Critical Care Congress

PHOENIX – Pneumonia, dehydration, and septicemia topped the list of risk factors associated with the need for cardiopulmonary resuscitation during hospitalization for a major surgical procedure in 1 in 500 patients, a retrospective analysis found.

The large sample studied shows that having emergency rather than elective surgery, being older, being African American, and lacking health insurance were also associated with greater odds of needing CPR in this cohort, Dr. Ashima Das of Rainbow Children’s Hospital in Cleveland reported.

© KatarzynaBialasiewicz/Thinkstock

A review of 12,631,502 patient records found in the 2009 and 2010 National Inpatient Sample showed that 0.2% of all major surgery patients between 18 and 64 years went into cardiac arrest during their surgical hospitalization. Patients with postoperative pneumonia were at 3.05 (95% confidence interval = 2.75-3.39, P < .0001) times higher risk for needing CPR; meanwhile, major surgery patients with postoperative dehydration or other fluid and electrolyte disruptions faced an increased risk of 3.50 (95% CI = 3.18-3.85, P < .0001), Dr. Das reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Septicemia posed a 2.60 greater risk (95% CI = 2.34-2.86, P < .0001). The odds ratio of needing CPR for patients with coagulopathy was 2.54 (95% CI = 2.30-2.81, P < .0001).

Dr. Das and her colleagues found that 80% of the 23,858 surgical procedures performed in patients who also needed CPR were emergent rather than elective. Patients’ risk of cardiac arrest increased by 1.02 ( 95% CI = 1.01-1.03, P < .0001) with every year of age, while African Americans had a slightly higher risk of needing CPR, compared with whites (OR, 1.51; 95% CI = 1.35-1.68; P < .0001), as did the uninsured, compared with the insured (P < .0001).

The authors of this study said they had no relevant financial disclosures.

[email protected]

On Twitter @whitneymcknight

PHOENIX – Pneumonia, dehydration, and septicemia topped the list of risk factors associated with the need for cardiopulmonary resuscitation during hospitalization for a major surgical procedure in 1 in 500 patients, a retrospective analysis found.

The large sample studied shows that having emergency rather than elective surgery, being older, being African American, and lacking health insurance were also associated with greater odds of needing CPR in this cohort, Dr. Ashima Das of Rainbow Children’s Hospital in Cleveland reported.

© KatarzynaBialasiewicz/Thinkstock

A review of 12,631,502 patient records found in the 2009 and 2010 National Inpatient Sample showed that 0.2% of all major surgery patients between 18 and 64 years went into cardiac arrest during their surgical hospitalization. Patients with postoperative pneumonia were at 3.05 (95% confidence interval = 2.75-3.39, P < .0001) times higher risk for needing CPR; meanwhile, major surgery patients with postoperative dehydration or other fluid and electrolyte disruptions faced an increased risk of 3.50 (95% CI = 3.18-3.85, P < .0001), Dr. Das reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Septicemia posed a 2.60 greater risk (95% CI = 2.34-2.86, P < .0001). The odds ratio of needing CPR for patients with coagulopathy was 2.54 (95% CI = 2.30-2.81, P < .0001).

Dr. Das and her colleagues found that 80% of the 23,858 surgical procedures performed in patients who also needed CPR were emergent rather than elective. Patients’ risk of cardiac arrest increased by 1.02 ( 95% CI = 1.01-1.03, P < .0001) with every year of age, while African Americans had a slightly higher risk of needing CPR, compared with whites (OR, 1.51; 95% CI = 1.35-1.68; P < .0001), as did the uninsured, compared with the insured (P < .0001).

The authors of this study said they had no relevant financial disclosures.

[email protected]

On Twitter @whitneymcknight

PHOENIX – Pneumonia, dehydration, and septicemia topped the list of risk factors associated with the need for cardiopulmonary resuscitation during hospitalization for a major surgical procedure in 1 in 500 patients, a retrospective analysis found.

The large sample studied shows that having emergency rather than elective surgery, being older, being African American, and lacking health insurance were also associated with greater odds of needing CPR in this cohort, Dr. Ashima Das of Rainbow Children’s Hospital in Cleveland reported.

© KatarzynaBialasiewicz/Thinkstock

A review of 12,631,502 patient records found in the 2009 and 2010 National Inpatient Sample showed that 0.2% of all major surgery patients between 18 and 64 years went into cardiac arrest during their surgical hospitalization. Patients with postoperative pneumonia were at 3.05 (95% confidence interval = 2.75-3.39, P < .0001) times higher risk for needing CPR; meanwhile, major surgery patients with postoperative dehydration or other fluid and electrolyte disruptions faced an increased risk of 3.50 (95% CI = 3.18-3.85, P < .0001), Dr. Das reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Septicemia posed a 2.60 greater risk (95% CI = 2.34-2.86, P < .0001). The odds ratio of needing CPR for patients with coagulopathy was 2.54 (95% CI = 2.30-2.81, P < .0001).

Dr. Das and her colleagues found that 80% of the 23,858 surgical procedures performed in patients who also needed CPR were emergent rather than elective. Patients’ risk of cardiac arrest increased by 1.02 ( 95% CI = 1.01-1.03, P < .0001) with every year of age, while African Americans had a slightly higher risk of needing CPR, compared with whites (OR, 1.51; 95% CI = 1.35-1.68; P < .0001), as did the uninsured, compared with the insured (P < .0001).

The authors of this study said they had no relevant financial disclosures.

[email protected]

On Twitter @whitneymcknight

PHOENIX – The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases the length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

M. Alexander Otto/Frontline Medical News

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.

[email protected]

PHOENIX – The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases the length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

M. Alexander Otto/Frontline Medical News

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.

[email protected]

PHOENIX – The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases the length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

M. Alexander Otto/Frontline Medical News

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.

[email protected]

PHOENIX – Intravenous acetaminophen was no better than oral acetaminophen at relieving pain in neurocritical ICU patients with stroke and other conditions in a retrospective study at Virginia Commonwealth University in Richmond.

From May 2012 to April 2013, 312 patients – about a quarter of all neuroscience ICU admissions – got a median of three 1,000-mg doses of IV acetaminophen (Ofirmev), usually every 6 hours as needed. By 3 hours after their first dose, those with a median baseline pain score of 4 on a 10-point scale had dropped 1.5 points and remained there when reassessed at 6 hours. Pain was measured either by patient report or nurse assessment, using vital signs, grimacing, and other measures.

About the same number of patients received oral acetaminophen, usually 650 mg, also every 6 hours. At 3 hours, patients with an initial median score of 4 had dropped a mean of 1.7 points; at 6 hours, they had fallen by about 2 points from baseline. Many of the patients in both the intravenous and oral groups needed rescue opioids, usually fentanyl.

Intracranial hemorrhages were the most common diagnoses in both the oral and intravenous groups, followed by subarachnoid hemorrhages and traumatic brain injuries.

The study begins to answer a question on the minds of many health care providers: Is it worth paying $33 for a dose of intravenous acetaminophen when oral acetaminophen costs 5 cents a pill?

Alex Otto/Frontline Medical News

“This was completely surprising to us. Everything that we learn in pharmacy school says IV is going to be more effective than oral. We thought we’d see a difference, but we didn’t,” said lead investigator Dan Nichols, a third-year pharmacy student at Virginia Commonwealth University, Richmond.

“In fact, oral was actually more effective in traumatic brain injury patients,” as well as in patients who received rescue opioids and the small number in whom acetaminophen was the only pain medication needed, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

As with any intravenous drug, IV acetaminophen bypasses the vagaries of the gastrointestinal tract, so its pharmacokinetics are much quicker than oral formulations. Peak plasma concentrations come at the end of the 15 minute infusion.

That might translate to quicker pain relief; the investigators next plan to compare pain scores at 1 and 2 hours, and analyze whether Glasgow Coma Score, surgery, and other confounders make a difference.

In the meantime, “we and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better,” said senior investigator Gretchen M. Brophy, Pharm.D., of the departments of pharmacy and neurosurgery at VCU.

For now, VCU has restricted intravenous acetaminophen to one dose per patient.

The mean age in the study was 55 years, and just over half the patients were men.

Dr. Brophy is a speaker for Cadence Pharmaceuticals, the maker of intravenous acetaminophen. There was no outside funding for the work.

[email protected]

PHOENIX – Intravenous acetaminophen was no better than oral acetaminophen at relieving pain in neurocritical ICU patients with stroke and other conditions in a retrospective study at Virginia Commonwealth University in Richmond.

From May 2012 to April 2013, 312 patients – about a quarter of all neuroscience ICU admissions – got a median of three 1,000-mg doses of IV acetaminophen (Ofirmev), usually every 6 hours as needed. By 3 hours after their first dose, those with a median baseline pain score of 4 on a 10-point scale had dropped 1.5 points and remained there when reassessed at 6 hours. Pain was measured either by patient report or nurse assessment, using vital signs, grimacing, and other measures.

About the same number of patients received oral acetaminophen, usually 650 mg, also every 6 hours. At 3 hours, patients with an initial median score of 4 had dropped a mean of 1.7 points; at 6 hours, they had fallen by about 2 points from baseline. Many of the patients in both the intravenous and oral groups needed rescue opioids, usually fentanyl.

Intracranial hemorrhages were the most common diagnoses in both the oral and intravenous groups, followed by subarachnoid hemorrhages and traumatic brain injuries.

The study begins to answer a question on the minds of many health care providers: Is it worth paying $33 for a dose of intravenous acetaminophen when oral acetaminophen costs 5 cents a pill?

Alex Otto/Frontline Medical News

“This was completely surprising to us. Everything that we learn in pharmacy school says IV is going to be more effective than oral. We thought we’d see a difference, but we didn’t,” said lead investigator Dan Nichols, a third-year pharmacy student at Virginia Commonwealth University, Richmond.

“In fact, oral was actually more effective in traumatic brain injury patients,” as well as in patients who received rescue opioids and the small number in whom acetaminophen was the only pain medication needed, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

As with any intravenous drug, IV acetaminophen bypasses the vagaries of the gastrointestinal tract, so its pharmacokinetics are much quicker than oral formulations. Peak plasma concentrations come at the end of the 15 minute infusion.

That might translate to quicker pain relief; the investigators next plan to compare pain scores at 1 and 2 hours, and analyze whether Glasgow Coma Score, surgery, and other confounders make a difference.

In the meantime, “we and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better,” said senior investigator Gretchen M. Brophy, Pharm.D., of the departments of pharmacy and neurosurgery at VCU.

For now, VCU has restricted intravenous acetaminophen to one dose per patient.

The mean age in the study was 55 years, and just over half the patients were men.

Dr. Brophy is a speaker for Cadence Pharmaceuticals, the maker of intravenous acetaminophen. There was no outside funding for the work.

[email protected]

PHOENIX – Intravenous acetaminophen was no better than oral acetaminophen at relieving pain in neurocritical ICU patients with stroke and other conditions in a retrospective study at Virginia Commonwealth University in Richmond.

From May 2012 to April 2013, 312 patients – about a quarter of all neuroscience ICU admissions – got a median of three 1,000-mg doses of IV acetaminophen (Ofirmev), usually every 6 hours as needed. By 3 hours after their first dose, those with a median baseline pain score of 4 on a 10-point scale had dropped 1.5 points and remained there when reassessed at 6 hours. Pain was measured either by patient report or nurse assessment, using vital signs, grimacing, and other measures.

About the same number of patients received oral acetaminophen, usually 650 mg, also every 6 hours. At 3 hours, patients with an initial median score of 4 had dropped a mean of 1.7 points; at 6 hours, they had fallen by about 2 points from baseline. Many of the patients in both the intravenous and oral groups needed rescue opioids, usually fentanyl.

Intracranial hemorrhages were the most common diagnoses in both the oral and intravenous groups, followed by subarachnoid hemorrhages and traumatic brain injuries.

The study begins to answer a question on the minds of many health care providers: Is it worth paying $33 for a dose of intravenous acetaminophen when oral acetaminophen costs 5 cents a pill?

Alex Otto/Frontline Medical News

“This was completely surprising to us. Everything that we learn in pharmacy school says IV is going to be more effective than oral. We thought we’d see a difference, but we didn’t,” said lead investigator Dan Nichols, a third-year pharmacy student at Virginia Commonwealth University, Richmond.

“In fact, oral was actually more effective in traumatic brain injury patients,” as well as in patients who received rescue opioids and the small number in whom acetaminophen was the only pain medication needed, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

As with any intravenous drug, IV acetaminophen bypasses the vagaries of the gastrointestinal tract, so its pharmacokinetics are much quicker than oral formulations. Peak plasma concentrations come at the end of the 15 minute infusion.

That might translate to quicker pain relief; the investigators next plan to compare pain scores at 1 and 2 hours, and analyze whether Glasgow Coma Score, surgery, and other confounders make a difference.

In the meantime, “we and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better,” said senior investigator Gretchen M. Brophy, Pharm.D., of the departments of pharmacy and neurosurgery at VCU.

For now, VCU has restricted intravenous acetaminophen to one dose per patient.

The mean age in the study was 55 years, and just over half the patients were men.

Dr. Brophy is a speaker for Cadence Pharmaceuticals, the maker of intravenous acetaminophen. There was no outside funding for the work.

[email protected]

PHOENIX – Adding a protocol of bundled nonpharmacologic interventions to the currently recommended standard of care nearly halved the amount of time patients spent delirious in the intensive care unit, a study has shown.

The combination of soothing music, natural light, routine cognitive stimulation, and the use of any necessary patient vision or hearing aids, added to standard ICU mobility and sedation protocols, also reduced the odds of developing any delirium, when researchers controlled for age, dementia, APACHE II score, and mechanical ventilation.

The data are from a prospective pre- and post–quality improvement cohort evaluation of the percentage of time patients spent delirious during their total medical ICU stay, rather than just the prevalence of delirium.

“We think this study really brings something unique to the knowledge of ICU delirium,” Ryan Rivosecchi, Pharm.D., a second-year resident at the University of Pittsburgh, said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. “Delirium is a disease of a waxing and waning nature, and purely going on its prevalence may not tell the full story.”

Currently, the recommendation with the highest level of evidence for preventing ICU delirium, as noted in the 2013 updated SCCM guidelines for pain, agitation, and delirium, is early mobilization. There are scant other evidence-based recommendations for how to prevent and treat the condition, leaving “a lot of practitioners wondering how they should take care of their delirious patients,” Dr. Rivosecchi said.

Delirium experienced during ICU stays has been associated with some form of residual cognitive impairment in more than 70% of patients and increases in lengths of stay by as many as 15 days. Delirium in the ICU has also been associated with a nearly 20% increase in mortality rates 6 months after admission to the ICU.

Noting that his institution already adhered to the standard recommendations for early mobility and sedation algorithms, Dr. Rivosecchi said he and his colleagues conducted the study at the University of Pittsburgh’s 24-bed medical ICU, in hopes of providing an additional evidence-based intervention to reduce ICU delirium.

Among 729 adult patients screened between September 2013 and April 2014, 230 patients who had not been in the ICU prior to MICU admission, and who did not present with delirium or baseline cognitive impairment, were chosen for the pre–quality improvement phase.

The post–quality improvement arm of the study comprised 253 patients who met the same criteria as did those in the first arm. The median age for both groups was 59 years. Slightly more than half of all patients were male.

The primary outcome was the total time a patient spent delirious throughout the entire MICU stay, as measured six times daily, every 4 hours, via the Intensive Care Delirium Screening Checklist. “Patients evaluated as ‘delirious’ at time point A were considered delirious for the next 4 hours until they were evaluated again at time point B,” Dr. Rivosecchi said.

During the first 3 months of the study, nurses on the MICU floor were unaware that baseline data about their unit were being collected. In the fourth month, the investigators discussed their observations with the nursing staff, and with the nursing director and clinician on the unit.

Several unique interventions, distilled from these meetings and a review of protocols already in place, were combined with findings from a systematic review of the literature, into one preventive protocol named M.O.R.E.: Music; Opening of blinds; Reorientation and cognitive stimulation; Eye and ear protocol.

After the nurse meetings, another month passed before the post–quality improvement phase of the study began. The nurses were once again unaware data were being collected; however, according to Dr. Rivosecchi, not only did the entire medical staff, including the pharmacists, embrace the new protocol, but the nurses were so enthusiastic about it they collaborated on a poem to express their intentions to the patients and the patients’ families. Copies of the poem were placed in zippered pouches that included a sleep mask, ear plugs, and headphones, distributed to each MICU patient to help them block out unnecessary stimulation.

“The delirium prevention care bag was an idea the nurses came up with on their own to really help the patients out,” Dr. Rivosecchi said.

Signage detailing the specific actions included in the mnemonic M.O.R.E. was posted throughout the MICU to make it easier for the nursing staff to remember, although how the nurses implemented the protocol was left to them, Dr. Rivosecchi said.

The signs advised that MICU patients be exposed to at least 1 hour of “relaxing/soothing” music per nurse shift, and that if the patient were not actually viewing the television, it be kept off.

To help patients maintain a normal diurnal rhythm, nurses were advised to angle patients so that they could have a view of a window that was kept open from morning until evening to allow in as much natural light as possible.

Rather than employ the typical “alert and orient times three” protocol, the staff was instructed to create mental tasks for the patients, such as asking them their names and how they preferred to be addressed, and to reorient patients by discussing with them the status of their hospitalization.

If patients were accustomed to wearing visual or hearing aids, the nurses were asked to encourage them to use the aids while in the MICU.

The group of 230 studied before M.O.R.E. was in place had 36 patients who experienced delirium, compared with 24 of the 253 patients observed after the interventions were instituted.

The total reduction in the amount of time these patients spent in delirious states was 40.4%. The first arm’s total time spent delirious was 16.1% (1,088 out of 6,747 hours), compared with 9.6% (485 out of 5, 071 hours) of the total time in the second arm (P < .001).

The typical length of stay for the first arm was 58 hours, and 68 hours in the second.

At baseline, there was a statistically significant difference in illness severity as measured by APACHE II scores between the groups: The first had a score of 15, while the second had a score of 17 (P = .002), although according to Dr. Rivosecchi, both arms followed the same predictive value of mortality at 24 hours (7.5% vs. 11.1%, P = .21).

Also of note, Dr. Rivosecchi said, was that there was a higher use of the benzodiazepines lorazepam and midazolam, commonly associated with higher rates of delirium, in the second phase of the study.

In a subanalysis using risk factors reported in the literature, the investigators determined that age, severity of illness, the use of mechanical ventilation, home anticholinergic use, and home antipsychotic use increased the odds of delirium, as did baseline depression or respiratory disease. After the researchers controlled for these factors, the M.O.R.E. protocol reduced the risk of developing delirium by 57% (odds ratio, 0.43, 95% confidence interval 0.24 - 0.77).

Statistically significant predictors of delirium were mechanical ventilation (OR 2.09, CI 1.11-3.91, P = .022), APACHE II score (1.07, CI 1.02 -1.11, P = .002) and dementia (5.12, CI 1.8 -14.3, P = .91).

“I was extremely surprised by the results, particularly since we had greater benzodiazepine use and arguably a sicker patient population in the post phase,” said Dr. Rivosecchi. “I definitely did not expect a 40% reduction.”

Despite the nurses’ enthusiasm, the study did not actually track their adherence to the protocol, a weakness Dr. Rivosecchi said he and his colleagues hoped to address in future evaluations of the protocol.

Meanwhile, according to Pamela Smithburger, Pharm.D., Dr. Rivosecchi’s mentor and the senior author on the paper, use of the M.O.R.E. protocol is now being rolled out across all ICUs within the University of Pittsburgh Medical Center’s entire system, which includes 13 hospitals, and that as the implementation continues, she will be collecting data on patient outcomes systemwide.

“Each ICU will be able to modify the M.O.R.E. protocol to best fit their work flow, culture, and environment,” Dr. Smithburger said in an interview.

The cost to do so comes down to time and staff education. “We utilized tools and resources already available, but by combining them into one protocol, improved outcomes.”

[email protected]

On Twitter @whitneymcknight

PHOENIX – Adding a protocol of bundled nonpharmacologic interventions to the currently recommended standard of care nearly halved the amount of time patients spent delirious in the intensive care unit, a study has shown.

The combination of soothing music, natural light, routine cognitive stimulation, and the use of any necessary patient vision or hearing aids, added to standard ICU mobility and sedation protocols, also reduced the odds of developing any delirium, when researchers controlled for age, dementia, APACHE II score, and mechanical ventilation.

The data are from a prospective pre- and post–quality improvement cohort evaluation of the percentage of time patients spent delirious during their total medical ICU stay, rather than just the prevalence of delirium.

“We think this study really brings something unique to the knowledge of ICU delirium,” Ryan Rivosecchi, Pharm.D., a second-year resident at the University of Pittsburgh, said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. “Delirium is a disease of a waxing and waning nature, and purely going on its prevalence may not tell the full story.”

Currently, the recommendation with the highest level of evidence for preventing ICU delirium, as noted in the 2013 updated SCCM guidelines for pain, agitation, and delirium, is early mobilization. There are scant other evidence-based recommendations for how to prevent and treat the condition, leaving “a lot of practitioners wondering how they should take care of their delirious patients,” Dr. Rivosecchi said.

Delirium experienced during ICU stays has been associated with some form of residual cognitive impairment in more than 70% of patients and increases in lengths of stay by as many as 15 days. Delirium in the ICU has also been associated with a nearly 20% increase in mortality rates 6 months after admission to the ICU.

Noting that his institution already adhered to the standard recommendations for early mobility and sedation algorithms, Dr. Rivosecchi said he and his colleagues conducted the study at the University of Pittsburgh’s 24-bed medical ICU, in hopes of providing an additional evidence-based intervention to reduce ICU delirium.

Among 729 adult patients screened between September 2013 and April 2014, 230 patients who had not been in the ICU prior to MICU admission, and who did not present with delirium or baseline cognitive impairment, were chosen for the pre–quality improvement phase.

The post–quality improvement arm of the study comprised 253 patients who met the same criteria as did those in the first arm. The median age for both groups was 59 years. Slightly more than half of all patients were male.

The primary outcome was the total time a patient spent delirious throughout the entire MICU stay, as measured six times daily, every 4 hours, via the Intensive Care Delirium Screening Checklist. “Patients evaluated as ‘delirious’ at time point A were considered delirious for the next 4 hours until they were evaluated again at time point B,” Dr. Rivosecchi said.

During the first 3 months of the study, nurses on the MICU floor were unaware that baseline data about their unit were being collected. In the fourth month, the investigators discussed their observations with the nursing staff, and with the nursing director and clinician on the unit.

Several unique interventions, distilled from these meetings and a review of protocols already in place, were combined with findings from a systematic review of the literature, into one preventive protocol named M.O.R.E.: Music; Opening of blinds; Reorientation and cognitive stimulation; Eye and ear protocol.

After the nurse meetings, another month passed before the post–quality improvement phase of the study began. The nurses were once again unaware data were being collected; however, according to Dr. Rivosecchi, not only did the entire medical staff, including the pharmacists, embrace the new protocol, but the nurses were so enthusiastic about it they collaborated on a poem to express their intentions to the patients and the patients’ families. Copies of the poem were placed in zippered pouches that included a sleep mask, ear plugs, and headphones, distributed to each MICU patient to help them block out unnecessary stimulation.

“The delirium prevention care bag was an idea the nurses came up with on their own to really help the patients out,” Dr. Rivosecchi said.

Signage detailing the specific actions included in the mnemonic M.O.R.E. was posted throughout the MICU to make it easier for the nursing staff to remember, although how the nurses implemented the protocol was left to them, Dr. Rivosecchi said.

The signs advised that MICU patients be exposed to at least 1 hour of “relaxing/soothing” music per nurse shift, and that if the patient were not actually viewing the television, it be kept off.

To help patients maintain a normal diurnal rhythm, nurses were advised to angle patients so that they could have a view of a window that was kept open from morning until evening to allow in as much natural light as possible.

Rather than employ the typical “alert and orient times three” protocol, the staff was instructed to create mental tasks for the patients, such as asking them their names and how they preferred to be addressed, and to reorient patients by discussing with them the status of their hospitalization.

If patients were accustomed to wearing visual or hearing aids, the nurses were asked to encourage them to use the aids while in the MICU.

The group of 230 studied before M.O.R.E. was in place had 36 patients who experienced delirium, compared with 24 of the 253 patients observed after the interventions were instituted.

The total reduction in the amount of time these patients spent in delirious states was 40.4%. The first arm’s total time spent delirious was 16.1% (1,088 out of 6,747 hours), compared with 9.6% (485 out of 5, 071 hours) of the total time in the second arm (P < .001).

The typical length of stay for the first arm was 58 hours, and 68 hours in the second.

At baseline, there was a statistically significant difference in illness severity as measured by APACHE II scores between the groups: The first had a score of 15, while the second had a score of 17 (P = .002), although according to Dr. Rivosecchi, both arms followed the same predictive value of mortality at 24 hours (7.5% vs. 11.1%, P = .21).

Also of note, Dr. Rivosecchi said, was that there was a higher use of the benzodiazepines lorazepam and midazolam, commonly associated with higher rates of delirium, in the second phase of the study.

In a subanalysis using risk factors reported in the literature, the investigators determined that age, severity of illness, the use of mechanical ventilation, home anticholinergic use, and home antipsychotic use increased the odds of delirium, as did baseline depression or respiratory disease. After the researchers controlled for these factors, the M.O.R.E. protocol reduced the risk of developing delirium by 57% (odds ratio, 0.43, 95% confidence interval 0.24 - 0.77).

Statistically significant predictors of delirium were mechanical ventilation (OR 2.09, CI 1.11-3.91, P = .022), APACHE II score (1.07, CI 1.02 -1.11, P = .002) and dementia (5.12, CI 1.8 -14.3, P = .91).

“I was extremely surprised by the results, particularly since we had greater benzodiazepine use and arguably a sicker patient population in the post phase,” said Dr. Rivosecchi. “I definitely did not expect a 40% reduction.”

Despite the nurses’ enthusiasm, the study did not actually track their adherence to the protocol, a weakness Dr. Rivosecchi said he and his colleagues hoped to address in future evaluations of the protocol.

Meanwhile, according to Pamela Smithburger, Pharm.D., Dr. Rivosecchi’s mentor and the senior author on the paper, use of the M.O.R.E. protocol is now being rolled out across all ICUs within the University of Pittsburgh Medical Center’s entire system, which includes 13 hospitals, and that as the implementation continues, she will be collecting data on patient outcomes systemwide.

“Each ICU will be able to modify the M.O.R.E. protocol to best fit their work flow, culture, and environment,” Dr. Smithburger said in an interview.

The cost to do so comes down to time and staff education. “We utilized tools and resources already available, but by combining them into one protocol, improved outcomes.”

[email protected]

On Twitter @whitneymcknight

PHOENIX – Adding a protocol of bundled nonpharmacologic interventions to the currently recommended standard of care nearly halved the amount of time patients spent delirious in the intensive care unit, a study has shown.

The combination of soothing music, natural light, routine cognitive stimulation, and the use of any necessary patient vision or hearing aids, added to standard ICU mobility and sedation protocols, also reduced the odds of developing any delirium, when researchers controlled for age, dementia, APACHE II score, and mechanical ventilation.

The data are from a prospective pre- and post–quality improvement cohort evaluation of the percentage of time patients spent delirious during their total medical ICU stay, rather than just the prevalence of delirium.

“We think this study really brings something unique to the knowledge of ICU delirium,” Ryan Rivosecchi, Pharm.D., a second-year resident at the University of Pittsburgh, said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. “Delirium is a disease of a waxing and waning nature, and purely going on its prevalence may not tell the full story.”

Currently, the recommendation with the highest level of evidence for preventing ICU delirium, as noted in the 2013 updated SCCM guidelines for pain, agitation, and delirium, is early mobilization. There are scant other evidence-based recommendations for how to prevent and treat the condition, leaving “a lot of practitioners wondering how they should take care of their delirious patients,” Dr. Rivosecchi said.

Delirium experienced during ICU stays has been associated with some form of residual cognitive impairment in more than 70% of patients and increases in lengths of stay by as many as 15 days. Delirium in the ICU has also been associated with a nearly 20% increase in mortality rates 6 months after admission to the ICU.

Noting that his institution already adhered to the standard recommendations for early mobility and sedation algorithms, Dr. Rivosecchi said he and his colleagues conducted the study at the University of Pittsburgh’s 24-bed medical ICU, in hopes of providing an additional evidence-based intervention to reduce ICU delirium.

Among 729 adult patients screened between September 2013 and April 2014, 230 patients who had not been in the ICU prior to MICU admission, and who did not present with delirium or baseline cognitive impairment, were chosen for the pre–quality improvement phase.

The post–quality improvement arm of the study comprised 253 patients who met the same criteria as did those in the first arm. The median age for both groups was 59 years. Slightly more than half of all patients were male.

The primary outcome was the total time a patient spent delirious throughout the entire MICU stay, as measured six times daily, every 4 hours, via the Intensive Care Delirium Screening Checklist. “Patients evaluated as ‘delirious’ at time point A were considered delirious for the next 4 hours until they were evaluated again at time point B,” Dr. Rivosecchi said.

During the first 3 months of the study, nurses on the MICU floor were unaware that baseline data about their unit were being collected. In the fourth month, the investigators discussed their observations with the nursing staff, and with the nursing director and clinician on the unit.

Several unique interventions, distilled from these meetings and a review of protocols already in place, were combined with findings from a systematic review of the literature, into one preventive protocol named M.O.R.E.: Music; Opening of blinds; Reorientation and cognitive stimulation; Eye and ear protocol.

After the nurse meetings, another month passed before the post–quality improvement phase of the study began. The nurses were once again unaware data were being collected; however, according to Dr. Rivosecchi, not only did the entire medical staff, including the pharmacists, embrace the new protocol, but the nurses were so enthusiastic about it they collaborated on a poem to express their intentions to the patients and the patients’ families. Copies of the poem were placed in zippered pouches that included a sleep mask, ear plugs, and headphones, distributed to each MICU patient to help them block out unnecessary stimulation.

“The delirium prevention care bag was an idea the nurses came up with on their own to really help the patients out,” Dr. Rivosecchi said.

Signage detailing the specific actions included in the mnemonic M.O.R.E. was posted throughout the MICU to make it easier for the nursing staff to remember, although how the nurses implemented the protocol was left to them, Dr. Rivosecchi said.

The signs advised that MICU patients be exposed to at least 1 hour of “relaxing/soothing” music per nurse shift, and that if the patient were not actually viewing the television, it be kept off.

To help patients maintain a normal diurnal rhythm, nurses were advised to angle patients so that they could have a view of a window that was kept open from morning until evening to allow in as much natural light as possible.

Rather than employ the typical “alert and orient times three” protocol, the staff was instructed to create mental tasks for the patients, such as asking them their names and how they preferred to be addressed, and to reorient patients by discussing with them the status of their hospitalization.

If patients were accustomed to wearing visual or hearing aids, the nurses were asked to encourage them to use the aids while in the MICU.

The group of 230 studied before M.O.R.E. was in place had 36 patients who experienced delirium, compared with 24 of the 253 patients observed after the interventions were instituted.

The total reduction in the amount of time these patients spent in delirious states was 40.4%. The first arm’s total time spent delirious was 16.1% (1,088 out of 6,747 hours), compared with 9.6% (485 out of 5, 071 hours) of the total time in the second arm (P < .001).

The typical length of stay for the first arm was 58 hours, and 68 hours in the second.

At baseline, there was a statistically significant difference in illness severity as measured by APACHE II scores between the groups: The first had a score of 15, while the second had a score of 17 (P = .002), although according to Dr. Rivosecchi, both arms followed the same predictive value of mortality at 24 hours (7.5% vs. 11.1%, P = .21).

Also of note, Dr. Rivosecchi said, was that there was a higher use of the benzodiazepines lorazepam and midazolam, commonly associated with higher rates of delirium, in the second phase of the study.

In a subanalysis using risk factors reported in the literature, the investigators determined that age, severity of illness, the use of mechanical ventilation, home anticholinergic use, and home antipsychotic use increased the odds of delirium, as did baseline depression or respiratory disease. After the researchers controlled for these factors, the M.O.R.E. protocol reduced the risk of developing delirium by 57% (odds ratio, 0.43, 95% confidence interval 0.24 - 0.77).

Statistically significant predictors of delirium were mechanical ventilation (OR 2.09, CI 1.11-3.91, P = .022), APACHE II score (1.07, CI 1.02 -1.11, P = .002) and dementia (5.12, CI 1.8 -14.3, P = .91).

“I was extremely surprised by the results, particularly since we had greater benzodiazepine use and arguably a sicker patient population in the post phase,” said Dr. Rivosecchi. “I definitely did not expect a 40% reduction.”

Despite the nurses’ enthusiasm, the study did not actually track their adherence to the protocol, a weakness Dr. Rivosecchi said he and his colleagues hoped to address in future evaluations of the protocol.

Meanwhile, according to Pamela Smithburger, Pharm.D., Dr. Rivosecchi’s mentor and the senior author on the paper, use of the M.O.R.E. protocol is now being rolled out across all ICUs within the University of Pittsburgh Medical Center’s entire system, which includes 13 hospitals, and that as the implementation continues, she will be collecting data on patient outcomes systemwide.

“Each ICU will be able to modify the M.O.R.E. protocol to best fit their work flow, culture, and environment,” Dr. Smithburger said in an interview.

The cost to do so comes down to time and staff education. “We utilized tools and resources already available, but by combining them into one protocol, improved outcomes.”

[email protected]

On Twitter @whitneymcknight

PHOENIX – A pediatric ICU protocol to minimize sedation during intubation did not reduce ventilator days among children with acute respiratory failure, compared with usual care, in a randomized trial of 2,449 children across 31 ICUs.

The results were published online Jan. 20 in JAMA.

Seventeen pediatric ICUs (PICUs) followed a protocol that included sedation adjustment at least every 8 hours based on phase of illness; arousal assessments during titration and weaning; daily extubation readiness testing when spontaneously breathing; and weaning off opioids and benzodiazepines if patients were on them for 5 or more days, instead of simply discontinuing them.

The 1,225 children on the protocol were ventilated a median of 6.5 days, the same length as the 1,224 children in the 14 usual-care PICUs. There were no differences in sedation-related adverse events, including inadequate pain and sedation control, clinically significant drug withdrawal symptoms, and unplanned endotracheal tube removal (JAMA 2015 [doi:10.1001/jama.2014.18399])

It’s become clear in recent years that intubated adults do better with lighter sedation, and the PICU findings don’t necessarily mean that children are somehow different. A more likely explanation of the findings is that the control PICUs were using a lighter touch, too; prior to randomization, all the PICUs implemented the same pain, sedation, and withdrawal scales.

In any case, the study does show that “targeting a sedation goal of patients who are calm, easily aroused, and readily evaluated is attainable and safe in children,” wrote registered nurse Martha Curley, Ph.D., of the University of Pennsylvania, Philadelphia, and her associates . The study results were published to coincide with Dr. Curley’s presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

The protocol patients had a median 9 days of opioids, versus 10 in the usual-care group, and they were awake and calm while intubated a median of 86% of days, versus 75% in the control group. However, intervention children had pain during about half of their days, while usual-care children reported pain during about quarter of their days. Intervention patients also had more agitation, and postextubation stridor, but fewer pressure sores. There were no differences in mortality between the groups.

Morphine was the primary protocol opioid, while fentanyl was used most often in the control group. Morphine was selected for the protocol because it has a longer duration of action, plus some sedative properties and less development of tolerance. The primary sedative in both groups was midazolam; about a quarter of protocol patients received dexmedetomidine, versus about half in the usual-care group.

Baseline patient characteristics were well matched between the two groups, except that the intervention group enrolled more patients younger than 2 years and more patients with bronchiolitis, both of whom are harder to sedate. Pneumonia, bronchiolitis, and acute respiratory failure due to sepsis were the most common diagnoses in both groups. The mean age of the children was 4.7 years.

The work, dubbed the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) study, was supported by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research. The lead author had no disclosures. One coauthor is an advisor for Philips, and another reported consultant and other fees from Cerus, Quark Pharmaceuticals, Biogen, GlaxoSmithKline, and other companies.

[email protected]

PHOENIX – A pediatric ICU protocol to minimize sedation during intubation did not reduce ventilator days among children with acute respiratory failure, compared with usual care, in a randomized trial of 2,449 children across 31 ICUs.

The results were published online Jan. 20 in JAMA.

Seventeen pediatric ICUs (PICUs) followed a protocol that included sedation adjustment at least every 8 hours based on phase of illness; arousal assessments during titration and weaning; daily extubation readiness testing when spontaneously breathing; and weaning off opioids and benzodiazepines if patients were on them for 5 or more days, instead of simply discontinuing them.

The 1,225 children on the protocol were ventilated a median of 6.5 days, the same length as the 1,224 children in the 14 usual-care PICUs. There were no differences in sedation-related adverse events, including inadequate pain and sedation control, clinically significant drug withdrawal symptoms, and unplanned endotracheal tube removal (JAMA 2015 [doi:10.1001/jama.2014.18399])

It’s become clear in recent years that intubated adults do better with lighter sedation, and the PICU findings don’t necessarily mean that children are somehow different. A more likely explanation of the findings is that the control PICUs were using a lighter touch, too; prior to randomization, all the PICUs implemented the same pain, sedation, and withdrawal scales.

In any case, the study does show that “targeting a sedation goal of patients who are calm, easily aroused, and readily evaluated is attainable and safe in children,” wrote registered nurse Martha Curley, Ph.D., of the University of Pennsylvania, Philadelphia, and her associates . The study results were published to coincide with Dr. Curley’s presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

The protocol patients had a median 9 days of opioids, versus 10 in the usual-care group, and they were awake and calm while intubated a median of 86% of days, versus 75% in the control group. However, intervention children had pain during about half of their days, while usual-care children reported pain during about quarter of their days. Intervention patients also had more agitation, and postextubation stridor, but fewer pressure sores. There were no differences in mortality between the groups.

Morphine was the primary protocol opioid, while fentanyl was used most often in the control group. Morphine was selected for the protocol because it has a longer duration of action, plus some sedative properties and less development of tolerance. The primary sedative in both groups was midazolam; about a quarter of protocol patients received dexmedetomidine, versus about half in the usual-care group.

Baseline patient characteristics were well matched between the two groups, except that the intervention group enrolled more patients younger than 2 years and more patients with bronchiolitis, both of whom are harder to sedate. Pneumonia, bronchiolitis, and acute respiratory failure due to sepsis were the most common diagnoses in both groups. The mean age of the children was 4.7 years.

The work, dubbed the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) study, was supported by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research. The lead author had no disclosures. One coauthor is an advisor for Philips, and another reported consultant and other fees from Cerus, Quark Pharmaceuticals, Biogen, GlaxoSmithKline, and other companies.

[email protected]

PHOENIX – A pediatric ICU protocol to minimize sedation during intubation did not reduce ventilator days among children with acute respiratory failure, compared with usual care, in a randomized trial of 2,449 children across 31 ICUs.

The results were published online Jan. 20 in JAMA.

Seventeen pediatric ICUs (PICUs) followed a protocol that included sedation adjustment at least every 8 hours based on phase of illness; arousal assessments during titration and weaning; daily extubation readiness testing when spontaneously breathing; and weaning off opioids and benzodiazepines if patients were on them for 5 or more days, instead of simply discontinuing them.

The 1,225 children on the protocol were ventilated a median of 6.5 days, the same length as the 1,224 children in the 14 usual-care PICUs. There were no differences in sedation-related adverse events, including inadequate pain and sedation control, clinically significant drug withdrawal symptoms, and unplanned endotracheal tube removal (JAMA 2015 [doi:10.1001/jama.2014.18399])

It’s become clear in recent years that intubated adults do better with lighter sedation, and the PICU findings don’t necessarily mean that children are somehow different. A more likely explanation of the findings is that the control PICUs were using a lighter touch, too; prior to randomization, all the PICUs implemented the same pain, sedation, and withdrawal scales.

In any case, the study does show that “targeting a sedation goal of patients who are calm, easily aroused, and readily evaluated is attainable and safe in children,” wrote registered nurse Martha Curley, Ph.D., of the University of Pennsylvania, Philadelphia, and her associates . The study results were published to coincide with Dr. Curley’s presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

The protocol patients had a median 9 days of opioids, versus 10 in the usual-care group, and they were awake and calm while intubated a median of 86% of days, versus 75% in the control group. However, intervention children had pain during about half of their days, while usual-care children reported pain during about quarter of their days. Intervention patients also had more agitation, and postextubation stridor, but fewer pressure sores. There were no differences in mortality between the groups.

Morphine was the primary protocol opioid, while fentanyl was used most often in the control group. Morphine was selected for the protocol because it has a longer duration of action, plus some sedative properties and less development of tolerance. The primary sedative in both groups was midazolam; about a quarter of protocol patients received dexmedetomidine, versus about half in the usual-care group.

Baseline patient characteristics were well matched between the two groups, except that the intervention group enrolled more patients younger than 2 years and more patients with bronchiolitis, both of whom are harder to sedate. Pneumonia, bronchiolitis, and acute respiratory failure due to sepsis were the most common diagnoses in both groups. The mean age of the children was 4.7 years.

The work, dubbed the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) study, was supported by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research. The lead author had no disclosures. One coauthor is an advisor for Philips, and another reported consultant and other fees from Cerus, Quark Pharmaceuticals, Biogen, GlaxoSmithKline, and other companies.

[email protected]

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

CDC / Jennifer Hulsey

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.

A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).

“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.

Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.

[email protected]

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

CDC / Jennifer Hulsey

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.

A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).

“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.

Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.

[email protected]

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

CDC / Jennifer Hulsey

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.

A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).

“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.

Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.

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