed in 2 sections: -1. Respondents provided responses based on a 'point prevalence' of clonidine and dexmedetomidine prescriptions, on day of completion. 2. Their local ICU sedation practice, their views on priority of sedation research, the A2B study and whether they believed ASD was more challenging during the Covid19 pandemic. The online survey was distributed via the UK Clinical Pharmacy Association Critical Care Group (UKCPA CCG), the NIHR Critical Care National Speciality Group (NSG), the UK Critical Care Research Group and Twitter. The survey remained active for 12 weeks from 30.3.2021 with reminders sent for completion every fortnight. Results: There were 121 respondents, all but 1 were ICU pharmacists. There are approximately 243 ICU pharmacist posts in the UK, this represents a response rate of approximately 50%. 37 (30%) of respondent reported clonidine (but not dexmedetomidine) was prescribed in their ICU;7 (6%) described dexmedetomidine only;and 76 (63%) reported both. In describing ASD during Covid-19 pandemic, 107 (88%) respondents reported it had become more challenging. 83 (69%) of respondents stated that clonidine usage increased during the pandemic (27 (22%) no change). 46 (39%) stated that dexmedetomidine usage increased during the pandemic (50 (42%) no change). Among the respondents 98 (81%) 'strongly agreed', and 20 (17%) 'agreed' that research involving ASD is a priority. A2B is set to compare clinical and cost effectiveness of propofol, clonidine, and dexmedetomidine as primary sedative for ICU patients. 49 (40%) of respondents reported participating in A2B. 65 (54%) respondents felt that A2B was a 'very important', and 63 (52%) said it was an 'important' research question. Conclusion: This survey reported widespread use of alpha-2-agonists in ASD practice. Almost two-thirds of ICUs report using both agents. Clonidine use is the most prevalent. Given the paucity of high quality clinical effectiveness and safety data for this drug, clinical trials which assess clinical effectiveness, including ASD are a priority. Respondents endorsed that ASD research is a priority, with ASD management much more challenging during the Covid19 pandemic. Limitations include that the design was a brief online survey;although had a high pharmacist response it did not incorporate the views of other members of the ICU team.
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Introduction: The COVID-19 pandemic caused a sudden and unprecedented surge in ICU admissions for severe acute respiratory failure. Whilst there is a wealth of knowledge surrounding risk factors for developing critical care myopathy and effects of prolonged ICU stay on functional outcomes,1,2 little was known about the pathophysiology, treatment or physical outcomes of patients admitted to ICU with COVID-19. In our organisation, patients recovering from the acute phase of COVID-19 demonstrated a range of presentations impacting rehabilitation whist in ICU. Objective: To explore whether time taken to wake post sedation hold impacts on functional outcomes of patients surviving ICU admission for COVID-19. Methods: A retrospective review of patients admitted to ICU with a primary diagnosis of COVID-19 between March-April 2020 was conducted at a large London NHS Foundation Trust. Electronic clinical notes were reviewed and the following data extracted: age, ethnicity, sex, BMI, pre-admission clinical frailty score, duration of sedation, days taken to wake from sedation, duration of mechanical ventilation (MV), ICU length of stay (LOS) and hospital LOS. Functional outcomes were defined using the Intensive Care Unit Mobility Score (ICUMS). Data were analysed using descriptive statistics, reported as absolute numbers, percentages (%) and median (range). Results: 203 patients were identified, 137 were excluded as 58 died, 3 were incidental findings of COVID-19, 67 had missing data due to paper notes or transfers in/out of the Trust and 9 were duplicate records. Sixty-six patients were included in the final analysis (Table 1). Patients could be categorised into four rehabilitation groups: 1 = Never requiring sedation and MV, 2 = Woke from sedation (defined as RASS ≥-1) within 72 hours with preserved muscle power (defined as ICUMS ≥5 on ICU discharge), 3 = Woke from sedation within 72 hours but myopathic (defined as ICUMS ≤4 on ICU discharge), 4 = Slow to wake (> 72 hrs). Those slow to wake following sedation hold (group 4) had an increased age, BMI, and higher proportion of nonwhite ethnicity. Neuromuscular blocking agents (NMBA) and steroid use was more prevalent in group 4 compared to the other groups. There was also increased midazolam administration and higher number of total sedative agents received by these patients. Those slow to wake had a lower ICUMS at ICU discharge than those waking with preserved strength or never sedated (3, 6, 9 respectively). Those who were slow to wake were ventilated for longer than the other groups. Time taken to wake from sedation also resulted in longer ICU and hospital LOS. Similar functional outcomes at hospital discharge were noted between all 4 groups (Table 1). Conclusion: Patients slow to wake from sedation following ICU admission for a primary diagnosis of COVID-19 had a longer ICU LOS, reduced functional ability at ICU discharge and a longer hospital LOS. These preliminary observational clinical data support the testable hypothesis that within in the ICU, COVID rehabilitation phenotypes may exist which warrants further investigation.
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Background: Recent renewed interest in regional anaesthesia during the COVID-19 pandemic has inspired the application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by Bispectral Index (BIS). In contrast, no studies have investigated the possible sedative effects of non-neuraxial regional anaesthesia. Aim: This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Methods: Forty patients presenting for forearm surgery were randomly allocated to two treatment arms (supraclavicular block and control). Their level of sedation was quantitatively monitored before surgery for 60 minutes. Specific feasibility outcomes were planned and data collected according to CONSORT 2010 recommendations. Results: Out of 48 patients screened, 41 (85.42%) were invited to participate, 40 (97.56%) consented and 100% completed the study. Four (10.00%) BIS electrodes needed replacement, inadequate contact was shown in three patients (7.50%), data collection and form completion were deemed “easy”, and block success rate was 100%. Differences in mean BIS between groups were < 5, and a difference of 10% between groups in the incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion: We propose that progression to formal RCT is feasible with modifications. Decrease in BIS value from baseline should be measured per patient, and clinically significant decrease should be estimated (we suggest a decrease of 10 or more), exclusion of emergency patients (starved for longer, more anxious, may affect BIS), the sample size should be 500 patients and multi-site involvement implemented.