NIHR Signal: A newer sedative agent may shorten length of stay in intensive care units

National Institute for Health Research Signal

Cruickshank M, Henderson L, MacLennan G, Fraser C, Campbell M, Blackwood B, Gordon A, Brazzelli M.  Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review.  Health Technology Assessment Volume 20 Issue 25 , 2016

Adults needing mechanical ventilation who were sedated with dexmedetomidine had reduced length of stay in intensive care and reduced duration of ventilation.

Various sedative drugs are available for use in England although it is unclear if one is better than the others. This review compared two alpha-2 agonist drugs (clonidine and dexmedetomidine) to other commonly used sedative drugs: propofol and the benzodiazepines midazolam and lorazepam for adults on mechanical ventilation.

A 2014 survey reported that, while clonidine is used in about a third of units, dexmedetomidine is not frequently used. The latter drug is expensive, and this review did not consider cost-effectiveness which will be an important factor if the drug is to be used more widely.

This review’s findings on dexmedetomidine support best practice guidelines which suggest modest benefits for non-benzodiazepines compared to benzodiazepines.

Moral distress: an inevitable part of neonatal and paediatric intensive care?

Field. D. et al. Archives of Disease in Childhood. doi:10.1136/archdischild-2015-310268

The paper by Prentice et al reports a systematic review of moral distress occurring in neonatal and paediatric intensive care units. This term, which may be unfamiliar to many readers, has been defined as the anguish experienced when a health professional makes a clear moral judgement about what action he/she should take but is unable to act accordingly due to constraints (societal, institutional or contextual).2 In a situation of moral distress, the health professional can see, from their point of view, that there is an ethically correct action but is powerless to act, a situation that will be familiar to all those who work in neonatal or paediatric intensive care teams.

Moral distress is not a new phenomenon, although the scenarios where it arises may have changed due to developments in society’s beliefs and the healthcare system and dramatic improvements in technology. Perhaps the most clear UK example of how the views of society at large have changed in this context over time comes from the trial of Dr Leonard Arthur (https://en.wikipedia.org/wiki/Leonard_Arthur; accessed 21 March 2016). In 1981, Dr Arthur, a paediatrician based in the English Midlands, was tried for attempted murder following the death of a newborn baby with Down’s syndrome whom he had prescribed ‘nursing care only’ and sedatives.

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Triage Decisions for ICU Admission: report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine

Torra, L.B. et al. Journal of Critical Care. Published online: 22 June 2016

Demand for intensive care unit (ICU) resources often exceeds supply, and shortages of ICU beds and staff are likely to persist. Triage requires careful weighing of the benefits and risks involved in ICU admission, while striving to guarantee fair distribution of available resources.

We must ensure that the patients who occupy ICU beds are those most likely to benefit from the ICU’s specialized technology and professionals. Although prognosticating is not an exact science, preference should be given to patients who are more likely to survive if admitted to the ICU but unlikely to survive or likely to have more significant morbidity if not admitted.

To provide general guidance for intensivists in ICU triage decisions, a task force of the World Federation of Societies of Intensive and Critical Care Medicine addressed four basic questions regarding this process. The team made recommendations and concluded that triage should be led by intensivists considering input from nurses, emergency medicine professionals, hospitalists, surgeons, and allied professionals.

Triage algorithms and protocols can be useful, but can never supplant the role of skilled intensivists basing their decisions on input from multidisciplinary teams. Infrastructures need to be organized efficiently, both within individual hospitals and at the regional level. When resources are critically limited, patients may be refused ICU admission if others may benefit more on the basis of the principle of distributive justice.

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Nutrition in burn injury: any recent changes?.

Berger, M. & Pantet O. Current Opinion in Critical Care. Post Author Corrections: June 16, 2016

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Image source: Justine Desmond – Wellcome Images // CC BY-NC-ND 4.0

Purpose of review: After major progress in the 1980s of burn resuscitation resulting, the last years’ research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers.

Recent findings: Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route.

Summary: Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.

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Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study

Zambon, M. et al. Critical Care Medicine. July 2016. 44(7). pp. 1347–1352

Objective: Mechanical ventilation contributes to diaphragmatic atrophy and dysfunction, and few techniques exist to assess diaphragmatic function: the purpose of this study was to quantify diaphragm atrophy in a population of critically ill mechanically ventilated patients with ultrasound and to identify risk factors that can worsen diaphragmatic activity.

Design: Prospective observational study.

Setting: ICU of a 1,200-bed university hospital.

Patients: Newly intubated adult critically ill patients.

Interventions: Diaphragm thickness in the zone of apposition was measured daily with ultrasound, from the first day of mechanical ventilation till discharge to the main ward.

Measurements and Main Results: Daily atrophy rate (ΔTdi/d) was calculated as the reduction in percentage from the previous measurement. To analyze the difference in atrophy rate (ΔTdi/d), ventilation was categorized into four classes: spontaneous breathing or continuous positive airway pressure; pressure support ventilation 5–12 cm H2O (low pressure support ventilation); pressure support ventilation greater than 12 cm H2O (high pressure support ventilation); and controlled mechanical ventilation. Multivariate analysis with ventilation support and other clinical variables was performed to identify risk factors for atrophy. Forty patients underwent a total of 153 ultrasonographic evaluations. Mean (SD) ΔTdi/d was –7.5% (12.3) during controlled mechanical ventilation, –5.3% (12.9) at high pressure support ventilation, –1.5% (10.9) at low pressure support ventilation, +2.3% (9.5) during spontaneous breathing or continuous positive airway pressure. At multivariate analysis, only the ventilation support was predictive of diaphragm atrophy rate. Pressure support predicted diaphragm thickness with coefficient –0.006 (95% CI, –0.010 to –0.002; p = 0.006).

Conclusions: In critically ill mechanically ventilated patients, there is a linear relationship between ventilator support and diaphragmatic atrophy rate.

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Defining Sepsis Mortality Clusters in the United States

Moore, J.X. et al. Critical Care Medicine. July 2016. 44 (7). pp. 1380–1387

Objectives: In the United States, sepsis is a major public health problem accounting for over 200,000 annual deaths. The aims of this study were to identify U.S. counties with high sepsis mortality and to assess the community characteristics associated with increased sepsis mortality.

Design: We performed a descriptive analysis of 2003 through 2012 Compressed Mortality File data. We defined sepsis deaths as deaths associated with an infection, classified according to the International Classification of Diseases, 10th Version.

Setting: Three thousand one hundred and eight counties in the contiguous U.S. counties, excluding Hawaii and Alaska.

Measurements and Main Results: Using geospatial autocorrelation methods, we defined county-level sepsis mortality as strongly clustered, moderately clustered, and nonclustered. We approximated the mean crude, age-adjusted, and community-adjusted sepsis mortality rates nationally and for clustering groups. We contrasted demographic and community characteristics between clustering groups. We performed logistic regression for the association between strongly clustered counties and community characteristics. Among 3,108 U.S. counties, the age-adjusted sepsis mortality rate was 59.6 deaths per 100,000 persons (95% CI, 58.9–60.4). Sepsis mortality was higher in the Southern U.S. and clustered in three major regions: Mississippi Valley, Middle Georgia, and Central Appalachia. Among 161 (5.2%) strongly clustered counties, age-adjusted sepsis mortality was 93.1 deaths per 100,000 persons (95% CI, 90.5–95.7). Strongly clustered sepsis counties were more likely to be located in the south (92.6%; p < 0.001), exhibit lower education, higher impoverished population, without medical insurance, higher medically uninsured rates, and had higher unemployment rates (p < 0.001).

Conclusions: Sepsis mortality is higher in the Southern United States, with three regional clusters: “Mississippi Valley,” “Middle Georgia,” and “Central Appalachia”: Regions of high sepsis mortality are characterized by lower education, income, employment, and insurance coverage.

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