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Patients who present in shock have high expected mortality and early resuscitation is crucial to improve their outcomes. The Critical Care Resuscitation Unit (CCRU) is a specialized unit at the University of Maryland Medical Center (UMMC) that prioritizes early resuscitation of critically ill patients. We hypothesized that lactate clearance and reduction of Sequential Organ Failure Assessment (SOFA) score during CCRU stay would be associated with lower in-hospital mortality.We performed a retrospective analysis of adult patients who were admitted to the CCRU between 01/01/2018-12/31/2018 and had a diagnosis of severe shock, determined by serum lactate ≥4 mmol/L. We excluded patients who died during CCRU stay. We used multivariable logistic regression to evaluate the association between lactate clearance and reduction in SOFA scores during CCRU stay and in-hospital mortality.Out of 1740 patients admitted to the CCRU in 2018, 172 (10%) had serum lactate ≥4 mmol/L. Twenty-two (13%) patients died during their CCRU stay. Our primary analysis included 129 patients with lactate clearance data and 136 patients with SOFA data. Average patients' age was 54 years, and median length of stay in the CCRU was 6 h 55 min. The average lactate and SOFA score on admission were 7.4 (3.8) mmol/L and 8.3 (4.7), respectively. Average lactate clearance was 1.9 (3.1) and average SOFA score reduction was 0.2 (2.9). In multivariable logistic regressions evaluating SOFA score and lactate separately, SOFA score reduction during CCRU stay was associated with lower in-hospital mortality (OR 0.83, 95% CI: 0.70-0.97) but lactate clearance was not (OR 0.90, 95% CI 0.78-1.03). In forward stepwise multivariable analysis containing both SOFA score and lactate values, SOFA score clearance during CCRU stay was still associated with decreased in-hospital mortality (OR 0.84, 95% CI 0.72-0.98).Care in the CCRU is more effective at reducing lactate than SOFA scores in patients with severe shock. However, SOFA score reduction in the resuscitation phase during the CCRU stay was associated with decreased odds of in-hospital mortality in this group of patients. Further studies are necessary to confirm our observations.

Blood pressure (BP) monitoring and management is essential in the treatment of acute aortic disease (AoD). Previous studies had shown differences between invasive arterial BP monitoring (ABPM) and non-invasive cuff BP monitoring (CBPM), but not whether ABPM would result in patients' change of clinical management. We hypothesized that ABPM would change BP management in AoD patients.This was a prospective observational study of adult patients with AoD admitted to the Critical Care Resuscitation Unit from January 2019 to February 2021. Patients with AoD and both ABPM and CBPM measurements were included. Clinician's BP management goals were assessed in real time before and after arterial catheter placement according to current guidelines. We defined change of management as change of current antihypertensive infusion rate or adding a new agent. We used multivariable logistic and ordinal regressions to determine relevant predictors.We analyzed 117 patients, and 56 (47%) had type A dissection. ABPM was frequently ≥10 mmHg higher than CBPM values. Among 40 (34%) patients with changes in management, 58% (23/40) had [ABPM-CBPM] differences ≥20 mmHg. ABPM prompted increasing current antihypertensive infusion in 68% (27/40) of patients. Peripheral artery disease (OR 13, 95% CI 1.18-50+) was associated with changes in clinical management, and ordinal regression showed hypertension and serum lactate to be associated with differences between ABPM and CBPM.ABPM was frequently higher than CBPM, resulting in 34% of changes of management, most commonly increasing anti-hypertensive infusion rates.

Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used to treat severe coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome; however, patient selection criteria have evolved throughout the pandemic. In this study, we sought to determine the association of patient mortality with time from positive COVID-19 test and infiltrate on chest radiograph (x-ray) to VV ECMO cannulation. We hypothesized that an increasing duration between a positive COVID-19 test or infiltrates on chest x-ray and cannulation would be associated with increased mortality. This is a single-center retrospective chart review of COVID-19 VV ECMO patients from March 1, 2020 to July 28, 2021. Unadjusted and adjusted multivariate analyses were performed to assess for mortality differences. A total of 93 patients were included in our study. Increased time, in days, from infiltrate on chest x-ray to cannulation was associated with increased mortality in both unadjusted (5-9, P = 0.002) and adjusted regression analyses (odds ratio [OR]: 1.49, 95% CI: 1.22-1.81, P0.01). Time from positive test to cannulation was not found to be significant between survivors and nonsurvivors (7.5-11, P = 0.06). Time from infiltrate on chest x-ray to cannulation for VV ECMO should be considered when assessing patient candidacy. Further larger cohort and prospective studies are required.

The COVID-19 pandemic was superimposed upon an ongoing epidemic of opioid use disorder and overdose deaths. Although the trend of opioid prescription patterns (OPP) had decreased in response to public health efforts before the pandemic, little is known about the OPP from emergency department (ED) clinicians during the COVID-19 pandemic.We conducted a pre-post study of adult patients who were discharged from 13 EDs and one urgent care within our academic medical system between 01/01/2019 and 09/30/2020 using an interrupted time series (ITS) approach. Patient characteristics and prescription data were extracted from the single unified electronic medical record across all study sites. Prescriptions of opioids were converted into morphine equivalent dose (MED). We compared the "Covid-19 Pandemic" period (C19, 03/29/2020-9/30/2020) and the "Pre-Pandemic" period (PP, 1/19/2020-03/28/2020). We used a multivariate logistic regression to assess clinical factors associated with opioid prescriptions.We analyzed 361,794 ED visits by adult patients, including 259,242 (72%) PP and 102,552 (28%) C19 visits. Demographic information and percentages of patients receiving opioid prescriptions were similar in both groups. The median [IQR] MED per prescription was higher for C19 patients (70 [56-90]) than for PP patients (60 [60-90], P0.001). ITS demonstrated a significant trend toward higher MED prescription per ED visit during the pandemic (coefficient 0.11, 95% CI 0.05-0.16, P = 0.002). A few factors, that were associated with lower likelihood of opioid prescriptions before the pandemic, became non-significant during the pandemic.Our study demonstrated that emergency clinicians increased the prescribed amount of opioids per prescription during the COVID-19 pandemic compared to the pre-pandemic period. Etiologies for this finding could include lack of access to primary care and other specialties during the pandemic, or lower volumes allowing for emergency clinicians to identify who is safe to be prescribed opioids.