BACKGROUND:There is limited data regarding the use of clinical assessment alone for neuromuscular blockade (NMB) titrations in the setting of acute respiratory distress syndrome (ARDS). OBJECTIVE:To compare the amount of cisatracurium (CIS) consumed when utilizing train-of-four (TOF)-guided NMB titrations or clinical assessment alone without TOF for continuous infusion (CI) administration. METHODS:A retrospective analysis was performed evaluating TOF-guided titrations compared with clinical assessment alone (non-TOF) for CI NMB with CIS. Individuals within the TOF group were assessed from January 2013 to December 2018 while those within the clinical assessment alone group were assessed from January 2021 to December 2024. Patients were excluded if they were less than 18 years old, had documentation of COVID-19 infection, were receiving extracorporeal membrane oxygenation, or had NMB initiated at an outside hospital. The primary objective was assessing drug utilization between groups. RESULTS:A total of 1047 and 553 individuals were screened resulting in 99 and 65 included for analysis in the TOF and non-TOF groups, respectively. The median cumulative CIS dose was 665 (472, 927) mg in the TOF group and 536 (400, 699) mg in the clinical assessment alone group, P = 0.011. The median infusion rate was 32% higher in the TOF group: 2.5 (1.8, 3.6) versus 1.9 (1.8, 2.4) µg/kg/min, P < 0.001, despite similar starting rates. Median drug costs were also significantly reduced when comparing the TOF group with the non-TOF group: $178 (126, 247) versus $143 (107, 187), P = 0.011. CONCLUSION AND RELEVANCE:This study assesses drug utilization when comparing TOF-guided NMB titration with clinical assessment alone in the modern ARDS era. Utilization of clinical assessment alone without TOF monitoring for CI CIS resulted in significantly reduced drug utilization and costs. Further studies are needed to assess the impact of clinical assessment alone on improvement of oxygenation.

BACKGROUND: Central venous catheters (CVCs) are associated with significant morbidity, mortality, and costs in the ICU. One strategy to reduce CVC complications is to avoid placing them altogether. Although norepinephrine (NE) is typically administered via a CVC, data increasingly suggest it may be safely administered via peripheral IV lines. RESEARCH QUESTION: Can protocolized administration of peripheral NE decrease CVC utilization? STUDY DESIGN AND METHODS: We implemented a protocol using peripheral IVs to administer NE infusion in our medical ICU (MICU) in March 2019. To determine the impact of our protocol on CVC placement, we compared the proportion of MICU patients who received a CVC before (July 1, 2017, to February 28th, 2019) and after (March 1, 2019 to December 31, 2023) protocol implementation. We then compared the change in CVC utilization in the MICU with that in all other ICUs in the same hospital from 2017 to 2023. We also evaluated the percentage of patients receiving the peripheral infusion who ultimately did not require a CVC during their index MICU stay. RESULTS: The average proportion of MICU patients who received a CVC decreased significantly after protocol initiation: pre, 59.5% vs post, 53.5%, P < .01. Central line utilization in the control ICUs remained consistent over the same period, with 60.5% in the pre-intervention period and 61.5% in the postintervention period (P = .34). In the MICU post-intervention period, there were 819 peripheral NE infusions, with 391 (47.4%) never receiving a CVC during their index MICU stay. Nine patients (1.1%) received extravasation treatment. INTERPRETATION: Implementation of a protocol using peripherally infused NE was found to be safe, feasible, and associated with a decrease CVC utilization over time. Our study provides further evidence that many patients prescribed NE do not require a central line, and protocolized administration can decrease the use of CVCs on a broader scale. CHEST Critical Care 2025; 3(4):100195

Introduction: Both pulse oximetry and blood gas co-oximetry are crucial technologies universally used in the care of critically ill patients. Both rely on the principle that oxyhemoglobin, deoxyhemoglobin and dyshemoglobins (such as methemoglobin) absorb near-infrared light of distinct waveforms which can be detected by a spectrophotometric device. Understanding the foundation of this technology as well as sources for error is crucial for physicians. We present a case of a woman without respiratory distress with refractory peripheral hypoxemia. Case Report: A 64-year-old woman with a history of congenital hemolytic anemia due to presumed red cell membrane defect, gastric bypass surgery, and newly diagnosed rectal adenocarcinoma treated with FOLFOX presented to the emergency department with incidental hypoxemia found during routine outpatient care. She was not in respiratory distress despite a peripheral saturation of 81% measured by pulse oximetry which did not improve with either high-flow nasal cannula or non-invasive positive pressure ventilation. Cross sectional imaging revealed normal lung parenchyma and a small, isolated subsegmental pulmonary embolism and anticoagulation was initiated. Due to refractory hypoxemia inconsistent with her pulmonary embolic burden, bedside critical care ultrasound was performed which revealed normal biventricular function and a negative bubble study. Arterial blood gas sent while receiving high flow nasal oxygen (100% at 40 lpm) a partial pressure of oxygen of 218 mmHg. Co-oximetry was reported as inconclusive due to interfering agents on two separate specimens. Her initial hemoglobin of 8.6 g/dL (baseline = 9.9 g/dL) decreased to 6.8 g/dL over twelve hours with no overt evidence of bleeding. Further laboratory findings of an elevated LDH (431 IU/L), decreased haptoglobin (<30 mg/dL), increased reticulocyte count, and elevated circulating free hemoglobin (260.4 mg/dL) supported a diagnosis of active hemolysis. Discussion: Pulse oximetry relies on several physiological assumptions including that blood contains only oxy- and deoxyhemoglobin. Co-oximetry expands this assumption by using additional light wavelengths to isolate common dyshemoglobins. The presence of any additional serum substances that absorb similar wavelengths can interfere with the detection system resulting in falsely low saturations (Table 1). Active hemolysis, such as in this case, can yield circulating free hemoglobin that results in falsely low pulse oximetry and co-oximetry oxygenation assessments. Other substances that may confound oximetry measurements include high levels of bilirubin, triglycerides, fetal hemoglobin, and inherited hemoglobinopathies. Understanding the principles of pulse oximetry and common sources of error is essential when considering the cause of profound hypoxemia in critically ill patients.

BACKGROUND:Damage biomarkers are helpful in early identification of patients who are at risk of developing acute kidney injury (AKI). Investigations are ongoing to identify the optimal role of stress/damage biomarkers in clinical practice regarding AKI risk prediction, surveillance, diagnosis, and prognosis.OBJECTIVE:To determine the impact of utilizing a clinical decision support system (CDSS) to guide stress biomarker testing in intensive care unit (ICU) patients at risk for drug-induced acute kidney injury (D-AKI).METHODS:A protocol was designed utilizing a clinical decision support system (CDSS) alert to identify patients that were ordered 3 or more potentially nephrotoxic medications, suggesting risk for progressing to AKI from nephrotoxic burden. Once alerted to these high-risk patients, the pharmacist determined if action was needed by ordering a stress biomarker test, tissue inhibitor of metalloproteinase-2-insulin-like growth factor-binding protein 7 (TIMP-2•IGFBP7). If the biomarker test result was elevated, the pharmacist provided nephrotoxin stewardship recommendations to the team. Pharmacists recorded the response to the clinical decision support alert, ordering, and interpreting the TIMP-2•IGFBP7, and information regarding clinical interventions. An alert in conjunction with TIMP-2•IGFBP7 as a strategy for AKI risk prediction and stimulant for patient care management was assessed. In addition, barriers and solutions to protocol implementation were evaluated.RESULTS:There were 394 total activities recorded by pharmacists for 345 unique patients. Ninety-three (93/394; 23.6%) actionable alerts resulted in a TIMP-2•IGFBP7 test being ordered. Thirty-one TIMP-2•IGFBP7 results were >0.3 (31/81; 38.3%), suggesting a high-risk of progression to AKI, which prompted 191 pharmacist/team interventions. On average, there were 1.64 interventions per patient in the low-risk patients, 3.43 in high-risk patients, and 3.75 in the highest-risk patients.CONCLUSION AND RELEVANCE:Stress biomarkers can be used in conjunction with CDSS alerts to affect therapeutic decisions in ICU patients at high-risk for D-AKI.

Patients with sickle cell disease can develop acute chest syndrome and are at high risk of developing pulmonary thrombosis. We report a case of a young woman with sickle cell disease who was hospitalized for vaso-occlusive crisis and subsequently developed worsening acute chest syndrome and stroke, discovered on point of care ultrasound to have right heart failure and a thrombus straddling a patent foramen oval. POCUS is highly specific for the detection of right heart dilation/dysfunction and should be a routine component of the assessment of acutely decompensating patients.

Groetzinger, Lara1; Barbash, Ian2; Lamberty, Phillip2; Donahoe, Michael2; Smith, Roy2; Rivera-Lebron, Belinda2 Author Information

Background: Reducing central venous catheter (CVC) utilization can reduce complications in the intensive care unit (ICU). While norepinephrine (NE) is traditionally administered via a CVC, lower concentrations may be safely administered via peripheral intravenous (PIV) lines. Objective: We aimed to describe the implementation of a pilot protocol utilizing PIVs to administer a low-dose and lower-concentration NE, review the number of CVCs avoided, and evaluate any adverse events. Methods: In a quaternary medical intensive care unit (MICU), from March 1, 2019, to February 29, 2020, we reviewed charts for CVC placement and adverse events from the pNE infusion. We also measured unit-level CVC utilization in all MICU patients and assessed the change in utilization associated with the peripheral norepinephrine (pNE) protocol. Results: Over a 1-year period, 87 patients received a pNE infusion. Overall, 44 patients (51%) never required CVC placement during their MICU stay. Three patients (3%) experienced adverse events, none of which were documented as serious and or required antidote for treatment. Implementation of the protocol was associated with a decrease in the number of patients at the unit level who received CVCs, even if they did not receive pNE. Conclusion and Relevance: In this small pilot study, we pragmatically demonstrated that pNE is safe and may reduce the need for CVC placement. This information can be used to aid in pNE protocol development and implementation at other institutions, but further research should be done to confirm the safety of routine use of pNE in clinical practice.

Purpose: Three continuous dosing strategies of cisatracurium (CIS) for acute respiratory distress syndrome (ARDS) have been described in the literature. After implementation of a ventilator synchrony protocol (VSP), we sought to determine which continuous CIS dosing strategy utilized the least amount of drug without compromising efficacy. Methods: We retrospectively reviewed patients with ARDS receiving continuous CIS from January 1, 2013 to December 31, 2018. We categorized patients into one of three dosing strategies: fixed dose (FD), titration based solely on train-of-four (TOF), or the VSP. We documented drug consumption and determined efficacy by comparing the change in PaO2/FiO(2) ratio (P/F) and oxygenation index (OI) from baseline up to 48 h. Results: A total of 1047 patients were screened, and 189 met inclusion criteria (VSP = 69, TOF = 99, FD = 21). Drug consumption (mg) was significantly lower in the VSP arm: 415 [IQR 318-528] compared to both the TOF: 665 [IQR 472-927] and the FD arms: 1730 [IQR 1695-1800], p < 0.001 for each. The change in P/F and OI from baseline were statistically equivalent at all time points. Conclusion: Without impacting efficacy of gas exchange, a protocol using ventilator synchrony for CIS titration required significantly less drug compared to TOF-based titration and a fixed dosing regimen. (C) 2021 Elsevier Inc. All rights reserved.

Groetzinger, Lara; Hainly, Julia; Svec, Sue; Donahoe, Michael; Lamberty, Phillip; Barbash, Ian Author Information

OBJECTIVES:First, to implement successfully a light-sedation protocol, favoring initial as-needed (prioritizing as-needed) boluses over continuous infusion sedation, and second, to evaluate if this protocol was associated with differences in patient-level sedative requirements, clinical outcomes, and unit-level longitudinal changes in pharmacy charges for sedative medications.DESIGN:Retrospective review comparing patients who received the prioritizing as-needed sedation protocol to similar patients eligible for the prioritizing as-needed protocol but treated initially with continuous infusion sedation.SETTING:Thirty-two bed medical ICUs in a large academic medical center.PATIENTS:A total of 254 mechanical ventilated patients with a target Riker Sedation-Agitation Scale goal of 3 or 4 were evaluated over a 2-year period. Of the evaluable patients, 114 received the prioritizing as-needed sedation protocol and 140 received a primary continuous infusion approach.INTERVENTIONS:A multidisciplinary leadership team created and implemented a light-sedation protocol, focusing on avoiding initiation of continuous sedative infusions and prioritizing prioritizing as-needed sedation.MEASUREMENTS AND MAIN RESULTS:Overall, 42% of patients in the prioritizing as-needed group never received continuous infusion sedation. Compared with the continuous infusion sedation group, patients treated with the prioritizing as-needed protocol received significantly less opioid, propofol, and benzodiazepine. Patients in the prioritizing as-needed group experienced less delirium, shorter duration of mechanical ventilation, and shorter ICU length of stay. Adverse events were similar between the two groups. At the unit level, protocol implementation was associated with reductions in the use of continuous infusion sedative medications.CONCLUSIONS:Implementation and use of a prioritizing as-needed protocol targeting light sedation appear to be safe and effective. These single-ICU retrospective findings require wider, prospective validation.

We read with interest the two recent retrospective comparative studies on standard (sCDT) versus ultrasound-assisted catheter-directed thrombolysis (usCDT) along with a very relevant editorial indicating the lack of good quality data to guide practice in our cost-effectiveness-based health system.1–3 All relevant comparative studies have been recently systematically reviewed by our group: while no difference was seen in the intermediate-risk subgroups, the high-risk (massive) pulmonary embolism (PE) groups had more favorable results with usCDT. For mortality, the observed rate for sCDT was three times as great as for usCDT (11.9% vs 3.6%), and we can be 95% confident that the mortality rate will be no greater than 9% for usCDT but possibly as high as 30% for sCDT.4 The Standard vs Ultrasound-assisted Catheter Thrombolysis for Submassive Pulmonary Embolism (SUNSET sPE) trial is an ongoing randomized, head-to-head, singleblinded clinical trial designed to address this controversy.5 Participants are randomized 1:1 to a usCDT catheter or a sCDT catheter. Technical details of the procedure are left to the discretion of the treating physician with a general guidance for short < 12-hour periods of thrombolysis to match the favorable outcomes demonstrated by the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Pulmonary Embolism (OPTALYSE PE) study.6 Trying to simulate real life practice termination is recommended when there is objective improvement of vital or echocardiographic signs (pragmatic trial). The primary outcome is clearance of pulmonary thrombus burden, assessed by post-procedure computed tomography angiography. This was chosen as thrombus clearance is the distinct assumed advantage of usCDT, but most importantly the only outcome we can power our randomized controlled trial since use of clinical outcomes would require thousands of patients. Secondary outcomes include resolution of right ventricular strain by echocardiography; improvement in pulmonary artery pressures; and 3and 12-month improvement in echocardiographic, functional capacity, and quality of life measures. We agree with Drs Klein and Shishehbor3 that we lack appropriate clinically relevant outcome definitions and that right ventricular to left ventricular (RV/LV) ratios and thrombus scores are soft endpoints, but hard clinical endpoints are fairly uncommon and a comparative study based on such endpoints will be difficult if not impossible to complete given the financial and time constraints of the required sample size. On the other hand, the SUNSET sPE trial is attempting to minimize bias, randomizing only intermediate high-risk (positive biomarkers and echocardiographic RV strain) patients and is specifically powered to prove (or disprove) the notion that ultrasound can increase thrombus clearance in human pulmonary arteries. SUNSET sPE started enrolling in May 2017 at the University of Pittsburgh Medical Center, and more recently two more centers (Emory University – Cardiology and Piedmont Heart Institute, both in Atlanta) are also actively adding patients to the study, which is anticipated to be completed in early 2020. The study is sponsored by the enrolling institutions and more recently received funding from the American Venous Forum to include a pilot study on biomarkers’ prediction of longer-term pulmonary sequelae (NCT02758574). We and our collaborators, based on the thoughtful design and conduct of this study, are hopeful that the results will be relevant to clinical practice and inform our treatment algorithm for patients with PE.

SESSION TITLE: Critical Care 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: To developed an adult mock code training curriculum and assess its development, feasibility, and acceptability for housestaff in the medical intensive care unit. METHODS: The mock code training program consists of online training materials for independent review and a 90-minute integrated didactic and simulation session. Trainees participate in a single mock code then rotate through four didactic modules: bag-mask ventilation, effective chest compressions, identification and treatment of shockable rhythms, and effective communication techniques. Finally, trainees participate in three additional mock code scenarios. Performance was evaluated for each mock code using an 11 item checklist based on learning objectives from the didactic material. Residents were evaluated on whether they performed or did not perform each learning objective. We also created a feedback survey based on program learning objectives to assess residents’ perceived confidence level in their ability to manage a cardiopulmonary arrest, as well as their confidence in skills taught during the didactic session. Confidence was measured on a 5 point Likert scale. Trainees completed the survey prior to and immediately following the training session. RESULTS: Over 4 months, 21 residents have participated in and evaluated the mock code training program. Resident performance increased from correctly performing 50% of the learning objectives during the first mock code to correctly performing 95% of the learning objectives during the last mock code. There was an increase in resident confidence between baseline and immediately after the session for all skills. The mean overall confidence in managing a cardiopulmonary arrest increased from 1.91 to 3.19. Mean confidence using an oral airway increased from 2.68 to 4.14. Mean confidence using a bag-valve mask increased from 3.10 to 3.81. Mean confidence performing effective chest compressions increased from 3.50 to 4.10. Mean confidence identifying shockable rhythms increased from 2.95 to 3.48. Mean confidence with defibrillation increased from 2.59 to 3.81. Mean confidence using effective communication techniques increased from 2.91 to 4.10. CONCLUSIONS: Preliminary results suggest that the mock code training program is feasible and acceptable to housestaff. Residents’ ability to manage cardiopulmonary arrest increased in both objective measurement and perceived confidence. Future work includes analyzing objective data on CPR effectiveness, bag-mask ventilation effectiveness, and time to defibrillation, as well as collecting six month follow up data. CLINICAL IMPLICATIONS: Management of cardiopulmonary arrests requires a high level of physician skill; however, their infrequent nature makes it hard to obtain the necessary exposure to develop that skill. We have developed a mock code training program that helps residents develop that skill. DISCLOSURES: No relevant relationships by Ian Barbash, source=Web Response No relevant relationships by Jared Chiarchiaro, source=Web Response No relevant relationships by Steven Fox, source=Web Response No relevant relationships by Phillip Lamberty, source=Web Response No relevant relationships by Stephanie Maximous, source=Web Response No relevant relationships by Rachel Pace, source=Web Response

Today NIV is an essential part of ICU care, but it is also used in many other venues, including the pre-hospital setting, emergency department, post-operative care unit, and medical and surgical wards. Chapter 13 discusses the machines used to deliver NIV, as well as its indications and contraindications. It also explains when and how to initiate NIV and describes how to adjust settings based on clinical information.