Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management.

Importance: Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice. Objective: To understand how clinicians personalize decisions about resuscitation in practice. Design, Setting, and Participants: This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023. Exposure: Online Qualtrics clinical vignette survey. Main Outcomes and Measures: Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs. Results: Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%). Conclusions and Relevance: These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.

Comparison of Administrative versus Electronic Health Record-based Methods for Identifying Sepsis Hospitalizations.

Rationale: Despite the importance of sepsis surveillance, no optimal approach for identifying sepsis hospitalizations exists. The Centers for Disease Control and Prevention Adult Sepsis Event Definition (CDC-ASE) is an electronic medical record-based algorithm that yields more stable estimates over time than diagnostic coding-based approaches but may still result in misclassification. Objectives: We sought to assess three approaches to identifying sepsis hospitalizations, including a modified CDC-ASE. Methods: This cross-sectional study included patients in the Veterans Affairs Ann Arbor Healthcare System admitted via the emergency department (February 2021 to February 2022) with at least one episode of acute organ dysfunction within 48 hours of emergency department presentation. Patients were assessed for community-onset sepsis using three methods: 1) explicit diagnosis codes, 2) the CDC-ASE, and 3) a modified CDC-ASE. The modified CDC-ASE required at least two systemic inflammatory response syndrome criteria instead of blood culture collection and had a more sensitive definition of respiratory dysfunction. Each method was compared with a reference standard of physician adjudication via medical record review. Patients were considered to have sepsis if they had at least one episode of acute organ dysfunction graded as "definitely" or "probably" infection related on physician review. Results: Of 821 eligible hospitalizations, 449 were selected for physician review. Of these, 98 (21.8%) were classified as sepsis by medical record review, 103 (22.9%) by the CDC-ASE, 132 (29.4%) by the modified CDC-ASE, and 37 (8.2%) by diagnostic codes. Accuracy was similar across the three methods of interest (80.6% for the CDC-ASE, 79.6% for the modified CDC-ADE, and 84.2% for diagnostic codes), but sensitivity and specificity varied. The CDC-ASE algorithm had sensitivity of 58.2% (95% confidence interval [CI], 47.2-68.1%) and specificity of 86.9% (95% CI, 82.9-90.2%). The modified CDC-ASE algorithm had greater sensitivity (69.4% [95% CI, 59.3-78.3%]) but lower specificity (81.8% [95% CI, 77.3-85.7%]). Diagnostic codes had lower sensitivity (32.7% [95% CI, 23.5-42.9%]) but greater specificity (98.6% [95% CI, 96.7-99.55%]). Conclusions: There are several approaches to identifying sepsis hospitalizations for surveillance that have acceptable accuracy. These approaches yield varying sensitivity and specificity, so investigators should carefully consider the test characteristics of each method before determining an appropriate method for their intended use.

Use of opioids for refractory dyspnoea in hospitalised patients with serious illness: a narrative review.

Refractory dyspnoea can be a challenging symptom to manage. Palliative care specialists are not always available for consultation, and while many clinicians may undergo training in palliative care, this education is not universal. Opioids are the most studied and prescribed pharmacological intervention for refractory dyspnoea; however, many clinicians hesitate to prescribe opioids due to regulatory concerns and fear of adverse effects. Current evidence suggests that rates of severe adverse effects, including respiratory depression and hypotension, are low when opioids are administered for refractory dyspnoea. Therefore, systemic, short-acting opioids are a recommended and safe option for the palliation of refractory dyspnoea in patients with serious illness, especially in a hospital setting that facilitates close observation. In this narrative review, we discuss the pathophysiology of dyspnoea; facilitate an evidence-based discussion on the concerns, considerations and complications associated with opioid administration for refractory dyspnoea; and describe one approach to managing refractory dyspnoea.

Identification of Patient Safety Threats in a Post-Intensive Care Clinic.

The extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study conducted at an academic, tertiary care medical center used qualitative survey data analyzed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorized into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviors (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.

Receipt of Recovery-Oriented Care Practices During Hospitalization for Sepsis.

Survivors of sepsis hospitalization are at high risk for postsepsis morbidity, readmission, and death, but these negative outcomes can be mitigated by receipt of recommended care practices. We sought to assess factors associated with the receipt of recommended recovery-oriented care practices during hospitalization for sepsis. We hypothesized that patients treated in the ICU may be more likely than ward-treated patients to receive recommended care practices given the increasing focus on survivorship in the critical care field. DESIGN: Observational cohort study. SETTING: Michigan Medicine, a tertiary academic medical center. PATIENTS: Adult patients discharged alive from a hospitalization with a primary diagnosis of sepsis or septic shock in 2019. We further limited our cohort to patients receiving longitudinal care viewable in the Michigan Medicine electronic health record to ensure ability to capture posthospital care and outcomes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three-hundred sixty-five sepsis hospitalizations met study inclusion criteria. Using structured chart review, we determined receipt of the following recovery-based care practices during hospitalization: medication optimization, functional status evaluation at discharge, sepsis education, and scheduled follow-up within 2 weeks. The cohort was 46.6% female, 81.1% White, with a median age of 64 years. 51.2% were treated in the ICU. Medication optimization occurred in 93.7%, functional status evaluation in 82.7%, sepsis education in 20.0%, and scheduled follow-up within 2 weeks in 54.5%. ICU-treated patients had lower receipt of medication optimization and follow-up scheduling but greater receipt of functional and mental health status evaluations. In multivariable models, ICU treatment was associated with lower odds of receiving medication optimization (adjusted odds ratio, 0.72; 95% CI, 0.03-0.69) and not associated with receipt of other care practices. CONCLUSIONS: Our study shows incomplete receipt of recommended recovery-based care practices during sepsis hospitalization in both ward and ICU-treated patients. Sepsis education and mental health evaluation were particularly uncommon.

The low value of pre-decannulation capped overnight ICU monitoring for pediatric patients.

OBJECTIVE: To determine the value of pre-decannulation capped overnight ICU monitoring for assessing decannulation-readiness in pediatric patients. METHODS: This study included all pediatric patients, age 18 and under, with a tracheostomy attempting decannulation at the University of Michigan between 2013 and 2018. Patients who underwent major airway reconstruction immediately prior to decannulation were excluded. Descriptive and comparative statistics were calculated to compare the sub-group of patients who underwent pre-decannulation capped overnight ICU monitoring to those who did not. RESULTS: 125 pediatric patients attempted decannulation for a total of 126 attempts with 105 attempts being eligible for inclusion. 75 eligible attempts included pre-decannulation capped overnight ICU monitoring, while 30 did not. Subsequent rates of successful decannulation were 97.33% (73/75) and 100.00% (30/30), respectively (P = 0.366; 95% CI -8.818-9.260). The pre-decannulation capped overnight ICU monitoring passing rate was 98.67% (74/75) despite a complication rate of 5.33% (4/75). Post-decannulation, 98.08% (102/104) of decannulated patients were monitored inpatient for a minimum of 24 h DISCUSSION: With similar rates of successful decannulation among both sub-groups and previous research demonstrating sufficient ambulatory testing accurately predicts successful decannulation, pre-decannulation capped overnight ICU monitoring is a low-value, high-cost test that can be safely discontinued without compromising patient care. Notably, our study excluded patients undergoing open airway reconstruction immediately prior to decannulation. The 24-h monitoring post-decannulation serves as a safety net for individuals who ultimately fail decannulation.

Training and Deployment of Medical Students as Respiratory Therapist Extenders during COVID-19.

Background: Early experience during the coronavirus disease (COVID-19) pandemic and predictive modeling indicate that the need for respiratory therapists (RTs) will exceed the current supply. Objective: We present an implemented model to train and deploy medical students in the novel role of "respiratory therapist extender" (RTE) to address respiratory therapist shortage during the COVID-19 pandemic. Methods: The RTE role was formulated through discussions with respiratory therapists. A three-part training, with both online and in-person components, was developed and delivered to 25 University of Michigan Medical Students. RTEs were trained in basic respiratory care, documentation, equipment preparation, and equipment processing for clinically stable patients. They operate in a tiered staffing model in which RTEs report to a single RT, thereby extending his/her initial capacity. Results: The first cohort of safely trained RTEs was deployed to provide patient care within 1 week of volunteer recruitment. Conclusion: Our experience has demonstrated that healthcare professionals, including medical students, can be quickly trained and deployed in the novel RTE role as a surge strategy during the COVID-19 pandemic. Because we urgently developed and implemented the RTE role, we recognize the need for ongoing monitoring and adaptation to ensure patient and volunteer safety. We are sharing the RTE concept and training openly to help address RT shortages as the pandemic evolves.