This study assesses changes in COVID-19 vaccination rates before and after the Ohio vaccine lottery announcement compared with national rates to control for the expansion of vaccine indications to ...adolescents.
Atrial Fibrillation in the ICU Bosch, Nicholas A.; Cimini, Jonathan; Walkey, Allan J.
Chest,
12/2018, Volume:
154, Issue:
6
Journal Article
Peer reviewed
Open access
Atrial fibrillation (AF) is the most common arrhythmia encountered in the ICU. Preexisting AF is highly prevalent among older patients with chronic conditions who are at risk for critical illness, ...whereas new-onset AF can be triggered by accelerated atrial remodeling and arrhythmogenic triggers encountered during critical illness. The acute loss of atrial systole and onset of rapid ventricular rates that characterize new-onset AF often lead to decreased cardiac output and hemodynamic compromise. Thus, new-onset AF is both a marker of disease severity as well as a likely contributor to poor outcomes, similar to other manifestations of organ dysfunction during critical illness. Evaluating immediate hemodynamic effects of new-onset AF during critical illness is an important component of rapid clinical assessment aimed at identifying patients in need of urgent direct current cardioversion, treatment of reversible inciting factors, and identification of patients who may benefit from pharmacologic rate or rhythm control. In addition to acute hemodynamic effects, new-onset AF during critical illness is associated with both short- and long-term increases in the risk of stroke, heart failure, and death, with AF recurrence rates of approximately 50% within 1 year following hospital discharge. In the absence of a strong evidence base, there is substantial practice variation in the choice of strategies for management of new-onset AF during critical illness. We describe acute and long-term evaluation and management strategies based on current evidence and propose future avenues of investigation to fill large knowledge gaps in the management of patients with AF during critical illness.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IMPORTANCE: Patients with septic shock may benefit from the initiation of corticosteroids. However, the comparative effectiveness of the 2 most studied corticosteroid regimens (hydrocortisone with ...fludrocortisone vs hydrocortisone alone) is unclear. OBJECTIVE: To compare the effectiveness of adding fludrocortisone to hydrocortisone vs hydrocortisone alone among patients with septic shock using target trial emulation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study from 2016 to 2020 used the enhanced claims-based Premier Healthcare Database, which included approximately 25% of US hospitalizations. Participants were adult patients hospitalized with septic shock and receiving norepinephrine who began hydrocortisone treatment. Data analysis was performed from May 2022 to December 2022. EXPOSURE: Addition of fludrocortisone on the same calendar day that hydrocortisone treatment was initiated vs use of hydrocortisone alone. MAIN OUTCOME AND MEASURES: Composite of hospital death or discharge to hospice. Adjusted risk differences were calculated using doubly robust targeted maximum likelihood estimation. RESULTS: Analyses included 88 275 patients, 2280 who began treatment with hydrocortisone-fludrocortisone (median IQR age, 64 54-73 years; 1041 female; 1239 male) and 85 995 (median IQR age, 67 57-76 years; 42 136 female; 43 859 male) who began treatment with hydrocortisone alone. The primary composite outcome of death in hospital or discharge to hospice occurred among 1076 (47.2%) patients treated with hydrocortisone-fludrocortisone vs 43 669 (50.8%) treated with hydrocortisone alone (adjusted absolute risk difference, −3.7%; 95% CI, −4.2% to −3.1%; P < .001). CONCLUSIONS AND RELEVANCE: In this comparative effectiveness cohort study among adult patients with septic shock who began hydrocortisone treatment, the addition of fludrocortisone was superior to hydrocortisone alone.
Although both leukocytosis and leukopenia have been considered Systemic Inflammatory Response Syndrome criteria, leukopenia is not generally considered a normal response to infection. We sought to ...evaluate the prognostic validity of leukopenia as a sign of sepsis-defining hematological organ dysfunction within the Sepsis-3 framework. We hypothesized that leukopenia is associated with higher risk of mortality than leukocytosis among patients with suspected infection.
We performed a retrospective cohort study using the Medical Information Mart v1.4 in Intensive Care-III database. Multivariable regression models were used to evaluate the association between leukopenia and mortality in patients with suspected infection defined by Sepsis-3.
We identified 5,909 ICU patients with suspected infection; 250 (4.2%) had leukopenia. Leukopenia was associated with increased in-hospital mortality compared with leukocytosis (OR, 1.5; 95% CI 1.1-1.9). After adjusting for demographics and comorbidities in the Sepsis-3 consensus model, leukopenia remained associated with increased risk of mortality compared with leukocytosis (OR 1.6, 95% CI 1.2-2.2). Further adjustment for the platelet component of the SOFA attenuated the association between leukopenia and mortality (OR decreased from 1.5 to 1.1). However, 83 (1.4%) of patients had leukopenia without thrombocytopenia and 14 had leukopenia prior to thrombocytopenia.
Among ICU patients with suspected infection, leukopenia was associated with increased risk of death compared with leukocytosis. Due to correlation with thrombocytopenia, leukopenia did not independently improve the prognostic validity of SOFA; however, leukopenia may present as a sign of sepsis prior to thrombocytopenia in a small subset of patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Septic shock is defined by the need for vasopressor agents to correct hypotension and lactic acidosis resulting from infection, with 30%-40% case fatality rates. The care of patients with worsening ...septic shock involves multiple treatment decisions involving vasopressor choices and adjunctive treatments. In this edition of “How I Do It”, we provide a case-based discussion of common clinical decisions regarding choice of first-line vasopressor, BP targets, route of vasopressor delivery, use of secondary vasopressors, and adjunctive medications. We also consider diagnostic approaches, treatment, and monitoring strategies for the patient with worsening shock, as well as approaches to difficult weaning of vasopressors.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Atrial fibrillation (AF) is a common complication of sepsis. It is unclear whether norepinephrine, an α- and β-agonist, and phenylephrine, an α-agonist, are associated with different heart rates ...among patients with sepsis and AF.
Among patients with sepsis and AF, what is the difference in heart rate after phenylephrine initiation vs norepinephrine initiation?
With the use of an extensive database, we identified patients with sepsis and AF at the time of norepinephrine or phenylephrine initiation. We estimated the difference in heart rate between patients who received phenylephrine or norepinephrine 1 and 6 h after vasopressor initiation with the use of multivariable-adjusted linear regression, tested for effect modification by heart rate, and stratified by baseline heart rate ≥ 110 or < 110 beats/min. Secondary outcomes included conversion to sinus rhythm, bradycardia, vasopressor duration, ICU and hospital length of stay, and hospital death. Exploratory analyses were adjusted for practices that occurred after vasopressor initiation; sensitivity analyses used interrupted time series to estimate the difference in average heart rate between patients who received phenylephrine or norepinephrine.
Among 1847 patients with sepsis and AF, 946 patients (51%) received norepinephrine, and 901 patients (49%) received phenylephrine. After multivariable adjustment, phenylephrine was associated with a lower heart rate at 1 h (−4 beats/min; 95% CI, −6 to −1; P < .001) and 6 h (−4 beats/min; 95% CI, −6 to −1; P = .004). Higher heart rate before vasopressor administration was associated with larger heart rate reduction in patients who received phenylephrine compared with norepinephrine. There were no differences in secondary outcomes. Results were similar in exploratory and sensitivity analyses.
In patients with sepsis and AF, the initiation of phenylephrine was associated with modestly lower heart rate compared with norepinephrine. Heart rate at vasopressor initiation appeared to be an important effect modifier. Whether modest reductions in heart rate are associated with clinical outcomes requires further study.
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