OBJECTIVES:
To summarize the most impactful articles relevant to the pharmacotherapy of critically ill adult patients published in 2021.
DATA SOURCE:
PubMed/MEDLINE.
STUDY SELECTION:
Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critical care patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2021, and December 31, 2021.
DATA EXTRACTION:
Candidate articles were organized by clinical domain based on the emerging themes from all studies. A modified Delphi process was applied to obtain consensus on the most impactful publication within each clinical domain based on overall contribution to scientific knowledge and novelty to the literature.
DATA SYNTHESIS:
The search revealed 830 articles, of which 766 were excluded leaving 64 candidate articles for the Delphi process. These 64 articles were organized by clinical domain including: emergency/neurology, cardiopulmonary, nephrology/fluids, infectious diseases, metabolic, immunomodulation, and nutrition/gastroenterology. Each domain required the a priori defined three Delphi rounds. The resultant most impactful articles from each domain included five randomized controlled trials and two systematic review/meta-analyses. Topics studied included sedation during mechanical ventilation, anticoagulation in COVID-19, extended infusion beta-lactams, interleukin-6 antagonists in COVID-19, balanced crystalloid resuscitation, vitamin C/thiamine/hydrocortisone in sepsis, and promotility agents during enteral feeding.
CONCLUSIONS:
This synoptic review provides a summary and perspective of the most impactful articles relevant to the pharmacotherapy of critically ill adults published in 2021.
Severe bleeding remains the most significant adverse effect associated with both warfarin and the direct oral anticoagulant agents. Due to the life-threatening nature of these bleeds, knowledge and understanding of agents that are able to rapidly overcome the anticoagulation effects of these medications is paramount to their use. Worldwide, the most commonly used agent for this indication is prothrombin complex concentrate (PCC). This review summarizes the evidence on the use of PCC in this population and provides practical information regarding patient-specific administration considerations.
T he incidence of sepsis and mortality rates have remained consistent over the years despite advances in therapy, with mortality rates reported to be as high as 23.6% for patients diagnosed with septic shock. 1,2 However, since 2014, how we identify sepsis and how we treat affected patients has changed substantially. 3,4 In addition, although the topic is beyond the scope of this article, controversy remains about which criteria should be used when screening for and diagnosing sepsis. 5 The purpose of this article is to provide an overview of some of the updates to the Surviving Sepsis Campaign (SSC) guidelines, adjustments in traditional approaches to the management of sepsis, and novel therapies that have yet to be described extensively in the literature, such as the use of ascorbic acid, thiamine, and angiotensin II. Surviving Sepsis Campaign Updates The main update in the 2016 SSC guideline recommendations was that the use of early goal-directed therapy (EGDT) did not confer a mortality benefit compared with standard of care. 6 In the important studies on which the 2016 SSC recommendations were based, the framework of EGDT was still used in the standard-of-care groups (early antibiotic administration and fluids for patients with hypotension); however, dynamic variables to assess fluid responsiveness were promoted over the use of static variables. 4 In 2018 the SSC released another update to their guidelines, recommending that fluid resuscitation and antibiotics should not be lumped into 3-and 6-hour bundles, but should be started within 1 hour of recognition of possible sepsis or septic shock. 7 However, whether this strategy should be considered a best practice remains controversial. In May 2018, the Infectious Diseases Society of America (IDSA) responded by not endorsing the SSC guidelines, especially as they pertained to a strict 1-hour bundle, because of concerns that a significant percentage of patients might receive antibiotics who are not actually infected. 8 By September 2018, additional concerns had been raised related to the release of the 1-hour bundle; the Society of Critical Care Medicine and the American College of Emergency Physicians released a joint statement advising that hospitals in the United States should not implement the 1-hour bundle
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