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Age, percentage TBSA burned, and the presence of inhalation injury have been used historically in the prediction of mortality in thermally injured patients despite other factors being also associated with mortality. Recent literature has identified novel factors associated with increased length of stay (LOS) and may provide a better prediction model for mortality in burn patients. The study objective was to perform a subset analysis of a multitude of known and novel variables for potential association with mortality. Demographics and injury characteristics along with during stay variables were collected and analyzed. This study is a re-analysis of a retrospective study examining variables associated with increased LOS. Of the 629 patients screened, 396 were included in the analysis. After univariable analysis, 35 variables had significant associations with mortality, including age, house fire, acute kidney injury, heart failure, inhalation injury, and history of diabetes. After multivariable analysis, the best performing model included heart failure, acute kidney injury, admission Glasgow Coma Scale score, and revised Baux score. Quantile analysis of age revealed greater than 60 years was most predictive of mortality. The best multivariable model for patients greater than 60 years old included heart failure, vasopressor use, acute respiratory distress syndrome, and TBSA burned. Considering only variables present on admission, the best multivariable model for patients greater than 60 years old included heart failure, % TBSA burned, and inhalation injury. The addition of variables into current prediction models and databases may be warranted.

BACKGROUND: Recent studies indicate critically ill patients with coronavirus disease 2019 (COVID-19) are hypermetabolic; however, protein requirements in critically ill COVID-19 patients are unknown. Our intent was to evaluate the nitrogen accretion response to varying protein intakes for critically ill ventilator-dependent patients with COVID-19. METHODS: Adult patients (age ≥ 18 years) with COVID-19, admitted to the intensive care unit (ICU) and who required mechanical ventilation were retrospectively evaluated. Patients received continuous enteral nutrition (EN), including supplemental protein boluses, and had a 24-h urine collection for determination of nitrogen balance (NBAL). Data are expressed as mean ± SD with a P-value < .05 as significant. RESULTS: Twenty-two patients provided 29 NBAL determinations. Protein intake from EN and protein supplements was 0.9 ± 0.7 g/kg/day at the time of the NBAL with an NBAL of -12.1 ± 10.9 g/day at 7 ± 4 days in the ICU. Combined caloric intake from EN and propofol at the time of the NBAL was 12 ± 8 kcal/kg/day. Nitrogen equilibrium (NBAL of -4 g/day or better) occurred in five patients. Patients achieving nitrogen equilibrium received more protein than those with a negative NBAL (1.2 ± 0.4 g/kg/day vs 0.8 ± 0.8 g/kg/day, P = .046). The linear regression for NBAL in response to graded increases in protein intake was as follows: NBAL = 8.5 × protein intake (g/kg/day) - 18.8 (r = 0.450, P < .001). CONCLUSION: Critically ill ventilator-dependent patients with COVID-19 exhibit significant variability in nitrogen accretion response to increases in protein intake and often have a markedly negative NBAL.

Objective To review the pharmacology, efficacy, and safety of oral cenobamate in the treatment of uncontrolled focal epilepsy. Data Sources The PubMed database and ClinicalTrials.gov were searched using the following terms: cenobamate, Xcopri, and YKP3089. Study Selection and Data Extraction Articles published in English between January 2000 and April 2020 related to pharmacology, safety, and clinical trials were assessed. Data Synthesis In a phase 2 trial, cenobamate reduced the median percentage change in seizure frequency from baseline by 56% compared with 22% for placebo ( P < 0.0001). In another phase 2 trial of multiple cenobamate doses, cenobamate reduced seizure frequency by 36% ( P = 0.0071) in the 100-mg group and 55% ( P < 0.0001) in both the 200- and 400-mg groups, compared to 24% with placebo. Adverse effects of cenobamate appear to be similar to those of other antiseizure medications and primarily affect the neurological system. Relevance to Patient Care and Clinical Practice In patients taking antiseizure medications who continue to have focal seizures, cenobamate has efficacy at multiple doses and is generally well tolerated. Cenobamate may be distinguished from other antiseizure medications by high rates of seizure freedom not seen in previous placebo-controlled trials, which has the potential to significantly improve quality of life. However, despite this efficacy, Drug Reaction with Eosinophilia and Systemic Symptoms may remain a significant concern with cenobamate. Conclusion As seen in clinical trials, cenobamate as an adjunctive, once-daily treatment represents an efficacious and generally well-tolerated therapy for patients with drug-resistant focal epilepsy.

The purpose of this case was to report the impact of early use of high-volume hemofiltration on a previously healthy male admitted after sustaining a high-voltage electrical injury. Initial labs revealed acute kidney injury secondary to rhabdomyolysis with myoglobinuria. The patient required fasciotomies to the three affected extremities and a right above the elbow amputation. Aggressive fluid resuscitation failed to maintain urine output above 20 mL/h. By 24 h, the patient had a 12.8 L positive fluid balance. High-volume hemofiltration was initiated at 60 mL/kg/h using a system with a high cut-off filter for acute kidney injury and volume management. Urine myoglobin was negative by day 3 and serum myoglobin decreased to 221.46 nmol/L. He was extubated on day 5, achieved euvolemia on day 6, and high-volume hemofiltration was discontinued on day 13 with subsequent full renal recovery. He underwent several staged surgeries for burn wound excision and grafting, and the left lower extremity was salvaged. His length of stay was prolonged due to multiple social barriers, but free of sepsis and pneumonia. Early initiation of high-volume hemofiltration with a high cut-off filter helped to expedite removal of acute kidney injury and enable more effective volume management to minimize complications of high-voltage electrical injury and its treatment and likely improve outcomes.

BACKGROUND Patients with traumatic brain (TBI) injury often require a high dosage of propofol, which can provide an excessive caloric intake. We evaluated our strategy of using liquid protein supplement boluses concurrently with high protein-containing enteral nutrition (EN) formulas and formula rate reduction to avoid caloric overfeeding and inadequate protein intake. METHODS Adult patients (aged >17 years) with TBI admitted to the trauma intensive care unit (TICU) who received concurrent propofol and EN were retrospectively reviewed. Caloric intakes from propofol and EN were obtained. Actual protein intake was compared with projected protein intakes from high protein content and standard protein content enteral formulas when given at an isocaloric intake. RESULTS Fifty-one patients were enrolled. Average caloric intake from propofol was 356 ± 243 kcal/d or 5 ± 3 kcal/kg/d (range

Purpose: The purpose of this study was to examine the incidence of rebound hypotension in patients with septic shock requiring both norepinephrine and vasopressin infusions once discontinuation of 1 of these agents is warranted. Methods: A multicenter, retrospective study was conducted in 3 hospitals within a single health system between January 1, 2016, and December 31, 2017. The study population included adults, 18 years and older, diagnosed with septic shock and requiring concurrent infusions of norepinephrine and vasopressin. The primary outcome evaluated the incidence of rebound hypotension within 24 hours after the first vasopressor was discontinued. Secondary outcomes included intensive care unit length of stay, hospital length of stay, total vasopressor duration, and the time to rebound hypotension after first vasopressor discontinuation. Results: A total of 69 patients were included in the study, 38 in the vasopressin discontinued first group and 31 in the norepinephrine discontinued first group. Rebound hypotension occurred in 82% of patients in the vasopressin discontinued first group compared with 48% in the norepinephrine discontinued first group ( P = .004). No differences were observed in secondary outcomes, including intensive care unit or hospital length of stay, total vasopressor duration, or the time to rebound hypotension. Conclusions: Discontinuation of norepinephrine before vasopressin may lead to less incidence of rebound hypotension in patients with septic shock who require concurrent norepinephrine and vasopressin infusions. Similar to previous studies, this study found no difference in secondary outcomes.