Vasopressor Medications Research Articles

Vasopressor-Inotropic Score: Review of Literature.

Patients undergoing cardiac surgery often receive vasopressor and inotropic medications during the surgical procedure and during intensive care unit (ICU) management following surgery. Patients with cardiogenic shock, septic shock, and other clinical disorders associated with shock also receive vasopressor medications during their ICU care. The level of support and the duration of support are likely associated with outcomes, including mortality and new organ dysfunction, such as acute kidney injury. The vasopressor-inotropic score provides a simple method to determine the level of support during the care of these patients; this score includes the infusion rates of norepinephrine, epinephrine, dopamine, dobutamine, and other inotropic medications. It has been studied in patients undergoing cardiac surgery, coronary artery bypass grafting, cardiac transplantation, left ventricular assist device implantation, septic shock, and traumatic brain injury. Higher scores are associated with poor outcomes and complications during ICU care. The studies analyzed in this review demonstrate the utility of the vasopressor-inotropic score in a variety of clinical disorders associated with shock. Electronic medical record systems should develop algorithms to calculate this score and provide continuous up-to-date measurements. This could help clinicians identify patients at risk for mortality and important complications, such as acute kidney injury.

The use of peripheral vasopressors and its implications for hospital medicine.

Vasopressor medications for circulatory shock have historically been administered through central venous catheters due to concern for extravasation injury when given peripherally. However, recent studies have demonstrated the safety of peripheral administration of vasopressor medications at lower doses and for a limited duration. Peripheral use of vasopressors is appealing to both patients and providers, as obtaining central access is an invasive procedure associated with the risk of pneumothorax, bleeding, and infection. Furthermore, waiting to initiate these medications until central access is obtained can lead to delays in care. Conversely, valid concerns remain regarding the risk of tissue extravasation associated with peripheral vasopressors, which can be life and limb threatening. We discuss the guidelines and data for optimal dose, duration, intravenous line (IV) size, IV location, and nursing IV site monitoring for peripheral vasopressors. We then explore adverse events associated with peripheral vasopressors. Finally, we describe how this practice change may impact hospital medicine providers.

Impact of immunotherapy combined with neoadjuvant chemotherapy or chemoradiotherapy on perioperative safety in locally advanced esophageal squamous cell carcinoma (LA-ESCC): A retrospective propensity score-matched analysis.

e16105 Background: Immunotherapy combined with chemotherapy (nICT) or chemoradiotherapy (nICRT) has become the latest option for patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC). The safety of this treatment remains uncertain. This study aims to evaluate the perioperative safety profile of nICT or nICRT among patients diagnosed with LA-ESCC. Methods: LA-ESCCpatients who underwent esophagectomy with or without neoadjuvant immunotherapy combining treatments (nIComT) at Jiangsu Cancer Hospital from January 2020 to January 2022 were included. A 1:1 propensity score matching (PSM) was used to balance demographic and oncologic characteristics between the two groups. The primary endpoint was postoperative complications, which were assessed by the Esophageal Cancer Complications Consensus Group (ECCG) criteria and the Clavien-Dindo criteria. Results: 1477 patients were screened, and a total of 873 patients were eligible for this study.Through PSM based on age, gender, body mass index, and clinical TNM stage, 118 pairs of patients were evenly allocated to the surgery-alone and nIComT groups. Compared to the surgery-alone group, the nIComT group showed slightly higher complication rates (66.1% vs 77.1%, P= 0.061). Grade Ⅰ or Ⅱ cardiovascular system complications appeared to be more common in the nIComT group than the surgery-alone group (57.6% vs 37.3%, P= 0.002). The cardiovascular system complications mainly included hypotension with sinus tachycardia (53.4% vs 34.7%, P= 0.004) which requires continuous pumping of vasopressor medications including dopamine, ephedrine, and norepinephrine during the perioperative period. It is noteworthy that patients in the nIComT group exhibited a higher incidence of perioperative diuretic and cardiotonic therapy due to congestive heart failure compared to the surgery-alone group (11.0% vs 5.1%, P= 0.094), although this disparity did not attain statistical significance. The nIComT group exhibited a notable increase in the percentage of patients requiring perioperative blood transfusion (35.6% vs 16.9%, P= 0.001), as well as an extended operation duration (277 ± 66 vs 246 ± 62 mins, P< 0.001), when compared to the surgery-alone group. Additionally, there was also a trend towards a higher proportion of patients in the nIComT group requiring intraoperative blood transfusion due to excessive blood loss (7.6% vs 2.5%, P= 0.075). The surgery-alone group ( n= 1) and the nIComT group ( n= 3) showed no significant differences in 30-day mortality rates ( P= 0.614). Conclusions: Our findings revealed a heightened incidence of cardiovascular complications among patients received nIComT, underscoring the significance of perioperative circulatory interventions. Further prospective studies are needed for validation.

Limb Necrosis in the Setting of Vasopressor Use.

It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis. To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy. A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded. The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups. The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.

(476) - Impact of Cumulative Vasopressor and Inotrope Medications on Outcomes in Cardiogenic Shock: A Cardiogenic Shock Working Group Report

(476) - Impact of Cumulative Vasopressor and Inotrope Medications on Outcomes in Cardiogenic Shock: A Cardiogenic Shock Working Group Report

Accidental hypothermia in the largest emergency hospital in North-Eastern Romania.

Accidental hypothermia (AH) presents a significant mortality risk, even in individuals with good health. Early recognition of the parameters associated with negative prognosis could save more lives. This was a pilot, retrospective observational study, conducted in the largest Emergency Hospital in North Eastern Romania, which included all patients with AH (defined as body temperature below 35°C), hospitalized and treated in our hospital between 2019 and 2022. A total of 104 patients with AH were included in our study, 90 of whom had data collected and statistically analyzed. The clinical, biological, and therapeutic parameters associated with negative outcomes were represented by a reduced GCS score (p=0.024), diminished systolic and diastolic blood pressure (p=0.007 respectively, 0.013), decreased bicarbonate (p=0.043) and hemoglobin levels (p=0.002), the presence of coagulation disorders (p=0.007), as well as the need for administration of inotropic or vasopressor medications (p=0.04). In this pilot, retrospective, observational study, the negative outcomes observed in patients with AH hospitalized in the largest Emergency Hospital in North-Eastern Romania were associated with several clinical, biochemical, and therapeutic factors, which are easy to identify in clinical practice. Recognizing the significance of these associated factors empowers healthcare practitioners to intervene at an early stage to save more lives.

Association of Shock Indices with Peri-Intubation Hypotension and Other Outcomes: A Sub-Study of the KEEP PACE Trial.

Based on current evidence, there appears to be an association between peri-intubation hypotension and patient morbidity and mortality. Studies have identified shock indices as possible pre-intubation risk factors for peri-intubation hypotension. Thus, we sought to evaluate the association between shock index (SI), modified shock index (MSI), and diastolic shock index (DSI) and peri-intubation hypotension along with other outcomes. The present study is a sub-study of a randomized controlled trial involving critically ill patients undergoing intubation. We defined peri-intubation hypotension as a decrease in mean arterial pressure <65 mm Hg and/or a reduction of 40% from baseline; or the initiation of, or increase in infusion dosage of, any vasopressor medication (bolus or infusion) during the 30-min period following intubation. SI, MSI, and DSI were analyzed as continuous variables and categorically using pre-established cut-offs. We also explored the effect of age on shock indices. A total of 151 patients were included in the analysis. Mean pre-intubation SI was 1.0 ± 0.3, MSI 1.5 ± 0.5, and DSI 1.9 ± 0.7. Increasing SI, MSI, and DSI were significantly associated with peri-intubation hypotension (OR [95% CI] per 0.1 increase = 1.16 [1.04, 1.30], P = .009 for SI; 1.14 [1.05, 1.24], P = .003 for MSI; and 1.11 [1.04, 1.19], P = .003 for DSI). The area under the ROC curves did not differ across shock indices (0.66 vs 0.67 vs 0.69 for SI, MSI, and DSI respectively; P = .586). Increasing SI, MSI, and DSI were significantly associated with worse sequential organ failure assessment (SOFA) score (spearman rank correlation: r = 0.30, r = 0.40, and r = 0.45 for SI, MSI, and DSI, respectively, all P < .001) but not with other outcomes. There was no significant impact when incorporating age. Increasing SI, MSI, and DSI were all significantly associated with peri-intubation hypotension and worse SOFA scores but not with other outcomes. Shock indices remain a useful bedside tool to assess the potential likelihood of peri-intubation hypotension. ClinicalTrials.gov identifier - NCT02105415.

Implementation and Evaluation of Weight-Based Vasopressors in Intensive Care Units.

Background: Vasopressors, including norepinephrine, epinephrine, and phenylephrine are commonly used to maintain mean arterial pressure (MAP) in critically ill patients. Despite their frequent use, the optimal dosing strategy for vasopressors remains understudied. Objective: The purpose of this study is to evaluate the implementation of a weight-based (WB) dosing strategy using ideal body weight compared to a non-weight-based (NWB) dosing strategy for vasopressors in critically ill patients. Methods: This is a retrospective chart review of patients admitted to intensive care units receiving vasopressor medications for greater than or equal to 4 hours. Patients received either an NWB or a WB vasopressor dosing strategy. The primary endpoint was the time to achieve goal MAP. Results: This study included 153 patients in the NWB vasopressor dosing group and 183 in the WB dosing group. The median time to achieve goal MAP in the NWB group was 24 minutes versus 21 minutes in the WB group (P = 0.1713). There were no significant differences in secondary outcomes including number of vasoactive agents required, hospital length of stay, and duration of mechanical ventilation. Subgroup analysis of patients with extremes of body mass index did not show a difference in time to achieve goal MAP. In a subgroup analysis of patients with septic shock, a higher percentage of patients in the WB group received corticosteroids than the NWB group patients (14% vs. 54%; P ≤ 0.001). Conclusion and relevance: There was no difference in time to achieve goal MAP when using a WB or NWB vasopressor dosing approach. Institutions should employ a consistent dosing strategy for vasopressors with either an NWB or WB approach.

Utilization of Hospice Resources in Adult Intensive Care Units: A Comparison Between Users and Non-Users

The application of palliative care is limited and challenging in intensive care units (ICUs) because of complex factors such as time constraints and unpredictable disease progression. Although research results and international consensus stress the early use of palliative care, utilization remains low, resulting in increased risks of ineffective medical care and poor quality of death. Improving this situation requires a comprehensive understanding of the palliative condition in ICUs. This study was designed to investigate the utilization of hospice resources in adult ICUs and to compare this utilization between users and non-users. This retrospective correlation study recruited cases from the adult ICU database of a medical center in northern Taiwan between June and July 2022. Descriptive statistics, independent t-test and chi-square were used to analyze the data. A total of 1,181 records were analyzed, including 458 (38.8%) females and 723 (61.2%) males. Two hundred and seventeen cases (18.4%) used hospice resources. Although 124 (10.4%) of the 1181 cases were identified as "in urgent need of hospice resources" (i.e., died within 30 days of ICU admission), 25 (20.2%) did not use these resources. Significant differences between the urgent-need cases who did and did not use hospice resources were found in terms of age, disease type, degree of frailty, cardiac arrest, infection, state of consciousness, intubation and tracheostomy status, inotropic and vasopressor medication, renal replacement, ECMO placement, delirium, and Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment Scores. The roughly 20% of ICU patients in urgent needs of palliative care who did not utilize palliative care resources highlight the needs for continued discussion to better assist patients on palliative care decision-making. The findings show multifaceted differences between those who did and did not access palliative care. Future studies should design and test strategies to facilitate the identification of palliative care needs and ensure the effective allocation of palliative care resources in ICUs.

A Least Absolute Shrinkage and Selection Operator-Derived Predictive Model for Postoperative Respiratory Failure in a Heterogeneous Adult Elective Surgery Patient Population

Postoperative respiratory failure (PRF) is associated with increased hospital charges and worse patient outcomes. Reliable prediction models can help to guide postoperative planning to optimize care, to guide resource allocation, and to foster shared decision-making with patients. Can a predictive model be developed to accurately identify patients at high risk of PRF? In this single-site proof-of-concept study, we used structured query language to extract, transform, and load electronic health record data from 23,999 consecutive adult patients admitted for elective surgery (2014-2021). Our primary outcome was PRF, defined as mechanical ventilation after surgery of > 48 h. Predictors of interest included demographics, comorbidities, and intraoperative factors. We used logistic regression to build a predictive model and the least absolute shrinkage and selection operator procedure to select variables and to estimate model coefficients. We evaluated model performance using optimism-corrected area under the receiver operating curve and area under the precision-recall curve and calculated sensitivity, specificity, positive and negative predictive values, and Brier scores. Two hundred twenty-five patients (0.94%) demonstrated PRF. The 18-variable predictive model included: operations on the cardiovascular, nervous, digestive, urinary, or musculoskeletal system; surgical specialty orthopedic (nonspine); Medicare or Medicaid (as the primary payer); race unknown; American Society of Anesthesiologists class ≥ III; BMI of 30 to 34.9 kg/m2; anesthesia duration (per hour); net fluid at end of the operation (per liter); median intraoperative FIO2, end title CO2, heart rate, and tidal volume; and intraoperative vasopressor medications. The optimism-corrected area under the receiver operating curve was 0.835 (95% CI,0.808-0.862) and the area under the precision-recall curve was 0.156 (95% CI, 0.105-0.203). This single-center proof-of-concept study demonstrated that a structured query language extract, transform, and load process, based on readily available patient and intraoperative variables, can be used to develop a prediction model for PRF. This PRF prediction model is scalable for multicenter research. Clinical applications include decision support to guide postoperative level of care admission and treatment decisions.

Comparison of survival by vasoactive-inotropic score in patients receiving veno-arterial extracorporeal life support.

After the initiation of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for hemodynamic support, patients often require vasopressor and inotropic medications to support their blood pressure and cardiac contractility. The vasoactive-inotropic score (VIS) is a standardized calculation of vasopressor and inotrope equivalence, which uses coefficients for each medication to calculate a total value. This study evaluated the association between the 30-day survival of patients receiving V-A ECMO support and the VIS calculated 24 h after ECMO cannulation (VIS24). This was a single-center, retrospective, observational cohort study. The median VIS24 of the entire cohort was 6.0, and was determined as a cutoff for comparison. Patients with a VIS24 < 6.0 were assigned to a group, and those with a VIS24 ≥ 6.0 were assigned to a second group. Patients with a VIS24 < 6.0 had higher 30-day survival than those with a VIS24 ≥ 6.0 (54.5% vs 41.4%; p = 0.03). The group with a VIS24 < 6.0 also had significantly improved survival to decannulation of ECMO support; however, there was no difference in the survival to hospital discharge. We conducted a secondary analysis of quartiles and determined that individuals with a VIS24 > 11.4 had the lowest survival in the cohort. This finding may help identify patients with the lowest probability of 30-day survival in those receiving V-A ECMO for hemodynamic support.

Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic.

A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic. We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021. Two academic medical centers in the Chicago metropolitan area. Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness. None. The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7). In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.

Do vasoactive medications impact donor hearts clinical outcomes in pediatric heart transplantation?

There is limited data examining donor vasopressor and/or inotrope medications (vasoactives) on pediatric orthotopic heart transplant (OHT) outcomes. We aim to evaluate the effects of vasoactives on pediatric OHT outcomes. The United Network for Organ Sharing database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. Exclusion criteria included multiorgan transplants and recipient age >18. Donors receiving vasoactives at the time of procurement were compared to donors not on vasoactives, including the number of vasoactives and the type. End-points of interest were survival at 30 days and 1year as well as post-transplant rejection at 1year. Logistic and Cox models were used to quantify survival end-points. Of 6462 donors, 3187 (49.3%) were receiving at least one vasoactive. Comparing any vasoactive medication versus none, there was no difference in 30-day survival (p= .27), 1 year survival (p= .89), overall survival (p= .68), or post-transplant rejection (p= .98). There was no difference in 30-day survival for donors receiving 2 or more vasoactive infusions (p= .89), 1 year survival (p= .53), overall survival (p= .75), or post-transplant rejection at 1year (p= .87). Vasopressin was associated with decreased 30-day mortality (OR=0.22; p= .028), dobutamine with decreased 1-year mortality (OR=0.37; p= .036), overall survival (HR=0.51; p= .003), and decreased post-transplant rejection (HR=0.63; p= .012). There is no difference in pediatric OHT outcomes when the cardiac donor is treated with vasoactive infusions at procurement. Vasopressin and dobutamine were associated with improved outcomes. This information can be used to guide medical management and donor selection.

COVID-Associated Cast-Forming Cholangiopathy: A Commentary on Disease Mechanism, Treatment, and Prognosis.

The complete impact of COVID-19 infection continues to develop since the onset of the COVID-19 pandemic. COVID-19 cholangiopathy has been recently described in a subset of patients who recovered from severe COVID-19 infection. The most common phenotype of patients suffering from COVID-19 cholangiopathy had severe infection requiring a stay in the intensive care unit, mechanical ventilation and vasopressor medications. Patients with COVID-cholangiopathy present with severe and prolonged cholestatic liver injury. In cases where biliary cast formation is identified, we defined the entity as "COVID-19 cast-forming cholangiopathy". This subset of COVID-19 cholangiopathy is not well understood and there are no standardized diagnosis or management to this date. The reported clinical outcomes are variable, from resolution of symptoms and liver test abnormalities to liver transplant and death. In this commentary, we discuss the proposed pathophysiology, diagnosis, management, and prognosis of this disease.

Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization

Introduction Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting. Methods A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters. Results A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort.

Clinical Pearls

Extubating patients as soon as possible is recommended to prevent adverse physical and cognitive outcomes. Hemodynamic stability is often listed as a criterion for extubation; however, the evidence is conflicting regarding the safety of extubation while the patient is receiving vasopressor medications. In addition, little is known about actual bedside practice in such situations.Costa and colleagues surveyed clinicians to examine their reported practice of extubation with patients receiving vasopressor therapy. They found One-third of respondents stated that they would extubate a patient receiving a continuous infusion of vasopressors.About one-quarter reported that it would depend on the type of medication being used.Almost 58% stated that their unit did not have a protocol or that they did not know if there was a protocol for this practice.Clinicians working in a surgical intensive care unit (ICU) and those who provide direct patient care at least 50% of the time more often said they would extubate patients receiving vasopressors.Extubation of patients receiving a vasopressor varied significantly by unit type and provider role. The authors recommend further research to explore the safety of this practice and examine existing protocols in ICUs.See Article, pp 127-130Parents with children in the pediatric intensive care unit (PICU) rely on the health care team to discuss their child’s possible morbidities and risk of mortality. These are called prognostic conversations. However, very little research has addressed the impact of prognostic conversations on post–intensive care syndrome in families in the PICU.Rissman and colleagues surveyed parents and health care providers at discharge from the PICU. They found Findings support the need for prognostic conversations to occur multiple times and using multiple formats throughout the PICU hospitalization, in order to appropriately prepare families for possible post-PICU morbidities.See Article, pp 118-126Although a necessary therapy, mechanical ventilation can cause significant stress and anxiety in patients. Management of these responses continues to be via medications such as antipsychotics, analgesics, and sedatives. However, these may produce adverse effects that could increase length of stay and cost of care and could contribute to long-term adverse outcomes.Golino and colleagues evaluated the impact of live music therapy as a nonpharmacologic intervention to reduce anxiety, pain, and agitation in adult patients receiving mechanical ventilation. They found Findings show music therapy reduces pain and agitation in adults receiving mechanical ventilation. Further research is needed, but nonpharmacologic interventions such as music therapy may reduce the need for pain and anxiety medications.See Article, pp 109-115The implementation of checklists during intensive care unit (ICU) rounds helps facilitate evidence-based practice and improve patient outcomes. However, checklists are sometimes not used as intended, and customization of the checklist may affect reliability and quality of care.King and colleagues created a paper-based assessment tool that one critical care nurse could use to reliably assess ABCDEF bundle care checklist items during rounds. They evaluated the tool with 2 independent nurses during rounds on 53 patients and found that Although tool item improvements are needed, findings support having one critical care nurse serve as checklist prompter to reliably assess ABCDEF bundle care during ICU rounds.See Article, pp 92-99

Lack of Useful Predictors of Dignity-Related Distress Among the Critically Ill as Assessed With the Patient Dignity Inventory.

Many intensive care unit patients are awake (ie, alert and engaging in conversation), actively experiencing many facets of their critical care. The Patient Dignity Inventory can be used to elicit sources of distress in these patients. We examined the administrative question as to which awake intensive care unit patients should be evaluated and potentially treated (eg, through palliative care consultation) for distress. Should the decision to screen for distress be based on patient demographics or treatment conditions? This was a retrospective cohort study of 155 adult patients from 5 intensive care units of one hospital from 2019 to 2020. Each patient had ≥48 hours without delirium, dementia, or sedation. The Patient Dignity Inventory has 25 items to which patients responded on a 1 (not a problem) to 5 (an overwhelming problem) scale. Multiple complete, stepwise forward, and stepwise backward logistic regression models were created among patient and treatment variables for predicting thresholds of the mean among the 25 items. There were 50% (78/155; 95% confidence interval [CI], 42-58) of patients with significant dignity-related distress (mean score ≥1.60). There were 34% (52/155; CI, 26-42) of patients with severe dignity-related distress (mean score ≥1.92; previously associated with often feeling like wanting to die). Models including combinations of vasopressor medication (protective of distress), tracheostomy (greater risk of distress), and female gender (greater risk of distress) had some predictive value. However, all combinations of potential predictors had misclassification rates significantly >20%. Identification of subsets of patients with little potential benefit to screening for dignity-related distress would have a reduced workload of palliative care team members (eg, nurses or social workers). Our results show that this is impractical. Given that approximately one-third of critical care patients who are alert and without delirium demonstrate severe dignity-related distress, all such patients with prolonged intensive care unit length of stay should probably be evaluated for distress.

983: PERIPHERAL VASOPRESSOR INFUSION FOR SHOCK: A QUALITY ASSESSMENT PROJECT IN A COMMUNITY ICU

Introduction: Vasopressor medications in shock are generally administered via central line but placement requires technical proficiency and in community ICU/ED settings, provider availability is not guaranteed around the clock. Evaluating the feasibility of peripheral vasopressor use in a real-world community hospital-based ICU allows us to explore alternative options. The primary objective was to assess the incidence of infiltration, skin necrosis, or limb loss resulting from peripheral vasopressor administration. A secondary objective was to assess the size and location of peripheral intravenous lines and the need for secondary central IV accesses. Institutional IRB approval was obtained. Methods: EMR records for all patients admitted with shock (any type) to a 12-bed community medical ICU receiving vasopressor support during 2018 were individually chart reviewed by a staff intensivist. The local sentinel event reporting system, and physician and nursing documentation were reviewed for any incidence of IV extravasation, or limb damage/loss. Pharmacy records of phentolamine/nitroglycerin paste orders ensured all cases of extravasation were captured. Results: There were 136 unique admissions requiring vasopressor support in 2018. 37.5 % of patients had central lines placed already while 44.9% of patients had vasopressors infused via peripheral IV. Of the 61 patients with peripheral IVs, 30 (49.2%) required placement of a central line. Vasopressors used included phenylephrine (47.1%), norepinephrine (41.9%), vasopressin (7.4%), dobutamine (2.9%) and epinephrine (0.7%). The average duration of vasopressor infusion through peripheral access was 592 mins. There were 8 episodes of infiltration amongst the peripheral IV group, with no episodes of skin damage or necrosis. The median IV size was 20 gauge, and the incidence of infiltration showed no significant association with gauge size (95%CI: -1.4, 0.61; P = 0.43). Conclusions: This dataset suggests that cutaneous infiltration of vasoactive medications is infrequent. Within this patient sample topical nitroglycerine or IV phentolamine, an antidote for cutaneous, drug-induced vasoconstriction, was rarely required. Gauge size in peripheral vasopressor administration appeared to make no difference.

Vasopressors and Pressure Injury Risk in the Critically Ill

We have not done any further analysis; therefore, we still do not know the exact etiological factor (vasopressor vs shock sequelae vs overall severity of illness) that places the patient at increased risk for PI. We strongly suspect that vasopressors and especially vasopressin play a significant role in PI development. Although we know that cutaneous manifestations associated with vasopressor medications exist, the evidence is not strong as to whether the associated gangrene is related to vasopressors or to the sequelae of shock that the vasopressors were administered to treat.When patients are receiving vasopressors, PI interventions such as more frequent repositioning or small repositioning shifts may be indicated, depending on the support surface in use and the patient’s individual tissue tolerance. For example, in patients with anasarca, tissue tolerance is severely compromised and increased frequency of repositioning/off-loading may be necessary. The use of prophylactic multilayer silicone foam dressings, if they are not already in use, should be considered as well.Interestingly, in the International Pressure Injury Guidelines published in 2019, skin temperature is mentioned as a potential PI risk factor because it can affect tissue tolerance to mechanical loads. In addition, patients who are diaphoretic may be more susceptible to pressure.Lateral rotation should not be used for repositioning patients because the lateral movement can actually increase shear and thus increase PI risk. Foam wedges are effective if you can use them to off-load pressure adequately. Pillows can be effective, as well, as long as these devices are used to prop the patient in a 30° side-lying position.

Management of an Uncorrected Tetralogy of Fallot for Caesarean Section Using Low-Dose Combined Spinal Epidural Anaesthesia Under Advanced Haemodynamic Monitorization

Since management of parturients with uncorrected tetralogy of Fallot reported until now lacks advanced cardiac haemodynamic monitoring, we aimed to present anaesthetic management of a parturient with uncorrected tetralogy of Fallot scheduled for caesarean section by addressing the challenges in the management based on the advanced haemodynamic monitoring due to the expected high-risk maternal morbidity and mortality in this particular case. Hereby, we provided haemodynamic stability with little requirement for vasopressor medication by using low-dose combined spinal epidural anaesthesia in a parturient with uncorrected tetralogy of Fallot scheduled to undergo caesarean delivery.