We used Delphi methodology to provide guidance on gender equality and equity issues in professional life in intensive care, where information is evolving and no clear standard exists. A 12-member Steering Committee (7 women, 5 men) from 7 countries and 46 international panelists [(23 women, 21 men, 2 preferred not to disclose; median age 52 (33–75) years] from 32 countries (43

Optimizing drug dosing in critically ill patients is complex due to dynamic changes in pharmacokinetics and pharmacodynamics driven by disease-related physiology and interventions such as extracorporeal devices. Inadequate dosing may lead to therapeutic failure, whereas excessive dosing can exceed the patient's physiologic reserve, increasing the risk of adverse effects. As the medication experts on the interprofessional ICU team, critical care pharmacists are uniquely equipped to address the complex pharmacotherapeutic needs of critically ill patients. Key responsibilities include proactive medication management; providing education to clinicians, patients, and families; addressing drug-related questions; guideline development and implementation; and monitoring medication safety and efficacy.

This article provides a focused update to the clinical practice guideline on the treatment and management of people with COVID-19, developed by the Infectious Diseases Society of America. The guideline panel presents 9 updated recommendations on the use of nirmatrelvir/ritonavir, remdesivir, and molnupiravir, in adults with mild to moderate COVID-19. The recommendations are based on evidence derived from a systematic literature review and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The panel also provides a section on how to apply these recommendations, including an algorithm on the selection of antivirals.

This article provides a focused update to the clinical practice guideline on the treatment and management of patients with coronavirus disease 2019, developed by the Infectious Diseases Society of America. The guideline panel presents a recommendation on the use of the anti-severe acute respiratory syndrome coronavirus 2 neutralizing antibody pemivibart as pre-exposure prophylaxis. The recommendation is based on evidence derived from a systematic review and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Information on pemivibart is included in the U.S. Food and Drug Administration Emergency Use Authorization for this agent.

This article provides a focused update to the clinical practice guideline on the treatment and management of patients with coronavirus disease 2019 (COVID-19), developed by the Infectious Diseases Society of America. The guideline panel presents a recommendation on the use of abatacept in hospitalized adults with severe or critical COVID-19. The recommendation is based on evidence derived from a systematic literature review and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

Sedation is often required to facilitate comfort and provide necessary care for patients who are critically ill and require mechanical ventilation. Intravenous sedatives are the current standard of care in this patient population. Inhaled volatile agents that are routinely used for general anesthesia, like isoflurane and sevoflurane, are also being explored for their potential role in the ICU setting. Already, inhaled volatile agents are prescribed for routine ICU sedation in several countries, though their use for ICU sedation is not approved by United States regulatory authorities as of the time of this writing. The efficacy and safety profiles of inhaled sedatives for short-term use are well understood through decades of experience in the operating room. Their rapid onset and elimination via the lungs, potential opioid-sparing effects, and preservation of spontaneous breathing make them intriguing potential alternatives or adjuncts to standard-of-care sedation during critical illness. Technological advancements, consisting of compact vaporizers, volatile agent reflectors, and scavenger systems, allow the delivery of inhaled sedatives via modern ICU ventilators. However, these systems require specialized clinical training and considerations. Rigorous clinical trials evaluating the use of inhaled volatile agents for prolonged sedation of patients receiving mechanical ventilation remain limited, and whether these theoretical advantages translate to patient-centered benefit, relative to intravenous agents, remains unknown. Recent findings suggest prolonged deep sedation with inhaled sevoflurane predisposes to nephrogenic diabetes insipidus and acute kidney injury during critical illness, and that it is potentially harmful in patients with ARDS. Isoflurane may have a more favorable safety profile, but rigorous data are sparse on isoflurane use for more than a few days. This narrative review evaluates the evidence regarding the use of inhaled sedatives in patients in ICU who require mechanical ventilation. It also provides an overview of the clinical and technical aspects of this therapy to inform health care providers of a novel option, in many countries, for the sedation of patients undergoing mechanical ventilation.

As the first part of several focused updates to the clinical practice guideline on the treatment and management of COVID-19 in adults, children, and pregnant people, developed by the Infectious Diseases Society of America, the panel presents four new recommendations. These recommendations include pre-exposure prophylaxis for immunocompromised persons and treatment of severe or critical COVID-19. The panel’s recommendations are based upon evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.

OBJECTIVES:The goal of this task force was to examine the 1992 definition of the intensivist, identify gaps, and initiate a path forward to define a concise and practical definition that could be applied globally. DESIGN:A modified Delphi technique was used to develop a revised definition and roles of the intensivist. We determined a priori that 75% or greater participant agreement for the definition and essential roles of the intensivist was required. SETTING:A task force consisting of physicians, a respiratory therapist, advanced practice providers, and a pharmacist that practice in critical/intensive care medicine, in various settings, was established with the goal of evaluating and revising the previous definition considering evolving healthcare. SUBJECTS:The task force participated in online questionnaires related to the definition and roles of the intensivist. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The task force agreed on the following definition of an intensivist: "A physician who has successfully completed an accredited program or equivalent critical care/intensive care medicine training and maintains advanced certification (if available); and shows dedication to the area of critical/intensive care medicine in the way of professional work." Additionally, the task force determined a list of essential roles of the intensivist categorized into Direct Clinical Care, Unit Management/Unit Involvement, Responsibility to the Community, and Administration and Leadership. CONCLUSIONS:The revised definition of the intensivist seeks to integrate the intensivist in the current realm of team-based healthcare. The intensivist is a physician who provides care to critically ill patients in collaboration with an interprofessional team. Establishment of a single, revised definition is intended to render clarity of an intensivist's role and responsibilities for patients, families, and the interprofessional team.

BACKGROUND:Intensive care unit (ICU) staffing models increasingly use advanced practice providers (APPs), with unclear implications for clinical practice patterns. Sedation strategy is a modifiable determinant of clinical outcomes that might differ by staffing model. METHODS:This retrospective cohort study evaluated adults admitted to two medical ICUs in a quaternary teaching hospital, whose staffing differed only by APPs or residents. Patients requiring invasive ventilation for at least 48 h were included. The primary outcome was association of staffing model with sedative exposure during the first week of mechanical ventilation. Time to extubation and vital status at discharge were also assessed. RESULTS:Of 337 included patients, 96 % received continuous sedation on the day of intubation. Admission to the APP ICU was associated with significantly lower benzodiazepine exposure (adjusted OR 0.63; 95 % CI 0.40-0.99; p = 0.04) and higher propofol exposure (adjusted OR 1.73; 95 % CI 1.07-2.79; p = 0.03) on day of intubation. Cumulative benzodiazepine and opioid exposures over the first week after intubation were significantly less, and cumulative propofol exposure significantly more in the APP ICU despite similar sedation depth achieved between ICUs. Receipt of propofol on the first day was associated with shorter time to extubation (adjusted HR 1.45, 95 % CI 1.07-1.98; p = 0.02) and lower in-hospital mortality (adjusted OR 0.55, 95 % CI 0.33-0.93; p = 0.02). CONCLUSION:Patients admitted to an APP-staffed ICU were more likely to have sedation management reflective of best practice, and this practice was associated with shorter time to extubation and lower mortality.

Rationale: There is a paucity of data, and no consensus, about the composition of interdisciplinary teams of healthcare workers (HCWs) who provide care in intensive care units (ICUs). Objectives: To delineate the nature and variation of HCW staff composition in U.S. adult ICUs before the COVID-19 pandemic. Methods: A national survey of 574 adult ICUs inquired about ICU staffing. Two sets of survey items asked about 1) "availability to provide care" in ICUs for 11 HCW types, collapsed into six groupings; and 2) the presence in formal ICU clinical rounds of nine HCW types, collapsed into six groupings. Bedside nurses were assumed to be involved in both categories. Analysis was descriptive, seeking to examine the predominant and full range of staffing patterns. Results: Of surveyed ICUs, 94% were in metropolitan areas, 63% in teaching hospitals, 74% had >250 beds, 66% cared for mixed adult patient types (e.g., medical-surgical), median ICU bed count was 20 (interquartile range, 12-25), and 27% used some form of telemedicine. In addition to bedside nurses, the core staffing group comprised intensivists, respiratory therapists and pharmacists; in 88% of ICUs all were available to provide care. However, there were 28 different combinations of the six groupings (intensivists, respiratory therapists, pharmacists, attending physician support, advanced bedside nurse support, nurse aides), with the most common one, present in 38% of ICUs, including all six. Ninety-six percent of ICUs had interprofessional rounds at least 5 days per week; 78% had them on weekends. Among the ICUs with rounds, 61% of weekday rounding teams included all of intensivists, respiratory therapists, and pharmacists. Nutrition, rehabilitation, and social support practitioners each participated in rounds in 35-80% of ICUs and altogether in 28% of ICUs. Except for intensivists, all HCW types participated much less commonly in weekend than in weekday rounds. Conclusions: ICU care almost always included a core team of bedside nurses, intensivists, respiratory therapists, and pharmacists. Beyond that core, great variability was seen in the presence of many other HCW types. Almost all ICUs had interprofessional rounds, with three-fourths also having them on weekends.

Rationale: The association of interprofessional team member workload with intensive care unit (ICU) outcomes is understudied. Objectives: To evaluate the association of patient-to-intensivist ratio (PIR), patient-to-respiratory therapist ratio (PRTR), and patient-to-clinical pharmacist ratio (PpharmR) with hospital mortality. Methods: We conducted a retrospective study of adults admitted from the emergency department to an ICU with acute respiratory failure or sepsis within two U.S. healthcare systems (2013-2018). Our primary exposures were patient-to-clinician ratios (PIR, PRTR, and PpharmR) averaged over the ICU stay; our primary outcome was hospital mortality. We used multivariable mixed-effects regression, with patient-to-clinician ratios modeled as restricted cubic splines (four knots). We primarily considered each exposure separately, then included all ratios together. Results: Our cohort included 45,036 patients (mean age, 66.0 [standard deviation, 16.6] years; 23,420 [52.0%] men) across 27 ICUs within 24 hospitals. Of these, 29,326 (65.1%) had acute respiratory failure, 32,434 (72.0%) had sepsis, and 9,675 (21.5%) died in the hospital. The average PIR was 9.3 (standard deviation, 3.6), and the average PRTR was 7.9 (standard deviation, 3.2); the average PpharmR was 15.0 (standard deviation, 5.5) among patients (n = 8,950 of 45,036) in ICUs with clinical pharmacists (n = 8 of 27). We found no significant association between average daily PIR (Wald test for all spline terms: P = 0.24) or PRTR (P = 0.18) and hospital mortality in the full cohort; similarly, among patients in ICUs with pharmacists, no significant association of PpharmR with mortality was observed (P = 0.08). Models including ratios together yielded similar null results. Conclusions: We did not identify an association of any average daily patient-to-clinician ratio with hospital mortality for U.S. ICU patients with sepsis or respiratory failure.

The care of critically ill patients requires an interprofessional team. Critical care pharmacists are essential members of that interprofessional team. The purpose of these Consensus Recommendations is to present standards and guidance for individual pharmacists, institutions, and standard-setting bodies regarding best practices for the team integration of critical care pharmacists. Twenty one individuals were invited to serve on an interprofessional expert panel. A modified Delphi approach was used to structure the consensus process for generating the consensus recommendation statements. A total of 10 consensus recommendation statements were developed along with implementation guidance, process and outcome metrics, and a future agenda for research and advocacy.

Objectives: To evaluate the relationship among ICU patient-to-pharmacist ratio, perceived quality of patient care, and pharmacist burnout. Design: A prospective, multicenter, time-motion study conducted over a 10-month period (from May 1, 2022, to February 28, 2023). Setting: Adult ICU, PICU, or neonatal ICU. SUBJECTS: ICU clinical pharmacists Interventions: None. Measurements and Main Results: Overall, 128 ICU pharmacists completed 703 unique time-motion observation days and recorded their time associated with direct/indirect patient care activities, Maslach Burnout Inventor survey scores, and perceived quality of patient care provided (5-point Likert scale). Total pharmacist time on direct and indirect patient care activities were 5.9 ± 1.9 and 3.3 ± 1.7 hours per shift, respectively. The number of assigned patients in the ICU and overall (ICU and non-ICU) per shift was 19.3 ± 12.9 and 23.4 ± 17.9, respectively. The overall frequency of pharmacist burnout was 38.1%. Burnout was associated with incremental increases in the number of assigned total patients (odds ratio [OR], 1.03; 95% CI, 1.01–1.05) and overtime worked (OR, 1.18; 95% CI, 1.03–1.35). Higher compared with lower perceived quality of patient care was associated with significantly smaller assigned ICU patients (17.0 ± 7.4 vs. 30.6 ± 23.8, respectively; p < 0.001). Additional direct patient care time allocated per patient was predictive of a high quality of care perception (OR, 1.53; 95% CI, 1.03–2.05). Burnout was inversely associated with high quality of care (OR, 0.59; 95% CI, 0.36–0.96). The ICU patient-to-pharmacist ratio between 16:1 and 19:1 was associated with the highest perceived quality of patient care and comprehensive patient assessment completion rates. Conclusions: Critical care pharmacist practice models across healthcare institutions are inconsistent regarding patient assignments and time allocated toward direct and indirect patient care activities. The ICU patient-to-pharmacist ratio range between 16:1 and 19:1 may optimize quality of care and burnout risk at large academic institutions.

OBJECTIVES:Extracorporeal membrane oxygenation (ECMO) is a critical intervention for patients with severe cardiac or respiratory failure. However, pharmacological management for ECMO-supported patients presents unique challenges due to alterations in drug pharmacokinetics and pharmacodynamics induced by the ECMO circuit and underlying critical illness. This position paper identifies key research priorities in ECMO pharmacology using a structured Delphi consensus process and provides a focused review of current evidence and knowledge gaps to inform future research and clinical practice. DATA SOURCES:An international panel of 25 ECMO pharmacology experts from 13 countries representing the ECMO Pharmacology Network contributed to this position paper. Literature was reviewed to summarize current evidence and identify knowledge gaps in ECMO pharmacology. STUDY SELECTION:The Delphi process involved iterative, anonymous voting by the expert panel to propose key research priorities. Items selected were based on their perceived importance to improving clinical outcomes and advancing pharmacological management in ECMO-supported patients. DATA EXTRACTION:Key research priorities were identified, and a detailed literature review was conducted for each, focusing on pharmacokinetics/pharmacodynamics, related therapeutic challenges, and knowledge gaps. Future research directions were outlined. DATA SYNTHESIS:Six critical ECMO pharmacotherapy research priorities were identified: 1) pharmacokinetics/pharmacodynamics reporting, 2) interactions between ECMO and renal replacement therapy, 3) antimicrobial dosing, 4) analgesia and sedation for pain and agitation, 5) sedation and neuromuscular blocking agents for increased work of breathing, and 6) anticoagulation. The review for the key research priorities highlighted substantial gaps in the existing literature, emphasizing the need for comprehensive studies addressing these issues to enhance pharmacotherapy in ECMO patients, improve clinical outcomes, and contribute to the development of evidence-based guidelines for this complex population. CONCLUSIONS:ECMO presents unique challenges to drug pharmacokinetics and pharmacodynamics, complicating pharmacotherapy in critically ill patients. Further research addressing identified gaps is essential to develop evidence-based treatment strategies and enhance patient outcomes.