BackgroundSedation practices in an ICU have shifted significantly in the past 20 years toward the use of minimizing sedation in mechanically ventilated patients. While minimizing sedation is clearly in the best interest of patients, data are lacking about how this approach affects patients’ experiences.MethodsWe interviewed mechanically ventilated patients receiving minimal sedation, over a 6-month period in an ICU, in order to explore their emotional, comfort, and communication experiences. Their responses were compared with the responses of their available family members regarding their attitudes and perceptions of the patients’ experiences.ResultsSeventy-five percent of the patients agreed or strongly agreed that they experienced pain, and 50% agreed or strongly agreed that they were comfortable. Half of the patients agreed or strongly agreed that they preferred to be kept awake. Five patients (31%) indicated that they were frustrated while 17 relatives (89%) agreed or strongly agreed that the patients were frustrated. When controlling for age and gender of respondents, family members perceived higher levels of patient pain (least square [LS] mean [95% CI]: 4.2 [3.7, 4.7] vs. 3.1 [2.5, 3.8]; p=0.022), frustration (LS mean [95% CI]: 4.2 [3.7, 4.6] vs. 3.2 [2.6, 3.9]; p=0.031), and adequate communication with nurses and doctors (LS mean [95% CI]: 3.9 [3.5, 4.4] vs. 3.1 [2.4, 3.7]; p=0.046) than the patients themselves.ConclusionPatients tolerated minimal sedation without significant frustration while mechanically ventilated despite experiencing discomfort. Patient and family member perceptions of the patient experience may differ, especially in regards to pain and frustration. The use of a communication tool can facilitate understanding of patient experiences and preferences.

Purpose The outbreak of the novel coronavirus (COVID-19) required clinicians to use knowledge of therapeutic mechanisms of established drugs to piece together treatment regimens. The purpose of this study is to examine the trends in medication utilization among COVID-19 patients across the United States using a national dataset. Methods We conducted a cross-sectional study of the COVID-19 cohort in the Cerner Real-World Data ™ warehouse, which includes de-identified patient information for encounters associated with COVID-19 from December 1, 2019 through June 30, 2020. The primary variables of interest were medications given to patients during their inpatient COVID-19 treatment. We also collected demographics, calculated the proportion of patients with each medication, and stratified by demographic variables. Findings Our sample included 51,169 inpatients from every region of the United States. Males and females were equally represented, and the majority of patients were white and non-Hispanic. The largest proportion of patients were older than 45 years old. Steroids had the highest utilization among all patients (56.5%), followed by hydroxychloroquine (17.4%), tocilizumab (3.1%), and lopinavir/ritonavir (1.1%). We found substantial variation in medication utilization by region, race, ethnicity, sex, age and insurance status. Implications Variations in medication use are likely attributable to multiple factors, including the timing of the pandemic by region in the United States and processes by which medications are introduced and disseminated. This study is the first of its kind to assess trends in medication utilization in a national dataset and is the first large descriptive study of pharmacotherapy in hospitalized COVID-19 patients. It provides an important glimpse into prescribing patterns during a novel pandemic.

Introduction: Immunosuppressive agents are theorized to target the cytokine storm syndrome in COVID-19. However, the downstream effects regarding susceptibilities to secondary infection risk remains unknown. This study seeks to determine risk differences for secondary infections among COVID-19 patients who did and did not receive tocilizumab. Methods: We conducted a matched retrospective cohort study from two large, acute care hospitals in Western Connecticut from March 1, to May 31, 2020. We collected variables using manual medical record abstraction. The primary exposure variable was any dose of tocilizumab. The primary outcome was any healthcare-associated bacterial or fungal infection as defined by the National Healthcare Safety Network. We performed a Kaplan–Meier analysis to assess the crude difference in cumulative probability of healthcare-associated infection (HAI) across exposure groups. We also performed a multivariable Cox regression analysis to determine the hazard ratio for HAI by exposure group while controlling for potential confounders. Results: The Kaplan–Meier analysis demonstrated no difference in the cumulative probability of HAI across groups. The adjusted hazard of HAI for patients given tocilizumab was 0.85 times that of patients not given tocilizumab (95% confidence interval = 0.29, 2.52, P = 0.780) after controlling for relevant confounders. Conclusions: Tocilizumab did not increase the incidence of secondary infection among COVID-19 patients. Larger, randomized trials should evaluate infection as a secondary outcome to validate this finding.

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