Reducing Distress for Patients During Withdrawal of Mechanical Ventilation
Patients receiving opiates before WMV were 26% less likely to experience symptoms of distress.
Nearly all ICU patients undergoing palliative withdrawal of mechanical ventilation (WMV) experience symptoms of distress, but those given opiates beforehand are less likely to have an episode, suggesting a potential strategy to reduce suffering during end-of-life care.
“Withdrawal of Mechanical Ventilation in the Intensive Care Unit: A Prospective Observational Study,” in Chest Critical Care, tracked 153 intubated patients (mean age 70.2 years) across 12 ICUs from January 2021 to July 2022. In the hour before WMV, 90 patients received anticipatory doses of sedatives or analgesics, most commonly opiates (80 patients), followed by benzodiazepines (50 patients).
Distress symptoms measured by bedside ICU nurses were nearly universal following WMV, with 91% of patients experiencing at least one episode within three hours. Respiratory distress (90%) was most common, followed by pain (56%) and agitation (5%), with 41% of patients having more than three episodes.
Notably, patients receiving opiates before WMV were 26% less likely to experience distress symptoms. Morphine was the most common opiate administered, followed by fentanyl and hydromorphone.
“Our findings provide the strongest evidence to date that anticipatory dosing with opiates may reduce the risk of distress among patients undergoing WMV,” the study notes.
In addition, the study identified key predictors of post-withdrawal distress — longer ICU stays (more than 10 days), lower levels of consciousness, and distress before WMV. These findings may help inform monitoring and treatment of these patients.
“This study provides strong evidence that ICU teams can anticipate and reduce discomfort at the end-of-life during one of the most challenging and routinely conducted procedures in the ICU.”
Study limitations include convenience sampling from two centers and limited inclusion of rapid terminal weaning, which may reduce applicability to other ICU settings. In addition, clinical teams’ awareness of the study could have influenced how symptoms were assessed and managed.
Peripheral Norepinephrine Infusion Protocol in MICUs
Building on the protocol’s success, the health system broadened use to additional hospitals.
Medical ICUs can safely initiate norepinephrine through peripheral IVs rather than defaulting to central venous catheter (CVC) placement, potentially saving nearly half of patients from undergoing a procedure with known risks.
“Peripheral Norepinephrine Protocol Implementation Is Associated With Decreased Central Venous Catheter Placement in a Medical ICU,” in Chest Critical Care, reports a significant drop in CVC use (59.5% to 53.5%) after protocol adoption, with minimal risk of adverse events.
An academic hospital with six types of ICUs introduced the protocol for peripheral norepinephrine infusion in March 2019. The study compared central line use before and after protocol implementation to assess the strategy’s impact on CVC placement and patient outcomes.
The protocol specified a lower-concentration norepinephrine infusion (8 mg/250 mL), with defined limits on dose (less than 0.5 mcg/kg/min) and duration (maximum of 48 hours), and strict criteria for peripheral IV placement and monitoring. Bedside nurses inspected lines every two hours, supported by specific education to identify and manage any complications.
From July 2017 through December 2023, the MICU recorded more than 15,000 admissions, with over half of patients receiving central lines. After protocol implementation in 2019, central line use decreased by 7% compared with control ICUs — roughly 14 fewer CVC placements per month.
Among patients who received peripheral norepinephrine infusions, nearly half (47%) never received a CVC. Building on the protocol’s success, the health system broadened the use to include additional vasopressors and hospitals starting in April 2025.
“This peripheral vasopressor guideline outlines recommendations for the use of dopamine, epinephrine, NE [norepinephrine] and phenylephrine at various doses for up to 48 hours,” the study notes. It also provides guidance on IV placement and monitoring, and prompt extravasation management.
Study limitations include possibly underestimating central line placement after transfer out of the MICU. It also lacked data on protocol adherence, dosing and other factors that could have influenced CVC use.
The Letters to the Editor section in October’s Critical Care Nurseincludes several letters related to this subject: one on clinical and safety concerns about midline catheters, another on risks associated with peripheral vasopressors, one more on midline catheters and a response from the study authors.
Benefits of Increased Potassium for Patients With ICDs
Patients receiving potassium supplements were 24% less likely to have critical outcomes.
Increasing potassium levels in patients with cardiovascular disease and implantable cardioverter-defibrillators (ICDs) at high risk for ventricular arrhythmias significantly lowered that risk for several critical outcomes.
“Increasing the Potassium Level in Patients at High Risk for Ventricular Arrhythmias,” in The New England Journal of Medicine, notes that patients receiving potassium supplements were 24% less likely to have critical outcomes. “Among participants with any cardiovascular disease who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization for arrhythmia or heart failure, or death from any cause than standard care,” the trial adds. It cautions the use of the protocol in patients with, or at risk of, renal disease.
In a trial in Denmark of 1,200 patients with an eGFR of at least 30 mL per minute per 1.73 m2, split between intervention and standard groups, 22.7% of patients (136 of 600) receiving a treatment regimen to increase plasma potassium levels (4.5 to 5.0 mmol per liter) had one of the primary outcomes, compared with 29.2% in the standard group (175 of 600). Hospitalization for those with either very high or low potassium levels was similar in each group.
“In this trial, we were only looking at this one group of patients and the results are really only directly applicable to that patient group, notes lead author Henning Bundgaard in a related article in Medscape. “But our perception is that higher potassium intake would also be of benefit in the broader population.”
He adds: “The recommendation in the US is to eat 4.7 grams of potassium a day. Less than 5% of the American population gets that much. Back in time, when we ate more raw food, we were eating between 5-10 g and even up to 30 grams.”
Sleep Medications for ICU Patients Ranked by Risk Factor
Benzodiazepines significantly increased delirium risk and should be avoided for sleep.
A review of oral sleep medications frequently used in intensive care settings assesses their risk and potential effects on delirium and guide clinicians on how different medications work.
“Oral Medications for Sleep in Nonintubated ICU Patients and Their Impact on Delirium,” in Chest Physician, notes available options, cites relevant studies and ranks the medication choices from low to highest risk. “Pharmacologic agents are generally not recommended due to risks of adverse effects and lack of consistent evidence for benefit but can be considered on a case-by-case basis,” the review notes.
The review identifies two medications as low risk (melatonin and ramelteon) and one as low to moderate risk (gabapentin). The low-risk medications are “first-line pharmacologic options” because trials have shown benefits, including reduced delirium with ramelteon.
Although gabapentin receives only a caution about high doses potentially causing confusion in older patients, the two moderate-risk medications (trazodone and clonidine) have potential adverse effects of note. Trazodone carries a risk of cognitive effects, and clonidine is associated with low blood pressure or heart rate.
The review classifies an assortment of medications as high risk, including zolpidem and other “Z-drugs,” hydroxyzine and diphenhydramine, all of which are associated with increased delirium. Antipsychotics, such as quetiapine, also fall into the high-risk category because despite potentially reducing delirium duration they can cause cognitive and metabolic issues.
Alone in the highest-risk category are benzodiazepines, which “significantly increase delirium risk and should be avoided for sleep unless no safer options exist.” Concluding that any sleep aid should be used with caution, the review adds, “Individualized treatment considering patient comorbidities and risk factors is crucial in optimizing sleep while minimizing adverse outcomes.”
AABB’s New Recommendation for Patients With AMI
Clinicians should weigh individual patient risks and implement specific interventions.
The Association for the Advancement of Blood & Biotherapies (AABB) recommends a more liberal transfusion approach for hospitalized patients with acute myocardial infarction (AMI), advising clinicians to administer blood when hemoglobin drops to 10 grams/deciliter.
“Red Cell Transfusion in Acute Myocardial Infarction: AABB International Clinical Practice Guidelines,” in Annals of Internal Medicine, flags a potential increase in mortality with the previously endorsed threshold of 7 to 8 g/dL. The update highlights the uncertainty of applying such restrictive thresholds across patient groups, especially for patients with AMI.
An AABB panel arrived at the new recommendation after a systematic review of four randomized trials involving patients with AMI and reanalyzing data using Cochrane methods and GRADE criteria. They applied a fixed-effects model and reframed the liberal threshold as the intervention, aligning the analysis with current clinical practice.
The analysis revealed a risk difference between transfusion strategies of 1.2% in 30-day mortality with a liberal transfusion strategy. Although patients received more blood and experienced additional adverse effects, the potential survival benefit outweighed the risks and the value of conserving the blood supply.
Despite the finding, the panel cautions that liberal transfusions may not be appropriate for all patients with AMI, given differences in medical history, clinical presentation and hemodynamic status. Clinicians should weigh individual risks and implement specific interventions.
“Strategies include optimizing fluid status peri-transfusion, slowing transfusion rate, prescribing diuretics, achieving the target Hb more gradually, and transfusing during renal replacement therapy sessions for renal failure,” the panel suggests.
Strengths of the recommendation include alignment with recent reviews and population-based data, rigorous GRADE methodology, and contributions from a diverse panel of clinicians with expertise in AMI. Limitations include uncertainty about patient preferences, exclusion of non-AMI populations, and the need to tailor transfusion thresholds to individual patient characteristics.
Revised Guidelines Address Pediatric Blood Clots
The 24 guidelines are conditional except one related to renal vein thrombosis that is rated strong.
A multidisciplinary panel updated guidelines for treating pediatric patients with blood clots. The guidelines are evidence-based and include reviews of benefits and harms, and clinical implementation guidance.
“American Society of Hematology [ASH]/International Society on Thrombosis and Haemostasis [ISTH] 2024 Updated Guidelines for Treatment of Venous Thromboembolism in Pediatric Patients,” in Blood Advances, notes that the panel revised the 2018 guidelines in some areas and added new areas of inquiry for direct oral anticoagulants (DOACs). “Key priorities are understanding the natural history of clinically unsuspected thrombosis across a range of patient subpopulations and obtaining real-world data on the use of DOACs in children,” the report adds.
Of the 24 guidelines, all are conditional except one related to renal vein thrombosis (RVT) that is rated strong. “For neonates with non-life-threatening RVT, the ASH/ISTH guideline panel recommends anticoagulation alone vs. thrombolysis followed by anticoagulation.” There is strong evidence for potential harm due to the bleeding risks of thrombolysis, but a related guideline suggests using both methods in life-threatening RVT situations.
The implementation guidance section provides detailed assessments of treatment options to help clinicians navigate the unique challenges of this group of pediatric patients, especially if an experienced pediatric hematologist is not available. The “panel agreed that providing further guidance on the use of anticoagulants and fibrinolytics in pediatric patients would be of value to many readers,” the report adds.
The guidance on unfractionated heparin, low molecular weight heparin, fondaparinux, vitamin K antagonists, rivaroxaban, dabigatran and tissue plasminogen activator gives clinicians a general overview of each, as well as advantages and disadvantages and a detailed approach to dosing and monitoring. “Although other anticoagulants may be used in children, there were limited published data to support their routine use for VTE [venous thromboembolism] treatment at the time of this guidance.”
President’s Column: On Purpose, With Gratitude
Last spring, AACN President Rebekah Marsh’s oldest sister was hospitalized in a neuroscience ICU. Having spent her career as a neuro ICU nurse, Marsh faced the delicate position of sharing end-of-life realities and offering her family some space for hope. Learn what she discovered about purpose and human connection.
Elevating Every Step: Jacob’s Journey
For Jacob Sumner, a cardiovascular ICU nurse in Missouri, every step in his life and career is about rising and growing. He lost 225 pounds, earned his certification, is pursuing a dual Master of Science in nursing leadership and MBA, and he mentors others. “I’m proud of being the mentor I wish I’d had.”