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.

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.

Impact of a sepsis tracking sheet and emergency department pharmacists on sepsis compliance measures: a prospective emergency department analysis.

INTRODUCTION: Compliance with core sepsis measures in Emergency Departments (ED) remains low, with a limited number of prospective trials highlighting strategies for improvement. METHODS: A prospective historically case-controlled observational analysis assessing the pre- and post -intervention impact of a sepsis tracking sheet (STS) and the involvement of ED pharmacists. PrimaryThe primary outcome was the improvement in compliance with core sepsis measures. SecondaryThe secondary outcome was to assess the frequency of respiratory interventions and mortality with pre-defined strata of fluid resuscitation (≤ 10, 10-20, 20-30, 30, ≥ 30 cc/kg of ideal body weight). RESULTS: 194 patients were enrolled over a six -month period with a 9.3% all-cause mortality and a 10.3% rate of new respiratory interventions after fluid boluses. Post-STS implementation compliance of repeat lactate measurement was 88% (vs. 33% pre-STS), broad-spectrum antibiotic administration within 3 h of presentation improved to 96% (vs. 20% pre-STS), blood cultures were drawn on 98% of patients (vs. 9% pre-STS), and 30 cc/kg fluid boluses were administered to 39% of patients (vs. 25% pre-STS). Of the 18 deaths and 21 respiratory interventions, only two patients fell into both categories. Mortality was highest in those patients that received greater than 30 cc/kg of fluid resuscitation (50%). Respiratory interventions were greatest in the strata receiving 10-20 cc/kg of fluids (47.6%). Patients receiving the lowest fluid aliquots of < 10 cc/kg had the highest clinical severity scores but did not have higher rates of historical diagnoses of volume overload. CONCLUSION: The ED -based implementation of a sepsis tracking sheet and the involvement of dedicated ED pharmacists was effective in improving core measures of sepsis compliance. Patients receiving higher fluid aliquots did not experience higher rates of respiratory interventions, though had higher all-cause mortality. No relationship could be identified between patients getting lower aliquots of fluid and prior diagnoses of volume overload.

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.

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.