To evaluate the early involvement of palliative care in the comprehensive treatment of trauma patients, the authors conducted a single center retrospective, observational study examining the effect of palliative care consultation following admission. All patients aged 18 years or older admitted to the trauma service whoalsoreceived a palliative care consultation were eligible for inclusion. The decision to consult palliative care was at the discretion of the trauma service and based on anticipated needs for complex decision making, complex social or family dynamics, and/or expectation of poor functional outcome. Patients were divided into early and late groups depending on the timing of palliative care consultation with a 3-day cut-off. This dichotomization was based on historical data and expert consensus. The primary outcome was the interaction of timing of palliative care consultation with healthcare utilization.
Over 5000 patients were admitted during the study period of which only 154 patients (3.0% of all admissions) met final inclusion criteria. Within the cohort, 60 patients (38%) received early consultation while 94 patients (61%) received late consultation. The overall mean time to consultation was 6.8 days, with an average of 1.27 days in the early group and 10.38 days in the late group. Demographically the groups were similar, however, patients in the late group had significantly more days on mechanical ventilation, more tracheostomies, and more surgical feeding tubes. Length of stay was significantly associated with timing of consultation with late patients having a near three-fold longer overall hospitalization and ICU length of stay, and a near 2.5 higher median cost of hospitalization. Interestingly, mortality and discharge to hospice were no different between groups with a combined in-hospital mortality and hospice discharge being 63.3% in the early group and 61.7% in the late group.
Authors of the study denote several limitations, many inherent to the retrospective study design, but namely the lack of standardized consultation criteria for involving palliative care. The subjective nature of consultation criteria and the stigmata associated with early involvement of palliative care can heavily bias practices and therefore skew results. However, that is the point. The discrepancy in invasive procedures, vent days, hospitalization length, and cost with no difference in in-hospital mortality or hospice discharge would suggest many patients would benefit from earlier palliative care involvement allowing for value-congruent care and patient-centered decision making. Standardized criteria for the early involvement of palliative care is likely beneficial and compliment the movement spearheaded by the American College of Surgeons Committee on Trauma and its Palliative Care Best Practices Guidelines.
Thoracic Ultrasonography (TUS) has seen a significant increase in utilization in the ICU for a range of indications including lung, cardiac and venous assessments. Observational research and systematic reviews have repeatedly demonstrated that the use of Point of Care Ultrasound in its various iterations (RUSH, FREE, etc.) is associated with a change in diagnosis and/or management. The question remains, however, whether these changes in clinical impression translate to explicit changes in the implementation of critical care plans and patient-centered outcomes. To that end, Heldeweg et al recently published their Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan) trial.
The aim of this prospective, multicenter, international trial was to not only assess the impact of TUS on changes to management, but also verify the execution of these intended changes. The authors also looked at whether TUS contributed specifically to a change in patients’ fluid balance. All adults being admitted to an intensive care unit in two academic, and two non-university hospitals were included leading to a total of 725 TUS examinations evaluated. These institutions utilized TUS as a routine in the management of their ICU patients, and included operators with a wide-range skills including those with minimal experience requiring supervision, to those with a high-level of experience and certification. This contributes to the study’s pragmatic validity and generalizability. The TUS procedure itself included assessment of the lungs, heart, diaphragm, and IVC as clinically indicated. The authors found that around half of TUS led to a change in clinical impression and a management change in 39% of cases. Crucially, however, 89% of these management changes were able to be executed within 8 hours, and those that indicated a change in the patient’s fluid management ultimately, indeed, led to a change in fluid balance. Hence, this trial provides evidence that TUS is more than just a tool for rapid confirmation of a clinical suspicion – it, in fact, leads to significant change in management plans as well as downstream impacts of those changes as well such as a more neutral fluid balance in patients with fluid management directed by TUS. These findings are valuable in establishing the utility of TUS in the critical care setting while further future studies evaluating longer term patient outcomes and the evaluation of TUS-based strategies of fluid management are conducted.
The goal of this retrospective review was to identify subtypes of right ventricular dysfunction that contribute to cardiovascular collapse and mortality in acute respiratory distress syndrome (ARDS). This was a single center study performed at Queen Elizabeth Hospital, Birmingham between April 2016 and December 2021. All patients who met Berlin criteria for ARDS and received a transthoracic echocardiogram within 7 days of diagnosis were evaluated for inclusion. Exclusion criteria included coronavirus-2 diagnosis, mechanical circulatory support, and pre-existing right ventricle (RV) or left ventricle (LV) dilation or dysfunction. Clinical criteria examined included chest radiograph opacification, ARDS severity, dead space fraction, dynamic compliance, and vasopressor dose. The TTE criteria examined evaluated RV function, RV dilation, presence of septal dyskinesis, and LV stroke volume.
There were four distinct subphenotypes identified by latent class analysis. Class 1 involved no RV or LV dilation and dysfunction and was present in 43.3% of patients. This group had the lowest mortality at 19.4%. Class 2 involved mild RV dilation without dysfunction and was present in 23.5% of patients. These patients had slightly higher mortality at 39.4%. Class 3 was categorized by both RV dilation and systolic dysfunction. This was seen in 12.7% of patients but had the highest mortality at 78.4%. Finally, Class 4 involved normal RV size and function but a hyperdynamic LV. This involved 20.5% of patients and had the second highest mortality at 59.1%.
By identifying different subtypes of cardiac failure in ARDS using routine parameters obtained on TTE, the authors have found an easy, noninvasive way to classify cardiac dysfunction in ARDS. By identifying patient phenotypes (especially those with higher mortality), clinicians might provide improved prognostication and targeted therapies to left vs right sided cardiac dysfunction. Limitations of the study include its retrospective nature, single-center cohort, and exclusion of patients with pre-existing cardiac conditions.
