The Critical Care Crisis of Opioid Overdoses in the United States

The August 2017 issue of Annals of the American Thoracic Society included this article by Stevens and colleagues.

Rationale:  Opioid abuse is increasing, but its impact on critical care resources in the United States is unknown.

Objective:  We hypothesized that there would be a rising need for critical care among opioid-associated overdoses in the United States.

Methods:  We analyzed all adult admissions using a retrospective cohort study from 162 hospitals in 44 states discharged between January 1, 2009 – September 31, 2015 to describe the incidence of intensive care unit (ICU) admissions for opioid overdose over this time. Admissions were identified using the Clinical Data Base/Resource ManagerTM of Vizient, Inc, the successor to the University Health System Consortium.

Results:  Our primary outcome was opioid-associated overdose admissions to the ICU. The outcome was defined based on previously validated ICD-9 codes. Our secondary outcomes were in-hospital death and markers of ICU resources. The final cohort included 22,783,628 admissions; 4,145,068 required ICU care. There were 52.4 ICU admissions for overdose per 10,000 ICU admissions over the entire study (95% confidence intervals: 51.8-53.0 per 10,000 ICU admissions). During this time period, opioid overdose admissions requiring intensive care increased 34%, from 44 per 10,000 (95% CI: 43 to 46 per 10,000) to 59 per 10,000 ICU admissions (95% CI: 57 to 61 per 10,000, p<0.0001). The mortality rate of patients with ICU admissions with overdoses averaged 7% (95% CI: 7.0-7.6%) but increased to 10% in 2015 (95% CI: 8.8-10.8%).

Conclusions:  The number of deaths of ICU patients with opioid overdoses increased substantially in the seven years of our study, reflecting increases in both the incidence and mortality of this condition. Our findings raise the need for a national approach to developing safe strategies to care for patients with overdose in the ICU, to providing coordinated resources in the hospital for patients and families, and to helping survivors maintain sobriety on discharge.

The full paper can be accessed by subscribers to the “Annals of the American Thoracic Society” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Management of multidrug-resistant Pseudomonas aeruginosa in the intensive care unit: State of the art

This paper by Maraolo et al was published in the August 2017 issue of “Expert review of anti-infective therapy”.

Introduction:  Pseudomonas aeruginosa (PA) is one of the most important causes of healthcare-related infections among Gram-negative bacteria. The best therapeutic approach is controversial, especially for multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains as well as in the setting of most severe patients, such as in the intensive care unit (ICU).

Areas covered:  This article addresses several points. First, the main microbiological aspects of PA, focusing on its wide array of resistance mechanisms. Second, risk factors and the worse outcome linked to MDR-PA infection. Third, the pharmacological peculiarity of ICU patients, that makes the choice of a proper antimicrobial therapy difficult. Eventually, the current therapeutic options against MDR-PA are reviewed, taking into account the main variables that drive antimicrobial optimization in critically ill patients. Literature search was carried out using Pubmed and Web of Science.

Expert commentary: Methodologically rigorous studies are urgently needed to clarify crucial aspects of the treatment against MDR-PA, namely monotherapy versus combination therapy in empiric and targeted settings. In the meanwhile, useful options are represented by newly approved drugs, such as ceftolozane/tazobactam and ceftazidime/avibactam. In critically ill patients, at least as empirical approach, a combination therapy is a prudent choice when a MDR-PA strain is suspected.

The full paper can be accessed by subscribers to “Expert Review of Anti-Infective Therapy” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Latest issue of “Journal of Critical Care” Volume 40 August 2017

The content page ofjournal of critical care.png this issue can be accessed via this link

Articles published in this issue include “Impact of duration of hypotension prior to norepinephrine initiation in medical intensive care unit patients with septic shock: A prospective observational study”, “Clinical variables associated with poor outcome from sepsis-associated acute kidney injury and the relationship with timing of initiation of renal replacement therapy”, “Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care” and “Time delays associated with vasoactive medication preparation and delivery in simulated patients at risk of cardiac arrest”.

A personal subscription to the journal is required to access the full text of these articles direct from this website.  However, articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  This can be done either in person or via this link if you are a registered member of the library.

Real-Time Surveillance of Influenza Morbidity: Tracking Intensive Care Unit Resource Utilization

This research by Baker et al was published in the August 2017 issue of Annals of the American Thoracic Society

Rationale:  Existing real-time surveillance of influenza morbidity, based primarily upon time-trended U.S. hospitalization and death data, is inadequate. These surveillance methods do not accurately predict hospital resource requirements or sufficiently capture the public health impact of the current influenza season.

Objective:  To determine the feasibility and potential usefulness of tracking surrogate markers of influenza morbidity among patients hospitalized with influenza.

Methods:  We performed a pilot study at three tertiary care referral hospitals and retrospectively collected and analyzed data on patients admitted with influenza during the 2013-2014 influenza season. We analyzed traditional influenza surveillance metrics, including weekly statistics on admissions and deaths, as well as weekly rates and trends of intensive care unit (ICU), mechanical ventilation, and extracorporeal membrane oxygenation (ECMO) utilization.

Results:  In our three-hospital cohort, 431 patients were hospitalized with influenza and spent a total of 1,520 days in ICUs. Eighty-six (20%) of these patients required 1,080 days of mechanical ventilation, and 17 (4%) patients received 229 days of ECMO. Trends of ICU and mechanical ventilation use were similar but differed notably from trends of ECMO use, hospitalization, and death. In particular, at two hospitals, increases in utilization of ICU and mechanical ventilation among patients with influenza occurred several weeks after increases in hospitalization rates. Furthermore, ICU, mechanical ventilation, and ECMO utilization rates at the three-hospital network remained elevated for several weeks after the influenza-associated hospitalization rate declined.

Conclusions:  Surrogate markers of influenza severity were feasible to collect and revealed trends of ICU resource utilization that differed notably from trends of hospitalization and death given by traditional influenza surveillance metrics. A national network of sentinel hospitals that prospectively collects, time-trends, and reports additional influenza morbidity data would be useful to hospital administrators, hospital epidemiologists, infection preventionists, and public health officials.

The full paper can be accessed by subscribers to the “Annals of the American Thoracic Society” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Spiritual Care in the ICU: Perspectives of Dutch Intensivists, ICU Nurses, and Spiritual Caregivers

This article was published in the August 2017 issue of the “Journal of Religion and Health” and written by Willemse and colleagues.

Since there are no scientific data available about the role of spiritual care (SC) in Dutch ICUs, the goal of this quantitative study was twofold: first, to map the role of SC as a part of daily adult ICU care in The Netherlands from the perspective of intensivists, ICU nurses, and spiritual caregivers and second, to identify similarities and differences among these three perspectives. This study is the quantitative part of a mixed methods approach. To conduct empirical quantitative cohort research, separate digital questionnaires were sent to three different participant groups in Dutch ICUs, namely intensivists, ICU nurses, and spiritual caregivers working in academic and general hospitals and one specialist oncology hospital. Overall, 487 participants of 85 hospitals (99 intensivists, 290 ICU nurses, and 98 spiritual caregivers) responded. The majority of all respondents (>70%) considered the positive effects of SC provision to patients and relatives: contribution to mental well-being, processing and channeling of emotions, and increased patient and family satisfaction. The three disciplines diverged in their perceptions of how SC is currently evolving in terms of information, assessment, and provision. Nationwide, SC is not implemented in daily ICU care. The majority of respondents, however, attached great importance to interdisciplinary collaboration. In their view SC contributes positively to the well-being of patients and relatives in the ICU. Further qualitative research into how patients and relatives experience SC in the ICU is required in order to implement and standardize SC as a scientifically based integral part of daily ICU care.

The full paper can be accessed by subscribers to the “Journal of Religion and Health” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 296 13th August 2017

The critcal care reviews296th Critical Care Reviews Newsletter, contains the best critical care research and open access articles from across the medical literature in the last week.  The highlights of this issue are the LICORN randomized clinical trial, evaluating levosimendan in low output states post cardiac surgery; an expert statement on the management of atypical hemolytic uremic syndrome; and narrative reviews on paroxysmal sympathetic hyperactivity after acute brain injury, perioperative fluid management and persistent air leaks.

The full text of the newsletter can be accessed via this link.

Critical Care Reviews Newsletter 295 6th August 2017

This latest edition of the Critical Care Reviews Newsletter includes randomised controlled trials on “Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC)” and “Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients with Acute Ischemic Stroke and Large Vessel Occlusion.”  Systematic reviews and meta-analysis include “Could remifentanil reduce duration of mechanical ventilation in comparison with other opioids for mechanically ventilated patients?” and “Intensive versus standard lowering of blood pressure in the acute phase of intracranial haemorrhage: a systematic review and meta-analysis.”  Also included are observational studies on “Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients” and “How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study.”

The full text of the newsletter can be accessed via this link.