Our meta-analysis suggested a significant association between OSA and recurrent AF after catheter ablation. The use of CPAP in patients with OSA is associated with reduced risk of recurrent AF after catheter ablation.

PurposeAlcohol withdrawal syndrome (AWS) is commonly treated in medical ICUs and typically requires high resource utilization. Dexmedetomidine for AWS has not been extensively investigated, and guidelines regarding its use are lacking. We evaluated the association between dexmedetomidine use in AWS and ICU length of stay (LOS).MethodsWe performed a multi-institutional retrospective cohort study of patients in the ICU with the primary diagnosis of AWS. ICU LOS of those treated with benzodiazepines alone vs. benzodiazepines plus dexmedetomidine was compared. Negative binomial regression was performed to test whether dexmedetomidine use was associated with increased ICU LOS after adjustment for age, gender, body mass index, and the time between hospital and ICU admission.ResultsFour hundred thirty-eight patients from eight institutions were included. Patients treated with benzodiazepines plus dexmedetomidine had higher Clinical Institute Withdrawal Assessment for Alcohol scores at ICU admission, spent longer on the medical wards prior to ICU admission, and had longer unadjusted ICU LOS (p < 0.0001). After covariate adjustment, dexmedetomidine remained associated with longer ICU LOS (relative mean to non-dexmedetomidine group 2.14, 95% CI 1.78–2.57, p < 0.0001).ConclusionsCompared to benzodiazepines alone, dexmedetomidine for the treatment of AWS was associated with increased ICU LOS. These results provide evidence that dexmedetomidine may increase resource utilization.

Unplanned extubations are uncommon occurrences in the intensive care unit (ICU) that can have harmful and potentially fatal implications. Understanding the mechanisms and etiologies behind these events is vital to present future unplanned extubations. This study was undertaken to identify variables that place patients at greatest risk of self-extubation and possible need for re-intubation.METHODS: Unplanned extubations were identified in 55 patients across 3 different ICUs (medical, surgical and cardiothoracic) with 118 ICU beds at a tertiary medical center in Dallas, Texas between May 2020 and January 2021. A retrospective cohort review of all unplanned extubations was performed. The ICU nursing staff's years of experience data was collected from onboarding documentation. Nursing experience was categorized to inexperienced (<= 4 working years) and experienced (>4 working years). Clinical information including the primary nurse on duty as well as whether the patient was re-intubated was collected from each patient's chart. The information was organized into a 2-by-2 contingency table and a Fisher Exact Test was performed. RESULTS:The mean working experience in nurses working in the ICU at the time of January 2021 was 5.32 years. Of all ICU nurses, 61.8% had less than 4 years of clinical experience after graduating nursing school. When looking at unplanned extubation episodes, 72.7% of events occurred with inexperienced nurses and 27.3% of events were with experienced nurses. Out of the 55 unplanned extubation events, 23 (41.2%) cases required re-intubation. Nursing experience was a significant predictor of need for re-intubation with those paired with inexperienced nurses with higher propensity for re-intubation (p¼0.0264).CONCLUSIONS: Nursing care may be an important factor that contributes to a patient's likelihood of unplanned extubation. Nursing level of experience appears to be a risk factor for re-intubation risk after unplanned extubations with less experienced nurses associated with a higher risk of re-intubation. Unfortunately, many factors could play into this finding including lack of workplace experience, nursing comfort with notifying providers for sedation orders, as well as differences in shift preference in younger versus experienced nurses. Our retrospective study had a small study population which limited the overall power of this study and our ability to further elucidate specific risk factors for re-intubation.CLINICAL IMPLICATIONS: Unplanned extubations have the potential to cause physical trauma to the upper airways and complications due to removal of the endotracheal tube with inflated cuffs. Previous studies have shown re-intubation of patients is required in 45% of patients and up to 20% of patients have difficult re-intubation after unplanned extubations. Our study showed a similar re-intubation rate of 41.2%. Monitoring unplanned extubation rates in the ICU is a critical monitoring tool that can allow for improved protocols to prevent harm in ventilated patients. Further studies to pinp...

Self-extubation is an uncommon but real phenomenon occurring in ICUs with harmful and potentially fatal implications. Understanding the surrounding variables and mechanisms at play that put an intubated patient at risk for these events is vital to prevent future unplanned extubations. This study was undertaken to identify the factors placing patients at greatest risk of self-extubation and later need for reintubation, namely time of day.METHODS: 55 patients (62% male) with a mean age of 50 were identified across 5 ICUs and 118 ICU beds from a tertiary medical center in Dallas, TX were identified to have self-extubated from 2019 to 2020. A retrospective cohort review of all unplanned extubations was performed. Patient data was organized into two-by-two contingency tables and analyzed using Fisher's Exact Test. RESULTS:Neither age nor gender were statistically significant predictors for reintubation after self-extubation (p¼0.21 and p¼0.61, respectively). 24 self-extubations occurred during the day shift (7am-7pm) and 31 occurred during the night shift (7pm-7am). It was statistically more likely for patients to require reintubation during the night shift (p¼0.042). Self-extubation at shift change (6am-8am or 6pm-8pm) was not a statistically significant predictor of need for reintubation (p¼0.218).CONCLUSIONS: Patients who self-extubated during night shift were more likely to require reintubation than those during day shift. Despite adequate handoff from providers and other staff, cross-cover night teams may be less familiar with the patients and a lack of multidisciplinary rounding at night may lead to more conservative management and more frequent reintubation. Less frequent physician rounding during night shift also may mean that patients are self-extubating because planned extubations are less likely to occur overnight and physicians are less likely to evaluate a patient unless alerted to a change in clinical status. Additionally, if the primary team is considering a next day extubation, sedation holidays at night may play a role in increasing self-extubation. Ultimately, multiple factors contribute and further research into medications administered, respiratory plan of care, and patient specific factors may be able to identify risk factors for overnight self-extubation.CLINICAL IMPLICATIONS: By attempting to understand why patients are self-extubating we will be able to better care for our ventilated patients and ensure that they are safe while in our care. Patients self-extubating during the night shift are requiring reintubation at a higher rate, indicating potential room for improvement in our ICUs, whether this be in nursing education of the team's plan, making sure our nursing staff has adequate training and experience to handle ventilated patients, or creating a plan that involves more frequent rounding on patients by physicians and respiratory therapists during the night shift.

INTRODUCTION: Intravascular lymphoma (IVL) is a rare subtype of lymphoma proliferating in the lumen causing small vessel occlusion. Antemortem diagnosis is difficult. The majority of cases are diagnosed from autopsy. We report a patient with IVL who presented with sepsis of unknown source complicated by multiorgan failure. CASE PRESENTATION:A 58-year-old male with hypertension and chronic obstructive lung disease presented with fever for 3 weeks and was found to be hypotensive. Laboratory investigation was remarkable for platelet count of 84,000 per microliter, serum creatinine 3 mg/dl, aspartate aminotransferase of 50 units per liter (U/L), total bilirubin of 5 mg/dl, ferritin of 1265 microgram per liter, lactate dehydrogenase of 2051 U/L. Blood, respiratory and urine cultures were negative. CT abdomen and pelvis did not reveal a septisis source. Transthoracic echocardiogram showed a preserve ejection fraction without tamponade. Hemodynamic data from pulmonary artery catheter showed wedge pressure of 14, and mixed venous oxygen saturation of 72. He was diagnosed with septic shock with unknown source and multiorgan failure. He was treated with broad spectrum antimicrobials including Meropenem, Vancomycin and Micafungin. He was started on continuous renal replacement therapy. His clinical course continued to deteriorate. The family decided to withdraw life support. He expired on hospital day 11. An autopsy revealed intravascular large B-cell lymphoma.DISCUSSION: IVL is an extremely rare extranodal lymphoma, predominantly affecting elderly patients. The incidence remains unknown due to its rarity. The clinical presentation is variable, ranging from asymptomatic, constitutional B symptoms to multiorgan failure caused by vessel occlusion. IVL can be diagnosed by the presence of large lymphoma cells within small-tomedium blood vessels. Antemortem diagnosis of IVL is difficult due to lack of pathognomonic features or tumor markers. Symptoms could mimic other more common diseases since the clinical manifestations are heterogeneous which could lead to a delayed or missed diagnosis. IVL is aggressive and usually disseminated at the time of diagnosis. Treatment is systemic chemotherapy.CONCLUSIONS: While IVL is an extremely rare subtype of lymphoma, it should be considered in the differential diagnosis of unexplained multiorgan failure with no other clear cause. The diagnosis of IVL requires a high index of suspicion and should be suspected in patients suggestive relevant clinical findings which may lead to early treatment and better outcomes.