Critically-ill Patients Research Articles

Lung ultrasound to predict gas-exchange response to prone positioning in COVID-19 patients: A prospective study in pilot and confirmation cohorts

PurposeTo examine whether lung ultrasound prior to prone positioning can predict the resulting gas-exchange response. Materials and methodsThis is a prospective observational study on critically-ill COVID-19 patients with a pilot and confirmation cohort. Lung ultrasound examinations were performed before prone positioning and gas-exchange parameters were recorded before and after position change. ResultsA total of 79 patients, 36 in the pilot cohort and 43 in the confirmation cohort, were included. In the pilot cohort, a moderate correlation between pre-turn lung ultrasound score index (LUSI) and change in PaO2/FiO2 after prone positioning was found. These findings were corroborated and extended upon in the confirmation cohort. The confirmation cohort found that anterior LUSI had the strongest correlation with follow-up time-points 1, 6, 12, and 24 h after prone positioning, with strength of correlation gradually increasing up to 24 h. In a multivariate model anterior aeration loss (odds ratio 0.035; 95%CI 0.003–0.319 for anterior LUSI >50%) and higher pre-turn PaCO2 (odds ratio 0.479 95% CI 0.235–0.979) were negatively predictive of a PaO2/FiO2 increase ≥20 mmHg. ConclusionsAnterior LUSI, in addition to other clinical parameters, may be used to aid COVID-19 respiratory strategy and a clinician's decision to prone.

The Issue of Pharmacokinetic-Driven Drug-Drug Interactions of Antibiotics: A Narrative Review.

Patients in intensive care units (ICU) are at high risk to experience potential drug-drug interactions (pDDIs) because of the complexity of their drug regimens. Such pDDIs may be driven by pharmacokinetic or pharmacodynamic mechanisms with clinically relevant consequences in terms of treatment failure or development of drug-related adverse events. The aim of this paper is to review the pharmacokinetic-driven pDDIs involving antibiotics in ICU adult patients. A MEDLINE Pubmed search for articles published from January 2000 to June 2022 was completed matching the terms “drug-drug interactions” with “pharmacokinetics”, “antibiotics”, and “ICU” or “critically-ill patients”. Moreover, additional studies were identified from the reference list of retrieved articles. Some important pharmacokinetic pDDIs involving antibiotics as victims or perpetrators have been identified, although not specifically in the ICU settings. Remarkably, most of them relate to the older antibiotics whereas novel molecules seem to be associated with a low potential for pDDIs with the exceptions of oritavancin as potential perpetrator, and eravacicline that may be a victim of strong CYP3A inducers. Personalized therapeutic drug regimens by means of available web-based pDDI checkers, eventually combined with therapeutic drug monitoring, when available, have the potential to improve the response of ICU patients to antibiotic therapies.

Donepezil treatment is associated with improved outcomes in critically ill dementia patients via a reduction in delirium.

During hospital admissions, patients with dementia are at risk for developing delirium, an acute state of brain failure associated with significant morbidity. There are currently no pharmacologic tools to treat or prevent delirium. Decreased cholinergic signaling plays a role in the pathophysiology of both disorders. Whether enhanced pre-hospital cholinergic signaling in patients with dementia improves outcomes during critical illness remains unknown. We utilized the Medical Information Mart for Intensive Care III (MIMIC-III) database to determine whether pre-hospital donepezil use was associated with improved outcomes during critical illness in dementia patients. We identified 2734 subjects with dementia admitted to the intensive care unit (ICU; 447 received donepezil). After adjusting for confounders, patients with dementia who were receiving donepezil had a significantly reduced in-hospital and 90-day mortality, ICU length of stay, and duration of mechanical ventilation. Donepezil use was associated with, and its benefit was mediated by, reduced delirium. Patients with dementia who are treated with donepezil have improved outcomes during critical illness and reductions in delirium. No pharmacologic treatments exist to reduce delirium in patients with dementia. Donepezil improves outcomes during critical illness in patients with dementia. Improved outcomes are mediated by a reduction in hospital delirium. Future studies in patients with dementia should prospectively evaluate donepezil in the prevention of delirium.

Assessment of Admission COVID-19 Associated Hyperinflammation Syndrome Score in Critically-Ill COVID-19 Patients.

PurposeWe aimed to evaluate the relation between admission COVID-19 associated hyperinflammatory syndrome (cHIS) score and intensive care unit (ICU) outcomes.Materials and MethodsPatients with laboratory confirmed COVID-19 admitted to our ICU between 20th March 2020-15th June 2021 were included. Patients who received immunomodulatory treatment except corticosteroids were excluded. Main outcomes were ICU mortality and invasive mechanical ventilation (IMV) requirement after ICU admission.ResultsThree hundred and seventy patients with a median (IQR) age of 66 (56-77) were analyzed. Median admission cHIS score was 3 (2-4). A cHIS score ≥3 was found to be associated with ICU mortality (sensitivity = 0.63, specificity = 0.50; p < 0.01) and IMV requirement after ICU admission (sensitivity = 0.61, specificity = 0.51; p < 0.01). Patients with an admission cHIS score ≥3 (n = 199) had worse median admission APACHEII, SOFA scores and PaO2/FiO2 ratio than others (n = 171) (p < 0.01). IMV requirement after ICU admission (38.5% vs 26.1%;p = 0.03), ICU (36.2% vs 25.1%;p = 0.02), hospital (39.1% vs 26.9%;p = 0.01) and 28th day (28.1% vs 19.1%;p = 0.04) mortality were higher in patients with admission cHIS score ≥3 than others (p < 0.01). Age <65 years, malignancy and higher admission SOFA score were independent variables associated with admission cHIS score ≥3.ConclusionCritically-ill COVID-19 patients with admission cHIS score ≥3 have worse disease severity and outcomes than other patients.

Association between Vital Signs Fluctuations and Pain Severity among Critically-ill Patients

Background: Pain is a critical issue in the Intensive Care Unit and need a proper management to improve patient's outcome and reduce the pain consequences in critically ill patients since patient in the intensive care unit being unable to reporting pain. Therefore, assessment vital signs frequently may be helpful. Methods: A descriptive-correlational design was conducted in the present study. A purposive sample of 135 subjects who had met the study's inclusion criteria were targeted. The data collection started from January 18thto April 7th, 2022. Results: Patients were silently suffering pain during all three assessment phases pre-during and 20 minutes’ post-routine nursing procedures. Of equal importance, there is a statistically significant association between the overall pain score and overall vital signs pre, during and post nursing procedures. Conclusions: The pain severity had reached its highest level during nursing procedures, as it showed a severe unacceptable pain score, which is both clinically and ethically unacceptable. And there was a significant statistical difference, which was authenticated through vital signs readings during nursing procedures and within 20 minutes compared to pre-nursing procedures. Recommendations: It is recommended to depend the changes in vital readings because it is considered important indicator of pain presence and its severity among patients who are unable to express their pain in the intensive care units. Also a highly recommended that Intensive Care Units use up-to-date clinical protocols to measure pain.

Bioelectrical impedance analysis during deresuscitation: correlation and agreement with cumulative fluid balance in ICU patients.

Bioelectrical impedance analysis (BIA) is a promising tool to evaluate the body composition of critically-ill patients. The present study aimed to assess its value as a fluid management monitoring tool during standardized deresuscitation strategy. A historical cohort of critically-ill adult patients with fluid overload and continuous renal replacement therapy was used to explore both relationship and agreement between changes in cumulative fluid balance and BIA-derived hydration variables within the 5days following initiation of deresuscitation strategy using net ultrafiltration. Correlations were described using Spearman's rank correlation coefficient, and agreement using Bland-Altman analysis for repeated measurements. Sixty-one couples of fluid shift measurements from 30 patients were analyzed. The deresuscitation strategy induced a negative mean (± SD) cumulative fluid balance (-4.2 ± 3.8 L) and a significant decrease in extra- and intracellular water (P < 0.001). Decreases in extra- and intracellular water were independent of weight variations inputted in the BIA device. Total body water (rho = 0.63), extracellular water (rho = 0.68), and intracellular water (rho = 0.67) were significantly correlated with cumulative fluid balance (all P values < 0.001). The limits of agreement did not allow interchangeability for a delta of 2L between cumulative fluid balance and BIA-derived hydration variables (P > 0.05). BIA hydration-derived variables are significantly correlated with cumulative fluid balance but the large limits of agreements exclude interchangeability of the measures.

The incidence of propofol infusion syndrome in critically-ill patients.

PRIS is a potentially fatal syndrome characterized by various clinical symptoms and abnormalities. Experts suggest that propofol treatment duration ≥48 h or dose ≥83 μg/kg/min is associated with developing PRIS. We hypothesized PRIS might be underdiagnosed due to the overlap of PRIS clinical manifestations with critical illnesses. Multihospital, retrospective study of adult patients who received continuous propofol infusion ≥48 h or dose ≥60μg/kg/min for >24 h since admission were assessed for the development of PRIS. The incidence of PRIS was 2.9% with a PRIS-associated mortality rate of 36.8%. In PRIS patients, propofol was administered at a median dose of 36.4 μg/kg/min and over a median duration of 147.0 h. The development of PRIS was observed at a median of 125.0 h post-propofol initiation and a cumulative dose of 276.5 mg/kg. The development of metabolic acidosis (78.9%), cardiac dysfunction (52.6%), hypertriglyceridemia (100%), and rhabdomyolysis (26.3%) were observed in our PRIS patients. PRIS can often be overlooked and underdiagnosed. It is important to monitor for early signs of PRIS in patients who are on prolonged propofol infusion. Prompt recognition and interventions can minimize the dangers resulting from PRIS.

Hermeneutic phenomenology of lived experience of family caregivers of critically-ill patients sustained by healthcare technologies in Benin City, Nigeria

Background: Critical illness causes a severe financial impact on households not only because of illness-related inability to work but also because of the cost of medical care. Although the patients have the potential for recovery, they are usually presented with a life-threatening situation. Our study aimed to explore the lived experience of family caregivers caring for critically-ill patients. Materials and Methods: A qualitative study using a hermeneutic phenomenological design, to explore the lived experience of ten family caregivers caring for critically-ill patients admitted to the University of Benin Teaching Hospital, Benin-city in 2022. This study followed a hermeneutic phenomenological design using an in-depth interview of ten family caregivers who met the inclusion criteria: a family member who participated actively in the care was included. Data were collected, transcribed, and analyzed using Nvivo software and Paul Ricoeur’s theory for interpretation. Results: Based on Paul Ricoeur’s theory of interpretation, five themes were identified as the experience of family caregivers: caring neglect, psychological support, and words of encouragement, lack of confidence in nursing intervention, hopeless situation, and financial burden. Conclusion: This study shows that understanding the experience of family caregivers provides better and quality care. It also found that the hospital management needs to be aware of the identified caring neglect among family caregivers and provide a comprehensive health policy to accommodate their physiological needs while in the hospital

EVALUATION OF CLOTTING FACTORS IN HOSPITALIZED CRITICALLY-ILL INDIVIDUALS WITH SUSPECTED COVID-19

The Coronavirus Disease 2019 (COVID-19), that results of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, manifests with dysfunction of hemostasis and thrombosis. This study aims to evaluate laboratory parameters of hemostasis in hospitalized individuals with suspected COVID-19. Individuals aged 18 years or older with suspected COVID-19 admitted to two hospitals were invited to participate in this study. The study inclusion period was from April 2020 to March 2021. The study was approved by the institutional ethics committees. The diagnosis of COVID-19 was confirmed by positive SARS-CoV-2 real-time reverse-transcription polymerase chain reaction. Antithrombin, factor V, factor VII, factor XI, factor XII, factor XIII and prothrombin assays were performed using the Multiplex immunoassay technique (ThermoFisher Scientific, Vienna, Austria). Propensity score matching for sex and age were estimated by a logistic regression model for COVID-19 and non-COVID-19 individuals in the R software. The proportions found in each group were compared by Fisher's exact test, when the variable was categorical, and by the Mann-Whitney test, when it was continuous. Linear regression was performed adjusting the levels of clotting factors and antithrombin for the severity score (Sequential Organ Failure Assessment - SOFA). Correlation between SOFA, clotting factors and antithrombin in individuals with COVID-19 were performed by using the Spearman test. Only very strong correlations (≥0.9) were considered; p-value<0.05 was considered statistically significant. A total of 151 individuals were included in the study, of whom 138 (91.4%) with the diagnosis of COVID-19 and 13 (8.6%) non-COVID-19. After 2:1 matching, 26 individuals with COVID-19 and 13 non-COVID-19 participated in the study. In the univariate analysis, the group of COVID-19 had higher levels of antithrombin, factor V, factor VII, factor XI and prothrombin compared to the non-COVID-19 group. However, after adjusting for SOFA, only the levels of factor XI and prothrombin remained different between the groups (higher in the COVID-19) (p=0.04 and p=0.04, respectively). We found no association between factor XI and prothrombin with mortality. However, we found a very strong correlation between coagulation factors V and VII (r=0.923, p<0.0001). Our results show that plasma levels of antithrombin, factor V, factor VII, factor XI and prothrombin were higher in the COVID-19 when compared with non-COVID-19 group of critically-ill patients, but the difference was lost after adjusting the analysis for SOFA. Only the levels of factor XI and prothrombin remained significant in the COVID-19 group after adjustment. This finding suggests that the severity of the disease rather than viral etiology was the main determinant of the difference in the plasma levels of these proteins. We also showed a strong correlation between factor V and VII in our study. Indeed, factor VII is the major trigger of coagulation in vivo . Therefore, it is possible that factor V and VII could act together to boost coagulation and promote thrombus formation in patients with COVID-19. Our study suggests that increased levels of procoagulant factors in hospitalized critically-ill individuals with suspected COVID-19 are rather related to disease severity than to its cause.

Effect of Tocilizumab in Terms of Hospital Stay and Mortality Pattern Among Patients with Severe Versus Critically-ill COVID-19 Patients: A Comparative Analytic Study

Background and Objectives: Most patients with mild and moderate COVID-19 infection recover with standard care therapy. Mortality in patients with severe illness and those critically ill is high. Tocilizumab acts by blocking interleukin-6 receptors and shows promising results in severe disease. Aim of this study was to assess the effect of Tocilizumab in severe and critically ill COVID-19 patients in terms hospital stay and reducing the risk of death. Methods: In this comparative analytical, single-center study undertaken in DHQ university teaching hospital Gujranwala, forty-four patients were enrolled after an informed consent through non-probability consecutive sampling. The patients were categorized based on oxygen requirement as severe (oxygen requirement 10 L/min) and critically ill patients (oxygen requirement 15 L/min). All patients were treated with injection Tocilizumab (8mg per kg body weight) using criteria based on oxygen requirement (10L/min or more) and increased levels of any two of the laboratory investigations including CRP, D-Dimers, serum ferritin and LDH. Sociodemographic and clinical profile were collected using a semi-structured proforma. Outcome of interest was hospital stay and mortality. Comparison of effect of Tocilizumab was analyzed in regards to age, sex, laboratory investigations and stated outcome using Pearson's Chi-squared test. P-value of ≤0.05 was considered statistically significant. Data were analyzed using SPSS version 24.0. Results: Of 44 COVID-19 patients, 26 (59.1%) had severe disease and 18 (40.9%) were critically ill. We did not observe any statistical difference between these two categories as regards age, sex, hospital stay or presence of co-morbid conditions. However, there were 17 (94%) deaths observed among critically ill patients, while one patient died with severe disease. This mortality difference was found statistically significant (p&lt;0.001). Conclusion: Tocillizumab has shown significant effect to reduce mortality and minimizing hospital stay amongst COVID-19 patients with severe disease only with minimal effect in critically ill patients. Tocilizumab may be introduced early in treatment plan for severe COVID-19 patients.

38 Resuscitative TEE Collaborative Registry: Development and Implementation of a Multicenter Registry for Focused Transesophageal Echocardiography (TEE) in the Emergency Department and Intensive Care Settings

38 Resuscitative TEE Collaborative Registry: Development and Implementation of a Multicenter Registry for Focused Transesophageal Echocardiography (TEE) in the Emergency Department and Intensive Care Settings

A new (q*, S) policy to manage inventory for low shelf life products facing deterioration in quality and age differentiated requirements

Inventory management of products with short shelf life is a critical problem for managers due to its unique characteristics. The efficient and economical planning to manage inventory of such products is important and the complexity multiplies when such products face a deterioration in quality/effectiveness during its shelf life. This paper proposes a new (q*, S) policy with its mathematical model which will help to establish an efficient and economical system which could handle the above situation. The efficiency of this policy is evaluated by considering blood platelets as an example. Platelet transfusions are vital in patients undergoing chemotherapy and those suffering massive bleeding. Shortage of platelets can lead to cancellation or postponement of major operations and excessive storage can lead to wastage due to its low shelf life. For those patients undergoing chemotherapy and bone marrow transplantations (critical illness patients), young platelets (3 to 4 days’ shelf life) are highly preferred, as it can give significant increase in platelet count and increase the interval between transfusions. However, for general surgery and traumatology patients (less critical cases), platelets of any age will serve the purpose as the deficiency is temporary and bone marrow will be able to produce the required quantity. A new (q*, S) policy is proposed through this study to ensure the supply of young platelets for the treatment of critical illness patients and to strike a balance between the shortage in supply of platelets of any age (less critical illness patients) and the expiration of platelets. From the computational studies conducted, this policy is observed to outperform several existing policies discussed in the literature. Other considerations in this paper are fluctuations in demand in certain months and classification of central blood bank on the basis of the type of hospital it caters to. Another major contribution of this paper is the optimization of facility required to store platelets. Optimizing the order-up-to-level without considering the capacity could lead to wastage of resources as there could be lack of space for storing. Instead of predetermining the capacity of the blood bank to store platelets, the number of machines and its type is optimized in this study. So given a demand and cost profile, facility requirements and order-up-to-level to be maintained that could reduce the overall cost to minimum with reduced shortage and expiry can be determined.

106 Lipid Emulsion Therapy During Resuscitation of the Critically-Ill Poisoned Patient: A Prospective Cohort Study

Intravenous lipid emulsion (ILE) has emerged as a potential antidote for treatment of intoxication by lipophilic drugs. Despite conflicting pre-clinical (animal) data, its use continues to expand. The “lipid sink” theory, which is the prevailing theory on ILE mechanism of action, suggests that ILE generates a flux of drugs from the periphery into the vascular compartment, thereby reducing the target organ exposure and toxicity of lipophilic drugs. The primary aim of this pragmatic, real-life prospective cohort study was to compare efficacy (measured by patient survival to hospital discharge) of ILE during resuscitation of critically-ill poisoned patients intoxicated by xenobiotics with wide spectrum of lipophilicities (determined by the octanol water partition coefficient (Log P).

Using machine learning in prediction of ICU admission, mortality, and length of stay in the early stage of admission of COVID-19 patients.

The recent COVID-19 pandemic has affected health systems across the world. Especially, Intensive Care Units (ICUs) have played a pivotal role in the treatment of critically-ill patients. At the same time however, the increasing number of admissions due to the vast prevalence of the virus have caused several problems for ICU wards such as overburdening of staff and shortages of medical resources. These issues might have affected the quality of healthcare services provided directly impacting a patient’s survival. The objective of this research is to leverage Machine Learning (ML) on hospital data in order to support hospital managers and practitioners with the treatment of COVID-19 patients. This is accomplished by providing more detailed inference about a patient’s likelihood of ICU admission, mortality and in case of hospitalization the length of stay (LOS). In this pursuit, the outcome variables are in three separate models predicted by five different ML algorithms: eXtreme Gradient Boosting (XGB), K-Nearest Neighbor (KNN), Random Forest (RF), bagged-CART (b-CART), and LogitBoost (LB). With the exception of KNN, the studied models show good predictive capabilities when evaluating relevant accuracy scores, such as area under the curve. By implementing an ensemble stacking approach (either a Neural Net or a General Linear Model) on top of the aforementioned ML algorithms the performance is further boosted. Ultimately, for the prediction of admission to the ICU, the ensemble stacking via a Neural Net achieved the best result with an accuracy of over 95%. For mortality at the ICU, the vanilla XGB performed slightly better (1% difference with the meta-model). To predict large length of stays both ensemble stacking approaches yield comparable results. Besides it direct implications for managing COVID-19 patients, the approach presented serves as an example how data can be employed in future pandemics or crises.

INFRARED THERMOGRAPHY-BASED BODY-SURFACE THERMAL INHOMOGENEITY MONITORING TO ASSESS THE SEVERITY OF HYPOPERFUSION IN CRITICALLY ILL PATIENTS.

Background: Uneven body-surface thermal distribution is a manifestation of hypoperfusion and can be quantified by infrared thermography. Our aim was to investigate whether body-surface thermal inhomogeneity could accurately evaluate the severity of patients at risk of hypoperfusion. Methods: This was a prospective cohort study in which infrared thermography images were taken from unilateral legs of critically ill patients at high risk of hypoperfusion in a cardiac surgical intensive care unit. For each patient, five body-surface thermal inhomogeneity parameters, including standard deviation (SD), kurtosis, skewness, entropy, and low-temperature area rate (LTAR), were calculated. Demographic, clinical, and thermal characteristics of deceased and living patients were compared. The risk of mortality and capillary refill time (CRT) were chosen as the primary outcome and benchmarking parameter for hypoperfusion, respectively. The area under the receiver operating characteristic curve (AUROC) was used to evaluate predictive accuracy. Results: Three hundred seventy-three patients were included, and 55 (14.7%) died during hospital stay. Of inhomogeneity parameters, SD (0.738) and LTAR (0.768) had similar AUROC to CRT (0.757) for assessing mortality risk. Besides, there was a tendency for LTAR (1%-3%-7%) and SD (0.81°C-0.88°C-0.94°C) to increase in normotensive, hypotensive, and shock patients. These thermal parameters are associated with CRT, lactate, and blood pressure. The AUROC of a combined prediction incorporating three thermal inhomogeneity parameters (SD, kurtosis, and entropy) was considerably higher at 0.866. Conclusions: Body-surface thermal inhomogeneity provided a noninvasive and accurate assessment of the severity of critically ill patients at high risk of hypoperfusion.

Intravenous dantrolene in hypermetabolic syndromes: a survey of the U.S. Veterans Health Administration database

BackgroundIntravenous dantrolene is often prescribed for hypermetabolic syndromes other than the approved indication of malignant hyperthermia (MH). To clarify the extent of and indications for dantrolene use in conditions other than MH, we sought to document current practices in the frequency, diagnoses, clinical characteristics and outcomes associated with dantrolene treatment in critical care settings.MethodsInpatients receiving intravenous dantrolene from October 1, 2004 to September 30, 2014 were identified retrospectively in the U.S. Veterans Health Administration national database. Extracted data included; diagnoses of hypermetabolic syndromes; triggering drugs; dantrolene dosages; demographics; vital signs; laboratory values; in-hospital mortality; complications; and lengths of stay. Frequency and mortality of patients who did not receive dantrolene were obtained in selected diagnoses for exploratory comparisons.ResultsDantrolene was administered to 304 inpatients. The most frequent diagnoses associated with dantrolene treatment were neuroleptic malignant syndrome (NMS; N = 108, 35.53%) and sepsis (N = 47, 15.46%), with MH accounting for only 13 (4.28%) cases. Over half the patients had psychiatric comorbidities and received psychotropic drugs before dantrolene treatment. Common clinical findings in patients receiving dantrolene included elevated temperature (mean ± SD; 38.7 ± 1.3 °C), pulse (116.33 ± 22.80/bpm), respirations (27.75 ± 9.58/min), creatine kinase levels (2,859.37 ± 6,646.88 IU/L) and low pO2 (74.93 ± 40.16 mmHg). Respiratory, renal or cardiac failure were common complications. Mortality rates in-hospital were 24.01% overall, 7.69% in MH, 20.37% in NMS and 42.55% in sepsis, compared with mortality rates in larger and possibly less severe groups of unmatched patients with MH (5.26%), NMS (6.66%), or sepsis (41.91%) who did not receive dantrolene.ConclusionsIn over 95% of cases, dantrolene administration was associated with diagnoses other than MH in critically-ill patients with hypermetabolic symptoms and medical and psychiatric comorbidities. Exploratory survey data suggested that the efficacy and safety of dantrolene in preventing mortality in hypermetabolic syndromes other than MH remain uncertain. However, randomized and controlled studies using standardized criteria between groups matched for severity are essential to guide practice in using dantrolene.

Prevalence, characteristics and outcome of cardiac manifestations in critically-ill antiphospholipid syndrome patients

AimsAntiphospholipid syndrome (APS) is a rare autoimmune disease defined by thrombotic events occurring in patients with persistent antiphospholipid antibodies. Cardiac manifestations in critically-ill APS patients are poorly investigated. We conducted a study to assess the prevalence, the characteristics and the prognosis of cardiac manifestations in thrombotic APS patients admitted to intensive care unit (ICU). Methods and resultsA French, national, multicentre, retrospective study, conducted, from January 2000 to September 2018, including all APS patients admitted to 24 participating centres’ ICUs with any new thrombotic (arterial, venous or microvascular) manifestation. Cardiac manifestations were defined as any new cardiac abnormalities relying on clinical examination, cardiac biomarkers, echocardiography, cardiac magnetic resonance (CMR) and coronarography. One hundred and thirty-six patients (female 72%) were included. Mean age at ICU admission was 46 ± 15years. Cardiac manifestations were present in 71 patients (53%). In patients with cardiac involvement, median left ventricular ejection fraction (LVEF) was 40% [28–55], troponin was elevated in 93% patients, coronary angiogram (n = 19, 27%) disclosing a coronary obstruction in 21%. CMR (n = 21) was abnormal in all cases, with late gadolinium enhancement in 62% of cases. Cardiac manifestations were associated with a non-significant increase of mortality (32% vs. 19%, p = 0.08). After 1-year follow-up, median LVEF was 57% [44–60] in patients with cardiac involvement. ConclusionCardiac involvement is frequent in critically-ill thrombotic APS patients and may be associated to more severe outcome. Increased awareness on this rare cause of myocardial infarction with or without obstructive coronary artery is urgently needed.

Importance of absolute eosinophil count in covid-19 patients

Coronavirus 2 (SARS-CoV-2) has created worldwide healthcare problems and strained health resources. Reduced eosinophil levels are one of the unique discoveries that have been discovered in COVID 19 recently. The goal of this study is to establish the association between the mortality in COVID-19 with eosinopenia by retrospectively analysing data from fifty COVID-19 patients with varying illness severity, including moderate, severe, and critically ill. Fifty patients taken from Sree Balaji Medical College and Hospital, of which twenty five critically ill patients and twenty-five having moderate to severe COVID-19 infection at hospital admission were enrolled. After being admitted to the hospital, information on the patient's medical history, clinical symptoms, CT severity score, and outcomes were taken from their medical records. The study concluded that Compared to individuals with moderate and severe disorders, critical illness patients' eosinophil levels were much lower. Eosinophil levels gradually decreasing was found to be a separate factor which has been associated with mortality. Patients with COVID-19 who have eosinopenia have a considerably higher mortality rate. These values can be obtained by simple means such as obtaining peripheral blood, so this is an easy and an effective indicator in monitoring these patients.

Inflammatory Biomarkers Associated with In-Hospital Mortality in Critical COVID-19 Patients.

The COVID-19 pandemic poses global healthcare challenges due to its unpredictable clinical course. The aim of this study is to identify inflammatory biomarkers and other routine laboratory parameters associated with in-hospital mortality in critical COVID-19 patients. We performed a retrospective observational study on 117 critical COVID-19 patients. Following descriptive statistical analysis of the survivor and non-survivor groups, optimal cut-off levels for the statistically significant parameters were determined using the ROC method, and the corresponding Kaplan-Meier survival curves were calculated. The inflammatory parameters that present statistically significant differences between survivors and non-survivors are IL-6 (p = 0.0004, cut-off = 27.68 pg/mL), CRP (p = 0.027, cut-off = 68.15 mg/L) and IL-6/Ly ratio (p = 0.0003, cut-off = 50.39). Additionally, other statistically significant markers are creatinine (p = 0.031, cut-off = 0.83 mg/dL), urea (p = 0.0002, cut-off = 55.85 mg/dL), AST (p = 0.0209, cut-off = 44.15 U/L), INR (p = 0.0055, cut-off = 1.075), WBC (p = 0.0223, cut-off = 11.68 × 109/L) and pH (p = 0.0055, cut-off = 7.455). A survival analysis demonstrated significantly higher in-hospital mortality rates of patients with values of IL-6, IL-6/Ly, AST, INR, and pH exceeding previously mentioned thresholds. In our study, IL-6 and IL-6/Ly have a predictive value for the mortality of critically-ill patients diagnosed with COVID-19. The integration of these parameters with AST, INR and pH could contribute to a prognostic score for the risk stratification of critical patients, reducing healthcare costs and facilitating clinical decision-making.

Prolonged ICU Stay in Severe and Critically-Ill COVID-19 Patients Who Received Convalescent Plasma Therapy.

Background Convalescent plasma administration in severe and critically-ill COVID-19 patients have been proven to not provide improvement in patients' outcome, yet it is still widely used in countries with limited resources due to its high availability and safety. This study aims to investigate its effects on ICU mortality, ICU length of stay (LoS), and improvement of oxygen support requirements. Methods Data of all severe and critically-ill patients in our COVID-19 ICU was collected retrospectively between May and November 2020. We dichotomized the variables and compared outcome data of 48 patients, who received convalescent plasma to 131 patients, receiving standard of care. Data were analyzed using multiple logistic regression to make prediction models of mortality, length of stay, and oxygen support device requirement. Result Overall mortality rate in our COVID-19 ICU was 55.3%, with a median overall length of stay of 8 (4–11) days. Less patients that received convalescent plasma presented with the need for mechanical ventilation on ICU admission (p < 0.001), but with comparable PaO2 to FiO2 (P/F) ratio (p=0.95). Factors that confounded mortality were obesity (aOR = 14.1; 95% CI (1.25, 166.7); p=0.032), mechanical ventilation (aOR = 333; 95% CI (4.5,1,000); p < 0.001), higher neutrophil-to-lymphocyte ratio (NLR) (aOR = 7.32; 95% CI (1.82, 29.4); p=0.005), and lower P/F ratio (aOR = 7.70; 95% CI (2.04, 29.4); p=0.003). ICU LoS was longer in patients, who had prior history of hypertension (aOR = 2.14; 95% CI (1.05, 4.35); p=0.036) and received convalescent plasma (aOR = 3.88; 95% CI (1.77, 8.05); p < 0.001). Deceased patients, who received convalescent plasma, stayed longer in the ICU with a mean length of stay of 12.87 ± 5.7 days versus 8.13 ± 4.8 days with a significant difference (U = 434; p < 0.000). The chance of improved oxygen support requirements was lower in obese patients (aOR = 9.18; 95%CI (2.0, 42.1); p < 0.004), mechanically ventilated patients (aOR = 13.15; 95% CI (3.75, 46.09); p < 0.001), patients with higher NLR (aOR = 2.5; 95% CI (1.07, 5.85); p=0.034), and lower P/F ratio (aOR = 2.76; 95% CI (1.1, 6.91); p=0.031). Conclusion The length of stay of patients in the convalescent plasma group was significantly longer than the control group. There was no effect of convalescent plasma in ICU mortality and no improvement was observed in terms of oxygen support requirements.