Erkan Hassan

Therapeutic considerations in the management of agitated or delirious critically ill patients

Agitation and delirium in the critical care unit are common problems that at times are difficult to treat. The difficulty stems from few placebo‐controlled or even blinded trials evaluating various therapies. In addition, the literature in these areas is scattered through various journals in a variety of disciplines. Pharmacologic and nonpharmacologic techniques may achieve the therapeutic objective for these patients. Since no one drug will achieve the goals in every patient, therapy must be tailored to the characteristics and needs of each individual.

Using technology to prevent adverse drug events in the intensive care unit.

Critically ill patients are particularly susceptible to adverse drug events (ADEs) due to their rapidly changing and unstable physiology, complex therapeutic regimens, and large percentage of medications administered intravenously. There are a wide variety of technologies that can help prevent the points of failure commonly associated with ADEs (i.e., the five “Rights”: right patient; right drug; right route; right dose; right frequency). These technologies are often categorized by their degree of complexity to design and engineer and the type of error they are designed to prevent. Focusing solely on the software and hardware design of technology may over- or underestimate the degree of difficulty to avoid ADEs at the bedside. Alternatively, we propose categorizing technological solutions by identifying the factors essential for success. The two major critical success factors are: 1) the degree of clinical assessment required by the clinician to appropriately evaluate and disposition the issue identified by a technology; and 2) the complexity associated with effective implementation. This classification provides a way of determining how ADE-preventing technologies in the intensive care unit can be successfully integrated into clinical practice. Although there are limited data on the effectiveness of many technologies in reducing ADEs, we will review the technologies currently available in the intensive care unit environment. We will also discuss critical success factors for implementation, common errors made during implementation, and the potential errors using these systems.

Managing anemia in the critically ill patient.

Anemia of critical illness is a multifactorial condition caused by phlebotomy, ongoing blood loss, and inadequate production of red blood cells. It occurs early in the course of critical illness. Although red blood cell transfusion is the treatment of choice for immediate management of anemia in the intensive care unit, controversy surrounds the most appropriate hemoglobin concentration or hematocrit “trigger.” Therapeutic options, including blood‐conservation tools, minimization of phlebotomy, erythropoietic agents, and investigational oxygen‐carrying agents, may be alternatives to red blood cell transfusions in critically ill patients with anemia. Patient selection for erythropoietic agents will depend on further work dealing with outcomes and the total cost of care in managing the anemia of critical illness.

Intravenous to Oral Conversion of Antihypertensives: A Toolkit for Guideline Development

Objective: To provide a toolkit of information for hospitals to use in developing intravenous to oral conversion protocols for antihypertensives. Data Sources: Articles describing intravenous to oral conversion protocols for any therapeutic category were identified in an English-language MEDLINE search (1990-April 2010) using a wide variety of MeSH terms. References from selected articles were reviewed for additional material. Study Selection and Data Extraction: Experimental and observational English-language studies and review articles that focused on oral transition of intravenous drugs were selected. Data Synthesis: Most of the literature on conversion from intravenous to oral formulations involves antimicrobials. There is considerable evidence documenting reduced costs and improved patient flow through the health-care system following implementing these protocols with drugs like antimicrobials, histamine-2 receptor antagonists, and proton pump inhibitors. Although antihypertensives have not been studied, principles and implementation strategies used for other drug classes can be applied to antihypertensives. Guidance is provided on framing the problem, issues surrounding oral absorption principles, information pertaining to oral conversion in specific disease slates, and implementation and documentation strategies. Detailed tables of oral and intravenous antihypertensives are provided. Conclusions: We recommend that hospitals consider developing protocols on conversion of intravenous to oral antihypertensives in an attempt to reduce unnecessarily prolonged intravenous therapy. Information contained in this article can be used as a toolkit to select information specific to the characteristics of individual health-care systems.

Telemedicine and the Patient with Sepsis

Severe sepsis remains a significant medical problem affecting up to 18 million individuals worldwide. Mortality remains high ranging between 28% and 50%. Owing to this and the time-sensitive nature of this disease state, early identification and prompt interventions are necessary to improve outcomes. Technology associated with telemedicine may help in screening, identifying, and monitoring the attainment of the severe sepsis bundle elements in a timely manner. However, the heterogeneity of systemic inflammatory response syndrome and clinical assessment necessary to diagnose and assess patients with severe sepsis makes technology alone insufficient to improve the outcomes in these patients.

Current Issues Regarding the Use of Drotrecogin alfa (activated)

The key issues clinicians are facing regarding drotrecogin alfa (activated) include questions concerning the pathophysiology and appropriate patient selection for administration of this drug. In the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, the efficacy of drotrecogin alfa (activated) was demonstrated in patients with severe sepsis. Because of this trials strict inclusion and exclusion criteria, however, the applicability of the study criteria to different types of patients raises important issues. Coupling the data from the PROWESS trial with additional information being gained from expanding clinical experience, as well as additional studies, clinicians will be able to better understand and refine the use of activated protein C within their respective practices.

464: PREVALENCE OF ABNORMAL RESPIRATORY VITAL SIGNS AND ASSOCIATIONS WITH CRITICAL INTERVENTIONS IN ICU

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Several studies have described the alert burden of vital sign abnormalities in ICUs, few used detailed, continuously monitored measurements in large patient sample. The objective is to estimate the volume of alerts based on abnormalities of respiratory rate (RR) and O2 saturation (O2Sat), and subsequent critical respiratory interventions in a broad ICU patient sample. Methods: A multi-center, cross-sectional study of ICU patients from the Philips eICU Research Institute database (2013–2016) admitted in ICUs reliably charting respiratory interventions. Continuous vital signs were archived every 5 minutes and each patient stay was parsed into 15 mins intervals. Each interval was evaluated for the presence of RR (> 25bpm or < 12bpm) and O2Sat abnormalities (< 90%), and subsequent intervention (new ventilation or intubation, significant increase in FIO2, O2L, or PEEP based on predefined criteria). Statistical comparisons were made using Chi-square test for categorical measures or ANOVA for continuous measures. Results: A total of 446,295 adult patient unit stays contributed to 89,843,460 of 15 mins intervals in the final analysis, representing 156 hospitals and 266 ICUs (56% mixed, 21% cardiac/surgical, 8% medical, 15% others). 18%, 7% and 4% of the patient intervals had high RR, low RR and low O2Sat, respectively. 1% had both high RR and low O2Sat and were followed with highest probabilities of major interventions (ventilation/intubation, increased in O2L, FiO2, PEEP or any: 19%, 33%, 25%, 3% and 49%, respectively). In comparison, low RR without low O2Sat occurred in 7% of the intervals and were the least likely to receive interventions: 12%, 19%, 9%, 1% and 32%, respectively (p < 0.001). Conclusions: The prevalence of abnormal respiratory vital signs in the ICU was high. The majority of abnormal events weren’t responded to with new interventions. Smarter alerts need to use comprehensive data and differentiate vital sign abnormalities requiring critical interventions from those in less need of immediate attention.