Atrial fibrillation (AF) is the most common arrhythmia encountered in the ICU. Preexisting AF is highly prevalent among older patients with chronic conditions who are at risk for critical illness, whereas new-onset AF can be triggered by accelerated atrial remodeling and arrhythmogenic triggers encountered during critical illness. The acute loss of atrial systole and onset of rapid ventricular rates that characterize new-onset AF often lead to decreased cardiac output and hemodynamic compromise. Thus, new-onset AF is both a marker of disease severity as well as a likely contributor to poor outcomes, similar to other manifestations of organ dysfunction during critical illness. Evaluating immediate hemodynamic effects of new-onset AF during critical illness is an important component of rapid clinical assessment aimed at identifying patients in need of urgent direct current cardioversion, treatment of reversible inciting factors, and identification of patients who may benefit from pharmacologic rate or rhythm control. In addition to acute hemodynamic effects, new-onset AF during critical illness is associated with both short- and long-term increases in the risk of stroke, heart failure, and death, with AF recurrence rates of approximately 50% within 1 year following hospital discharge. In the absence of a strong evidence base, there is substantial practice variation in the choice of strategies for management of new-onset AF during critical illness. We describe acute and long-term evaluation and management strategies based on current evidence and propose future avenues of investigation to fill large knowledge gaps in the management of patients with AF during critical illness.

No abstract

Widespread vaccine administration is necessary to curb the COVID-19 pandemic. To overcome COVID-19 vaccine hesitancy, states have introduced various strategies to increase vaccine uptake. On May 12, 2021, the state of Ohio announced a lottery system to pay randomly selected vaccine recipients up to $1 million. 1 After initial reports that vaccine uptake had subsequently increased in Ohio, other states adopted similar vaccine payment lotteries. 2 However, the announcement of the Ohio vaccine lottery closely coincided with the US Food and Drug Administration expanding Emergency Use Authorization of the BNT162b2 (Pfizer-BioNTech) messenger RNA vaccine to adolescents aged 12 to 15 years on May 10, 2021. 3 We assessed changes in COVID-19 vaccination rates before and after the Ohio vaccine lottery announcement compared with national rates to control for the expansion of vaccine indications to adolescents.

Key Points Question What are the characteristics of intensive care unit admissions identified by 2 proposed pandemic ventilator allocation triage guidelines using Sequential Organ Failure Assessment scores when applied retrospectively to critically ill US patients who received mechanical ventilation? Findings In this cohort study of 40 439 admissions to intensive care units that received mechanical ventilation, the New York State guideline identified 9% who would likely meet criteria for the lowest priority for ventilator allocation compared with 4% from the original White and Lo guideline. Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with 39% survival to hospital discharge for admissions identified as lowest priority using the New York State guideline compared with 56% for admissions identified using White and Lo. Meaning Two distinct approaches to triage for mechanical ventilation showed little agreement, suggesting that further clinical assessment of different potential criteria for triage decisions is important to ensure equitable allocation of resources.