Critical Care Facilities Research Articles

Metal phosphide poisoning in a disaster-stricken area. Can early hemodialysis improve outcomes?

Phosphide metal poisoning results in tens of thousands of fatalities per year worldwide. The mortality in critically ill patients often exceeds 50%. The available treatment is supportive and there is no antidote. Dialysis is recommended to treat advanced complications but has not been prescribed early in the process. In this study we report our experience in using dialysis in the early hours of presentation of the patients and suggest it can favorably improve the prognosis. We also draw attention to the risk of suicide under conditions of chronic conflict such as those in northwestern Syria, and to the lack of necessary mental health support for patients after suicide attempts. Retrospective review of records of patients poisoned with aluminum phosphide and admitted to critical care facilities in northwestern Syria between July 2022 and June 2023. During the observation period 16 cases were encountered. Suicide was the reason of the poisoning in 15 patients, the median patient age was 18 years and over two thirds of the patients were female. Early dialysis was used in 11 patients who were critically ill and their mortality rate was 18%. Phosphide metal poisoning is common in the disasters stricken area of northwestern Syria. Most cases are suicidal and impact young females. Early dialytic interventions may favorably impact the outcomes.

General ward nurses detection and response to clinical deterioration in three hospitals at the Kenyan coast: a convergent parallel mixed methods study

BackgroundIn low and middle-income countries like Kenya, critical care facilities are limited, meaning acutely ill patients are managed in the general wards. Nurses in these wards are expected to detect and respond to patient deterioration to prevent cardiac arrest or death. This study examined nurses' vital signs documentation practices during clinical deterioration and explored factors influencing their ability to detect and respond to deterioration.MethodsThis convergent parallel mixed methods study was conducted in the general medical and surgical wards of three hospitals in Kenya's coastal region. Quantitative data on the extent to which the nurses monitored and documented the vital signs 24 h before a cardiac arrest (death) occurred was retrieved from patients' medical records. In-depth, semi-structured interviews were conducted with twenty-four purposefully drawn registered nurses working in the three hospitals' adult medical and surgical wards.ResultsThis study reviewed 405 patient records and found most of the documentation of the vital signs was done in the nursing notes and not the vital signs observation chart. During the 24 h prior to death, respiratory rate was documented the least in only 1.2% of the records. Only a very small percentage of patients had any vital event documented for all six-time points, i.e. four hourly. Thematic analysis of the interview data identified five broad themes related to detecting and responding promptly to deterioration. These were insufficient monitoring of vital signs linked to limited availability of equipment and supplies, staffing conditions and workload, lack of training and guidelines, and communication and teamwork constraints among healthcare workers.ConclusionThe study showed that nurses did not consistently monitor and record vital signs in the general wards. They also worked in suboptimal ward environments that do not support their ability to promptly detect and respond to clinical deterioration. The findings illustrate the importance of implementation of standardised systems for patient assessment and alert mechanisms for deterioration response. Furthermore, creating a supportive work environment is imperative in empowering nurses to identify and respond to patient deterioration. Addressing these issues is not only beneficial for the nurses but, more importantly, for the well-being of the patients they serve.

Additional Bicarbonate Infusion Complements WHO Rehydration Therapy in Children with Acute Diarrhea and Severe Dehydration Presenting with Severe Non-anion Gap Metabolic Acidemia: An Open Label Randomized Trial.

To assess the efficacy and safety of bicarbonate infusion in children with Acute Diarrhea and Severe Dehydration (ADSD) having severe Non-Anion Gap Metabolic Acidemia (sNAGMA). Children (aged 1-144 mo) with ADSD and sNAGMA (pH ≤7.2 and/or serum bicarbonate ≤15mEq/L) were enrolled in an open-label randomized design. Controls (n = 25) received WHO-recommended rehydration therapy with Ringer Lactate, while intervention group (n = 25) received additional bicarbonate deficit correction. Primary outcome was time taken to resolve metabolic acidemia (pH >7.30 and/or bicarbonate >15mEq/L). Secondary outcome measures were adverse outcome [composite of pediatric intensive care unit (PICU) transfer and deaths], acute care area free days in 5 d (ACAFD5), hospital stay, and adverse effects. Time taken to resolve metabolic acidemia was significantly lesser with intervention [median (IQR); 8h (4, 12) vs. 12h (8, 24); p = 0.0067]. Intervention led to acidemia resolution in significantly more children by 8h and 16h (17/25 vs. 9/25, p = 0.035 and 23/25 vs. 17/24, p = 0.018, respectively). Patients with fluid refractory shock needed lesser inotropes in intervention group [median Vasoactive Inotrope Score (VIS), 10.5 vs. 34]. Intervention led to significantly lesser adverse outcome (0/25 vs. 5/25, p = 0.049), and noticeably more ACAFD5 [median (IQR); 2 (1, 2) vs. 1 (1, 2); p = 0.12]. Two patients died in the control group while none in the intervention group. No adverse effect was documented. Additional calculated dose of bicarbonate infusion led to significantly early resolution of metabolic acidemia, lesser utilization of critical care facilities, and lesser adverse outcome in children with ADSD and sNAGMA, compared to standard therapy, with no adverse effect.

Current State of Brazilian Neurosurgery: Evaluation of Burden of Care and Case Volume

Low- and middle-income countries (LMICs) bear a heavier burden of neurosurgical diseases than high-income countries. Brazil, a growing middle-income country, holds promise as a health care market. However, there exists a lack of information to characterize the state of neurosurgical practice and access to care in Brazil. This study aimed to characterize neurosurgical practice in Brazil and identify barriers to care. A collaborative survey was developed with Brazilian neurosurgeons and distributed by the Brazilian Society of Neurosurgery. The survey gathered demographic information, practice characteristics, case volume, referral patterns, income sources, and assessed barriers using a Likert scale. Descriptive statistics were employed for data analysis. One-hundred and forty-nine neurosurgeons participated (response rate: 17.5%), representing various states in Brazil. Neurosurgeons practiced in more than 4 different hospital systems on average, with most consultations and procedures occurring in public hospitals. Common procedures included tumor surgeries, general neurosurgery, spine surgeries, trauma surgeries, and hydrocephalus management. Equipment shortage and systemic issues were identified as major barriers to care. Neurosurgical practice in Brazil exhibits diverse age distribution, widespread distribution across states, and involvement in both public and private hospitals. Survey insights shed light on neurosurgical workload and neurosurgical practice characterization. Lack of equipment and inadequate postoperative resources pose significant barriers to care. The findings highlight the need for investments in equipment, critical care facilities, and improved health care system coordination to enhance access to neurosurgical care in Brazil.

An equitable patient reallocation optimization and temporary facility placement model for maximizing critical care system resilience in disasters

Medical infrastructure disruptions during disasters pose a major threat to critically ill patients with advanced chronic kidney disease or end-stage renal disease. There is a need to assess the potential threat to critical care facilities from hazardous events to improve patient access to dialysis treatment. We propose optimization models for patient reallocation and temporary medical facility placement to equitably improve critical care system resilience. We leverage human mobility data in Texas to assess patient access to critical care facilities and dialysis centers under the simulated hazard impacts. The optimization model was formulated as an integer programming and solved by COIN-OR Branch-and-Cut (CBC) solver. The results show (1) the capability of the optimization model in efficient patient reallocation to alleviate disrupted access to dialysis facilities; (2) the importance of large facilities in maintaining the system functionality. The critical care system, particularly the network of dialysis centers, is heavily reliant on a few larger facilities, characteristic of scale-free networks, making it susceptible to targeted disruption, such as capacity failures. (3) Considering equity in the optimization model formulation reduces access loss for vulnerable populations in the simulated scenarios. (4) The proposed temporary facilities placement could improve access for the vulnerable population, thereby improving the equity of access to critical care facilities in disaster. The proposed patient reallocation optimization model and temporary facilities placement offer a data-driven and analytics-based decision support tool tailored to the needs of healthcare organizations across private and public sectors to proactively mitigate the potential loss of access to critical care facilities during disasters.

Bacterial Contamination on Reusable Pulse Oximeter Sensors in Intensive Care Units and Its Manual Disinfection by Alcohol and Sodium Hypochlorite

: Nosocomial infections may result from intensive care unit pulse oximeters. The descriptive study examined pulse oximeter sensor microbiological contamination and the efficacy of manual disinfection with alcohol and sodium hypochlorite in five hospital intensive care units. Sixty-eight reusable pulse oximeter sensors were swabbed, cultured, and evaluated after decontamination. In private and public hospitals, 12 (35.2%) and 13 (37.2%) pulse oximeters tested positive for bacteria. Alcohol 70% reduced the microbial load and more than 10% sodium hypochlorite. The study found that purposeful cleaning and disinfection reduce microorganisms. Alcohol was more efficacious than sodium hypochlorite. Critical care facilities should regularly clean reusable pulse oximeter sensors.

Euthyroidectomy under local versus general anesthesia in health camp settings in Uganda: a protocol for randomized prospective equivalence single-blind controlled trial

BackgroundEndemic goiter is highly prevalent in Uganda at 60.2%, contributing to the high surgical burden. While compelling evidence suggest that in selected cases, thyroidectomy under local anesthesia (LA) is associated with fewer post-operative complications, low costs, and short hospital stays, local anesthesia is not considered a priority technique for thyroidectomy in resource-constrained settings such as Uganda, despite having fewer general anesthesia (GA) and critical care providers. The objective of this trial is to compare euthyroidectomy under local versus general anesthesia among patients with grade 1–2 uncomplicated euthyroid goiter in Uganda.MethodsThis prospective equivalence randomized, single-blind controlled trial protocol will be conducted among eligible participants with grade 1–2 uncomplicated euthyroid goiters. The recruitment processes will start in October 2022 and end in April 2023. Consenting participants with an indication for thyroidectomy will be randomized into two arms of 29 participants in each arm during the Bulamu Health Care Organization surgical camps in Uganda.DiscussionThe primary outcome of this trial protocol is to compare the early post-operative complications of euthyroidectomy done under LA versus GA. The outcome variables include post-operative pain based on visual analogue scale, nausea, vomiting, hematoma formation, and transient voice changes determined at an interval of 6, 12, and 24 h and at 30 days.In addition, we shall compare the surgical site infection rates, procedure costs, hospital stay, and patients’ level of satisfaction based on a 5-point Likert scale and their willingness to undergo a similar surgery using the same anesthetic technique between the two groups. We hypothesize that euthyroidectomy under LA could potentially offer similar benefits as GA, reduce costs related to procedure, complications, and hospital stay while at the same time mitigating the unmet need for surgery attributable to shortage of general anesthesia providers and critical care facilities in low-income settings.Trial registrationPan African Clinical Trial Registry PACTR202208635457430. Registered on 11th August 2022. All items from the WHO trial registration data set are within the protocol. Version number and date: version 3, 15/03/2023.

Sequential APACHE II Scores for Prediction of Mortality in Patients with Severe Malaria and Admitted to Critical Care Facilities

Background/Aims: Both generic and disease specific prognostic scoring systems have been employed in areas of critical care. The score of Acute Physiology and Chronic Health Evaluation (APACHE) II is a generic point score which provides general assessment of illness and severity. In order to determine the mortality of critically ill malaria patients, this study aims to find the ideal time point for the APACHE II score.
 Materials and Methods: This longitudinal study was carried out after getting necessary ethics committee approval. Score of APACHE II on days 0, 2nd and 7th were evaluated and appropriate statistical tests were applied.
 Results: Out of 120 patients, 54 patients were of P. vivax, P. falciparum - 60 and six mixed infection patients. Mean APACHE II score was maximum on day 0 followed by day 2 and 7 in decreasing order. The APACHE II score was statistically greater on all days in patients who didn’t survive. The Receiver Operating Characteristic (ROC) curve when plotted showed score of APACHE II on day 2 - cut-off ≥14 to be the most valid in mortality prediction with a sensitivity of 64.28% and specificity of 87.80% as most of the results were on the left from the diagonal line and had greatest area under the curve.
 Conclusion: The prognostic score APACHE II was discovered to be helpful in patients with severe falciparum/vivax malaria who required intensive care treatment since the second day's sequential score significantly differentiates between survivors and non-survivors. The optimum cut-off for identifying individuals at high risk of mortality is 14, and the Day-2 APACHE II score is an ideal biomarker for predicting the outcomes of ICU patients.
 Recommendation: Malaria is a major cause of tropical sepsis in India leading to significant amount of mortality. Sequential APACHE II scoring instead of single time APACHE II score calculated on admission could have a role in evaluation of effectiveness of treatment, trend in recovery or dysfunction and prediction of mortality.

Outcomes of near-miss/adverse perioperative events during elective and emergency non-cardiac surgeries that required unplanned admissions to the intensive care unit of a tertiary care center: a retrospective cohort study

BackgroundThe near-miss/adverse events during elective and emergency non-cardiac surgeries requiring unplanned admissions to the intensive care unit (ICU) during the perioperative period are not known. Patients undergoing elective and emergency (E) noncardiac surgeries classified according to the American Society of Anesthesiologists physical status (ASA PS) (I–IV) were studied.ResultsFrom 01 January 2019 to 31 December 2020, 6584 patients above 18 years underwent non-cardiac surgeries at a tertiary care center in eastern India, of which 87.3% (n = 5754) were elective surgical cases, and 12.5% (n = 826) were emergency surgeries. 0.98% of the patients (n = 65) (26 men and 39 females) had serious adverse/near-miss events requiring unplanned admission to the ICU, of these, 50.7% (n = 33) were elective cases, in ASA PS I 12.3% (n = 8), ASA II 27.6% (n = 18) ASA III 9.2% (n = 6) and ASA IV 1.53% (n = 1) respectively and 49.3% (n = 32) were emergency cases in ASA PS I (E) 13.8% (n = 9) (13.8%), ASA II (E) 26.1% (n = 17), ASA III(E) 4.6% (n = 3) and ASA IV(E) 4.6% (n = 3) respectively. Near miss events were mainly due to (a) cardiac-related events seen in 37.5% (n = 25) patients, (b) hemorrhage seen in 25% (n = 16), and (c) airway-related issues seen in 16.1% (n = 11) patients respectively. The adverse events were mainly due to drug-related errors in 21.4% (n = 13) patients. 13.84% (n = 9) patients had died and 86.16% (n = 56) had survived due to the availability of critical care services.Emergency surgeries 25% (8 out of 32 patients) had a higher mortality rate due to adverse/near-miss events compared to elective surgeries which were 3.03% (1 out of 33 cases) respectively.ConclusionsEmergency non-cardiac surgeries were associated with higher rates of adverse/near-miss events. Early recognition and prompt management of critical adverse events during intraoperative and postoperative periods with the help of critical care facilities may improve clinical outcomes.

Evaluation of Characteristics and Outcomes of COVID-19 Between First Wave and Second Wave: Study From a Tertiary Cancer Care Centre, Delhi, India.

Background and objectives The second wave of coronavirus disease-19 (COVID-19) had several severe consequences in the form of rising cases, deaths, and overwhelming health infrastructure in India. However, the similarities and differences between the characteristics of the first and second waves have yet to be explained. The objectives of the study were to compare the incidence, clinical management, and mortality rates between two waves. Methods The COVID-19 data collated from Rajiv Gandhi Cancer Institute and Research Centre, Delhi between the first wave (1 April 2020 to 27 February 2021) and second wave (1 March 2021 to 30 June 2021) were evaluated in terms of incidence, the clinical course of the disease, and mortality rates. Results The number of subjects hospitalized in the first and second waves was 289 and 564, respectively. Compared to the first wave, the proportion of patients with severe disease was higher (9.7% vs. 37.8%). Several parameters such as age group, grade of disease, the reason for hospitalization, values of peripheral oxygen saturation, type of respiratory support, response to therapy, vital status, and others show statistically significant differences between the two waves (P<0.001). The mortality rate in the second wave was significantly higher (20.2% vs. 2.4%, P<0.001) than in the first wave. Interpretation and conclusions The clinical course and outcomes of COVID-19 significantly differ between the first and second waves. There is a higher incidence of hospitalized patients (66.1% vs. 33.9%) with drastically increased case fatality rate in the second wave. Disease severity in the first wave is four times lower than in the second wave. The second wave was quite devastating, which led to the shortage of critical care facilities and the loss of a significant number of lives.

EGS P17 No beds available for transfer! Experience of life saving pancreatic necrosectomies at a non-pancreatic upper GI unit

Abstract Background Infected necrotising pancreatitis (NP) has a high mortality. NICE recommends necrotising pancreatitis be managed at specialist pancreatic centres due to its challenging nature. However, timely transfer of patients from non-specialist centres to tertiary pancreatic units can be limited by critical bed availability. This problem is further compounded by the staffing issues and constraints on critical care facilities since the COVID19 pandemic. This situation places patients at high risk of mortality and poses the question as to whether lifesaving intervention can be offered within appropriate local upper GI non pancreatic units. We present our data from emergent pancreatic necrosectomies in a sub-set of critically ill patients for whom transfer to specialist care was not possible due to lack of availability of critical care beds. Methods A retrospective case series is presented over a two-year period at a non-pancreatic upper GI centre. Patients over a two-year period (2020–2022) were identified using clinical coding and operation note records. Data was collected on patient characteristics such as age, gender, and co-morbidities, as well as on their inflammatory markers on presentation, imaging modality used, nutritional status and duration of care in a high dependency unit. Complications, including death following pancreatic necrosectomy were also recorded. Only descriptive statistics were used in this audit. No advanced statistics were required. Data standards were assessed using fractions and then percentages for ease of understanding. Results A total of six patients were identified as having undergone emergency pancreatic necrosectomies. Patients included were all male with a mean age of 48 and an average BMI of 25.6. The mean number of days patients were in hospital prior to their necrosectomy was 42.6. On average patients had 5.5 CT scans prior to their necrosectomy. 50% of patients had organ failure requiring ventilatory support and/or hemofiltration. Comorbidities included diabetes mellitus, rheumatoid arthritis and Covid-19. Social factors such as excess alcohol consumption and cigarette smoking were also present. As per NICE guidance, 100% of patients were administered enteral nutrition through a nasojejunal tube during their admission. 50% of patients received parenteral nutrition after failure of enteral nutrition, in keeping with best practice. 100% underwent a pancreatic necrosectomy and 50% had further operations. The mean number of re-operations per patient was 2.3. The average number of days between admission and pancreatic necrosectomy was 42 days. 100% of patients had complications with 50% suffering from AKI and 33% patients were readmitted with pancreatitis related complications. One death was from post operative haemorrhage. Overall survival rate at this tertiary care centre was 83.3%. These patients are currently still being followed up. Conclusions The results of our audit have shown that necrotising pancreatitis can be managed outside of a specialist pancreatic centre providing there are appropriately skilled surgeons and critical care staff employed, who are confident in managing the condition. Complications at the centre, including death rates, were no higher than reported in the literature, suggesting patient safety was not adversely affected. Ideally, further audits will need to be carried out on a larger scale, potentially with multiple trusts involved, comparing specialist pancreatic centres to non-specialist facilities to ensure that the results of our audit are not limited to this tertiary care centre alone. The data in this audit stems from during the Covid-19 pandemic and therefore additional auditing will need to be done in case the pressures of the pandemic on healthcare services has impacted upon the results and findings, as well as the patient cohort.

Immunopathology of terminal complement activation and complement C5 blockade creating a pro-survival and organ-protective phenotype in trauma.

Traumatic haemorrhage (TH) is the leading cause of potentially preventable deaths that occur during the prehospital phase of care. No effective pharmacological therapeutics are available for critical TH patients yet. Here, we identify terminal complement activation (TCA) as a therapeutic target in combat casualties and evaluate the efficacy of a TCA inhibitor (nomacopan) on organ damage and survival in vivo. Complement activation products and cytokines were analysed in plasma from 54 combat casualties. The correlations between activated complement pathway(s) and the clinical outcomes in trauma patients were assessed. Nomacopan was administered to rats subjected to lethal TH (blast injury and haemorrhagic shock). Effects of nomacopan on TH were determined using survival rate, organ damage, physiological parameters, and laboratory profiles. Early TCA was associated with systemic inflammatory responses and clinical outcomes in this trauma cohort. Lethal TH in the untreated rats induced early TCA that correlated with the severity of tissue damage and mortality. The addition of nomacopan to a damage-control resuscitation (DCR) protocol significantly inhibited TCA, decreased local and systemic inflammatory responses, improved haemodynamics and metabolism, attenuated tissue and organ damage, and increased survival. Previous findings of our and other groups revealed that early TCA represents a rational therapeutic target for trauma patients. Nomacopan as a pro-survival and organ-protective drug, could emerge as a promising adjunct to DCR that may significantly reduce the morbidity and mortality in severe TH patients while awaiting transport to critical care facilities.

Critical care bed capacity of Bangladesh: A Pre and Post COVID-19 pandemic survey

Background: Intensive care unit (ICU) is the backbone of critical care service delivery in a hospital. Bangladesh has been lagging behind in critical care service delivery since first ICU was established in 1978. In 2017-19 an international study reported that Bangladesh had 0.7 Critical care (ICU and HDU) bed per one lac population. This was quite low compared to South Asian countries. Growth of critical care beds across our country has been reported to be heterogeneous. The aim of this survey is to determine current strength and growth of critical care beds before the beginning of recent COVID pandemic and also at the height of pandemic when additional COVID ICUs and HDUs were introduced. Method: Data on number of ICUs and HDUs and their bed strength were obtained from different web sites of Govt. of Bangladesh as well through personal communication. Number of critical care beds were calculated at national and district level as number per one lac population. Ratio of critical care beds expressed in percentage with number of hospital beds in the hospital were calculated at national level. Data were also obtained on COVID ICU and HDU beds which were introduced temporarily from websites of ministry of Health, Govt. of Bangladesh. Results: As of now we documented (pre COVID pandemic) 2139 ICU beds (965 in Govt. hospitals) and 717 HDU beds (315 in Govt. hospitals) among 208 hospitals (Govt. hospitals 79+ Private hospitals 129) during our survey. Number of critical care beds per one lac population across the country is found to be 1.70. In hospitals with critical care beds the average ratio of critical care beds (ICU+HDU) beds compared to hospital beds is 4.34% across the country. Thirty eight of total 64 districts have no critical care facility (non COVID/pre COVID) in their local hospitals. During peak of pandemic Govt. of Bangladesh introduced and approved 1186 COVID ICU beds, 695 COVID HDU beds both at Govt. and private level on temporary basis in different hospitals including in some critical care deprived hospitals. Conclusion: Our survey concludes that growth and distribution of critical care beds (ICUS + HDUs) across Bangladesh is still heterogeneous and very much inadequate compared to the critical care need of the population. There was a temporary surge of new ICUs and HDUs to serve COVID patients at the height of COVID pandemic across the country. Health care planners of the country need to plan for developing adequate critical care man power as well as establish newer critical care facilities among existing hospitals who lack them. Bangladesh Crit Care J September 2022; 10(2): 88-98

Factors Influencing Emergency Department Nurses' Attitudes Toward Patients Who Attempted Suicide: A Mixed Methods Study.

Caring for patients who attempted suicide is essential to suicide prevention. The current mixed methods study clarified the factors influencing emergency department nurses' attitudes toward patients who attempted suicide. Questionnaires were distributed to 2,122 nurses at 73 critical care and medical center facilities in Japan; data of 419 participants were deemed valid and included in multiple regression analysis. Nurses' thoughts and emotions experienced when trying to empathize with patients, educational background, anxiety about caring for survivors of attempted suicide, severity of wounds inflicted during the suicide attempt, selfish behaviors by survivors, nurse-physician relationships, comparisons between survivors and other patients, and personal life experiences were identified as influencing factors. Training nurses to care for survivors of attempted suicide and fostering a climate in which nurses can easily collaborate with other specialists can help them understand such patients better. [Journal of Psychosocial Nursing and Mental Health Services, 61(5), 25-33.].

Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study.

Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.

Co-infection and ICU-acquired infection in COVID-19 ICU patients: a secondary analysis of the UNITE-COVID data set

BackgroundThe COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients.MethodsThis is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson’s Chi-squared and continuous variables by Mann–Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the “full” matching method.ResultsData were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO.ConclusionsIn patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids.Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021).Graphical abstract

Use of Nanomaterials for Diagnosis and Treatment: The Advancement of Next-Generation Antiviral Therapy.

Globally, viral illness propagation is the leading cause of morbidity and death, causing wreaking havoc on socioeconomic development and health care systems. The rise of infected individuals has outpaced the existing critical care facilities. Early and sophisticated methods are desperately required in this respect to halt the spread of the infection. Therefore, early detection of infectious agents and an early treatment approach may help minimize viral outbreaks. Conventional point-of-care diagnostic techniques such as computed tomography scan, quantitative real time polymerase chain reaction (qRT-PCR), X-ray, and immunoassay are still deemed valuable. However, the labor demanding, low sensitivity, and complex infrastructure needed for these methods preclude their use in distant areas. Nanotechnology has emerged as a potentially transformative technology due to its promise as an effective theranostic platform for diagnosing and treating viral infection, circumventing the limits of traditional techniques. Their unique physical and chemical characteristics make nanoparticles (NPs) advantageous for drug delivery platforms due to their size, encapsulation efficiency, improved bioavailability, effectiveness, immunogenicity, and antiviral response. This study discusses the recent research on nanotechnology-based treatments designed to combat new viruses.

Critical care practices in the world: Results of the global intensive care unit need assessment survey 2020.

BACKGROUNDThere is variability in intensive care unit (ICU) resources and staffing worldwide. This may reflect variation in practice and outcomes across all health systems.AIMTo improve research and quality improvement measures administrative leaders can create long-term strategies by understanding the nature of ICU practices on a global scale.METHODSThe Global ICU Needs Assessment Research Group was formed on the basis of diversified skill sets. We aimed to survey sites regarding ICU type, availability of staffing, and adherence to critical care protocols. An international survey ‘Global ICU Needs Assessment’ was created using Google Forms, and this was distributed from February 17th, 2020 till September 23rd, 2020. The survey was shared with ICU providers in 34 countries. Various approaches to motivating healthcare providers were implemented in securing submissions, including use of emails, phone calls, social media applications, and WhatsApp™. By completing this survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.RESULTSThere were a total 121 adult/adult-pediatrics ICU responses from 34 countries in 76 cities. A majority of the ICUs were mixed medical-surgical [92 (76%)]. 108 (89%) were adult-only ICUs. Total 36 respondents (29.8%) were 31-40 years of age, with 79 (65%) male and 41 (35%) female participants. 89 were consultants (74%). A total of 71 (59%) respondents reported having a 24-h in-house intensivist. A total of 87 (72%) ICUs were reported to have either a 2:1 or ≥ 2:1 patient/nurse ratio. About 44% of the ICUs were open and 76% were mixed type (medical-surgical). Protocols followed regularly by the ICUs included sepsis care (82%), ventilator-associated pneumonia (79%); nutrition (76%), deep vein thrombosis prophylaxis (84%), stress ulcer prophylaxis (84%), and glycemic control (89%).CONCLUSIONBased on the findings of this international, multi-dimensional, needs-assessment survey, there is a need for increased recruitment and staffing in critical care facilities, along with improved patient-to-nurse ratios. Future research is warranted in this field with focus on implementing appropriate health standards, protocols and resources for optimal efficiency in critical care worldwide.

Research ethics support during the COVID-19 epidemic: a collaborative effort by South African Research Ethics Committees

The COVID-2019 pandemic caused disruption of health services globally due to increased need for critical care facilities and collateral damage to routine healthcare services. Global and local research into disease pathogenesis and management strategies is central to a public health emergency response. South African legislation mandates that no health research may be conducted without approval from a registered Research Ethics Committee. For results to have maximum impact and relevance in a pandemic situation, ethics review and approval must be rapid and timeous, without compromising rigour and quality of review. This chapter argues that South African Research Ethics Committees were under-prepared for this task, largely due to gaps in national ethics guidance and the critical absence of the National Health Research Ethics Council. Although ethics guidance documents contain enabling clauses, no specified procedures for rapid review in emergencies exist. Consequently, and in an unprecedented initiative, several Research Ethics Committee chairpersons and members formed a spontaneous informal, ad hoc group, ‘Research Ethics Support in COVID-19 Pandemic’ (RESCOP), to share resources and support for managing the review of research related to COVID-19. The chapter outlines the processes put in place and mechanisms introduced by RESCOP in the interest of responsible and accountable, but rapid, ethics review. We describe good practices for rapid full ethics review of COVID-19 health research, including clinical trials. RESCOP’s innovative collaboration enabled rapid but thorough ethics review of research protocols during the epidemic. The processes established can serve as a good-practice model that could be adopted and adapted by other committees and future versions of national research ethics guidelines.

Integrated healthcare acoustics for patients, patient advocates, and staff in environments of care

COVID surges have demonstrated worldwide that overloaded critical care facilities cannot transform environments of care rapidly enough to satisfy patient, patient advocate, or staff expectations. Healthcare acoustics is identified as a vital yet understudied factor, linking the front lines of healthcare to patient well-being. Acoustic concerns are categorized, and existing architectural hardware and software means and proposed strategies are here discussed to be applied in both new and existing critical care facilities. Priority concerns focus on staff verbal and machine communications between single patient rooms with integral toilet/shower, adjacent corridors, nurse stations, and remote staff locations. The intent is to maintain uniformly high patient/staff communications and relevant documentation (e.g., for continuity of care, and liability) across all shifts. Integrated visual and acoustic communications between staff and equipment are explored, including projected machine display images minus noisy signals. Staff speech, background masking, and messaging to patients are considered via an “acoustic pillow,” and via a wireless headset for staff, permitting hands-free focus on empathetic patient care. HVAC can be supplied via low-velocity displacement air, served via perimeter floor ducting, and exhausted via toilet/showers. Integrated healthcare acoustics, arguably, can reduce patient and staff stresses critical to recovery and retention, respectively.