A Phase II Cluster-Crossover Randomized Trial of Fentanyl versus Morphine for Analgosedation in Mechanically Ventilated Patients.

Rationale: The continuous infusion of fentanyl or morphine is often prescribed to assist with analgesia and sedation (analgosedation) during mechanical ventilation. Objectives: To compare the effect of fentanyl versus morphine on patient-centered outcomes in ventilated patients. Methods: We conducted a cluster-randomized, cluster-crossover trial between July 2019 and August 2020 in two adult ICUs. We compared two continuous infusion regimens (fentanyl versus morphine). One ICU was randomized to the fentanyl-morphine sequence and the other to the morphine-fentanyl sequence. The primary outcome was the number of ventilator-free days at Day 28. Secondary outcomes included, among others, duration of mechanical ventilation in survivors and ICU-free days at Day 28. Measurements and Main Results: Via cluster allocation, we randomized 737 patients. Of these, 56 were excluded because of the opt-out consent process, leaving 681 (344 to fentanyl and 337 to morphine) for primary analysis (median [interquartile range] age, 59 [44-69] years). Median ventilator-free days at Day 28 were 26.1 (20.7-27.3) in the fentanyl versus 25.3 (19.1-27.2) in the morphine group (median difference, 0.79 [95% confidence interval, 0.31 to 1.28], P = 0.001). ICU-free days were greater (P < 0.001) and length of stay in the ICU for survivors shorter (P < 0.001) in the fentanyl group. All other secondary outcomes were not statistically different by treatment group. Conclusions: Among adult patients requiring mechanical ventilation, compared with morphine, fentanyl infusion significantly increased the median number of ventilator-free days at Day 28. The choice of opioid infusion agent may affect clinical outcomes and requires further investigation.

The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study.

OBJECTIVE: To investigate the role of medical emergency teams in end-of-life care planning. DESIGN: One month prospective audit of medical emergency team calls. SETTING: Seven university-affiliated hospitals in Australia, Canada, and Sweden. PATIENTS: Five hundred eighteen patients who received a medical emergency team call over 1 month. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%.Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p = .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p = .089). CONCLUSIONS: Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

Prediction of tracheostomy in critically ill trauma patients: a systematic review.

BACKGROUND: Tracheostomy is relatively common in mechanically ventilated patients in the intensive care unit (ICU). The prediction of which patients will receive a tracheostomy is crucial to both clinical decision making and the design of targeted interventional trials of its timing. OBJECTIVES: We aimed to systematically review the literature to ascertain whether useful predictors of eventual tracheostomy can be identified, with a particular focus on trauma patients. DATA SOURCES AND REVIEW METHODS: We searched three electronic databases to identify all studies of any design evaluating potential predictors of tracheostomy in mechanically ventilated ICU patients. Bias was assessed using the Quality in Prognosis Studies tool. RESULTS: Of 140 potentially eligible studies, we identified 12 relevant observational studies recruiting a total of 119 945 mechanically ventilated patients, of whom 14 080 (11.7%) received a tracheostomy. Seven studies were performed in trauma populations and included 24 858 patients, of whom 6140 (24.7%) received a tracheostomy. Factors predictive of receiving a tracheostomy in the trauma population included patient factors (age and comorbidities), diagnostic factors (injury type and injury severity score), and intervention factors (craniotomy or laparotomy). Profound clinical and methodological heterogeneity prevented meaningful metaanalysis. Significantly, more predictors were present on the day of admission in trauma populations than in non-trauma patients with brain injury and in other populations (89.7% v 73.3% v 25.0%). CONCLUSION: There are a number of clinical factors associated with subsequent tracheostomy in mechanically ventilated patients, in particular trauma patients. Given the need to prevent patients from receiving an unnecessary tracheostomy, these findings indicate that better predictive models are needed before the conduct of interventional trials. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO registry no. CRD42018084987.

Improving the documentation of medical emergency team reviews.

OBJECTIVES: To improve the documentation of events surrounding medical emergency team (MET) calls and to audit the incidence of MET calls and subsequent patient outcomes. METHODS: Prospective audit and patient chart review before and after three simultaneous interventions: medical team education, addition of intensive care personnel to the MET and introduction of a dedicated medical documentation pro forma. Data collected included patient demographics (including outcomes), features of each MET call (criteria, timing and treatment) and the completeness of medical documentation using nine predetermined criteria. Baseline data were collected over 5 months, April to August 2005. Following a 2-week education period, data were collected for a further 4 months, September to December 2005. Apart from the principal investigators, medical and nursing staff were not aware of this research during either data collection period. RESULTS: There were 94 MET calls (10.3 per 1000 admissions) during the baseline period and 101 (14.2 per 1000 admissions) after the interventions. MET calls were more common in medical than surgical patients (34.9 v 12.9 calls per 1000 admissions; P < 0.001). Sixty of the 195 calls (30.7%) resulted in patients being transferred to a critical care area, and the overall in-hospital mortality following a MET call was 31.8%. The interventions resulted in a significant increase in the overall quantity and quality of medical documentation (in seven out of the nine criteria). The interventions were not associated with an increase in hospital resource utilisation, in particular hospital bed days or admissions to critical care areas. CONCLUSIONS: Critical-care resource utilisation and inhospital mortality risk following a MET call at our institution is high. Three simple interventions improved the quality of medical documentation but did not significantly increase overall resource utilisation or improve patient outcomes.