Search

Rationale: Predicted increases in heat-related weather phenomena will result in increasing heat exposures and heat injuries, like heat stroke. Prompt recognition, early intervention, and evidence-based management are necessary to optimize outcomes., Objectives: The objective of these guidelines was to develop evidence-based recommendations for the treatment of patients with heat stroke., Design: The Society of Critical Care Medicine convened a multidisciplinary panel of 18 international clinicians, comprising expertise in critical care, emergency medicine, neurocritical care, surgery, trauma/burn surgery, sports medicine, athletic training, military medicine, nursing, pharmacy, respiratory therapy, and one patient representative. The panel also included a guidelines methodologist specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including panel selection and voting., Methods: The panel members identified Patient, Intervention, Comparison, and Outcomes questions in two main areas: cooling modalities and medications that affect temperature. A systematic review for each question was conducted to identify the best available evidence, statistically analyze the evidence, and assess the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional clinical guidance., Results: The panel generated two strong recommendations, five good practice statements and one "only-in-the-context of research" statement. Active cooling measures are recommended over passive cooling methods, with cold- or ice-water immersion achieving the fastest cooling rate. This method should be prioritized where available. In heat stroke patients, there is no evidence to support pharmacological interventions that affect temperature control and they should be avoided., Conclusions: The guidelines task force provided recommendations for the management of patients with heat stroke. These recommendations should be considered along with the patient's clinical status and available resources., Competing Interests: Dr. Barletta is a consultant for Wolters Kluwer and a current member of Council for the Society of Critical Care Medicine. Dr. Stearns is employed by the Korey Stringer Institute, member of the USA Football Medical Advisory Panel, and received royalties as book editor for two books that contain material on heat illness. Dr. Siparsky received funding from UpToDate. Dr. Schultz disclosed government work; he is a U.S. Government employee. Dr. Bruno received funding from Hemcon. Dr. Bailey received funding from Radiometer and Baxter; she disclosed that she is a past President of the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2025 by the Society of Critical Care Medicine. All Rights Reserved.)

Competing Interests: Dr. Barletta is a consultant for Wolters Kluwer and a current member of Council for the Society of Critical Care Medicine. Dr. Stearns is employed by the Korey Stringer Institute, member of the USA Football Medical Advisory Panel, and received royalties as book editor for two books that contain material on heat illness. Dr. Siparsky received funding from UpToDate. Dr. Schultz disclosed government work; he is a U.S. Government employee. Dr. Bruno received funding from Hemcon. Dr. Bailey received funding from Radiometer and Baxter; she disclosed that she is a past President of the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Tapering opioids is an effective strategy to reduce the risks associated with long-term opioid therapy. However, patients' experience with tapering can influence the success of this treatment. Understanding patients' experiences with opioid tapering will allow for patient-centered approaches to be adopted to tailor interventions to achieve safe and successful taper outcomes. This paper aims to synthesize qualitative data capturing patients' experiences with opioid tapering for noncancer pain. Qualitative studies in English that explored patients' experiences with opioid tapering in noncancer pain were included. MEDLINE, Embase, Scopus, and PsycINFO were searched from inception to March 2023. Two authors independently selected the studies, extracted data, and assessed the quality of included studies using the Critical Appraisal Skills Programme. A meta-synthesis allowed for overarching themes to be identified to form a new interpretation of the data in the context of past literature. From 5714 articles identified, 10 studies were included that met the inclusion criteria after title/abstract screening and full-text review. These studies involved 218 patients with experience tapering opioids. Three key themes guiding the new meta-synthesis were identified: (1) patient-provider interactions, (2) individualized care, and (3) tactics to manage the opioid tapering process. This review demonstrated the role that patient-provider interactions, tailored care, and effective tapering strategies play in facilitating a favorable patient experience during the opioid tapering process. Future research should incorporate the themes identified in this review to optimize the patient's taper experience., Competing Interests: Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article., (Copyright © 2025 International Anesthesia Research Society.)

Objectives: COVID-19 treatment guidelines recommend baricitinib or tocilizumab for the management of hospitalized patients with COVID-19. We compared the effectiveness of baricitinib vs. tocilizumab on mortality and clinical outcomes among hospitalized patients with COVID-19., Design: Multicenter, retrospective, propensity-weighted cohort study using a target trial emulation approach., Setting: The National COVID Cohort Collaborative (N3C), which is the largest electronic health records data on COVID-19 in the United States. The setting included 75 hospitals., Patients: Adults who were hospitalized for COVID-19., Interventions: Newly initiated on baricitinib or tocilizumab., Measurements and Main Results: Our primary outcome was 28-day mortality. We used propensity scores with inverse probability of treatment weights (IPTWs) to control bias and confounding while comparing treatments. Among 10,661 individuals included in the study, 6,229 (58.4%) received baricitinib and 4,432 (41.6%) tocilizumab. Overall, the mean age of the cohort was 60.0 ± 15.1 years, 6429 (60.3%) were male, and 19.2% received invasive mechanical ventilation. After IPTW adjustment, baricitinib use was associated with lower 28-day mortality (odds ratio [OR], 0.91; 95% CI, 0.85-0.98) and hospital (OR, 0.88; 95% CI, 0.82-0.94) mortality compared with tocilizumab. Baricitinib was also associated with shorter hospital length of stay (incident rate ratio, 0.92; 95% CI, 0.90-0.94) and lower rates of hospital-acquired infections (OR, 0.86; 95% CI, 0.75-0.99), although no difference in ICU length of stay was noted between the two groups., Conclusions: In this large, diverse cohort of U.S. hospitalized adults with COVID-19, baricitinib was associated with significantly lower 28-day mortality, hospital mortality, shorter hospital length of stay, and less hospital-acquired infections compared with tocilizumab., Competing Interests: Dr. Higgins is supported by a National Health and Medical Research Council Investigator Grant (GNT2008447). Dr. Mehta is supported by the National Institute on Aging (1K01AG070329). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Enoxaparin is dosed according to actual body weight in treatment of arterial and venous thrombosis. Due to its hydrophilic nature, it distributes according to lean body mass which may be problematic when dosing obese patients as this may increase the risk of bleeding events in this population. The aim was to evaluate current therapeutic enoxaparin dosing strategies, including Antifactor Xa (AFXa) level monitoring, in obese patients and to identify factors that contribute to treatment failure and excess anticoagulation. A retrospective cohort study was conducted reviewing patients administered therapeutic enoxaparin between May 2020 and April 2021. Data were collected on patient characteristics, enoxaparin therapy, AFXa monitoring, and outcomes. Regression models were constructed to assess variables of interest to estimate any association with AFXa levels. In total 762 patients were included in the analysis. The mean initial weight-based dose was 0.95 mg/kg twice daily (SD: ± 0.12, IQR 0.92-1.01) and 1.04 mg/kg once daily (SD: ± 0.26, IQR 0.93-1.12) and 14.4% of patients had AFXa monitoring. Treatment failure was experienced by 2.2%, 5% experienced bleeding. There was no association between the mean actual milligram per kilogram weight-based twice daily doses and subtherapeutic, therapeutic and supratherapeutic AFXa levels (P = 0.135). Obesity was not included in the final regression models due to lack of significance. At a mean therapeutic enoxaparin dose of 0.95 mg/kg twice daily and 1.04 mg/kg once daily no excess in treatment failure or bleeding events were observed in obese patients compared to the product information. Obesity was not an independent variable that affected the achievement of target AFXa levels., (© 2024. Crown.)