The benefits of 24/7 in-house intensivist coverage for prolonged-stay cardiac surgery patients

ObjectiveThe objective of our study was to evaluate the efficacy of 24/7 in-house intensivist care for patients requiring prolonged intensive care unit (ICU) stay following cardiac surgery.MethodsA propensity-matched retrospective before-and-after observational study comparing 2 models of ICU physician staffing was undertaken. Previously, residents (with intensivist backup) provided care for patients after cardiac surgery (surgical ICU cohort). ICU physician staffing was modified with the implementation of 24/7 in-house board-certified intensivist coverage in a cardiac surgery ICU (cardiac surgery ICU cohort) for postoperative care. Patients with a prolonged ICU stay (ie, >48 hours) were identified and their outcomes analyzed for both models of care.ResultsPropensity matching between cohorts was successful for 271 patients (75.7%), with matched patients being used for comparison. There was no difference in ICU or 30-day mortality. There was also no difference in ICU length of stay (LOS); however, the median hospital LOS was significantly shorter in the cardiac surgery ICU cohort (12.3 vs 11.0 days; P < .01). There was a decrease in the proportion of patients receiving transfused red blood cells in the cardiac surgery ICU cohort (80.8% vs 65.7%; P < .001). The cardiac surgery ICU cohort had reduced complications relating to sepsis (4.7% vs 0.7%; P < .01) and renal failure (22.5% vs 12.5%; P < .01); however, the identification of neurologic dysfunction was significantly higher (11.1% vs 20.7%; P < .01).ConclusionsFor patients requiring a prolonged ICU stay, our model of 24/7 in-house intensivist coverage was not associated with changes in ICU LOS, nor ICU and 30-day mortality. However a reduction in blood product use, ICU complications, and total hospital LOS was observed

ISTH guidelines for antithrombotic treatment in COVID-19

Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID-19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, ISTH assembled an international panel of content experts, patient representatives, and a methodologist to develop recommendations on anticoagulants and antiplatelet agents for patients with COVID-19 in different clinical settings. We used the American College of Cardiology Foundation/American Heart Association methodology to assess level of evidence (LOE) and class of recommendation (COR). Only recommendations with LOE A or B were included. Panelists agreed on 12 recommendations: three for non-hospitalized, five for non-critically ill hospitalized, three for critically ill hospitalized, and one for post-discharge patients. Two recommendations were based on high-quality evidence, the remainder on moderate-quality evidence. Among non-critically ill patients hospitalized for COVID-19, the panel gave a strong recommendation (a) for use of prophylactic dose of low molecular weight heparin or unfractionated heparin (LMWH/UFH) (COR 1); (b) for select patients in this group, use of therapeutic dose LMWH/UFH in preference to prophylactic dose (COR 1); but (c) against the addition of an antiplatelet agent (COR 3). Weak recommendations favored (a) sulodexide in non-hospitalized patients, (b) adding an antiplatelet agent to prophylactic LMWH/UFH in select critically ill, and (c) prophylactic rivaroxaban for select patients after discharge (all COR 2b). Recommendations in this guideline are based on high-/moderate-quality evidence available through March 2022. Focused updates will incorporate future evidence supporting changes to these recommendations

Author Correction: Convalescent plasma for hospitalized patients with COVID-19: an open-label, randomized controlled trial (Nature Medicine, (2021), 27, 11, (2012-2024), 10.1038/s41591-021-01488-2)

In the version of this Article initially published, there was an omission in the member list for the CONCOR-1 Study Group. Valérie Arsenault (Héma-Québec, Montreal, Quebec, Canada) has now been included in the CONCOR-1 Study Group in the online version of the article

The Rise of Adaptive Platform Trials in Critical Care

As durable learning research systems, adaptive platform trials represent a transformative new approach to accelerating clinical evaluation and discovery in critical care. This Perspective provides a brief introduction to the concept of adaptive platform trials, describes several established and emerging platforms in critical care, and surveys some opportunities and challenges for their implementation and impact.<br/