Impact of a Divided Phenobarbital Load and Taper Compared With Lorazepam Symptom Triggered Therapy in Hospitalized Patients.

BACKGROUND: Benzodiazepines are the preferred treatment for alcohol withdrawal. Phenobarbital is an alternative in the setting of prescriber expertise or benzodiazepine contraindication. OBJECTIVE: To evaluate the efficacy and safety of a phenobarbital dosing strategy aimed at treating a spectrum of alcohol withdrawal symptoms across various patient populations. METHODS: Retrospective review of patients admitted with concerns of alcohol withdrawal between May 2018 and November 2022. Patients were separated into a before-after cohort of lorazepam or phenobarbital. The primary outcome was hospital length of stay (LOS). Secondary outcomes were intensive care unit (ICU) LOS, escalation of respiratory support, increased level of care (LOC), and incidence of delirium tremens and/or seizures. RESULTS: Two hundred and seventy-seven patients received lorazepam and 198 received phenobarbital. Hospital LOS was longer in the phenobarbital cohort compared with the lorazepam cohort (6.9 vs 9.3 days). There was no difference in ICU LOS. Level of care increases were fewer in the phenobarbital cohort (4 events vs 19 events). There were higher rates of non-invasive respiratory interventions in the lorazepam cohort and higher rates of mechanical ventilation in the phenobarbital cohort. Utilization of phenobarbital was attributed to a reduction in delirium tremens and seizures. CONCLUSION AND RELEVANCE: This study is novel because of the broad application of a phenobarbital order set across multiple levels of care and patient admission diagnoses. A risk targeted split load intravenous phenobarbital order set can safely be administered to patients with fewer escalations of care, seizures, delirium tremens, and respiratory care escalation.

Correlation of Sedation Depth During Critical Care Transport and Hospitalization.

Purpose: We aim to assess the impact of the exposure to deep versus light sedation by a critical care transport agency during prehospital and interhospital transport on hospital sedation levels, medication exposure, and outcomes of mechanically ventilated patients. Materials and Methods: Retrospective cohort review of mechanically ventilated adult critical care transport patients from January 1, 2019, to March 11, 2020, who arrived at an academic medical center. The primary outcome was the correlation of deep sedation during transport with deep sedation within the first 48 h of hospitalization (defined as Richmond Agitation Sedation Scale [RASS] -3 to -5). The secondary outcomes were duration of mechanical ventilation, hospital length of stay, intensive care unit (ICU) length of stay, inpatient mortality, delirium within 48 h, and coma within 48 h. Results: One hundred and ninety-eight patients were included, of whom 183 (92.4%) were deeply sedated during transport which persisted through the first 48 h of hospital care. Deep sedation during transport was not correlated with deep sedation in the hospital within the first 48 h (OR 2.41; 95% CI, 0.48-12.02). There was no correlation with hospital length of stay, ICU length of stay, duration of mechanical ventilation, or hospital mortality. Deep sedation during transport was not correlated with delirium or coma within the first 48 h of hospitalization. There was a negligible correlation between final transport RASS and initial hospital RASS which did not differ based on the lapsed time from handoff (<1 h corr. coeff. 0.23; ≥1 h corr. coeff. 0.25). Conclusions: Deep sedation was observed during critical care transport in this cohort and was not correlated with deep sedation during the first 48 h of hospitalization. The transition of care between the transport team and the hospital team may be an opportunity to disrupt therapeutic momentum and re-evaluate sedation decisions.

Neuromuscular Blocking Agent Use in Critical Care Transport Not Associated With Intubation.

OBJECTIVE: Variable indications exist for neuromuscular blocking agents (NMBAs) in the critical care transport setting beyond facilitation of intubation. METHODS: This retrospective cohort study included adult patients (≥ 18 years) who underwent critical care transport from July 1, 2020, to May 2, 2023, and received NMBAs during transport that was not associated with intubation. The primary outcome was the indication for NMBA administration. Secondary outcomes included the characterization of NMBA use, mean Richmond Agitation Sedation Scale score before NMBA administration, sedation strategy used, and continuation of NMBAs within 48 hours of hospital admission. RESULTS: One hundred twenty-six patients met the inclusion criteria. The most common indication for NMBA administration was ventilator dyssynchrony (n = 71, 56.4%). The majority of patients received rocuronium during transport (n = 113, 89.7%). The mean pre-NMBA Richmond Agitation Sedation Scale score was -3.7 ± 2.4. The most common sedation strategy was a combination of continuous infusion and bolus sedatives (76.2%). One hundred (79.4%) patients had sedation changes in response to NMBA administration. Seventy-two (57.1%) received NMBAs during the first 48 hours of their intensive care unit admission. CONCLUSION: NMBAs were frequently administered for ventilator dyssynchrony and continuation of prior therapy. Optimization opportunities exist to ensure adequate deep sedation and reassessment of NMBA indication.

Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bag Fluid Order Set.

BACKGROUND: Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care. OBJECTIVE: To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy. METHODS: Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events. RESULTS: One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen. CONCLUSION AND RELEVANCE: Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.

Sedation Practices of Mechanically Ventilated Patients During Critical Care Transport.

OBJECTIVE: Mechanically ventilated patients who receive deep levels of sedation have high mortality rates, longer lengths of stay, and longer duration of mechanical ventilation in the intensive care unit. Prior literature demonstrated a high frequency of deep sedation across all levels of care. Benzodiazepines have been attributed to similar morbidity and mortality findings. METHODS: This study was a descriptive retrospective review of mechanically ventilated adult critical care transport patients from January 1, 2019, to March 11, 2020. Our primary outcome was the percentage of patients who were deeply sedated at handoff to the receiving facility. Deep sedation was defined as a Richmond Agitation Sedation Scale of -3 to -5. Our secondary outcomes were the percentage of patients who received benzodiazepines; the number of unplanned extubations, crew injuries, and unsafe patient care situations; and the incidence of ventilator dyssynchrony. RESULTS: Five hundred fifty-three mechanically ventilated patients were transported. Ninety-three patients were excluded because they received paralytics during transport. Four hundred sixty patients were included in the analysis, 422 (91.7%) of whom were deeply sedated. Benzodiazepines were administered to 141 patients (30.6%). There were no differences observed in the secondary outcomes. CONCLUSION: Deep sedation and benzodiazepine administration were frequent during critical care transport of mechanically ventilated patients.

Evaluation of Nonintubated Analgesia Practices in Critical Care Transport.

OBJECTIVE: Current analgesia recommendations in the prehospital setting are not specific to critical care transport. Variation exists in the recommended agent and dosing strategies. Furthermore, there is a paucity of literature evaluating benzodiazepine and opiate coadministration, which may place patients at risk for respiratory decompensation. METHODS: This was a retrospective chart review of nonintubated adult critical care transport patients between July 1, 2020, and July 1, 2022, who received fentanyl or ketamine during transport. The primary outcome was the proportion of patients oversedated. The secondary outcomes were characterization of analgesic medication use during transport, the percentage of patients coadministered benzodiazepines, naloxone administration, and escalation of respiratory intervention. RESULTS: Three hundred seventy-six patients were administered fentanyl or ketamine during transport. Eleven patients were oversedated. Three hundred twenty-four patients received fentanyl monotherapy, and 52 received combination therapy. Patients who received benzodiazepines had higher odds of oversedation (odds ratio = 5.75; 95% confidence interval, 1.6-20.7). Two hundred thirty-six patients required an escalation in respiratory support, most commonly an increase from room air to nasal cannula. No patients had naloxone administered. CONCLUSION: The rate of oversedation of nonintubated adult critical care transport patients receiving fentanyl or ketamine is low. Coadministration of benzodiazepines increases the risk of oversedation.

Findings from a tandem clinician leadership intervention for emergency department cardiac arrest care during the COVID-19 pandemic.

INTRODUCTION: Cardiopulmonary arrest (CPA) care in the Emergency Department (ED) has had to be modified during the coronavirus disease (COVID-19) pandemic. Scarce literature exists on comfort of clinicians (defined as physicians, nurses & advanced practice providers-APP's) in these new roles and their perceived understanding of new algorithms. METHODS: Routine CPA care in our ED was modified during the COVID-19 pandemic. This involved clinicians in shared leadership roles alongside COVID-19 specific changes to CPA algorithms. The new protocol was operationalized through a two-step educational intervention involving didactic education and in-situ simulations. Univariate analyses using student's t-test assessed effectiveness of this educational intervention with clinician comfort as team leaders and perceived knowledge as primary outcomes on a scale of 1 (strongly disagree) to 5 (strongly agree). Subgroup analysis across physicians (attending & resident), nurses & APP's were also undertaken with an alpha of 0.05, and p values <0.05 were considered statistically significant. Secondary outcomes of task saturation, procedural safety and error prevention were also analyzed. RESULTS: Across 83 of 95 total participants, our primary outcome of clinician comfort in the team leader role improved from a mean value of 3.41 (SD: 1.23) pre-intervention to 4.11 (SD: 0.88) with a p-value <0.001 post intervention. Similar and statistically significant findings in clinician comfort were noted across all subgroups except attending physicians and APP's. Perceived knowledge increased from a mean value of 3.54 (SD: 1.06) pre-intervention to a mean value of 4.24 (SD: 0.67) with a p-value <0.001 post intervention. Similar and statistically significant findings in perceived knowledge were noted across all subgroups except APP's. Responses were registered in either the strongly agree or agree category with regards to task saturation (89%), procedural safety (93%) and error prevention (71%) across all clinicians post intervention. CONCLUSION: Our pilot investigation of the effectiveness of an educational intervention of a novel CPA protocol in the ED during the COVID-19 pandemic reached statistical significance with regards to clinician comfort in shared leadership roles and perceived knowledge. These findings suggest that the protocol is rapidly teachable, usable and can be efficiently disseminated across ED clinicians of varying experience, especially in pandemic settings. Further work regarding effectiveness of this new protocol in real life cardiac arrest scenarios is warranted.

Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care.

OBJECTIVE: High tidal volume ventilation is associated with ventilator-induced lung injury. Early introduction of lung protective ventilation improves patient outcomes. This study describes ventilator management during critical care transport and the association between transport ventilator settings and ventilator settings in the intensive care unit (ICU). METHODS: This was a retrospective review of mechanically ventilated adult patients transported to an academic medical center via a critical care transport program between January 2018 and April 2019. Ventilator settings during transport were compared with the initial and 6- and 12-hour postadmission ventilator settings. RESULTS: Three hundred eighty patients were identified; 114 (30%) received tidal volumes > 8 mL/kg predicted body weight at the time of transfer. The transport handoff tidal volume strongly correlated with the ICU tidal volume (Pearson r = 0.7). Patients receiving high tidal volumes during transport were more likely to receive high tidal volumes initially upon transfer (relative risk [RR] = 4.6; 95% confidence interval [CI], 3.3-6.5) and at 6 and 12 hours after admission (RR = 2.6; 95% CI, 1.8-3.8 and RR = 2.7; 95% CI, 1.7-4.3, respectively). CONCLUSION: Exposure to high tidal volumes during transport is associated with high tidal volume ventilation in the ICU, even up to 12 hours after admission. This study identifies opportunities for improving patient care through the application of lung protective ventilation strategies during transport.

The emergency department evaluation and management of massive hemoptysis.

INTRODUCTION: Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment. OBJECTIVE: The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician. DISCUSSION: Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology. CONCLUSION: Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.

Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging viral pathogen that causes the novel coronavirus disease of 2019 (COVID-19) and may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation in the most severe cases. OBJECTIVE: This narrative review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation. DISCUSSION: In severe cases, COVID-19 leads to hypoxemic respiratory failure that may meet criteria for acute respiratory distress syndrome (ARDS). The mainstay of treatment for ARDS includes a lung protective ventilation strategy with low tidal volumes (4-8 mL/kg predicted body weight), adequate positive end-expiratory pressure (PEEP), and maintaining a plateau pressure of < 30 cm H2O. While further COVID-19 specific studies are needed, current management should focus on supportive care, preventing further lung injury from mechanical ventilation, and treating the underlying cause. CONCLUSIONS: This review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.

Troubleshooting Hypoxemia After Placement of an Extraglottic Airway.

The case presented here highlights the feasibility of using an extraglottic airway device as a conduit for delivering high levels of lifesaving positive end expiratory pressure (PEEP), as well as other means of combating recalcitrant hypoxia. The case also highlights the merit of an approach to the hypoxic patient with an in-situ extraglottic airway device based not only on deciding if the device is functioning to maintain a patent airway, but also, simultaneously considering the patient's physiology. A 71 year old male suffered an out-of-hospital cardiac arrest. Part of his resuscitation included placement of a dual-balloon extraglottic airway device by EMS. He was hypoxic, but the device seemed to be providing for a patent airway without an air leak. There was also a favorable end-tidal carbon dioxide waveform. The flight team chose to the leave the device in place. PEEP was up-titrated to 17 cmH20 without issue. Sigh breaths, as well as breath holds, were also able to be delivered. The patient's hypoxia improved over the course of the patient's transport, and he ultimately did well.

Paramedic intubation: patient position might matter.

OBJECTIVE: Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model. METHODS: The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies. To assess past experience, participants self-reported the number of patients they attempted to intubate in the previous 12 months and the patient positions in which they attempted those intubations. Participants attempted to intubate nonembalmed cadavers in a controlled environment in three positions: on the floor, on a low stretcher to simulate the patient care compartment of an ambulance, and on an elevated stretcher. Paramedics were allowed a maximum of three intubation attempts of one minute each per cadaver. Endotracheal tube placement was verified by a single attending emergency physician using direct visualization. RESULTS: Self-reports of intubation attempts in the previous 12 months indicated that participants had attempted to intubate a mean of 6.4 patients per paramedic. Self-reported positions of patient intubations were 57% on the floor, 33% in the ambulance, 7% on a stretcher of unspecified height, and 3% in some other position. During the study, 84 paramedics performed 251 intubations on 42 cadavers. First-attempt and cumulative first- and second-attempt success rates were 77.4 and 89.3% for the floor position, 74.7 and 94.0% for the low stretcher (ambulance) position, and 86.9 and 96.4% for the elevated stretcher position, respectively. First attempt success was higher in the elevated stretcher position compared to the low stretcher position (OR = 2.25, 95% CI 1.01-5.00). No other position contributed to greater odds of ETI success either on the first or second attempt. CONCLUSIONS: Endotracheal intubation success was higher with the cadaver positioned on an elevated stretcher compared to a low stretcher. Paramedics must be aware of patient position when performing prehospital intubation.

Ventilator-associated pneumonia and intubation location in adults with traumatic injuries: Systematic review and meta-analysis.

BACKGROUND: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality among critically ill patients, particularly those who present with traumatic injuries. This review aims to determine whether patients with traumatic injuries who are intubated in the prehospital setting are at higher risk of developing VAP compared with those intubated in the hospital. METHODS: A systematic review of Medline, Scopus, and Cochrane electronic databases was conducted from inception to January 2021. Inclusion criteria were patients with traumatic injuries who were intubated in the prehospital or hospital settings with VAP as an outcome. Using a random-effects model, the risk of VAP across study arms was compared by calculating a summary relative risk with 95% confidence intervals. The results of individual studies were also summarized qualitatively. RESULTS: The search identified 754 articles of which 6 studies (N = 2,990) met the inclusion criteria. All studies were good quality based on assessment with the Newcastle Ottawa scale. Prehospital intubation demonstrated an increased risk of VAP development in two of the six studies. Among the six studies, the overall quality weighted risk ratio was 1.09 (95% confidence interval, 0.90-1.31). CONCLUSION: Traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared with those that are intubated in the hospital setting. LEVEL OF EVIDENCE: Systematic review and meta-analysis; Level IV.