Vasopressor Initiation Research Articles

Enhancing Sepsis Care at an Academic Emergency Department in a Resource-Constrained Setting: A Quality Improvement Initiative.

The early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study aimed to improve the proportion of patients receiving antibiotics within 1 hour of triage and compliance with sepsis bundles. A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 1, 2018, to December 31, 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. Thereafter, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared. The proportion of patients receiving antibiotics within 1 hour of triage improved from 44% to 84%, intravenous crystalloid administration within 3 hours improved from 62% to 94%, serum lactic acid measurement within 3 hours improved from 62% to 94%, and vasopressor initiation within 6 hours improved from 76% to 94%. The mortality rates decreased from 32% to 21% between the 2 study periods. This program emphasizes the impact of a structured quality improvement program on the process and outcomes of care.

Effect of timing of intubation on clinical outcomes of patients with septic shock: a retrospective cohort study.

Evidence-based data regarding the timing of the application of invasive mechanical ventilation among adults with septic shock is insufficient. The guidelines fail to provide clear advice about the optimal time to initiate this support. Consequently, we aimed to investigate whether early intubation could improve survival rates in septic shock patients. We conducted a retrospective analysis of the MIMIC-IV database to evaluate the effectiveness of early intubation on mortality in a cohort of septic shock patients. Adults diagnosed with septic shock, according to the Sepsis-3 definition, were included. They were categorized into an early intubation group (first 8h after vasopressor initiation) and a non-early intubation group (unexposed). A propensity score matching (PSM) analysis was used to balance the baseline characteristics between the two groups. The primary outcomes were 30-day and 90-day all-cause mortality rates. In addition, we employed the restricted cubic spline to analyze the potential non-linear relationship between the timing of intubation and 30-day or 90-day all-cause mortality. A total of 6864 adult patients, of whom 2048 were intubated in the first 8h, were evaluated in the final cohort. Following a 1:1 PSM procedure, 2786 patients were successfully paired. At 30days, 288 of 1393 patients (20.7%) in the early intubation group and 381 of 1393 patients (27.4%) in the non-early intubation group had died (hazard ratio [HR] 0.717; 95% confidence interval [CI] 0.616-0.836; p < 0.001). Similarly, the results also showed that early intubation was associated with a lower 90day all-cause mortality rate (HR 0.761; 95% CI 0.663-0.874; p < 0.001). Furthermore, ICU and hospital lengths of stay were significantly different between the groups (3.6 [1.9, 7.1] vs. 2.3 [1.3, 4.3]; p < 0.001 and 8.9 [5.4, 15.1] vs. 7.2 [4.5, 12.0]; p < 0.001). In the subgroup analysis, we further confirmed the robustness of our findings. Additionally, we found that the timing of intubation is inversely U-shaped correlated to the 30day all-cause mortality rate. Among adult patients with septic shock, the early initiation of invasive mechanical ventilation could improve clinical outcomes. The timing of intubation demonstrated an inverse U-shaped association with the 30day all-cause mortality rate, with the peak risk of death occurring at 50.5h after septic shock.

Evolving trends of pharmaceutical poisonings associated with QRS complex prolongation

Introduction Tricyclic antidepressants often cause drug-induced QRS complex prolongation in overdose but are now less commonly prescribed. We sought to determine, among a contemporary cohort of patients, the pharmaceuticals independently associated with QRS complex prolongation in acute overdose. Methods We performed secondary analysis of data from the Toxicology Investigators Consortium (ToxIC) Core Registry. We included adult patients presenting from January 2016 through March 2023 with acute or acute-on-chronic pharmaceutical exposures. The primary outcome was QRS complex prolongation >0.12 s. Secondary outcomes included cardiac arrest, death, ventricular dysrhythmia, intensive care unit admission, initiation of vasopressors, and treatment with sodium bicarbonate. We used a multivariable logistic regression model with QRS complex prolongation as the outcome and individual pharmaceuticals of interest as independent variables. We assessed yearly trends of the contribution of relevant pharmaceuticals to QRS complex prolongation since 2016. Results Of 11,945 patients in the total cohort (median age 37 years, 6,652 [55.7%] female), 366 (3.1%) developed QRS complex prolongation. Of 9,417 patients included in the model, 290 (3.1%) developed QRS complex prolongation. Amitriptyline, nortriptyline, doxepin, imipramine, noxiptiline, bupropion, flecainide, carvedilol, propranolol, diphenhydramine, and lamotrigine poisonings were independent predictors of QRS complex prolongation. Flecainide poisoning conferred the greatest odds of QRS complex prolongation (OR 574.1; 95% CI: 88.3–12,747). The contribution of tricyclic antidepressants to QRS complex prolongation decreased from 38.8% to 17.6% of all patients with QRS complex prolongation from 2016 to 2022. In 2022, the proportion of QRS complex prolongation from diphenhydramine (20.6%) surpassed that of tricyclic antidepressants. Discussion This study provides insights into contemporary pharmaceutical poisoning associated with QRS complex prolongation. Tricyclic antidepressants remain clinically relevant exposures but are no longer the most common cause of drug-induced QRS complex prolongation. Conclusions Bupropion, diphenhydramine, and antidysrhythmics are increasingly common causes of QRS complex prolongation, each associated with numerous severe outcomes in poisoning. Greater safety measures to protect patients from cardiovascular toxicity from these pharmaceuticals are warranted.

Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?

Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients. This was a retrospective analysis of the 2017-2018 ACS-TQIP database. We included adult (≥18years) trauma patients presenting with hypotension (lowest SBP <90mmHg) who received vasopressors within 6hours of admission. We excluded patients who had a severe head injury (Head-AIS >3) and those with spinal cord injury (Spine-AIS >3). Patients were stratified based on the time to receive vasopressors. Multivariable regression analyses were performed to identify the independent association between timing of vasopressor initiation and outcomes. 1049 patients were identified. Mean age was 55 ± 20years, and 70% of patients were male. The median ISS was 16 [9-24], 80% had a blunt injury, and the mean SBP was 61 ± 24mmHg. The median time to first vasopressor administration was 319 [68-352] minutes. Overall, 24-hour and in-hospital mortality rates were 19% and 33%, respectively. Every one-hour delay in vasopressor administration beyond the first hour was independently associated with decreased odds of 24-hour mortality (aOR: 0.65, P < 0.001), in-hospital mortality (aOR: 0.65, P < 0.001), major complications (aOR: 0.77, P = 0.003), and increased odds of longer ICU LOS (β + 2.53, P = 0.012). There were no associations between the timing of early vasopressor administration and 24-hour PRBC transfusion requirements (P > 0.05). Earlier vasopressor requirement among hypotensive trauma patients was independently associated with increased mortality and major complications. Further research on the utility and optimal timing of vasopressors during the post-injury resuscitative period is warranted. III therapeutic/care management.

One-Hour Bundle Protocols for Surgical Sepsis and Septic Shock in Surgical Intensive Care Unit: Clinical Outcome Aspects in the Thai Context.

Surgical sepsis is a syndrome occurring during the perioperative period with a high mortality rate. Since the one-hour bundle protocol was recommended to decrease sepsis-related morbidity and mortality in clinical practice, the protocol has been applied to surgical patients with sepsis and septic shock. However, clinical outcomes in these surgical patients remain unknown. Thus, this study aimed to compare survival outcomes in patients before and after the implementation of one-hour bundle care in clinical practice. In thisprospective cohort study, 401 surgical patients with sepsis were divided into two groups, with 195 patients undergoing the one-hour bundle from December 25, 2021, to March 31, 2024, and 206 patients undergoing usual care from January 1, 2018, to December 24, 2021, before the one-hour bundle protocol was implemented by the Surviving Sepsis Campaign (SSC). Demographic data, treatment processes, and clinical outcomes were recorded. After the one-hour bundle protocol was applied in surgical practice, the median survival time was significantly increased in surgical patients who underwent one-hour bundle care (95% confidence interval (CI): 12.32-19.68) (p= 0.016). Factors influencing the increase in the mortality rate were delays in fluid resuscitation of >2 hours, vasopressor initiation of >2 hours, and empirical antibiotics of >5 hours (p= 0.017, 0.028, and 0.008, respectively). One-hour bundle care for surgical patients with sepsis resulted in an increased median survival time. Delays in fluid resuscitation (>2 hours), vasopressor initiation (>2 hours), and empirical antibiotics (>5 hours) were factors associated with mortality.

Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice. To understand how clinicians personalize decisions about resuscitation in practice. This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023. Online Qualtrics clinical vignette survey. Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs. Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%). These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.

Clinical Response to Third-Line Angiotensin-II vs Epinephrine in Septic Shock: A Propensity-Matched Cohort Study.

The appropriate third-line vasopressor in septic shock patients receiving norepinephrine and vasopressin is unknown. Angiotensin-II (AT-II) offers a unique mechanism of action to traditionally used vasopressors in septic shock. The objective of this study was to compare the clinical efficacy and safety of third-line AT-II to epinephrine in patients with septic shock. A single-center, retrospective cohort study of critically ill patients was performed between April 1, 2019 and July 31, 2022. Propensity-matched (2:1) analysis compared adults with septic shock who received third-line AT-II to controls who received epinephrine following norepinephrine and vasopressin. The primary outcome was clinical response 24 hours after third-line vasopressor initiation. Additional efficacy and safety outcomes were investigated. Twenty-three AT-II patients were compared with 46 epinephrine patients. 47.8% of AT-II patients observed a clinical response at hour 24 compared with 28.3% of epinephrine patients (P = 0.12). In-hospital mortality (65.2% vs 73.9%, P = 0.45), cardiac arrhythmias (26.1% vs 26.1%, P = 0.21), and thromboembolism (4.3% vs 2.2%, P = 0.61) were not observed to be statistically different between groups. Administration of AT-II as a third-line vasopressor agent in septic shock patients was not associated with significantly improved clinical response at hour 24 compared with epinephrine. Although underpowered to detect meaningful differences, the clinical observations of this study warrant consideration and further investigation of AT-II as a third-line vasopressor in septic shock.

Investigating the Smoker's Paradox: Aortic Stenosis Patient Outcomes in Smokers

BackgroundSmoking is a major risk factor for premature atherosclerosis, myocardial infarction (MI), heart failure (HF), and sudden cardiac death. Studies suggest that smokers lose at least a decade of life expectancy compared to non-smokers. Despite these well-documented risks, the short-term mortality rates following acute coronary syndromes (ACSs) or related HF are lower in current smokers than non-smokers, a phenomenon known as the smoker's paradox. This study aimed to examine the influence of smoking on in-hospital outcomes for patients diagnosed with aortic stenosis (AS) in the United States and ascertain the presence of the smoker's paradox in this patient population. MethodsIn this study, we utilized the National Inpatient Sample (NIS) for the year of 2020 to identify all patients who were admitted for a principal diagnosis of aortic stenosis (AS). Subsequently, we isolated those patients with an ICD-10 code indicating smoking or tobacco use. To examine associations, both logistic and linear regression analyses were employed while adjusting for potential confounding factors. Our findings were considered significant if the 2-tailed p-value was 0.05 or lower. ResultsIn 2020, there were 102,615 hospitalizations with a principal diagnosis of aortic stenosis, 41,689 (40.6%) of these cases involved patients with a secondary diagnosis of smoking history or use. After accounting for factors such as age, race, gender, hospital bed size, location, teaching status, insurance coverage, income level, and Elixhauser comorbidities, we found that patients who smoked and had AS demonstrated a lower rate of in-hospital mortality (aOR 0.64, 95% CI 0.51 – 0.81), mechanical ventilation (aOR 0.77, 95% CI 0.67- 0.88), vasopressor initiation (aOR 0.79, 95% CI 0.64- 0.95), mechanical circulatory support (aOR 0.56, 95% CI 0.34-0.91), and hemodialysis initiation (aOR 0.56, 95% CI 0.47-0.67) when compared to non-smoking patients with AS (Figure 1). ConclusionOur study demonstrated that patients with a primary diagnosis of aortic stenosis (AS) and a history of smoking or tobacco use had significantly lower odds of in-hospital mortality, mechanical ventilation, vasopressor use, mechanical circulatory support, and hemodialysis initiation compared to their non-smoking counterparts with AS. To comprehensively understand the smoker's paradox and its influence on clinical outcomes for patients hospitalized with AS, it is crucial to carry out larger, methodologically rigorous investigations. Such studies will aid in revealing the underlying mechanisms and reasons behind the persistence of this paradox, despite its apparent contradiction, ultimately enhancing our understanding and informing more effective patient care strategies.

Investigating the Smoker's Paradox: Acute Myocardial Infarction Outcomes in Smokers

BackgroundNon-adherence is a barrier to the control of hypertension. This study Background.Smoking is known to negatively impact cardiovascular health and reduce life expectancy. However, the smoker's paradox suggests that current smokers with acute myocardial infarction (AMI) experience lower short-term mortality rates than non-smokers. This study investigates the effect of smoking on in-hospital outcomes for AMI patients in the United States, aiming to understand the presence of this paradox within this population. MethodsIn this study, we utilized the National Inpatient Sample (NIS) for the year of 2020 to identify all patients who were admitted for a principal diagnosis of AMI. Subsequently, we isolated those patients with an ICD-10 code indicating smoking or tobacco use. To examine associations, both logistic and linear regression analyses were employed while adjusting for potential confounding factors. Our findings were considered significant if the 2-tailed p-value was 0.05 or lower. ResultsIn 2020, there were 446,834 hospitalizations for AMI. Of these cases, 230,120 (51.5%) involved patients with a secondary diagnosis of smoking history or use. After accounting for various factors such as age, race, gender, hospital bed size, location, teaching status, insurance coverage, income level, and Elixhauser comorbidities, patients admitted for AMI with a secondary diagnosis of smoking use exhibited a lower rate of in-hospital mortality (aOR 0.58, 95% CI 0.55-0.63), mechanical ventilation (aOR 0.74, 95% CI 0.66-0.74), vasopressor initiation (aOR 0.69, 95% CI 0.64-0.76), mechanical circulatory support (aOR 0.52, 95% CI 0.46-0.57), and hemodialysis initiation (aOR 0.52, 95% CI 0.48-0.56). Notably, these patients also had higher odds of receiving percutaneous coronary intervention (PCI) (aOR 1.18, 95% CI 1.37-1.98) compared to non-smoking patients with AMI (Figure 1). ConclusionOur study showed that AMI patients with a smoking history had lower odds of in-hospital mortality, mechanical ventilation, vasopressor use, circulatory support, and hemodialysis initiation, but higher odds of PCI compared to non-smokers. To fully understand the smoker's paradox, larger, robust investigations are needed to reveal underlying mechanisms, and ultimately, inform more effective patient care strategies.

Investigating the Smoker's Paradox: Congested Heart Failure Outcomes in Smokers

BackgroundSmoking is a well-established risk factor for cardiovascular diseases, negatively impacting overall health and decreasing life expectancy. Intriguingly, the smoker's paradox suggests that current smokers diagnosed with congestive heart failure (CHF) may experience lower short-term mortality rates than their non-smoking counterparts. In this study, we investigate the effects of smoking on in-hospital outcomes for CHF patients in the United States, aiming to explore the presence and implications of this paradox within this population. MethodsIn this study, we analyzed data from the 2020 National Inpatient Sample (NIS) to identify patients admitted primarily for congestive heart failure (CHF). We then focused on patients with ICD-10 codes indicative of smoking or tobacco use. To investigate the associations, we utilized logistic and linear regression analyses, adjusting for potential confounders. Results with a 2-tailed p-value of 0.05 or lower were deemed statistically significant. ResultsIn 2020, a total of 513,730 hospitalizations were recorded for congestive heart failure (CHF). Among these cases, 247,575 (48.2%) involved patients with a secondary diagnosis of smoking history or use. After adjusting for factors such as age, race, gender, hospital bed size, location, teaching status, insurance coverage, income level, and Elixhauser comorbidities, CHF patients with a secondary smoking diagnosis demonstrated lower rates of in-hospital mortality (aOR 0.55, 95% CI 0.51-0.62), vasopressor initiation (aOR 0.56, 95% CI 0.48-0.65), mechanical circulatory support (aOR 0.33, 95% CI 0.24-0.44), and hemodialysis initiation (aOR 0.44, 95% CI 0.37-0.52). ConclusionOur study revealed that CHF patients with a smoking history exhibited lower odds of in-hospital mortality, vasopressor use, mechanical circulatory support, and hemodialysis initiation in comparison to non-smokers. To gain a comprehensive understanding of the smoker's paradox, it is essential to conduct more extensive, robust investigations that uncover the underlying mechanisms, ultimately informing the development of more effective patient care strategies.

Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units.

Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.

Application of Machine Learning Models to Biomedical and Information System Signals From Critically Ill Adults

Machine learning (ML)-derived notifications for impending episodes of hemodynamic instability and respiratory failure events are interesting because they can alert physicians in time to intervene before these complications occur. Do ML alerts, telemedicine system (TS)-generated alerts, or biomedical monitors (BMs) have superior performance for predicting episodes of intubation or administration of vasopressors? An ML algorithm was trained to predict intubation and vasopressor initiation events among critically ill adults. Its performance was compared with BM alarms and TS alerts. ML notifications were substantially more accurate and precise, with 50-fold lower alarm burden than TS alerts for predicting vasopressor initiation and intubation events. ML notifications of internal validation cohorts demonstrated similar performance for independent academic medical center external validation and COVID-19 cohorts. Characteristics were also measured for a control group of recent patients that validated event detection methods and compared TS alert and BM alarm performance. The TS test characteristics were substantially better, with 10-fold less alarm burden than BM alarms. The accuracy of ML alerts (0.87-0.94) was in the range of other clinically actionable tests; the accuracy of TS (0.28-0.53) and BM (0.019-0.028) alerts were not. Overall test performance (F scores) for ML notifications were more than fivefold higher than for TS alerts, which were higher than those of BM alarms. ML-derived notifications for clinically actioned hemodynamic instability and respiratory failure events represent an advance because the magnitude of the differences of accuracy, precision, misclassification rate, and pre-event lead time is large enough to allow more proactive care and has markedly lower frequency and interruption of bedside physician work flows.

Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study

BackgroundVasopressors are traditionally administered via central access, but newer data suggest peripheral administration may be safe and avoid delays and complications associated with central line placement. Research questionHow commonly are vasopressors initiated through peripheral IVs in routine practice? Is vasopressor initiation route associated with in-hospital mortality? Study design and methodsThis retrospective cohort study included adults hospitalized with sepsis (11/2020-9/2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. Results594 patients received vasopressors within 6 hours of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594, 67.3%). Patients with peripheral vs central initiation were similar; body mass index was the only patient factor independently associated with initiation route (aOR of peripheral initiation [per 1 kg/m2 increase]: 0.98, 95%CI: 0.97-1.00, p=0.015). Hospital had a large impact on initiation route (median OR: 2.19, 95%CI: 1.31-3.07). Compared to central, peripheral initiation was faster (median 2.5 vs 2.7 hours from hospital arrival, p=0.002) but associated with less initial norepinephrine use (84.3% vs 96.8%, p=0.001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%, aOR 0.66, 95%CI: 0.39-1.12). There was no documented tissue injury from peripheral vasopressors. Of patients with peripheral initiation, 135/400 (33.8%) never had a central line placed. InterpretationPeripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, there was wide practice variation not explained by patient case-mix and lower use of first-line norepinephrine with peripheral administration, suggesting additional standardization may be needed.

Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis.

To compare guideline-based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH. Single-center, retrospective cohort study. Tertiary care academic medical center in Detroit, Michigan. Adult patients with or without PH hospitalized and diagnosed with sepsis from November 1, 2013 through December 31, 2019. Patients with sepsis were assigned to one of two groups based on a previous PH diagnosis or no PH diagnosis. None. The primary outcome was incidence of respiratory support escalation within 72 h from sepsis time zero. Respiratory support escalation included high-flow nasal cannula, bilevel positive airway pressure, or intubation. One-hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non-PH patients (32.7% vs. 11.5%; p = 0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 h of time zero compared with non-PH patients (3.8% vs. 42.3%; p < 0.001). Vasopressor initiation was more common in patients with PH compared with the non-PH group (40.4% vs. 19.2%; p = 0.018). PH diagnosis was the only independent predictor of respiratory support escalation. During initial sepsis management when compared with patients without PH, patients with PH had increased instances of respiratory support escalation within 72 h of sepsis time zero despite lower fluid resuscitation volumes.

Should we initiate vasopressors earlier in patients with septic shock: A mini systemic review.

Septic shock treatment remains a major challenge for intensive care units, despite the recent prominent advances in both management and outcomes. Vasopressors serve as a cornerstone of septic shock therapy, but there is still controversy over the timing of administration. Specifically, it remains unclear whether vasopressors should be used early in the course of treatment. Here, we provide a systematic review of the literature on the timing of vasopressor administration. Research was systematically identified through PubMed, Embase and Cochrane searching according to PRISMA guidelines. Fourteen studies met the eligibility criteria and were included in the review. The pathophysiological basis for early vasopressor use was classified, with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII. We found that mortality was 28.1%-47.7% in the early vasopressors group, and 33.6%-54.5% in the control group. We also investigated the issue of vasopressor responsiveness. Furthermore, we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use. Based on the literature review, we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.

INITIATION TIMING OF VASOPRESSOR IN PATIENTS WITH SEPTIC SHOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Background: Vasopressor plays a crucial role in septic shock. However, the time for vasopressor initiation remains controversial. We conducted a systematic review and meta-analysis to explore its initiation timing for septic shock patients. Methods: PubMed, Cochrane Library, Embase, and Web of Sciences were searched from inception to July 12, 2023, for relevant studies. Primary outcome was short-term mortality. Meta-analysis was performed using Stata 15.0. Results: Twenty-three studies were assessed, including 2 randomized controlled trials and 21 cohort studies. The early group resulted in lower short-term mortality than the late group (OR [95% CI] = 0.775 [0.673 to 0.893], P = 0.000, I2 = 67.8%). The significance existed in the norepinephrine and vasopressin in subgroup analysis. No significant difference was considered in the association between each hour's vasopressor delay and mortality (OR [95% CI] = 1.02 [0.99 to 1.051], P = 0.195, I2 = 57.5%). The early group had an earlier achievement of target MAP ( P < 0.001), shorter vasopressor use duration ( P < 0.001), lower serum lactate level at 24 h ( P = 0.003), lower incidence of kidney injury ( P = 0.001), renal replacement therapy use ( P = 0.022), and longer ventilation-free days to 28 days ( P < 0.001). Conclusions: Early initiation of vasopressor (1-6 h within septic shock onset) would be more beneficial to septic shock patients. The conclusion needs to be further validated by more well-designed randomized controlled trials.

Abstract P142: Association Of COVID-19 With Hypertensive Crises Outcomes

Introduction: Patients with hypertension who contracted COVID-19 had increased risk of severe disease and hospitalization compared to those without. This analysis aimed to explore the effect of a concurrent COVID-19 diagnosis on patients admitted due to a hypertensive emergency in the first nine months of the pandemic. Methods: We examined data from the 2020 National Inpatient Sample to identify patients who were admitted for hypertensive emergency. We used ICD-10 codes to distinguish between those with and without a COVID-19 diagnosis. We employed logistic and linear regression analyses and accounted for potential confounders. We deemed the results as statistically significant when the 2-tailed p-value was &lt;0.05. Results: In 2020, there were 1,221,535 hospitalizations for a principal diagnosis of hypertensive emergency with 9590 (0.78%) involving patients with a secondary diagnosis of COVID-19. After accounting for confounding factors, patients admitted for hypertensive emergency with COVID-19 exhibited a higher rate of in-hospital mortality (aOR 3.58, 95% CI 2.94-4.35), vasopressor initiation (aOR 1.88, 95% CI 1.27-2.77), and hemodialysis initiation (aOR 1.87, 95% CI 1.65-2.12) (Figure 1). These patients had longer hospital stays (7.90 days vs. 5.23 days, p&lt;0.001) and incurred higher overall hospital costs ($78,775 vs. $61,331, p&lt;0.001). Conclusion: Infection with COVID-19 appeared to play a significant role in patients admitted for hypertensive emergency. As COVID-19 settles into an endemic virus, the question of how its pathophysiology may drive more complicated disease in severely hypertensive patients remains an important point of study.

Abstract P141: Association Of Female Sex With Outcomes Of Hypertensive Emergencies

Introduction: There are well established sex differences in incidence and degrees of hypertension. We conducted an analysis aimed at uncovering sex differences in the outcomes amongst patients that were admitted due to hypertensive emergency. Methods: We analyzed the 2020 National Inpatient Sample to evaluate patients primarily admitted for hypertensive emergencies and then further stratified these patients by sex. To discern potential correlations, we used logistic and linear regression analyses, factoring in potential confounding variables. We considered results statistically significant when the 2-tailed p-value was &lt;0.05. Results: In 2020, there were 1,221,535 hospitalizations for a principal diagnosis of hypertensive emergency, including 581,855 (47.6%) females. After accounting for various factors such as age, race, hospital bed size, location, teaching status, insurance coverage, income level, and Elixhauser comorbidities, female patients admitted for hypertensive emergency exhibited a lower rate of in-hospital mortality (aOR 0.82, 95% CI 0.77-0.87), vasopressor initiation (aOR 0.66, 95% CI 0.60-0.73), mechanical circulatory support (aOR 0.47, 95% CI 0.37-0.59), and hemodialysis initiation (aOR 0.95, 95% CI 0.92-0.98) when compared with males (Figure 1). Conclusion: In hospital admissions for hypertensive emergency in 2020, females had better outcomes when compared with males. Further research is required to uncover why such sex differences exist.

Who is at risk of clinical deterioration? Adverse events among trauma patients undergoing intra-hospital transport for emergent computerized tomography

Introduction Computerized tomography is an essential element of the early diagnostic stages of trauma care for hemodynamically stable patients. However, there are inherent challenges and risks associated with the intra-hospital transport of critically injured trauma patients to the radiology suite and during the scanning process itself. We examined the frequency and nature of adverse events during computerized tomography among critically injured patients. Methods This is a retrospective cohort study of adverse event in critically injured adult (&gt;18 years old) trauma patients who underwent emergent computerized tomographic scan following evaluation in the trauma bay over a 22-month period who were either admitted to the intensive care unit or the operating room post computerized tomography. Data was abstracted from the hospital's trauma registry and chart review of electronic medical records. The frequency of adverse events during computerized tomography and the associated patient transport phases was recorded. Multivariable logistic regression was performed to assess the impact of adverse event on 7-day in-hospital mortality. Results Of the 526 critically injured trauma patients who underwent computerized tomographic scan during the study period, 17.3% (91/526) experienced one or more adverse event. The most common adverse events were hypotension n = 50 (9.5%), hypertension n = 18 (3.4%), initiation of vasopressors n = 11 (2.1%) and vomiting n = 8 (1.5%). One patient required re-intubation following endotracheal tube dislodgement and one patient required intubation following hypoxia post-sedation for agitation. Patient factors independently associated with adverse event were mechanical ventilation and blood product administration. When adjusted for injury severity score and age, patients who experienced adverse event were at increased odds of death (odds ratio: 2.2, 95% confidence interval: 1.11–4.36) compared to those who did not experience adverse event. Conclusion Adverse events occur frequently in critically injured patients undergoing emergent trauma computerized tomography and may significantly impact clinical outcomes. This study provides important information to guide system and process-level improvements including optimized designs of the built environment and safety-informed protocols for high-risk patients undergoing emergent trauma computerized tomography.

Comparison of Early Versus Late Adjunctive Vasopressin and Corticosteroids in Patients With Septic Shock.

Vasopressin (VP) and hydrocortisone (HC) have been shown to improve outcomes in patients with septic shock. However, there is very little literature addressing the impact of the timing of the combination. This study was conducted to evaluate the impact of early versus late initiation of both VP and HC on time to shock reversal in septic shock patients. This was a retrospective study conducted at a tertiary academic medical center. Data were collected from system-generated reports, which were used to identify patients with septic shock who were admitted to an intensive care unit (ICU) and received both VP and HC. The primary endpoint was time to shock reversal. Patients were divided into the "early" group if both VP and HC were initiated within 12 hours of vasopressor initiation or into the "late" group if either VP or HC (or both agents) were initiated after 12 hours of vasopressor initiation. A total of 122 patients were included in the analysis. Early initiation was associated with a shorter time to shock reversal (34 hours vs 65 hours; P = 0.012) compared to late initiation. There were no differences in ICU length of stay, mortality, the number patients requiring renal replacement therapy, or the duration of mechanical ventilation in either group. Our study addressed a major gap in the literature and suggests that adding the combination of VP and HC within 12 hours of septic shock may be associated with improved patient outcomes.