Coincidental multisystemic organ failure and dress syndrome in the context of septic shock

Learning Objectives: Dermatologic emergencies are well described in the critically-ill patients; however, the underlying cause may be difficult to isolate when other life-threatening conditions coexist. Methods: We describe the case of a 45-year-old female with history of morbid obesity and hypertension, admitted for septic arthritis of the right hip. She had a remote history of bilateral hip replacements for developmental hip dysplasia, and more recently a surgical revision of a loose right acetabular component. The patient presented to an outside facility with sepsis secondary to infected right hip (blood cultures positive for Methicillin-Resistant Staphylococcus aureus) after her recent hip revision. She was started on intravenous vancomycin in addition to surgical removal of the components and placement of a vancomycin-impregnated spacer. Her condition deteriorated into septic shock despite subsequent multiple antibiotic regimens, and required escalation of care to our institution where she was found to be in persistent vasopressor- dependent shock with multi-organ failure. A moderately-sized fluid collection in the right vastus intermedius was evidenced in further imaging. A generalized erythematous skin rash of approximately 90% of her body area was noted, as well as peripheral eosinophilia, fever and elevated liver function tests. Dermatology was consulted and her condition was attributed to “Drug-reaction with eosinophilia and Systemic Symptoms” (DRESS Syndrome), due to prior antibiotic therapies (most probable Vancomycin). Although vancomycin had been discontinued at the outside hospital when the rash began, it was overlooked that her indwelling antibiotic spacer was comprised of vancomycin. She was taken to the operating room for source control and removal of the spacer and started on high dose systemic steroids. Results: A multidisciplinary team approach of this case was crucial, as finding a balance between immunosuppression and the systemic infection was particularly challenging. DRESS syndrome is a life-threatening condition, and may reach a menacing 10% mortality with multisystemic involvement, thus the intensivist should be mindful of the precipitating factors for DRESS, particularly those lying deep within the patient

Older patients\u27 perceptions of medication importance and worth: an exploratory pilot study

BACKGROUND: Cost-related medication non-adherence may be influenced by patients\u27 perceived importance of their medications. OBJECTIVES: This exploratory pilot study addresses three related but distinct questions: Do patients perceive different levels of importance among their medications? What factors influence perceptions of medication importance? Is perceived importance associated with perceived worth of medications, and does expense impact on that association? METHODS: Study participants included individuals aged \u3eor=60 years who were taking three or more prescription drugs. Semi-structured, in-person interviews were conducted to measure how patients rated their medications in terms of importance, expense and worth. Factors that influenced medication importance were identified using qualitative analysis. Ordinal logistic regression analyses were employed to examine the association between perceived importance and perceived worth of medications, and the impact of expense on that association. RESULTS: For 143 prescription drugs reported by 20 participants, the weighted mean rating of medication importance was 8.2 (SD 1.04) on a scale from 0 (not important at all) to 10 (most important). Patients considered 38% of these medications to be expensive. The weighted mean rating of worth was 8.4 (SD 1.46) on a scale from 0 (not worth it at all) to 10 (most worth). Three major factors influenced medication importance: drug-related (characteristics, indications, effects and alternatives); patient-related (knowledge, attitudes and health); and external (the media, healthcare and family caregivers, and peers). Regression analyses showed an association between perceived importance and perceived worth for inexpensive medications (odds ratio [OR] 2.23; p = 0.002) and an even greater association between perceived importance and perceived worth for expensive medications (OR 4.29; p \u3c 0.001). DISCUSSION: This study provides preliminary evidence that elderly patients perceive different levels of importance for their medications based on factors beyond clinical efficacy. Their perception of importance influences how they perceive their medications\u27 worth, especially for medications of high costs. Understanding how patients perceive medication importance may help in the development of interventions to reduce cost-related non-adherence

Use of Early Ketamine Sedation and Association With Clinical and Cost Outcomes Among Mechanically Ventilated Patients With COVID-19: A Retrospective Cohort Study.

OBJECTIVES: To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes. DESIGN: Retrospective cohort study. SETTING: Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021. PATIENTS: Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization. INTERVENTION: The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day. MEASUREMENTS: Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders. MAIN RESULTS: Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06-1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08-1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12-1.27]). There were no associations for hospital LOS (17 [10-27] vs. 17 [9-28], MR: 1.05 [0.99-1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95-1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92-1.21]). Total hospital cost was higher (median $72,481 vs.$65,584, MR: 1.11 [1.05-1.19]). CONCLUSIONS: In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients

Use of Early Ketamine Sedation and Association With Clinical and Cost Outcomes Among Mechanically Ventilated Patients With COVID-19: A Retrospective Cohort Study

OBJECTIVES:. To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes. DESIGN:. Retrospective cohort study. SETTING:. Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021. PATIENTS:. Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization. INTERVENTION:. The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day. MEASUREMENTS:. Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders. MAIN RESULTS:. Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06–1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08–1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12–1.27]). There were no associations for hospital LOS (17 [10–27] vs. 17 [9–28], MR: 1.05 [0.99–1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95–1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92–1.21]). Total hospital cost was higher (median $72,481 vs.$65,584, MR: 1.11 [1.05–1.19]). CONCLUSIONS:. In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study.

PURPOSE Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). METHODS An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. RESULTS The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. CONCLUSION Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation A Report From the GARFIELD-AF Registry

IMPORTANCE Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes