Opioid versus Benzodiazepine-based Sedation for Mechanically Ventilated Patients in the Internal Medicine Ward.

BACKGROUND: Opioid-base sedation is considered the first line choice in ventilated patients in intensive care units (ICU). Few studies have examined sedation in ventilated patients outside the ICU. A pilot program was initiated in the internal medicine ward A at Meir Hospital in Kfar Saba, Israel. A new sedation protocol was implemented for opioid-based versus benzodiazepine-based sedation in ventilated patients. OBJECTIVES: To compare the rates and intensity of delirium between patients who received opioid-based sedation vs. benzodiazepine-based sedation. To compare parameters related to morbidity and mortality. METHODS: We conducted a retrospective before-after intervention study based on data collection. Patients who were admitted to the internal medicine ward A from January 2020 to January 2021 and required sedation and ventilation were included. Demographic data, medical history data, admission data, Richmond Agitation and Sedation Scale scores, hemodynamic parameters, reports of falls and self-harm, and data regarding unplanned extubation were collected, as well as the need for additional sedative drugs. RESULTS: Chronic hypertension was more common in the opioid group. Delirium intensity tended to be higher in the benzodiazepine group. The number of ventilation days was significantly higher in the benzodiazepine group, as was the number of times adjuvant sedation was required. CONCLUSIONS: Opioid-based sedation outside the ICU was associated with shorter ventilation days, tendency toward lower intensity of delirium, and reduction in requirement of adjuvant sedative drugs compared to benzodiazepine-based sedation. Further studies are required to confirm the findings.

Epidural vs. systemic analgesia in the Intensive Care Unit: retrospective study of patient outcomes.

BACKGROUND: Patients admitted to the Intensive Care Unit (ICU) often experience acute pain. Causes include major surgery, multisystem trauma, and pancreatitis. Most ICU patients who require pain management are treated with systemic analgesia, usually intravenous opioids. This study compared the rate of pain and delirium scores, as well as mortality and morbidity between ICU patients treated with systemic vs. epidural analgesia. METHODS: This retrospective analysis included patients who were in the ICU from January 2011 to June 2021, admitted due to thoracic, abdominal, pelvic, or lower limb surgery; pancreatitis; multiple rib fractures, or multisystem trauma. Data included demographics, admission parameters and indication, VAS score, Richmond Agitation and Sedation Score, in-hospital morbidity, and mortality, medical history, and medications. RESULTS: There was no significant difference in demographics, chronic medications, and past illness, excluding chronic obstructive pulmonary disease, peripheral vascular disease, and past cerebral vascular disease. ICU length of stay was shorter in the epidural group, but overall hospital length of stay was not. Except for increased need for dialysis in the systemic analgesia group, disease severity was similar in both groups. The epidural group had fewer days on mechanical ventilation and lower 28-day mortality, as well as fewer episodes of delirium, although pain scores were similar. There was no difference between groups in the need for physical restraints or antipsychotics for delirium. CONCLUSIONS: Epidural analgesia reduced the number of delirium events and was associated with a shorter ICU stay, fewer ventilation days and a lower mortality rate. Further research is needed to confirm these findings.

Thiamine Administration and the Prevalence of Delirium in the Intensive Care Unit: A Retrospective Before and After Interventional Study.

BACKGROUND: Thiamine is an essential co-factor for aerobic intracellular respiration, nerve conduction, and muscle contraction. Thiamine deficiency is common in the intensive care unit (ICU). Delirium is a frequent unwanted symptom among critical ill patients. Although the exact cause of ICU-associated delirium is unknown, abnormal nutrition and thiamine deficiency may contribute to the etiology. OBJECTIVES: To compare the prevalence of delirium among ICU patients who received thiamine with those who did not and to compare morbidity and mortality. METHODS: A retrospective study was conducted among ICU patients admitted 2014-2018. Routine thiamine administration began in 2016. Collected data included patient demographics, medical history, indication for ICU admission, hospital admission times, ventilation days, inotropic therapy, hemodialysis, tracheostomy, 28-day mortality, and need for anti-psychotic therapy. Group A received thiamine, group B did not. All data were statistically analyzed according to type. RESULTS: The study included 930 patients: 465 patients in group A and 465 in group B. At admission and throughout the hospitalization severity of disease parameters was worse in group A compared to group B, including acute physiology and chronic health evaluation (APACHE) score, admission lactate level, ventilation days, inotropic support, renal replacement therapy, tracheostomy, and ICU hospitalization. Group A had fewer delirium events without difference of maximal delirium score. No difference in mortality rate was observed. CONCLUSIONS: Thiamine administration was associated with lower delirium prevalence despite longer ICU admission times and higher disease severity parameters at admission and during ICU stay.

Low molecular weight heparin for venous thromboembolism prophylaxis in general Intensive Care Unit patients: an anti-factor Xa level-based approach.

BACKGROUND: Venous thromboembolism (VTE) in the Intensive Care Unit (ICU) is associated with significant morbidity and mortality therefore prevention is imperative to reduce its burden. VTE prophylaxis in ICU patients is primarily pharmacological using low molecular weight heparin (LMWH). Plasma anti-factor Xa (anti-FXa) levels may be used to measure LMWH activity. This study aims to determine the proportion of acutely ill patients in a general ICU receiving standard VTE prophylaxis that achieve adequate peak or trough anti-FXa prophylactic levels and to determine the effect of LMWH dose adjustment in patients not achieving adequate anti-FXa prophylactic levels. METHODS: Peak and trough anti-FXa levels were measured at four and 23 hours respectively after receiving the second consecutive daily enoxaparin 40 mg sc injection. Patients in whom peak anti-FXa levels were found to be sub-prophylactic (<0.2 IU/mL), were dose escalated to enoxaparin 60 mg once daily. Peak and trough levels were repeated as above. RESULTS: Sixty-one percent of study patients (N.=46) were found to have sub-prophylactic peak anti-FXa levels. Twenty-seven patients received an increased enoxaparin dose of 60 mg/d. Of these, nine patients (33.3%) still failed to achieve the target prophylactic peak anti-FXa level (0.2-0.4 IU/mL). Male gender and high body mass index (BMI) were significantly and strongly correlated with sub-prophylactic anti-FXa levels. CONCLUSIONS: Most ICU patients in this study did not achieve recommended prophylactic anti-FXa levels while receiving a standard dose of enoxaparin and these levels failed to increase after enoxaparin dose escalation in a significant proportion of patients. High BMI and male gender are associated with sub-prophylactic levels of anti-FXa in critically ill patients.

Catastrophic anti-phospholipid syndrome with Libman-Sacks endocarditis following eltrombopag therapy for immune thrombocytopenic purpura: A case report.

BACKGROUND: Immune thrombocytopenic purpura (ITP) is an autoimmune disease, with accelerated destruction of platelets, estimated to affect 1.6-3.9 in 100,000 adults every year in the European Union. Glucocorticoids and intravenous immunoglobulins are common drug therapies. In refractory cases, drugs that enhance thrombopoiesis may be used. Eltrombopag is a thrombopoietin receptor agonist, known to increase platelet count in patients with refractory ITP. Thrombotic adverse events have been described in association with Eltrombopag administration. CASE REPORT: A young female patient of Ethiopian ancestry with systemic lupus erythematosus, triple Antiphospholipid (APLA) positive serology and refractory ITP who received Eltrombopag and 2 weeks later developed catastrophic APLA syndrome with severe Libman-Sacks endocarditis of the mitral and aortic valves, multiple intracerebral infracts and arterial thrombosis of the left upper limb. CONCLUSION: Eltrombopag is a salvage drug, used in refractory ITP. Thrombotic adverse events, some of which may be life-threatening, are a possible complication, especially in high-risk patients.

The postoperative blood-sparing efficacy of oral versus intravenous tranexamic acid after total knee replacement.

To assess the blood-sparing efficacy of tranexamic acid (TA) administered orally or via a variable IV infusion, 80 healthy patients undergoing elective total knee replacement were studied according to a prospective, controlled, randomized, single-blinded study design. Patients were allocated to one of four treatment groups. In group TA-long, 30 min before deflation of the limb tourniquet, an IV bolus dose of TA 15 mg/kg was administered over 30 min. Thereafter, a constant IV infusion of 10 mg . kg(-1) . h(-1) was administered until 12 h after final deflation of the limb tourniquet. In group TA-short, a similar regimen was followed; however, the constant IV infusion was discontinued 2 h after final deflation of the limb tourniquet (time of discharge from the postanesthesia care unit). Thereafter, oral TA 1 g was administered after 6 and 12 h. In group TA-oral, 60 min before surgery an oral dose of TA 1 g was administered. After surgery, a similar dose of TA was administered every 6 h for the next 18 h. In the control group, TA was not administered. At patient discharge, postoperative allogeneic blood administration was significantly more in group Control when compared with each of the three TA treatment groups. Because oral drug administration is simple and does not require specific infusion equipment, the authors suggest that oral TA is a superior blood-sparing strategy compared with IV drug administration.

A comparison of three techniques for acute postoperative pain control following major abdominal surgery.

STUDY OBJECTIVES: To compare the analgesic efficacy of a nonsteroidal antiinflammatory drug (NSAID) alone (basic pain treatment) with that of NSAID in conjunction with either intravenous (IV) patient-controlled analgesia (IV-PCA) or intermittent epidural morphine (epidural morphine), among patients recovering from major intraabdominal surgery; and to assess the fixed and variable costs of providing the respective acute pain treatment modalities. DESIGN: Prospective, nonrandomized study. SETTING: Postanesthesia care unit (PACU) and surgical departments of a large referral hospital. PATIENTS: All patients (n = 358) treated by our Acute Pain Service (APS) who were recovering from major intraabdominal surgery (colectomy, cholecystectomy, colostomy, gastrectomy, splenectomy). MEASUREMENTS AND MAIN RESULTS: The structure of our APS, analgesic regimens, and the associated patient monitoring and event-response algorithms are detailed. Data of 358 patients recovering from major intraabdominal surgery and treated according to one of the three treatment protocols were collected and analyzed. The cost of providing our APS and the nursing time required to monitor and treat patients in each treatment group were also calculated. The median visual analog scale (VAS) scores were low in all three treatment groups (23.5 mm vs. 6 mm vs. 4, for the basic pain treatment, IV-PCA, and epidural morphine groups, respectively). However, the median VAS was significantly (p < 0.04) lower among patients who received epidural morphine than either the IV-PCA or basic pain treatment groups. Similarly, the number of patients who had at least one episode of a pain VAS >30 mm was significantly (p < 0.04) lower in the epidural morphine group than either of the other two groups. The frequency of nausea and vomiting was similar among the groups. However, the frequency of postoperative pruritus was significantly (p < 0.001) higher in the epidural morphine group than the other two groups. Patient satisfaction was unaffected by group allocation. Institutional costs per patient and the nursing time required to provide the APS were lowest in the basic pain treatment group. CONCLUSIONS: Considering the respective pain profiles, complication rates, and institutional costs associated with the three analgesic regimens analyzed, the basic pain Treatment alone constitutes a useful alternative to the other two analgesic regimens assessed.