136. Telemedicine for Adolescent and Young Adult Long-acting Reversible Contraception Initial Follow-up Visit: Outcomes Over 1 Year

Purpose: Telemedicine for adolescent and young adult (AYA) care, including long-acting reversible contraception (LARC) care, was quickly implemented in response to the COVID-19 pandemic. Therefore, outcomes of telemedicine LARC care is understudied. We compare outcomes of AYAs receiving LARC follow-up care via telemedicine and in-person over 1 year. Methods: This cohort study includes patients who had LARC, intrauterine device (IUD) or implant, inserted between 4/1/20-3/31/21 and attended an initial LARC follow-up visit at 4 US Adolescent Medicine clinics. Initial LARC follow-up visit was defined as the first visit within 12 weeks of insertion. Eligible patients were 13-26 years old, had LARC inserted without sedation, and had LARC in place for at least 12 weeks. We compared outcomes over 1 year between patients attending the initial follow-up visit via telemedicine (telemedicine attendees) to those who completed the visit in-person (in-person attendees). Outcomes included patient-reported side effects, medical menstrual management, acne management, IUD malposition or expulsion, sexually transmitted infection (STI) testing and results, and LARC removal. Descriptive statistics described the sample and compared groups. Adjusted Poisson regression examined factors associated with number of visits and adjusted logistic regression models examined the association between initial visit modality and initiation of medical menstrual management. Site-specific institutional review board approvals were obtained. Results: Our study included 194 AYAs, ages 13.9-25.7 years (mean 18.7 years, SD = 2.3) who attended an initial follow-up visit. Most AYAs (n = 168, 86.6%) attended only one visit in the 12 weeks post-insertion. Telemedicine attendees comprised 40.2% of the sample. Telemedicine and in-person attendees were similar with regards to site of LARC insertion (p =.43), age (p =.17), race/ethnicity (p =.25), prior pregnancy (p =.95), complex medical diagnoses (p =.32), menstrual diagnoses (p =.11), and reason for LARC (p =.82). In-person attendees were more likely to have the IUD than telemedicine attendees (p =.003). Bivariate analyses showed similar frequency of patient-reported symptoms over 1 year between groups. Outcomes of menstrual management (OR = 1.02, CI: 0.40-2.60), number of visits attended (RR = 1.08, CI: 0.99-1.19), acne management (p =.28), IUD expulsion (p =.13), IUD malposition (p =.51), and LARC removal (p =.95) were similar between groups. In-person attendees were more likely to have STI testing done (p =.001) than telemedicine attendees. However, no positive STI tests were captured in either group. Conclusions: Roughly two-fifths of patients presenting to an initial LARC follow-up visit did so via telemedicine. Type of LARC may influence modality of follow-up visit. Except for STI testing, outcomes over 1 year were similar regardless of the first visit modality. Reassuringly, no positive STI tests were detected in either group over 1 year of follow-up. More research is needed to determine if the decrease in STI testing for patients seeking care via telemedicine is clinically significant. Telemedicine may play an important role in AYA LARC follow-up care, and more research is needed in this area. Sources of Support: N/a.

Abstracts of WSM 2023

The proceedings contain 112 papers. The topics discussed include: pediatric sedation for magnetic resonance imaging. the use of intranasal dexmedetomidine to enable a nurse-led, no intravenous access pediatric sedation for radiological procedures at a district general hospital;outcomes in octogenarians undergoing head and neck cancer surgery in a tertiary referral center;the environmental sustainability of propofol use and wastage in total intravenous anesthesia practice;are our patients opioid aware? an audit of take-home analgesia at Charing Cross Hospital, London;evaluating the clinical use of nitrous oxide in our pediatric theatre;implementing a dedicated COVID-19 post intensive care unit follow-up clinic to improve the follow-up of patients in a district general hospital;move to NRfit: the impact of the introduction of new epidural needles on post-dural puncture headache rate;and creating an emergency induction checklist for doctors providing last-minute cover across multiple hospital sites.

Inhaled Sedation in Patients with COVID-19-Related Acute Respiratory Distress Syndrome: An International Retrospective Study.

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic and the shortage of intravenous sedatives has led to renewed interest in inhaled sedation for patients with acute respiratory distress syndrome (ARDS). We hypothesized that inhaled sedation would be associated with improved clinical outcomes in COVID-19 ARDS patients. METHODS: Retrospective international study including mechanically ventilated patients with COVID-19 ARDS who required sedation and were admitted to 10 European and US intensive care units. The primary endpoint of ventilator-free days through day 28 was analyzed using zero-inflated negative binomial regression, before and after adjustment for site, clinically relevant covariates determined according to the univariate results, and propensity score matching. RESULTS: A total of 196 patients were enrolled, 78 of whom died within 28 days. The number of ventilator-free days through day 28 did not differ significantly between the patients who received inhaled sedation for at least 24 h (n = 111) and those who received intravenous sedation only (n = 85), with medians of 0 (interquartile range [IQR] 0-8) and 0 (IQR 0-17), respectively (odds ratio for having zero ventilator-free days through day 28, 1.63, 95% confidence interval [CI], 0.91-2.92, p = 0.10). The incidence rate ratio for the number of ventilator-free days through day 28 if not 0 was 1.13 (95% CI, 0.84-1.52, p = 0.40). Similar results were found after multivariable adjustment and propensity matching. CONCLUSION: The use of inhaled sedation in COVID-19 ARDS was not associated with the number of ventilator-free days through day 28.

Efficacy of high-flow nasal oxygenation compared with laryngeal mask airway in children undergoing ambulatory oral surgery under deep sedation: A randomized controlled non-inferiority trial.

Background: High-flow nasal oxygenation (HFNO) has been suggested as an alternative oxygenation method during procedural sedation. This randomized, non-inferiority trial evaluated the safety and efficacy of HFNO compared with laryngeal mask airway (LMA) in pediatric ambulatory oral surgery under deep sedation. Methods: In total, 120 children aged 2-7 years (weight: 10-30 kg) were equally assigned into two groups, namely, HFNO with propofol total intravenous anesthesia infusion (HFNO-IV) or LMA with propofol total intravenous anesthesia infusion (LMA-IV). The primary objective was to monitor carbon dioxide (CO2) accumulation during perioperative surgery. Secondary objectives included monitoring transcutaneous oxygen saturation, grade exposure to the surgical field, perioperative adverse events, or other events. The predefined non-inferiority margin was 7 mmHg. During the COVID-19 pandemic, a novel WeChat applet was implemented to gather follow-up data after discharge. Results: Non-inferiority could be declared for HFNO relative to LMA (mean difference in transcutaneous CO2 (TcCO2) = -1.4 mmHg, 95% CI: -2.9, 0.1 mmHg; P > 0.05). The pre-surgical TcCO2 of the HFNO-IV group (45.4 ± 4.5 mmHg) was similar to that of the LMA-IV group (44.0 ± 3.5 mmHg), within the clinically acceptable normal range. All the children maintained SpO2 levels of >97%. The surgical field exposure score of the HFNO group was significantly better than that of the LMA group. There was no significant difference between the two groups regarding risk or adverse events. Conclusion: HFNO was not inferior to LMA for maintaining oxygenation and ventilation in patients undergoing pediatric ambulatory oral surgery under deep sedation under strict isolation from the oral cavity to the upper airway.

Comparison of Sedation and Analgesia Requirements in Patients With SARS-CoV-2 Versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-Venous ECMO.

BACKGROUND: Increased analgosedation requirements have been described in patients with acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. There is a paucity of data comparing sedation requirements in patients on ECMO for ARDS secondary to SARS-CoV-2 versus other etiologies of respiratory failure. OBJECTIVE: To compare sedation and analgesia requirements in adult patients with SARS-CoV-2 versus non-SARS-CoV-2 ARDS requiring veno-venous (VV) ECMO support. METHODS: We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support. 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 following ECMO cannulation. RESULTS: We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with 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. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs 43.2%, P < 0.01). CONCLUSION AND RELEVANCE: Patients with ARDS on VV-ECMO support require multiple analgosedative agents with concomitant use of nonparenteral adjunct agents. Further studies are needed to evaluate optimal analgosedation strategies in patients on ECMO support.

Usefulness of Inhaled Sedation in Patients With Severe ARDS Due to COVID-19.

BACKGROUND: Sedation in intensive care is fundamental for optimizing clinical outcomes. For many years the world has been facing high rates of opioid use, and to combat the increasing opioid addiction plans at both national and international level have been implemented.1 The COVID-19 pandemic posed a major challenge for health systems and also increased the use of sedatives and opioid analgesia for prolonged periods of time, and at high doses, in a significant proportion of patients. In our institutions, the shortage of many drugs for intravenous (IV) analgosedation forces us to alternatives to replace out-of-stock drugs or to seek sedation goals, which are difficult to obtain with traditional drugs at high doses.2 METHODS: This was an analytical retrospective cohort study evaluating the follow-up of subjects with inclusion criteria from ICU admission to discharge (alive or dead). Five end points were measured: need for high-dose opioids (≥ 200 µg/h), comparison of inhaled versus IV sedation of opioid analgesic doses, midazolam dose, need for muscle relaxant, and risk of delirium. RESULTS: A total of 283 subjects were included in the study, of whom 230 were administered IV sedation and 53 inhaled sedation. In the inhaled sedation group, the relative risks (RRs) were 0.5 (95% CI 0.4-0.8, P = .045) for need of high-dose fentanyl, 0.3 (95% CI 0.20-0.45, P < .001) for need of muscle relaxant, and 0.8 (95% CI 0.61-1.15, P = .25) for risk of delirium. The median difference of fentanyl dose between the inhaled sedation and IV sedation groups was 61 µg/h or 1,200 µg/d (2.2 ampules/d, P < .001), and that of midazolam dose was 5.7 mg/h. CONCLUSIONS: Inhaled sedation was associated with lower doses of opioids, benzodiazepines, and muscle relaxants compared to IV sedation. This therapy should be considered as an alternative in critically ill patients requiring prolonged ventilatory support and where IV sedation is not possible, always under adequate supervision of ICU staff.

Electroencephalography spectral edge frequency and suppression rate-guided sedation in patients with COVID-19: A randomized controlled trial.

Background: Sedation in coronavirus disease 2019 (COVID-19) patients has been identified as a major challenge. We aimed to investigate whether the use of a multiparameter electroencephalogram (EEG) protocol to guide sedation in COVID-19 patients would increase the 30-day mechanical ventilation-free days (VFD). Methods: We conducted a double-blind randomized clinical trial. We included patients with severe pneumonia due to COVID-19 who required mechanical ventilation (MV) and deep sedation. We randomized to the control (n = 25) or multiparameter group (n = 25). Sedation in the intervention group was administered following the standard institutional protocols together with a flow chart designed to reduce the propofol administration dose if the EEG suppression rate was over 2% or the spectral edge frequency 95 (SEF95) was below 10 Hz. We performed an intention-to-treat analysis to evaluate our primary outcome (30-day VFD). Results: There was no difference in VFD at day 30 (median: 11 [IQR 0-20] days in the control group vs. 0 [IQR 0-21] days in the BIS multiparameter group, p = 0.87). Among secondary outcomes, we documented a 17% reduction in the total adjusted propofol administered during the first 5 days of the protocol [median: 2.3 (IQR 1.9-2.8) mg/k/h in the control group vs. 1.9(IQR 1.5-2.2) mg/k/h in the MP group, p = 0.005]. This was accompanied by a higher average BIS value in the intervention group throughout the treatment period. Conclusion: A sedation protocol guided by multivariate EEG-derived parameters did not increase the 30-day VFD. However, the intervention led to a reduction in total propofol administration.

Excessive Sedation as a Risk Factor for Delirium: A Comparison between Two Cohorts of ARDS Critically Ill Patients with and without COVID-19.

Excessive sedation is associated with poor outcome in critically ill acute respiratory distress syndrome (ARDS) patients. Whether this prognostic effect varies among ARDS patients with and without COVID-19 has yet to be determined. We compared the prognostic value of excessive sedation­in terms of delirium, length of stay in intensive care unit (ICU-LOS) and ICU mortality­between COVID-19 and non-COVID-19 critically ill ARDS patients. This was a second analysis of prospectively collected data in four European academic centers pertaining to 101 adult critically ill ARDS patients with and without COVID-19 disease. Depth of sedation (DOS) and delirium were monitored through processed electroencephalogram (EEG) and the Confusion Assessment Method for ICU (CAM-ICU). Our main exposure was excessive sedation and how it relates to the presence of delirium, ICU-LOS and ICU mortality. The criterion for excessive sedation was met in 73 (72.3%) patients; of these, 15 (82.2%) and 58 (69.1%) were in non-COVID-19 and COVID-19 ARDS groups, respectively. The criteria of delirium were met in 44 patients (60.3%). Moreover, excessive sedation was present in 38 (86.4%) patients with delirium (p < 0.001). ICU death was ascertained in 41 out of 101 (41.0%) patients; of these, 37 (90.2%) had excessive sedation (p < 0.001). The distribution of ICU-LOS among excessive-sedated and non-sedated patients was 22 (16−27) vs. 14 (10.5−19.5) days (p < 0.001), respectively. In a multivariable framework, excessive sedation was independently associated with the development of delirium (p = 0.001), increased ICU mortality (p = 0.009) and longer ICU-LOS (p = 0.000), but only in COVID-19 ARDS patients. Independent of age and gender, excessive sedation might represent a risk factor for delirium in COVID-19 ARDS patients. Similarly, excessive sedation shows to be an independent predictor of ICU-LOS and ICU mortality. The use of continuous EEG-based depth of sedation (DOS) monitoring and delirium assessment in critically ill COVID-19 patients is warranted.

Rapid sequence intubation and the role of the emergency medicine pharmacist: Literature update.

DISCLAIMER: In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY: RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION: While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.

Impact of Early Tracheostomy on Weaning From Ventilation and Sedation in COVID-19 Pregnant and Early Postpartum Patient: Two Case Reports.

Pregnant women are at high risk of coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome (ARDS) and the need for mechanical ventilation. There is no literature on the optimal strategy for the management of difficult-to-wean pregnant and early postpartum patients. We report two cases of pregnant women with COVID-19 pneumonia and ARDS, who required mechanical ventilation and high doses of analgesia, and sedation with neuromuscular blocking agents to facilitate ventilation and oxygenation. Both patients had a tracheostomy procedure to facilitate weaning from mechanical ventilation and sedation. Shortly after tracheostomy, sedation and analgesia, along with ventilatory support were weaned off. Both patients were discharged home. These cases propose early tracheostomy as a strategy to facilitate weaning from mechanical ventilation and sedation in pregnant and early postpartum patients.