Burden In Intensive Care Units Research Articles

Life-prolonging treatment restrictions and outcomes in patients with cancer and COVID-19: an update from the Dutch Oncology COVID-19 Consortium

Aim of the studyThe coronavirus disease 2019 (COVID-19) pandemic significantly impacted cancer care. In this study, clinical patient characteristics related to COVID-19 outcomes and advanced care planning, in terms of non-oncological treatment restrictions (e.g. do-not-resuscitate codes), were studied in patients with cancer and COVID-19. MethodsThe Dutch Oncology COVID-19 Consortium registry was launched in March 2020 in 45 hospitals in the Netherlands, primarily to identify risk factors of a severe COVID-19 outcome in patients with cancer. Here, an updated analysis of the registry was performed, and treatment restrictions (e.g. do-not-intubate codes) were studied in relation to COVID-19 outcomes in patients with cancer. Oncological treatment restrictions were not taken into account. ResultsBetween 27th March 2020 and 4th February 2021, 1360 patients with cancer and COVID-19 were registered. Follow-up data of 830 patients could be validated for this analysis. Overall, 230 of 830 (27.7%) patients died of COVID-19, and 60% of the remaining 600 patients with resolved COVID-19 were admitted to the hospital. Patients with haematological malignancies or lung cancer had a higher risk of a fatal outcome than other solid tumours. No correlation between anticancer therapies and the risk of a fatal COVID-19 outcome was found. In terms of end-of-life communication, 50% of all patients had restrictions regarding life-prolonging treatment (e.g. do-not-intubate codes). Most identified patients with treatment restrictions had risk factors associated with fatal COVID-19 outcome. ConclusionThere was no evidence of a negative impact of anticancer therapies on COVID-19 outcomes. Timely end-of-life communication as part of advanced care planning could save patients from prolonged suffering and decrease burden in intensive care units. Early discussion of treatment restrictions should therefore be part of routine oncological care, especially during the COVID-19 pandemic.

Activation of Central Alpha 7 Nicotinic Acetylcholine Receptor Reverses Suppressed Immune Function of T Lymphocytes and Protects Against Sepsis Lethality.

Sepsis remains the leading cause of high mortality and huge financial burden in intensive care units (ICU), but with scarce effective treatments due to refractory multiple organ dysfunction and persistent immunosuppression. Treatments that aim at modulating immune function and attenuating multiple organ injury will certainly benefit septic cases. Alpha 7 nicotinic acetylcholine receptor (α7nAchR) has been reported with potent immunomodulatory properties in various diseases as the essential mediator of the cholinergic anti-inflammatory pathway (CAP). Few studies have demonstrated the potential effect of central α7nAchR on the progression and prognosis of septic response, while its expression was first discovered on neurons and most abundant in the central nervous system. In the present study, it was found severe damage of multiple organs under the operation of cecal ligation and puncture (CLP) in rats, including heart, liver, kidneys, and lungs, as evidenced by abnormal histomorphology and notable elevation of injury markers. Concurrently, the function of spleen CD4+ T cells was disrupted under septic challenge, accompanied by polarization of helper T cell (Th)2, which exhibited outward signs of immunosuppression. Intracerebroventricular injection of PNU282987, a selective agonist of α7nAchR, significantly alleviated multiple organ injury, reversed immunosuppressive state, and improved the outcome of septic rats, while they were exacerbated by treatment with methyllycaconitine, a selective antagonist of α7nAchR. This study provides the first evidence that activation of central α7nAchR is beneficial for attenuating multiple organ dysfunction as well as abnormal immune response, and improving the prognosis of rats when exposed with sepsis.

Acinetobacter baumannii Coordinates Urea Metabolism with Metal Import To Resist Host-Mediated Metal Limitation.

ABSTRACTDuring infection, bacterial pathogens must adapt to a nutrient metal-limited environment that is imposed by the host. The innate immune protein calprotectin inhibits bacterial growth in vitro by chelating the divalent metal ions zinc (Zn2+, Zn) and manganese (Mn2+, Mn), but pathogenic bacteria are able to cause disease in the presence of this antimicrobial protein in vivo. One such pathogen is Acinetobacter baumannii, a Gram-negative bacterium that causes pneumonia and bloodstream infections that can be complicated by resistance to multiple antibiotics. A. baumannii inhibition by calprotectin is dependent on calprotectin Mn binding, but the mechanisms employed by A. baumannii to overcome Mn limitation have not been identified. This work demonstrates that A. baumannii coordinates transcription of an NRAMP family Mn transporter and a urea carboxylase to resist the antimicrobial activities of calprotectin. This NRAMP family transporter facilitates Mn accumulation and growth of A. baumannii in the presence of calprotectin. A. baumannii is found to utilize urea as a sole nitrogen source, and urea utilization requires the urea carboxylase encoded in an operon with the NRAMP family transporter. Moreover, urea carboxylase activity is essential for calprotectin resistance in A. baumannii. Finally, evidence is provided that this system combats calprotectin in vivo, as deletion of the transporter impairs A. baumannii fitness in a mouse model of pneumonia, and this fitness defect is modulated by the presence of calprotectin. These findings reveal that A. baumannii has evolved mechanisms to subvert host-mediated metal sequestration and they uncover a connection between metal starvation and metabolic stress.

Staffing needs of an intensive care unit in consideration of applicable hygiene guidelines--an exploratory analysis

The patient burden in intensive care units (ICU) has continually increased worldwide over the past decades. Age, co-morbidities and an increasing complexity of conditions and treatments increase the number of patients who are either colonized or infected with antibiotic-resistant pathogens. To prevent nosocomial infections, hygiene guidelines play an important role. In this paper, we investigate the time needed for nursing of five hypothetical critically ill patients in the intensive care unit. The results show that current staffing is not sufficient under the given hygiene guidelines and that a nurse to patient ratio of one will be necessary to meet the requirements. In a national survey of university hospitals, however, we found that the current nurse to patient ratio is 1: 2.47 in German intensive care units. The apparent staffing shortage is compensated by an extraordinary personal commitment of nurses caring for patients in the ICU.

Pattern of Neonatal Admissions and Outcome in an Intensive Care Unit (ICU) of a Tertiary Care Paediatric Hospital in Bangladesh – A One-Year Analysis

Objective: To describe the characteristics of neonates admitted to intensive care unit (ICU) and their outcome in a tertiary care paediatric hospital in Bangladesh. Study Design: Retrospective, descriptive study. Setting and Duration of Study: Paediatric intensive care unit in Dhaka Shishu Hospital from January to December 2011. Methods: Data was retrieved from file records of all admitted neonates regarding age, gender, gestational age, birth and admission weight, reason for admission and outcome. Results: During this study period, the total number of patients admitted was 191; most of them were neonates (146, 76.4%). Among the 146 neonates, the highest number comprised of birth asphyxia (55, 37.7%), followed by serious bacterial infections (sepsis, pneumonia, meningitis) (30, 20.5%) preterm low birth weight (LBW) babies (28, 19.2%), surgical conditions (congenital diaphragmatic hernia, oesophageal atresia with trachea-oesophageal fistula, Hirschsprung disease and anorectal malformations) (18, 12.3%), respiratory distress syndrome (RDS) (9, 6.2%), and congenital heart disease (6, 4.1%). Out of 146 patients, 42 expired (28.8%). Most of the expiries were due to sepsis (35.7%); followed by prematurity (21.4%), perinatal asphyxia (19.0%) and surgical conditions (14.3%). Conclusion: Birth asphyxia, septicaemia, and prematurity were the main reasons for neonatal admissions in ICU, while case fatality was highest for septicaemia. Regular antenatal visits, safe delivery practice and timely referral to tertiary care hospitals may result in decreased burden in ICU and also better outcome. DOI: http://dx.doi.org/10.3329/jbcps.v31i3.20979 J Bangladesh Coll Phys Surg 2013; 31: 134-139

Risk factors and pathogens involved in early ventilator-acquired pneumonia in patients with severe subarachnoid hemorrhage

Ventilator-acquired pneumonia (VAP) is a common burden in intensive care unit (ICU) patients, but, to date, specific data are not available in patients with severe aneurysmal subarachnoid hemorrhage (SAH). A single neuro-ICU retrospective analysis of 193 patients with SAH requiring mechanical ventilation (MV) ≥48 h admitted from January 2005 to May 2010 was undertaken. The diagnosis of early VAP was prospectively upheld during a multidisciplinary staff meeting, according to the American Thoracic Society (ATS) 2005 guidelines with a threshold of 7 days after the onset of MV. Patients had a median age of 53 (44-62) years and 70 (36 %) were male. The median Glasgow coma scale (GCS) score before MV was 9 (5-14). 142 (74 %) patients had a World Federation of Neurosurgeons (WFNS) score ≥III. Aneurysm was secured with an endovascular coiling procedure in 162 (84 %) patients. 81 (48.7 %) patients declared an early VAP. On multivariate analysis, male sex (odds ratio [OR] 2.26, 95 % confidence interval [CI] [1.14-4.46]), use of mannitol before day 7 (OR 3.03, 95 % CI [1.54-5.95]), and achieving enteral nutrition ≥20 kcal kg(-1) day(-1) after day 7 (OR 2.91, 95 % CI [1.27-6.67]) remained independent risk factors of VAP. The main pathogens involved were methicillin-susceptible Staphylococcus aureus (MSSA) (34.9 %), Haemophilus influenzae (28.1 %), Streptococcus pneumoniae (15.5 %), and Enterobacteriaceae (10.7 %). Early VAP was associated with a longer duration of MV and ICU stay, but not with an excess of mortality. Early VAP bears significant morbidity in patients with severe SAH. Pathogens involved in early VAP are susceptible to antibiotics. Among modifiable risk factors of VAP, early enteral nutrition could be an easy and effective target.

Bacteria killing nanotechnology Bio-Kil effectively reduces bacterial burden in intensive care units

A contaminated hospital environment has been identified as an important reservoir of pathogens causing healthcare-associated infections. This study is to evaluate the efficacy of bacteria killing nanotechnology Bio-Kil on reducing bacterial counts in an intensive care unit (ICU). Two single-bed rooms (S-19 and S-20) in the ICU were selected from 7 April to 27 May 2011. Ten sets of new textiles (pillow cases, bed sheets, duvet cover, and patient clothing) used by patients in the two single-bed rooms were provided by the sponsors. In the room S-20, the 10 sets of new textiles were washed with Bio-Kil; the room walls, ceiling, and air-conditioning filters were treated with Bio-Kil; and the surfaces of instruments (respirator, telephone, and computer) were covered with Bio-Kil-embedded silicon pads. Room S-19 served as the control. We compared the bacterial count on textiles and environment surfaces as well as air samples between the two rooms. A total of 1,364 samples from 22 different sites in each room were collected. The mean bacterial count on textiles and environmental surfaces in room S-20 was significantly lower than that in room S-19 (10.4 vs 49.6 colony-forming units [CFU]/100 cm2; P < 0.001). Room S-20 had lower bacterial counts in air samples than room S-19 (33.4–37.6 vs 21.6–25.7 CFU/hour/plate; P < 0.001). The density of microbial isolations was significantly greater among patients admitted to room S-19 than those to room S-20 (9.15 vs 5.88 isolates per 100 patient-days, P < 0.05). Bio-Kil can significantly reduce bacterial burden in the environment of the ICU.

EPIDÉMIOLOGIE DES ENTÉROBACTÉRIES BLSE ISOLÉES DES URINES ET POUMONS EN RÉANIMATION

Introduction : The nosocomial infections are of a heavy diagnosstic and therapeutic burden in intensive care unit (ICU). The aim of this study is to determine the epidemiology of ESBL-E as an origin infections of urinary and pulmonary infections diagnosed in ICU. Material and methods : This is a retrospective study conducted over a period of one year which runs from 1st March 2010 to end February 2011 analyzing the results of cellular and microbiological exams of urine and lung samples; and their corresponding antibiograms. Results : Over three hundred and sixty two positive tests, 167 strains of Enterobacteriaceae were isolated (46%); fifty six secretory Enterobacteriaceae ESBL producing were isolated with 33.5%. Separately, Enterobacteriaceae accounted for 84% of bacteria isolated from urine samples against 31.3% of the lung. The proportion of ESBL-E is 33.3% in urine and 33.7% in the lungs. The distribution of ESBL-E shows a predominance of Klebsiella producing about 59%, 44% of all klebsiella are producing ESBL. Discussion : multidrug resistance caused by ESBL-E is a universally finding. The results of this study show the gradual increase in their prevalence as important etiological agents of nosocomial infections and therfore their release into the local health environment. Conclusion : It is necessary again to emphasize the importance of hospital hygiene and good rules of antibiotics to limit the spread of MDR bacilli and avoid the therapeutic impasse.

Ventilator-associated pneumonia: A review

Ventilator-associated pneumonia (VAP) is the most frequent intensive-care-unit (ICU)-acquired infection, with an incidence ranging from 6 to 52% [1,2,3,4]. Several studies have shown that critically ill patients are at high risk for getting such nosocomial infections [3,4]. VAP continues to be a major cause of morbidity, mortality and increased financial burden in ICUs [5,6,7,8]. Over the years there has been a significant advance in our understanding of ventilator associated pneumonia. This article reviews the various aspects of VAP such as definition, risk factors, etiological agents, diagnosis, treatment and prevention with emphasis on the recent advances.