Background: The optimal indication, dose, and timing of corticosteroids in sepsis is controversial. Here, we used reinforcement learning to derive the optimal steroid policy in septic patients based on data on 3051 ICU admissions from the AmsterdamUMCdb intensive care database. Methods: We identified septic patients according to the 2016 consensus definition. An actor-critic RL algorithm using ICU mortality as a reward signal was developed to determine the optimal treatment policy from time-series data on 277 clinical parameters. We performed off-policy evaluation and testing in independent subsets to assess the algorithm’s performance. Results: Agreement between the RL agent’s policy and the actual documented treatment reached 59%. Our RL agent’s treatment policy was more restrictive compared to the actual clinician behavior: our algorithm suggested withholding corticosteroids in 62% of the patient states, versus 52% according to the physicians’ policy. The 95% lower bound of the expected reward was higher for the RL agent than clinicians’ historical decisions. ICU mortality after concordant action in the testing dataset was lower both when corticosteroids had been withheld and when corticosteroids had been prescribed by the virtual agent. The most relevant variables were vital parameters and laboratory values, such as blood pressure, heart rate, leucocyte count, and glycemia. Conclusions: Individualized use of corticosteroids in sepsis may result in a mortality benefit, but optimal treatment policy may be more restrictive than the routine clinical practice. Whilst external validation is needed, our study motivates a ‘precision-medicine’ approach to future prospective controlled trials and practice.

Summary: Background: Coronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed. Methods: The objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching. Results: A total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344. Conclusion: In this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

Sugammadex has been approved for reversal of neuromuscular blockade by vecuronium and rocuronium in adults undergoing surgery. Although widely used in the operating room, sugammadex has not been investigated in the intensive care unit setting. This study aimed to evaluate the use of sugammadex in critically ill patients with a focus on known drug-related adverse reactions. In this single-center, retrospective, observational study, 91 critically ill patients who were administered sugammadex while in the ICU were evaluated. Electronic health records were reviewed, and baseline data, as well as indication and incidence of complications possibly related to sugammadex, were retrospectively collected. The most common procedures requiring neuromuscular blockade followed by reversal with sugammadex were bronchoscopy, percutaneous dilatative tracheostomy, and percutaneous endoscopic gastrostomy. Within 2 h following administration of sugammadex, skin rash and use of antihistamines were reported in 4 patients (4.4%) in total; bradycardia was observed in 9 patients (9.9%), and respiratory adverse events were described in 3 patients (3.3%). New-onset bleeding up to 24 h after sugammadex was reported in 7 patients (7.7%), 3of whom received transfusions of packed red blood cells. Sugammadex was well tolerated in critically ill patients and could be considered for reversal of neuromuscular blockade in this population. Larger prospective studies are required to determine the safety profile and evaluate the potential benefit and indications of sugammadex in the critical care setting.

Background: Evidence suggests differences in medical practice and patient outcomes between male and female physicians and surgeons. To date, no such relationships were investigated in anaesthesiologists. This study aimed to investigate an association between anaesthesiologists’ sex and anaesthesia quality metrics as well as outcomes. Methods: We performed a population-based, single-centre, retrospective cohort study. Data were gathered from all patients undergoing anaesthesia between 1 January 2014 and 31 March 2022 at a large tertiary centre in Vienna, Austria. We examined 30-day mortality in relation to the sex of the anaesthesiologist after adjusting for various patient, physician, and hospital factors. Additionally, we assessed anaesthesiologists’ sex and several anaesthesia quality benchmarks. Results: The final dataset included 94,254 cases. The study showed a very small but statistically significant correlation between male anaesthesia providers and an elevated risk for all-cause mortality within 30 days (adjusted odds ratio [aOR]: 1.0026; 95% confidence interval [CI], 1.0003–1.0048). Both male and female anaesthesiologists demonstrated similar proficiency in managing hemodynamic stability, blood glucose levels, preventing postoperative acute kidney injury (AKI) and lung-protective ventilation. However, male anaesthesiologists showed slightly higher adherence to guidelines for PONV prophylaxis. Conclusions: In a dataset of nearly 95,000 cases, there was a clinically marginal but statistically significant association between male provider sex and 30-day mortality.

The development of competencies in anaesthesia residents is assessed by direct observation of their performance and written and oral examinations. Little is known about how residents’ competencies are reflected by objective data in anaesthetic records. We investigated whether performance metrics derived from electronic anaesthesia records are associated with anaesthesia residents’ progress of training and European written examination timing and results. We recruited 46 anaesthesia providers who trained at the Vienna University Hospital between September 2013 and June 2021, and we reviewed the anaesthesia records of all cases they managed during the study period. We derived six performance measures based on perioperative data routinely collected: intraoperative hypotension and hypothermia, glycaemic control, postoperative nausea and vomiting prevention, lung-protective ventilation, and postoperative kidney injury. We evaluated the association between these quality metrics with training level and written exam completion status in anaesthesia residents after adjusting for patient and surgical factors. We found a statistically significant association between the level of training and most performance measures. The probability of preventing intraoperative hypotension increased (OR 1.16, 95% CI 1.12 – 1.20) with the level of training, as did the probability of preventing hypothermia (OR 1.08, 95% CI 1.05 – 1.11) and administering appropriate postoperative nausea and vomiting prophylaxis (OR 1.21, 95% CI 1.15 – 1.27). However, the odds of preventing acute kidney injury decreased (OR 0.91, 95% CI 0.83 – 0.99), as did the use of lung-protective ventilation (OR 0.94, 95% 0.92 – 0.97). All participating residents who took the written exam passed it, precluding a direct pass versus fail comparison, but the exam completion status was associated with increased odds of lung-protective ventilation (OR 1.42, 95% CI 1.03 – 1.95) and decreased odds of preventing intraoperative hypotension (OR 0.7, 95% CI 0.49 – 0.99). Glycaemic control was not associated with either of the training milestones. The training level of anaesthesia residents had a significant association with several performance metrics. Passing the written exam only had a modest effect. Performance measures based on patient outcomes and intraoperative care may serve as assessment methods for anaesthesia residents’ progress tracking.