New research was presented at the 2016 Critical Care Congress, the Society of Critical Care Medicine’s annual meeting, from February 20 to 24 in Orlando. The features below highlight some of the studies emerging from the conference that focused on emergency medicine.
Sedation, Analgesia, & RSI in the ED
The Particulars: The appropriate use of sedation and analgesia are crucial to optimizing the management of patients undergoing intubation. However, studies suggest that this management is often inadequate, particularly after performing rapid sequence intubation (RSI) in patients with paralysis. Use of a prescribing pathway in the ED may improve the time from intubation to sedative and analgesic administration.
Data Breakdown: Researchers compared sedation and analgesia administration in patients undergoing RSI in the ED before and after implementation of an electronic prescribing pathway for a study. The average time from RSI to sedation administration was 28.7 minutes for the pre-intervention group, compared with a time of 24.0 minutes in the post-intervention group. The average time from RSI to opioid analgesic administration decreased from 78.0 minutes before the intervention to 40.2 minutes after.
Take Home Pearl: Adding an electronic prescribing pathway in the ED does not appear to decrease time to sedation administration among patients undergoing RSI, but does appear to significantly decrease the time from RSI to analgesic administration.
Recognizing CIRCI in the ED
The Particulars: The treatment of critical illness-related corticosteroid insufficiency (CIRCI) remains controversial, but data suggest that corticosteroid administration during early septic shock may improve 28-day survival. Little is known about how well EDs recognize patients with possible CIRCI.
Data Breakdown: For a study, medical records of patients with an admission diagnosis of severe sepsis or septic shock were reviewed for the timing of corticosteroid administration for vasopressor refractory shock and the incidence of testing cortisol levels. Corticosteroids were administered to only 13% of patients in the ED, compared with a 49% rate that was observed in the ICU. A random cortisol was drawn prior to ICU admission in 4% of patients, compared with a rate of 45% for patients after ICU admission. Among patient with a random cortisol draw, 22% had a level lower than 10 mcg/dL, 39% had a level of 10-20 mcg/dL, and 30% had a level higher than 20 mcg/dL.
Take Home Pearls: Among patients with an admission diagnosis of severe sepsis or septic shock, CIRCI appears to be under-recognized by emergency physicians. More than one-half of patients who have a random cortisol draw appear to have levels suggestive of moderate to high CIRCI.
ED LOS & Outcomes in Mechanical Ventilation
The Particulars: Previous research suggests that delaying the transfer of critically ill patients from the ED to the ICU increases ICU length of stay (LOS) and mortality. However, few studies have explored if a delay in transfer of more than 6 hours increases mortality rates, ICU LOS, or hospital LOS.
Data Breakdown: A chart review of patients place on mechanical ventilation was conducted for a study to compare outcomes among those who had an ED LOS of 6 hours or longer with those of patients with an ED LOS of less than 6 hours. Both groups had similar ICU and hospital LOS. However, patients who survived to hospital discharge had shorter ED LOS when compared with those with in-hospital deaths. The rate of survival to discharge was 80% for those with a shorter ED LOS, compared with a rate of 71% for those with longer ED LOS.
Take Home Pearl: Mechanically ventilated patients with an ED LOS of less than 6 hours appear to have more favorable outcomes and higher survival rates when compared with those with longer ED LOS.
Assessing Telecritical Care
The Particulars: Little is known about the impact of telecritical care programs on ICU and hospital mortality among adult patients.
Data Breakdown: Study investigators compared patient outcomes in community hospitals before and after implementation of an adult telecritical care program that was operated from a remote support center. The table below depicts key findings that emerged in the analysis:
|Transfer to another acute care hospital||8.74%||7.92%|
|Variable ICU cost per patient||$1,546||$1,395|
Take Home Pearls: Implementation of a telecritical care program appears to decrease patient transfers to a higher level of care and reduce ICU and hospital mortality rates. In addition, telecritical care programs appear to reduce ICU costs.
Fluids & Antibiotics for Pediatric Septic Shock
The Particulars: Guidelines recommend administering fluids and antibiotics for children with suspected severe sepsis or septic shock within 60 minutes of presentation in order to improve outcomes. Data are limited on the rate of adherence to these guidelines in pediatrics.
Data Breakdown: For a small study, researchers reviewed the charts of children who presented to the ED with severe sepsis or septic shock. More than half of the patients (54.5%) received fluid boluses, among whom 42.9% received 20 cc/kg; 21.4% received 40 cc/kg; and 35.7% received 60 cc/kg. The average time to fluid administration was:
- 140 minutes for those who received 20 cc/kg.
- 240 minutes for those who received 40 cc/kg.
- 111 minutes for those who received 60 cc/kg.
Most patients received antibiotics in the ED, with an average time to administration of these drugs of about 155 minutes.
Take Home Pearls: The average time that it takes to administer fluid resuscitation and antibiotics appears to be well over the recommended timeframe of 60 minutes in pediatric patients presenting to the ED with severe sepsis or septic shock. Additional research is needed to understand the possible barriers to adherence with current guidelines.
For more information on these studies and others that were presented at SCCM 2016, visit http://www.sccm.org/Education-Center/Annual-Congress/Pages/default.aspx.