Discussion Questions

Group,

Articles were previously distributed, but are also attached to this email for reference.
Please review the articles and the discussion questions. Feel free to answer the questions or bring up your own discussion points! Let's make this as interactive as we can!
Also, please include what you are eating for dinner, since we are usually talking about these articles over a nice meal at Del Alma I'm currently eating a cheese quesadilla and Girl Scout cookies. Responses are due by March 20 at 5pm to get attendance credit.


Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM

1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper?

2) Would this study change your current practice?

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...)


Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice?

3) What's up with the chest wall foreign bodies even in the conservative group?


Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive.

3) Why do you think longer surgical time leads to more sub-therapeutic levels?


-Serfin

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM


1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper?

I did not expect a difference in mortality prior to reading the study... although I was surprised there was not a difference in delirium free days or ventilator free days.

2) Would this study change your current practice?

I don't think so. I still think amount of sedation should be tailored to the individual patient based on what they can tolerate. Less is more but this is not possible in all patients.

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...)

I agree. I worry that no sedation may cause some PTSD... but Post-ICU syndrome may be improved with no sedation.




Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?

I think I would love to try the interventional group. I think almost all the patients we admit would be successfully treated with this method. I am not sure how the ED will feel about housing a patient for 5 hours though...

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice?

I would like to see the study comparing our current practice to either of these options. I like the idea of having outpatient options.

3) What's up with the chest wall foreign bodies even in the conservative group?




Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?

I think we should not automatically bump up the dose, but I think a closer monitoring of the Xa levels would be a consideration in high risk patients. Although after talking to pharmacy monitoring levels is not quick. It is measured 4 hrs after third dose of Lovenox … then it is a send out which can take > 24 hours. So I don't know how realistic it is.

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive.

Absolutely. I think we should check some of our patients that get a VTE while on Lovenox so we can get an idea of how effective we were being in our treatment. I also think that the group that was subtherapeutic on the first dose tended to stay subtherapeutic. So maybe after one check they should be switched to another agent?

3) Why do you think longer surgical time leads to more sub-therapeutic levels?

This I am not sure about. I cant come up with the pathophysiology explanation on why this would be.

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM

1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper?

I was expecting this study to demonstrate a significantly different amount of delirium between the two groups, but they were essentially the same. I did not expect difference in mortality though. This paper would be unlikely to change my practice, I have seen people completely awake working with PT intubated while others cannot tolerate any amount of decreased sedation.

Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?

I think both approaches are reasonable in our population of spontaneous pneumothorax without respiratory symptoms. I think either approach is reasonable, but would rather not have to place two chest tubes in a person if the return for recurrence of symptoms. On the other hand, placing a chest tube for a short time in the ED to resolve pneumothorax is more traditional and less of a jump from our current practice.


Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?

I think that bumping up doses would be more feasible. Adding Xa assay at our institution would be extremely cumbersome and would lead to multiple days without changes in dose while still adding cost. At a larger institution this may be feasible, but I would argue that at most institutions this is not. On the other hand, I do feel that the fear surrounding prophylactic dosing causes significant morbidity, when doses are skipped post operatively, in the form of PE/DVT. This is especially true in ortho surgery where aspirin is preferred peri-operatively due to perceived bleeding risk of lovenox. Increasing these doses at baseline may be met with more pushback than normal.

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM

1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper? I did not expect to see a difference between the two for mortality, but I was surprised to see how few self extubations there were. I would have thought there would be more particularly in the non-sedated group.

2) Would this study change your current practice? I do not think this will change my practice. It is interesting that there was 1 day difference between the groups in regards to delirium but I do not think this is significant enough to make changes on how we manage ventilated patients.

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...) I think this would lead to a lot more PTSD symptoms in ICU patients.



Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described? I think this would depend on the patient in front of us. If it was a healthy young person with a small-moderate pneumo, I would feel more comfortable with the interventional management and maybe for the right patient the conservative management. It is interesting that they take out a chest tube after observing for 5 hours. I could see trying this intervention again with patients who have no history of prior PTX and are young and healthy. I think this intervention makes me more comfortable than the conservative management.

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice? I think it changes for certain patients who have more reserve. It would be interesting to see if further comparison studies come out.



Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients? I think we still need to adjust for each individual patient. Some of the doses were appropriate for certain patients even if it was a small percentage of the group. The authors made note of increasing BMI as part of the reason they thought an increasing dose was needed. As our patients get larger we might need to look at more of a weight based approach. I know it is something I don’t always take into account.

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive. I agree, do we need to start drawing and looking at more anti-Xa levels in our patients? Particularly the higher risk patients.

3) Why do you think longer surgical time leads to more sub-therapeutic levels? I wonder if it has to do with prolonged exposure to agents like propofol? From my brief search it looks like it can have an adverse reaction of thrombosis but I could not find anything directly related to anti-Xa levels.

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM

1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper?

•I did not expect a difference in mortality. Rather, I expected a difference in ICU delirium and days off the ventilator but there was no difference between the groups with respect to these outcomes.

2) Would this study change your current practice?
•This would not change my current practice. I believe we still need to tailor sedation packages to the patient, what they can tolerate, etc. I did, however, find it interesting that they would wean sedation to half when it was resumed, or keep the sedation off completely after the sedation interruption if the patient could handle this. I think it would be nice to keep the patient on a lower dose of sedation when/if we are able and, of course, if they tolerate it.

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...)
•This would be interesting to investigate. I agree with Ashley - I worry that incidence of PTSD would be increased however we may get the benefit on the back-end of less Post-ICU syndrome.


Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?
•I would like to try to conservative group. There were lower PTX recurrence rates, increased time to PTX recurrence if the patient were to have a recurrence and lower adverse events all without an increase in time to symptom relief or time to complete resolution. To me, it's a no brainer if you observe the patient and provide strict return instructions.

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice?
•I would still tailor treatment to each individual patient, discuss all options and allow them to make the final decision. Though I do believe the conversation would vary from patient to patient regarding my recommended treatment plan (conservative vs. interventional).

3) What's up with the chest wall foreign bodies even in the conservative group?
•I'm wondering if the FB in the conservative group were those that ended up requiring intervention?


Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?
•I do not think we should automatically increase the dose in cancer patients. I had wondered about testing anti-Xa in patients to assess how adequately we are treating them adequately however, it seems this would be difficult to implement.

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive.
•Definitely. Maybe this could be a future QI project.

3) Why do you think longer surgical time leads to more sub-therapeutic levels?
•I'm at a loss for why this would occur. I did a quick literature search but it does not appear anyone has studied this.

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM

1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper?

a. I did not think there would be a mortality difference to begin with. The key is light sedation, not RASS -5 all day everyday as some nurses may prefer . The patient’s RASS score between the two arms in this study was not dissimilar therefore outcomes should not have been significantly different.

2) Would this study change your current practice?

a. No it would not change my practice. I tend to prefer light sedation based on RASS scores in order to ensure comfort but not too heavy to prevent physiological effort towards weaning off the ventilator.

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...)

a. That’s a very good question. I imagine PTSD could be significant if pain was not controlled adequately or if the patient does not rest. On the flip side, I can also see a scenario where keeping someone comatose with sedation could lead to Post-ICU syndrome. However in this study, it seems they did a good job in controlling pain and keeping people at an appropriate RASS score therefore possibly limiting the aforementioned outcomes.


Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?

a. It’s interesting that their “interventional” protocol would probably be our conservative protocol. The general standard is to be more conservative with small PTX <2cm with repeat CXR in 4 hours and if enlarging or symptomatic, then a small tube is warranted. I like this standard.

b. I would consider being more conservative if we had the aggressive follow-up protocol similar to this study but until then, I need more studies to show that these sizeable PTX are safe to watch.

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice?

a. As stated earlier, I would be interested in trying a more conservative approach, possibly the study’s intervention protocol (removing the tube the same day) with close follow-up. That would relieve a lot of burdens for everyone.

3) What's up with the chest wall foreign bodies even in the conservative group?

a. I assume this includes the people who were initially in the conservative group but for various reasons ended up with a chest tube anyway.


Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?

a. Why not 30 mg BID ? This appears to be a standard in trauma patients

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive.

a. Yes, I thought so too. That’s where the study could have been even better. A control and study group with anti-Xa levels on both sides. I suspect it would be predictive for DVTs with subtherapeutic levels.

3) Why do you think longer surgical time leads to more sub-therapeutic levels?

a. More venous stasis, endothelial injury and hypercoagulability secondary to more cancer burden. Essentially worsening of the triad.

4) What a great paper from a young DO surgeon!

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM
1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper?

-- No mortality difference expected; however, I did expect to see a large difference in self-extubation events requiring re-intubation. Unfortunately, this data was only reported when patients required reintubation within 1 hour. Why weren't the total numbers of self-extubations reported? And what about the reintubation rate after 1 hour?

2) Would this study change your current practice?

-- I would like to see more data, specifically regarding surgical patients and outside of populations covered by universal healthcare.

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...)

-- Good question. That 1:1 nursing ratio could have affected these outcomes, though.


Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?

-- Not me. This study does make me feel better about the small pneumothoraces that we observe for a few hours before repeating a CXR... sounds like they are a bit hardier of a group than I give them credit for.

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice?

-- I would like to see a more aggressive "conservative" intervention and then compare the groups. I prefer to visualize the immediate re-expansion of a pneumothorax on CXR after placing a chest tube and connecting to wall suction. Also, these patients have a lot of follow-up appointments...

3) What's up with the chest wall foreign bodies even in the conservative group?

-- These things happen when you're smoking between 4.8 and 8.1 packs of cigarettes per day, I suppose. (Surely something went wrong with these numbers...)


Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?

-- I agree. Repeat the study to confirm the data, and if all is consistent, make it a standard as with Lovenox 30 mg BID among trauma patients.

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive.

-- Perhaps they will consider this in a larger, sufficiently powered study.

3) Why do you think longer surgical time leads to more sub-therapeutic levels?

-- Agree with Bunry: More complex disease process, more stasis/endothelial injury/etc.

Olsen HT, et al. Nonsedation or Light Sedation in Critically Ill Mechanically Ventilated Patients. 2020 NEJM

1) What are your thoughts on the results of this study, did you expect a difference in mortality before reading the paper? I would have thought that no sedation would have had quicker times weaning off the vent but not a mortality difference. I do think they have very normal sized patients as their highest weight of a patient was 92kg.

2) Would this study change your current practice? No especially as I am still developing my current practice guidelines. I agree with the ashley and others in that sedation should be individualized and a no sedation plan for all sounds traumatic.

3) I wonder if there would be a difference in PTSD symptoms or Post-ICU syndrome (memory impairment, weakness, etc...) I would have guested that post-ICU syndrome would be less in the no-sedation side-arm but with the risk of PTSD in certain patients. I have also read about patients on vent's walking around ICU's with PT before extubation. I wonder if people can handle more than we want to allow them.


Brown SGA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. 2020 NEJM

1) Both interventions are quite different than our current approach, who would be comfortable transitioning to the interventional or conservative group as described?

-I think this conservative approach would be difficult here as it depends nursing to get supplemental O2. I think most would fail and get put into intervention or admission with that alone. The intervention group is interesting to me as on IR, I watched them use a blood patch on a pneumothorax after percutaneous lung bx. There is every literature to support the blood patches decrease pneumothorax specifically after a perc lung bx. I wonder if We could apply that to a spontaneous pneumothorax that persisted after the small Chest tube and aspiration and 4 hours recheck.

2) This article does not provide a "slam-dunk" regarding a superior treatment, in fact it can only state non-inferiority. Would this level of data change your practice?

-I think this study shows me there are lots of ways to skin a cat and and that people are more tough then I would have thought. Their ER must be patient.

3) What's up with the chest wall foreign bodies even in the conservative group?

- I would bet this is d/t the conservative management group's 15% that ended up getting a procedure and had an intern leave suture in the wound....



Kramme K, et al. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. 2020 JACS

1) This article reports that the unadjusted dosage of Lovenox group had a higher VTE rate without a change in bleeding risk. Should we just bump up the dose automatically in cancer patients?

-​ I think a higher initial dose of lovenox day 1&2 would be interesting because they didn't check levels until day 3 anyway. So if they are subtherapeutic at day 3 and then day 4 also, thats 4 days potentially they are at a higher risk for VTE. Also heparin has a higher affinity to Xa than lovenox. This might play into the study as almost half of the control arm had heparin given.

2) It would have been interesting to have a measurement of the anti-Xa levels in the non-adjusted group to see if that level was independently predictive.

-​I think it would be interesting.

3) Why do you think longer surgical time leads to more sub-therapeutic levels?

-more complicated surgery maybe indicating progressed cancer leading to impaired hepatic function. Quicker surgeries could have patients with better clearance of AC medications....

Nonsedation or light sedation in critically ill mechanically ventilated patients

1.I was shocked at the 90 day mortality in general for both groups and then reminded myself of the age range involved and the reason they were intubated which was mostly medical. I don’t think I made a presumption on mortality secondary to light vs no sedation because to me I was too worried about all the complications (self-TURPing, self extubating etc) in the nonsedation group. If I had I don’t think it would surprise me that there would be no difference.

2.No. I do think that our light sedation protocol could include more SATs during the day and like they did in the study if the patient wasn’t having an issue with being intubated then leaving the sedation off for longer periods of time. And I appreciated the use of nonpharmacological means prior to restarting sedation like ambulation. I think using a less sedation package and encouraging more ambulation of our ventilated patients would lead to better outcomes and less Post ICU syndrome and I think this could be accomplished with a sedation plan. My qualms with the no sedation plan is that they had higher opioid use not crazy higher but it was more and that in and of itself is sedation.

3.That would be the more interesting question to study. I do believe it would have an impact but I think it would be interesting to see how it would play out. I feel like PTSD may be higher in the nonsedation group but post ICU would be less in the nonsedation group.


Conservative VS interventional treatment for spontaneous PTX

1.I would definitely be comfortable in a more liberal interventional approach. I think placing a perc tube and going straight to waterseal and then placing a hemlich or the three way stop cock after a period of observation and then DC them to come back in follow up would be appropriate. I think I would have a hard time discharging a large enough PTX without a tube like they did in the conservative group. In theory I could see why it could be safe after a period of observation but they were symptomatic enough to come in and sending them home with known pathology I think would be hard.

2.It would not. I think it raises interesting points and would make me proceed with something I had already been considering trying but not enough to change a practice in entirety unless there were more papers on the same topic.

3.If you give people a hole they will stick something through it………………


Prophylactic Enoxaparin Adjusted by Anti Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical oncology patients

1.No. I think with the other factors effecting therapeutic level it would be dependent on more than just them having cancer.

2.Agreed.

3.It could be similar to the obesity thing and decreased absorption and circulation given the hypotension and decreased renal clearance. A multitude of things could contriute