Hypoxia In Patients Research Articles

Epidemiological, demographic and clinical profile of traumatic brain injury patients

Context: Traumatic brain injury is a major public health problem worldwide with increasing incidence and severity in developing countries. In India, it becomes a huge burden on society with a lack of proper preventive measures, public awareness, traffic sense and pre-hospital care. Therefore we studied the epidemiological profile and factors predicting outcome. Aims: To study the epidemiological, demographic profile of TBI patients to help to improve the healthcare facilities. Setting and design: It is an observational prospective study. Methods and materials: Overall 2134 patients with TBI were enrolled. The data was collected according to the predesigned proforma. The demographic, epidemiological, clinical variables were analysed to determine the current trends and outcomes. Result: The male: female ratio was 2.21:1 with most cases from the age group of 21-30 years ( 29.42%). RTA was the mode of injury in 64.48% of cases. Overall mortality was 10.91%. Overall descriptive data was suggestive of poor outcome in old patients, referred cases, acute SDH and brainstem lesions, hypoxic and hypotensive patients, associated injuries, pre-existing disease and with higher Rotterdam and ISS scores. Conclusion: The outcome is dependent on factors like geographical, demographic, pre-hospital, and patient-related. With knowledge about the causes, patterns, and distribution the prognosis of TBI patients can be improved.

Differential Redox State and Iron Regulation in Chronic Obstructive Pulmonary Disease, Acute Respiratory Distress Syndrome and Coronavirus Disease 2019

In patients affected by Acute Respiratory Distress Syndrome (ARDS), Chronic Obstructive Pulmonary Disease (COPD) and Coronavirus Disease 2019 (COVID-19), unclear mechanisms negatively interfere with the hematopoietic response to hypoxia. Although stimulated by physiological hypoxia, pulmonary hypoxic patients usually develop anemia, which may ultimately complicate the outcome. To characterize this non-adaptive response, we dissected the interplay among the redox state, iron regulation, and inflammation in patients challenged by either acute (ARDS and COVID-19) or chronic (COPD) hypoxia. To this purpose, we evaluated a panel of redox state biomarkers that may integrate the routine iron metabolism assays to monitor the patients’ inflammatory and oxidative state. We measured redox and hematopoietic regulators in 20 ARDS patients, 20 ambulatory COPD patients, 9 COVID-19 ARDS-like patients, and 10 age-matched non-hypoxic healthy volunteers (controls). All the examined pathological conditions induced hypoxia, with ARDS and COVID-19 depressing the hematopoietic response without remarkable effects on erythropoietin. Free iron was higher than the controls in all patients, with higher levels of hepcidin and soluble transferrin receptor in ARDS and COVID-19. All markers of the redox state and antioxidant barrier were overexpressed in ARDS and COVID-19. However, glutathionyl hemoglobin, a candidate marker for the redox imbalance, was especially low in ARDS, despite depressed levels of glutathione being present in all patients. Although iron regulation was dysfunctional in all groups, the depressed antioxidant barrier in ARDS, and to a lesser extent in COVID-19, might induce greater inflammatory responses with consequent anemia.

Reversal of SARS-CoV2-Induced Hypoxia by Nebulized Sodium Ibuprofenate in a Compassionate Use Program.

IntroductionSodium ibuprofenate in hypertonic saline (NaIHS) administered directly to the lungs by nebulization and inhalation has antibacterial and anti-inflammatory effects, with the potential to deliver these benefits to hypoxic patients. We describe a compassionate use program that offered this therapy to hospitalized COVID-19 patients.MethodsNaIHS (50 mg ibuprofen, tid) was provided in addition to standard of care (SOC) to hospitalized COVID-19 patients until oxygen saturation levels of > 94% were achieved on ambient air. Patients wore a containment hood to diminish aerosolization. Outcome data from participating patients treated at multiple hospitals in Argentina between April 4 and October 31, 2020, are summarized. Results were compared with a retrospective contemporaneous control (CC) group of hospitalized COVID-19 patients with SOC alone during the same time frame from a subset of participating hospitals from Córdoba and Buenos Aires.ResultsThe evolution of 383 patients treated with SOC + NaIHS [56 on mechanical ventilation (MV) at baseline] and 195 CC (21 on MV at baseline) are summarized. At baseline, NaIHS-treated patients had basal oxygen saturation of 90.7 ± 0.2% (74.3% were on supplemental oxygen at baseline) and a basal respiratory rate of 22.7 ± 0.3 breath/min. In the CC group, basal oxygen saturation was 92.6 ± 0.4% (52.1% were on oxygen supplementation at baseline) and respiratory rate was 19.3 ± 0.3 breath/min. Despite greater pulmonary compromise at baseline in the NaIHS-treated group, the length of treatment (LOT) was 9.1 ± 0.2 gs with an average length of stay (ALOS) of 11.5 ± 0.3 days, in comparison with an ALOS of 13.3 ± 0.9 days in the CC group. In patients on MV who received NaIHS, the ALOS was lower than in the CC group. In both NaIHS-treated groups, a rapid reversal of deterioration in oxygenation and NEWS2 scores was observed acutely after initiation of NaIHS therapy. No serious adverse events were considered related to ibuprofen therapy. Mortality was lower in both NaIHS groups compared with CC groups.ConclusionsTreatment of COVID-19 pneumonitis with inhalational nebulized NaIHS was associated with rapid improvement in hypoxia and vital signs, with no serious adverse events attributed to therapy. Nebulized NaIHS s worthy of further study in randomized, placebo-controlled trials (ClinicalTrials.gov: NCT04382768).Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00527-2.

Awake Proning for Nonintubated Adult Hypoxic Patients with COVID-19: A Systematic Review of the Published Evidence.

ABSTRACTObjective: Awake proning is an intervention that is being advocated for COVID-19 patients and has been suggested to improve the oxygenation, thereby decreasing oxygen requirements. We performed this systematic review with the aim of appraising the latest published evidence on the clinical effectiveness of awake proning in COVID-19 patients.Data sources: PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar, and one trial registry were searched until September 23, 2020, for studies on the use of awake proning for nonintubated COVID-19 patients.Study selection: Published or in-press peer-reviewed randomized control trials, case-control trials, and prospective or retrospective cohort studies in English language only were sought, assessing the effectiveness of awake proning for nonintubated patients diagnosed with COVID-19.Data results: We included 21 published studies (19 single arm and 2 with comparison group). Twenty-three registered clinical trials were identified. No randomized clinical trial has been published so far.Conclusions: Awake proning is probably safe and effective in enhancing oxygenation in nonintubated COVID-19 patients; however, there is insufficient evidence. Further high-quality clinical trials are urgently needed to assess the effectiveness of awake proning on a variety of patient-centered outcomes.How to cite this article: Parashar S, Karthik AR, Gupta R, Malviya D. Awake Proning for Nonintubated Adult Hypoxic Patients with COVID-19: A Systematic Review of the Published Evidence. Indian J Crit Care Med 2021;25(8):906–916.

The relationship of tidal volume and driving pressure with mortality in hypoxic patients receiving mechanical ventilation.

To determine whether tidal volume/predicted body weight (TV/PBW) or driving pressure (DP) are associated with mortality in a heterogeneous population of hypoxic mechanically ventilated patients. A retrospective cohort study involving 18 intensive care units included consecutive patients ≥18 years old, receiving mechanical ventilation for ≥3 days, with a PaO2/FiO2 ratio ≤300 mmHg, whether or not they met full criteria for ARDS. The main outcome was hospital mortality. Multiple logistic regression (MLR) incorporated TV/PBW, DP, and potential confounders including age, APACHE IVa® predicted hospital mortality, respiratory system compliance (CRS), and PaO2/FiO2. Predetermined strata of TV/PBW were compared using MLR. Our cohort comprised 5,167 patients with mean age 61.9 years, APACHE IVa® score 79.3, PaO2/FiO2 166 mmHg and CRS 40.5 ml/cm H2O. Regression analysis revealed that patients receiving DP one standard deviation above the mean or higher (≥19 cmH20) had an adjusted odds ratio for mortality (ORmort) = 1.10 (95% CI: 1.06-1.13, p = 0.009). Regression analysis showed a U-shaped relationship between strata of TV/PBW and adjusted mortality. Using TV/PBW 4-6 ml/kg as the referent group, patients receiving >10 ml/kg had similar adjusted ORmort, but those receiving 6-7, 7-8 and 8-10 ml/kg had lower adjusted ORmort (95%CI) of 0.81 (0.65-1.00), 0.78 (0.63-0.97) and 0.80 0.67-1.01) respectively. The adjusted ORmort in patients receiving 4-6 ml/kg was 1.26 (95%CI: 1.04-1.52) compared to patients receiving 6-10 ml/kg. Driving pressures ≥19 cmH2O were associated with increased adjusted mortality. TV/PBW 4-6ml/kg were used in less than 15% of patients and associated with increased adjusted mortality compared to TV/PBW 6-10 ml/kg used in 82% of patients. Prospective clinical trials are needed to prove whether limiting DP or the use of TV/PBW 6-10 ml/kg versus 4-6 ml/kg benefits mortality.

Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure

Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.

Clinical value of electrical impedance tomography (EIT) in the management of patients with acute respiratory failure: a single centre experience

Objective. We will describe our clinical experience using electrical impedance tomography (EIT) in the management of mechanical ventilation in patients with acute respiratory failure and to determine to which extent EIT-guided positive end-expiratory pressure (PEEP) setting differed from clinically set values. Approach. We conducted a retrospective, observational cohort study performed in a hub centre for the treatment of acute respiratory failure and veno-venous extracorporeal membrane oxygenation (ECMO). Main results. Between January 2017 and December 2019, EIT was performed 54 times in 41 patients, not feasible only in one case because of signal instability. More than 50% was on veno-venous ECMO support. In 16 cases (30%), EIT was used for monitoring mechanical ventilation, i.e. to evaluate recruitability or sigh setting. In 37 cases (70%), EIT was used to set PEEP both with incremental (11 cases in nine patients) and decremental (26 cases, 18 patients) PEEP trial. Clinical PEEP before the decremental PEEP trial (PEEPPRE) was 14.1 ± 3.4 cmH2O and clinical PEEP set by clinicians after the PEEP trial (PEEPPOST) was 13.6 ± 3.1 (p = ns). EIT analyses demonstrated that more hypoxic patients were higher derecruited when compared to less hypoxic patients that were, on the contrary, more overdistended (p < 0.05). No acute effects of PEEP adjustment based on EIT on respiratory mechanics or regional EIT parameters modification were observed. Significance. The variability of EIT findings in our population confirmed the need to provide ventilation settings individually tailored and EIT was confirmed to be an optimal useful clinical bedside noninvasive tool to provide real-time monitoring of the PEEP effect and ventilation distribution.

Placement of finger oximeter on the ear: comparison with oxygen saturation values taken from the finger.

Pulse oximetry is widely used to assess oxygen saturation (SpO2) in order to guide patient care and monitor the response to treatment. However, inappropriate oximeter probe placement has been shown to affect the measured oximetry values in healthy and normoxic outpatients. This study evaluated how treatment decisions might be impacted by SpO2 values obtained using a finger probe placed on the pinna of the ear in a cohort of 46 patients receiving non-invasive ventilation compared with values obtained from a probe on the finger and the results of arterial blood gas (ABG) (SaO2) analysis. Bland-Altman analysis was performed to evaluate agreement between the methods. Finger probe saturation was not statistically different from SaO2, with a mean difference of -0.66% (P>0.05). Saturation from the ear was significantly different (-4.29%; P<0.001). Subgroup analysis in hypoxic patients (SaO2<90%) showed a significant difference between ABG SaO2, and finger and ear SpO2. The study provides evidence that placement of a finger probe on the ear is unsafe clinical practice, potentially leading to patient mismanagement.

Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department.

BackgroundAwake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation.MethodsWe conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation.ResultsWe included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82).ConclusionsAmong COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.

Contextualising evidence-based recommendations for the second wave of the COVID-19 pandemic in India

Contextualising evidence-based recommendations for the second wave of the COVID-19 pandemic in India

Supplemental oxygen in Queen Elizabeth Central Hospital Malawi: a prospective cohort study of patients admitted to medical wards

Background: Oxygen is designated an essential drug by the World Health Organisation, and reduces mortality in hypoxic patients. In low-resource settings the provision of oxygen seldom meets its demand. This study explores predictors and observed time-course of hypoxaemia in order to help inform needs assessments for oxygen in hospitals in low- and middle-income countries. Methods: A prospective cohort study of adults with hypoxaemia admitted to medical wards of a teaching hospital in Malawi between February and March 2020. Vital signs and oxygen therapy were recorded daily. We analysed outcomes (death, discharge from hospital or ongoing inpatient care at 14 days after admission) using Kaplan-Meier and Cox regression time-to-event analysis. Results: 33 patients were recruited with median age 45 years (IQR 33-61). 13 (39%) were female. Median pre-treatment oxygen saturations were 84% (IQR 76-87%). Oxygen delivery devices were often shared with other patients (n=10, 33%) and the flow rate was often unknown (n=14, 47%), mostly because of broken equipment (n=8, 57%). Median duration of oxygen therapy was 3 days (IQR 1-7). Death occurred in 16 (49%). Hazard ratios for short oxygen therapy were reduced in patients who had a chest radiograph performed (HR 0.08, 95% CI 0.02–0.30), in ex-smokers (HR 0.01, 95% CI 0.00-0.22) and in never smokers (HR 0.03, 95% CI 0.00 – 0.78). Conclusions: Delivering oxygen therapy in lower-middle income countries is challenging; broken equipment and shared delivery devices prevented titration of flow rates. Patients were relatively young and at a high risk of death. Patients with a chest radiograph received oxygen for longer than those without. This hypothesis generating study can be used to build a more comprehensive understanding of oxygen supply need at the hospital level.

What is the real risk of COVID transmission during oxygenation?

Recently, I was called up to the intensive care unit (ICU) to intubate a hypoxic patient with coronavirus disease (COVID). Walking into the patient's room, I noted lots of people in personal protective equipment (PPE), most of whom I knew to be fully vaccinated. The patient was, indeed, hypoxic on high flow nasal cannula (HFNC). Could we put him on bi-level positive airway pressure (BiPAP) for better pre-oxygenation before rapid sequence intubation (RSI)? Nope. Hospital policy prevented the use of BiPAP (but not HFNC) on COVID patients. So, we had to accept sub-optimal pre-oxygenation because of a policy understandably designed to protect staff but that was not in the patient's best interest. Experiences like this really beg several important clinical questions: what is the risk associated with different approaches to oxygenation and how well does the PPE we wear work? Fortunately, 2 recent papers in JACEP Open address these questions. They give us additional data to help better understand our actual risk when treating patients with COVID. Emily Pearce and her colleagues at the University of New Mexico report on an experiment in which they estimate the exposure from different approaches to oxygen administration (aerosol generation with various approaches to oxygenation in healthy volunteers in the emergency department [ED]).1 They had 8 healthy volunteers, including the researchers themselves, breath normally in a positive pressure ED exam room while receiving oxygen from 3 devices: HFNC, non-rebreather mask (NRB), and continuous positive airway pressure (CPAP). The HFNC was tested at 15, 30, and 60 L/min flow. They used a spectrometer to measure both large and small droplet aerosols. Finally, they placed a procedural mask over the HFNC and NRB to evaluate the impact of the common approach of mask-over-oxygen device. Ultimately, they demonstrated that higher flow oxygen led to higher aerosol generation, and CPAP was actually associated with lower aerosol generation. Masks were helpful for reduction of small particulates but not with larger ones, at least not statistically with only 8 subjects. These findings help us understand that CPAP is actually relatively low risk, certainly less than HFNC, and placing a mask over the devices may help lower exposure risk. So, we now have more information about aerosol generation, but what about the extent to which PPE protects us against infection? Dr. Darren Braude and colleagues looked at this with a pragmatic approach. In their paper “Safety of air medical transport of patients with COVID-19 by personnel using routine personal protective equipment” they used an 8-base regional air medical consortium to describe the rate of infection among transport personnel after flying patients with COVID.2 They included only patients with known or suspected COVID and then describe oxygen therapy. Most patients were receiving some form of oxygen, but only 30% were intubated. Among 108 transport staff, the overall rate of COVID infection was under 2%. This is consisted with other descriptions of PPE effectiveness among EMS personnel.3 Taken together, these 2 papers provide additional information we can use to guide our approach to caring for COVID patients with respiratory distress while still protecting ourselves and our colleagues. It appears that CPAP is a relatively low risk approach to respiratory support, certainly it looks like a lower risk than HFNC or NRB. In addition, we have additional reassurance that the PPE we are using provides substantial protection against infection.

Nocturnal oximetry in the diagnosis of obstructive sleep apnea syndrome in potentially hypoxic patients due to neuromuscular diseases

IntroductionPolysomnography is the recommended method for the diagnosis of obstructive sleep apnea (OSA); however, it is expensive, uncomfortable, and inaccessible. Alternative diagnostic methods are necessary, and Nocturnal Oximetry (NO) has proven to be reliable. Nevertheless, there have been doubts about its accuracy in patients with a history of hypoxia. Hence, the objective of this study was to evaluate the performance of NO in patients with neuromuscular diseases (NMD). MethodThis was a cross-sectional study in patients with NMD suspected of having OSA. We performed a statistical analysis using Spearman's correlation coefficients (SCCs). We used the value of the area under the ROC curve (AUCROC), just as we calculated the sensitivities (Sens) and specificities (Spec) for the chosen variables. ResultsThe sample comprised 41 patients; 51.2% with muscular dystrophies and 48.8% with motor neuron diseases, with a predominance of men (63.4%). Median age was 42 (19.7–55) years, body mass index (BMI) was 27.9 (23.8–32) kg/m2, forced vital capacity was 67% (54%–76.5%), and maximum inspiratory pressure was-60 cmH2O (−87.5 to −50). The prevalence of OSA was 75.7%. We analyzed and selected the best four oximetric variables with the following performance in identifying the apnea/hypopnea index >5/h, ODI3/2, cutoff>5/h, AUCROC 0.919, Sens 82.3%, Spec 91.7%; ODI3/5, cutoff>11.2/h, AUCROC 0.904, Sens 82.3%, Spec 87.5%; ODI4/5, cutoff>6.02, AUCROC 0.839, Sens 70.6%, Spec 91.6%, and ODI5/5, cutoff>0.87/h, AUCROC 0.870, Sens 94.1%, and Spec 70.8%. ConclusionNO can be used as a diagnostic tool for OSA, even in patients with neuromuscular diseases and potentially hypoxic diseases.

Assessment of Hypoxic Tissue Fraction and Prediction of Survival in Cervical Carcinoma by Dynamic Contrast-Enhanced MRI.

Tumor hypoxia is a major cause of treatment resistance and poor survival in locally-advanced cervical carcinoma (LACC). It has been suggested that K trans and v e maps derived by dynamic contrast-enhanced magnetic resonance imaging can provide information on the oxygen supply and oxygen consumption of tumors, but it is not clear whether and how these maps can be combined to identify tumor hypoxia. The aim of the current study was to find the optimal strategy for calculating hypoxic fraction and predicting survival from K trans and v e maps in cervical carcinoma. K trans and v e maps of 98 tumors of four patient-derived xenograft models of cervical carcinoma as well as 80 patients with LACC were investigated. Hypoxic fraction calculated by using K trans maps correlated strongly (P < 0.0001) to hypoxic fraction assessed with immunohistochemistry using pimonidazole as a hypoxia marker and was associated with disease-free and overall survival in LACC patients. Maps of v e did not provide information on hypoxic fraction and patient outcome, and combinations of K trans and v e were not superior to K trans alone for calculating hypoxic fraction. These observations imply that K trans maps reflect oxygen supply and may be used to identify hypoxia and predict outcome in cervical carcinoma, whereas v e is a poor parameter of oxygen consumption and does not provide information on tumor oxygenation status.

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.

Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose. This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded. Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05). The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

Uncertainty Estimation of Biomedical Oximeters: Proposal for an Experimental Test-Bench

Abstract Paramagnetic oximeters are frequently used in clinical practice to measure and titrate the fraction of inspired oxygen (FiO2) administered to a hypoxic patient. Newborns are prone to several diseases leading to hypoxia but also to oxidative damage, therefore a precise measurement of administered oxygen is of paramount importance. In this study, we evaluated and compared the performance of four commonly used gas analyzers at a Neonatal Unit. A paramagnetic gas analyzer was considered the standard for reference. Gas mixing performed by blenders was also evaluated. We first assessed the stability and composition of O2 and medical air. A settling time study was conducted to estimate a steady-state. Results show how tested blenders underestimated the real measures when FiO2 was &amp;lt;50% and overestimated them when FiO2 ≥50%. In all the tested oximeters the FiO2 was underestimated by 1.18%, but the overall agreement with the gold standard was very good.

Outcome of hypoxic COVID-19 patients treated with dexamethasone-based treatment protocol in a designated COVID center

Background: Managing severe COVID-19 is a difficult situation in resource limited settings. With the inclusion of steroid based treatment guidelines, this can be made feasible in such settings.Methods: This was a hospital record based retrospective cohort study done at a designated COVID hospital. Data of all patients who were 18 years and above, hypoxic and required initiation of dexamethasone-based protocol were analysed. Hypoxia was defined as a finger pulse oximeter value less than 95%. The primary outcome was the percentage of patients who required a referral to the higher centre or died in hospital.Results: 109 patients with hypoxia with a mean age of 55.2±13.5 years and a median symptom duration of 4 days were analyzed. Seventy-eight (71%) patients were male and 81 (74.3%) had other comorbid illnesses. Of the 109 patients, 5 (4.6%) patients died in hospital, 22 (20.2%) patients were referred to higher center for further management and 82 (75.2%) patients could be treated and discharged. Those who were referred or died had lower SpO2, reduced time to initiation of protocol, more severe pneumonia, lower absolute lymphocyte count and lower platelet count. New onset diabetes was detected in 20 (18.3%) patients.Conclusions: Detection of hypoxia early and initiation of dexamethasone-based treatment protocol with timely referral of worsening patients can help to improve outcome in COVID-19 patients. This model can be effectively constructed in limited resource settings and can be of much help to the struggling health infrastructure.

The increase of the pulmonary blood flow inhigh-risk hypoxic patients with a bidirectional Glenn anastomosis.

An additional shunt in single ventricle patients with Glenn anastomosis may increase pulmonary flow at the expense of ventricle volume overloading. The performance of the modification depends on pulmonary resistance, indicating better results in favorable hemodynamic conditions. The study aims at analyzing the influence of precisely adjusted pulsatile shunt in borderline high-risk Glenn patients on early and late results. The study involved 99 patients (including 21 children) with the bidirectional Glenn and accessory pulsatile shunt (BDGS group), and 78 patients with the classic bidirectional Glenn anastomosis (BDG group). There was 1 death in the BDGS group and 4 deaths in the BDG group. No difference in mortality (P = 0.71) was found. The Fontan completion was achieved in 69 (88.5%) children in the BDG group and 18 (85.7%) patients in the BDGS group, without fatalities. No intergroup differences in postoperative pulmonary artery pressure (P = 0.10), ventilation time (P = 0.12), the McGoon ratio (P = 0.9), or chylothorax frequency (P = 0.14) were observed. Intensive care unit (P = 0.28) and hospitalization (P = 0.05) times were comparable. Echocardiography revealed no significant differences in the ventricle and atrioventricular valve function between groups. In the BDGS group, higher blood oxygen saturation (P = 0.03) and increase of the McGoon index (P = 0.002) were noted. Bidirectional Glenn anastomosis with precisely adjusted accessory pulmonary blood flow provides stable hemodynamics and adequate oxygen saturation in borderline, profoundly hypoxic patients. An advantageous pulmonary artery development before Fontan completion was observed.

Awake Self-Prone Positioning: Implementation During the COVID-19 Pandemic.

Prone positioning is a well-known beneficial intervention for patients with acute respiratory distress syndrome. As the COVID-19 pandemic emerged, hospitals rapidly adapted prone positioning for acutely ill patients into a new process: awake self-prone positioning. Could a large health care system safely and rapidly implement awake self-prone positioning in COVID-19 units to prevent respiratory failure from progressing among a surge of inpatients? The team extensively reviewed the literature. Using evidence from 22 case reports, peer-reviewed standards, and studies, they developed an awake self-prone positioning guideline. The guideline was implemented in April 2020 in critical care and COVID-19 units. Multimodal education included a concise guideline and real-time support from intensive care unit nurses, clinical nurse specialists, and nursing professional development specialists. Awake self-prone positioning was a new procedure, and relevant data were obtained from the electronic medical record. From March 18 to August 5, 2020, 1000 COVID-19-related admissions occurred; 272 patients had a high-flow nasal cannula, 111 (41%) of whom had documentation of awake self-prone positioning. This guideline is now an established part of COVID-19 care and has been integrated into practice in units caring for patients with the disease. Nurses adapted quickly to using awake self-prone positioning as a plan of care for hypoxic patients. This practice may help hospitals adjust care delivery for these patients and effectively maintain patients in non-intensive care units.

Methylprednisolone or dexamethasone, which one is superior corticosteroid in the treatment of hospitalized COVID-19 patients: a triple-blinded randomized controlled trial

BackgroundAlthough almost a year has passed since the Coronavirus disease 2019 (COVID-19) outbreak and promising reports of vaccines have been presented, we still have a long way until these measures are available for all. Furthermore, the most appropriate corticosteroid and dose in the treatment of COVID-19 have remained uncertain. We conducted a study to assess the effectiveness of methylprednisolone treatment versus dexamethasone for hospitalized COVID-19 patients.MethodsIn this prospective triple-blinded randomized controlled trial, we enrolled 86 hospitalized COVID-19 patients from August to November 2020, in Shiraz, Iran. The patients were randomly allocated into two groups to receive either methylprednisolone (2 mg/kg/day; intervention group) or dexamethasone (6 mg/day; control group). Data were assessed based on a 9-point WHO ordinal scale extending from uninfected (point 0) to death (point 8).ResultsThere were no significant differences between the groups on admission. However, the intervention group demonstrated significantly better clinical status compared to the control group at day 5 (4.02 vs. 5.21, p = 0.002) and day 10 (2.90 vs. 4.71, p = 0.001) of admission. There was also a significant difference in the overall mean score between the intervention group and the control group, (3.909 vs. 4.873 respectively, p = 0.004). The mean length of hospital stay was 7.43 ± 3.64 and 10.52 ± 5.47 days in the intervention and control groups, respectively (p = 0.015). The need for a ventilator was significantly lower in the intervention group than in the control group (18.2% vs 38.1% p = 0.040).ConclusionIn hospitalized hypoxic COVID-19 patients, methylprednisolone demonstrated better results compared to dexamethasone.Trial registrationThe trial was registered with IRCT.IR (08/04/2020-No. IRCT20200204046369N1).