IntroductionHypertonic saline (HTS) has been utilized in the treatment of several critical conditions including severe hyponatremia and elevated intracranial pressure. Current practice requires that HTS be administered through a central venous catheter (CVC). Midline catheters (MC) are a type of peripheral venous catheter (PIVC) placed in a large peripheral vein distal to the axillary vein. There are a few comprehensive studies investigating the efficacy of utilizing MCs for the administration of long-term HTS. MethodsA retrospective single center study performed at a tertiary care academic hospital, of patients admitted to the ICU for the administration of HTS through a MC. Data collected from 2019-2023 through a chart review of electronic medical records and recorded in REDCap.ResultsA total of 138 patients who received HTS via a MC were included in the analysis. Subjects were predominantly male (69.57%) and black (59.42%). The median age of the patient was 57 years ± 14.4 years old. The admission diagnoses included intracranial hemorrhage accounting for 67.39%, followed by altered mental status at 18.12%, trauma at 12.32% and sepsis at 7.25%.The concentrations of the HTS infusions were 2% NaCl in 54 patients, 3% NaCl in 82 patients, and 23% NaCl in 2 patients. The average duration of a continuous HTS infusion was 14 h and 34 min ± 15 h and 17 min. The average dosage rate was 86.03 ± 74.43 mL/h. Only one patient experienced thrombophlebitis. Thrombosis developed within the midline catheters for 5 patients. No complications related to drug extravasation or deep vein thrombosis were observed.ConclusionResults showed minor adverse events suggesting that MC may be a safe alternative for the administration of long-term HTS infusions. Midline catheters should be considered when weighing risk and benefits of HTS administration in the management of elevated intracranial pressure and severe hyponatremia.

BackgroundMidline catheters (MC) are 10-20 cm intravenous (IV) lines inserted in the peripheral veins of the upper arm and utilized for patients who require longer term IV access, making them advantageous in the intensive care unit (ICU). Guidelines on medication infusion through MC are limited and clinical practice varies. It is unclear how MC practice variation affects critical care fellowship experience.ObjectivesWe sought to investigate the relationship between institutional practices surrounding MC and the role of trainees.MethodsA survey was sent to all Critical Care Fellowship program directors investigating their use of MC. Program type, number of hospital beds and trainees were collected. The use of vasopressors (VP), hypertonic saline (HS), and parenteral nutrition (PN) through MC was assessed, as well as which providers were placing MC (interventional radiology (IR), fellows, residents, or advanced practice providers). Statistical analysis was performed using IBM SPSS statistics. Associations between clinical variables were assessed using Fisher's exact test.ResultsSeventy programs responded to the survey (30.4% response rate). Of these 70 programs, 53 (75.7%) reported MC use. IR placed MC at 79.2% of programs. Larger hospitals (≥500 beds) were significantly more likely to use IR (88.9% vs 58.8%, P = .025), while smaller hospitals more often utilized residents (17.6% vs 2.8%, P = .032). Among programs using MC, 66% administered vasopressors (VP), 62.3% used hypertonic saline (HS), and 20.8% gave parenteral nutrition (PN). Critically, programs with fellow-placed MC were significantly more likely to use VPs (93.3% vs 55.3%, P = .03) and PN (33.3% vs 15.8%, P = .030) compared to programs without fellow involvement. No differences in MC use were found across institution types, bed capacities, or trainee numbers.ConclusionsThough MC use in critical care ICUs in the US is prevalent, hospital factors appear to influence who is placing the MC and how MC are utilized.

BackgroundAdequate enteral nutrition is essential in critical illness, yet optimal delivery strategies remain debated. Rate-based and volume-based are commonly used, with prior studies suggesting improved caloric delivery with volume-based. However, real-world clinical outcomes, particularly with mixed protocols and in COVID-19 patients, are unclear. We hypothesized that volume-based would improve caloric delivery versus rate-based or mixed, and that critically ill COVID-19 patients would achieve a lower goal intake.MethodsThis single-center retrospective cohort study included ICU patients (2020-2023) receiving ≥48 h of enteral nutrition via rate-based, volume-based, or mixed strategies. The primary outcome was the percentage of prescribed intake achieved. Secondary outcomes included hospital and ICU length of stay, ventilator days, hospital-acquired pressure injuries and infections. Baseline illness severity was assessed using standard comorbidity and organ failure scores.ResultsAmong 324 patients, 24% achieved ≥80% of caloric goal, with no difference across feeding strategies (P = .30). Mixed feeding was associated with longer hospital and ICU stays, more ventilator days, and longer enteral nutrition duration (all P < .01). Mixed feeding was associated with higher pressure injury compared with rate-based (30% vs 16%, P = .03), with no association with hospital-acquired infections. Among patients achieving ≥80% prescribed intake, associations with ICU length of stay and ventilator days were no longer significant.COVID-19 status did not modify these associations, with longer stays in COVID-positive patients receiving mixed protocol.ConclusionsVolume-based did not improve total energy delivery. Mixed feeding was associated with worse clinical outcomes, likely reflecting greater illness complexity rather than causation. Consistency of nutrition delivery may be more important than protocol type. Prospective multicenter studies are needed.

Introduction/hypothesisThe chances of survival from sepsis are improved by early diagnosis and treatment. In the prospective SENSOR study, RNA biomarkers of innate immune neutrophil activation were examined in emergency department (ED) patients triggering an automated sepsis alert. We hypothesized that higher levels of blood RNA biomarkers related to neutrophil activation would be associated with progression to more severe forms of sepsis.MethodsAdult patients in the ED triggering a sepsis alert were consented, enrolled, and study samples were obtained during the ED visit. Additionally, study samples were collected from a convenience sample of 16 adult non-ED controls and 8 other adults with self-described infectious illnesses. Blood samples were drawn in RNA preservative (Tempus) and whole blood RNA was analyzed by droplet digital PCR (ddPCR) for RNA transcripts related to neutrophil response to infection by bacterial (DEFA1; ALPL, IL8RB/CXCR2), and viral (IFI27, RSAD2) pathogens. Bacterial burden in blood was quantitated by ddPCR of 16S ribosomal DNA. Separately, neutrophil elastase was measured in immunomagnetically captured CD66b+ neutrophils by a novel point-of-care device.ResultsPatients were grouped using both 'Sepsis-2' SIRS criteria, adjudicated by independent physicians, and 'Sepsis-3' criteria which uses a qSOFA score for categorizing the severity of illness. Across 72 enrolled sepsis alert patients, 62.5% showed positive RNA biomarkers for bacterial infection, and 8.3% were positive for viral markers, with only 2 cases that showed only a viral signal. Septic patients showed a 4-fold increase in RNA markers vs. those without infection (p < 0.05). However, no significant differences were observed in RNA levels between those with sepsis vs those with more severe forms of sepsis. Likewise, RNA biomarker levels did not discriminate patients with qSOFA≥2 from qSOFA = 1. In a subset of patients with zero and three hour blood samples (n = 27) it was found that changes in RNA levels (up or down), or neutrophil elastase activity, was strongly associated with progression to more severe forms of sepsis or a qSOFA score of ≥2.ConclusionsPatients progressing to more severe forms of sepsis did not have higher absolute levels of neutrophil activation RNA biomarkers (or higher bacterial burden in blood) compared to patients with sepsis. However, a change in RNA biomarkers or elastase between zero and three hours was strongly indicative of progression to more severe forms of sepsis.

Purpose: Midline catheters (ML) are long peripheral intravenous catheters placed in an upper extremity above the antecubital fossa via the basilic, cephalic, or brachial veins. These provide safe and comfortable long-term vascular access for critically ill patients. Central venous pressures (CVP) are obtained from central venous catheters (CVC) and are often used as resuscitation parameters. Given the proximity of ML to the axillary vein, we investigated if midline venous pressure (MVP) is comparable to CVP. Methods: This is an observational study conducted in adult critical care patients at a tertiary academic center. Inclusion criteria were patients with a CVC in the subclavian or internal jugular veins and a ML in place as part of standard ICU care. Pressure measurements were recorded from both catheters every 15 min over a 60-min period. Demographic, clinical, and physiological data points were collected. Continuous variables were analyzed using the t-test. Pearson correlation was used to evaluate the relationship between the paired variables. Results: We enrolled 50 patients with 5 pressure measurements taken per patient (n = 250). The mean MVP and CVP were 10.6 ± 6.4 mm Hg and 9.1 ± 6.3 mm Hg, respectively (P < .001). In Bland Altman analysis, the mean bias was -1.48 ± 3.99 mm Hg with limits of agreement of -9.3 mm Hg to 6.3 mm Hg. The Pearson correlation coefficient was 0.8 (P < .001). Conclusions: Our study investigated MVP as a correlate of CVP. Our results show a mean bias of -1.48 ± 3.99 mm Hg and a strong positive Pearson correlation coefficient of 0.8 between the MVP and the CVP. The large limits of agreement indicate MVP and CVP are not interchangeable. Despite this, clinically significant pressure values from CVCs and MLs trend similarly.

Sweeney, Brendan1; Kim, Justin2; Adnani, Ariana1; Wu, Maria1; Bheem, Rishika1; Saleem, Huma3; Akben, Seda3; Roth, Michael3; Alvina Teo, Yin Rong2; Shaykhinurov, Eduard2; Davison, Danielle4; Hawkins, Katrina5; Yamane, David5; Ivanovics, Sasa6 Author Information

Background: Although palliative medicine (PM) is more commonly being integrated into the intensive care unit (ICU), research on racial disparities in this area is lacking. Our objectives were to (a) identify racial disparities in utilization of PM consultation for patients who received ICU care and (b) determine if there were differences in the use of code status or PM consultation over time based on race. Materials and Methods: Retrospective analysis of 571 patients, 18 years and above, at a tertiary care institution who received ICU care and died during their hospital stay. We analyzed two timeframes, 2008-2009 and 2018-2019. Univariate analysis was utilized to evaluate baseline characteristics. A multivariate logistic regression model and interaction P values were employed to assess for differential use of PM consultation, do not resuscitate (DNR) orders, and comfort care (CC) orders between races in aggregate and for changes over time. Results: There was a notable increase in Black/African-American (AA) (54% to 61%) and Hispanic/Latino (2% to 3%) patients over time in our population. Compared to White patients, we found no differences between PM consultation and CC orders. There was a lower probability of DNR orders for Black/AA (adjusted odds ratio [aOR] 0.569; P = .049; confidence interval [CI]: 0.324-0.997) and other/unknown/multiracial patients (aOR: 0.389; P = .273; CI: 0.169-0.900). Comparing our earlier time period to the later time period, we found an increased usage of PM for all patients. Interaction P values suggest there were no differences between races regarding PM, DNR, and CC orders. Conclusions: PM use has increased over time at our institution. Contrary to the previous literature, there were no differences in the frequency of utilization of PM consultation between races. Further analysis to evaluate the usage of PM in the ICU setting in varying populations and geographic locations is warranted.

Objective Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. Interventions and Measurements We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.