ICU Complications Research Articles

Complications in patients with severe COVID-19 infection who required admission to an intensive care unit in a fourth-level hospital in Bogotá, Colombia

Objective: To analyze the complications experienced by patients admitted to the ICU with severe COVID-19 at a fourth-level hospital in Bogotá, Colombia. Materials and Methods: This retrospective, descriptive, cross-sectional study included 181 patients aged over 18 years with severe COVID-19 admitted to the ICU at Fundación Cardioinfantil from August 2020 to May 2021. Results: Infections were the most prevalent complication, occurring in 72.9% of patients, with pulmonary superinfections and tracheitis being the most common. Neuropathy was observed in 18.7% of patients. Swallowing disorders were noted in 74% of patients, with 52.5% continuing to experience swallowing difficulties at discharge, leading to gastrostomy in 4.9%. Acute kidney injury was present in 26.5% of patients; 7.1% required de novo renal replacement therapy, and 2.8% needed renal replacement therapy at discharge. Myocardial injury was documented in 13.8% of patients. Discussion: The study highlights the extensive range of complications affecting post-COVID-19 patients, particularly those with severe infections. Polyneuropathy and myopathy are reported in 25-45% of critically ill patients, whereas our study documented neuropathy in 18.7%. Swallowing disorders, occurring in 74% of patients, led to a gastrostomy rate of 4.9%, slightly above the literature range of 1.9%-4.8%. Tracheostomy, used as an alternative to reduce sedation and mechanical ventilation time, was performed in 21.5% of patients, resulting in reduced ICU and ward stays. Conclusions: The most frequent ICU complications were healthcare-associated infections, underscoring the importance of early detection and preventive strategies. Neuromuscular sequelae, such as neuropathy, are significant factors affecting patient outcomes, highlighting the need for targeted rehabilitation methods.

Assessing glycemic variability in critically ill patients: A prospective cohort study comparing insulin infusion therapy with insulin sliding scale

Glycemic variability (GV) has been associated with an increased mortality rate among critically ill patients. The clinical outcomes of having less GV even with slight hyperglycemia are better than those having tight glycemic control but higher GV. Insulin infusion remains the preferred method to control stress hyperglycemia in critically ill patients. However, its impacts on GV and clinical outcomes in critically ill patients still need further investigation. This study intended to evaluate the impact of insulin infusion therapy (IIT) compared to the insulin sliding scale (ISS) on the extent of GV and explore its impact on the clinical outcomes for critically ill patients. A prospective, single-center observational cohort study was conducted at a tertiary academic hospital in Saudi Arabia between March 2021 and November 2021. The study included adult patients admitted to ICUs who received insulin for stress hyperglycemia management. Patients were categorized into two groups based on the regimen of insulin therapy during ICU stay (IIT versus ISS). The primary outcome was the GV between the two groups. Secondary outcomes were ICU mortality, the incidence of hypoglycemia, and ICU length of stay (LOS). A total of 381 patients were screened; out of them, eighty patients met the eligibility criteria. The distribution of patients having diabetes and a history of insulin use was similar between the two groups. The GV was lower in the IIT group compared to the ISS group using CONGA (− 0.65, 95% CI [− 1.16, − 0.14], p-value = 0.01). Compared with ISS, patients who received IIT had a lower incidence of hypoglycemia that required correction (6.8% vs 2.77%; p-value = 0.38). In contrast, there were no significant differences in ICU LOS and ICU mortality between the two groups. Our study demonstrated that the IIT is associated with decreased GV significantly in critically ill patients without increasing the incidence of severe hypoglycemia. There is no survival benefit with the use of the IIT. Further studies with larger sample size are required to confirm our findings and elaborate on IIT's potential effect in reducing ICU complications in critically ill patients.

Abstract WP153: Factors Affecting Length of ICU Stay After Endovascular Thrombectomy for Acute Large Vessel Ischemic Stroke

Introduction: The advent of endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) ischemic stroke has reduced the overall ICU length of stay (LoS), especially for patients undergoing successful reperfusion. Prolonged ICU LoS is reported to be associated with worse clinical outcomes, but factors associated with prolonged LoS after MT are not established. Methods: A retrospective analysis of 499 patients undergoing EVT at a single large comprehensive stroke center from January 2015 to May 2020 was performed. Demographics, procedure variables, ICU LoS, ICU complications, and modified Rankin scale at discharge were collected. Multiple regression was used to identify independent variables affecting the ICU LoS. Additional analysis using t-test assuming unequal variances was performed for select variables. Results: The median age was 72 [61-82], 254 (51%) male & median NIHSS was 16 [10-20]. The average door-to-puncture time was 104 ±28 mins and the average procedure time 43.9 ±28.7. General anesthesia (GA) was administered in 257 (51%) patients. Successful reperfusion (TICI 2c-3) was achieved in 334 (67%) patients. Median ICU LoS was 3 days [1-5]. Patients with mRS 0-2 at discharge (33%) had shorter ICU LoS (2.8 vs 5.7, P<0.001). ASPECTS < 7 (6.9 vs 4.6, P=0.03), use of GA (6.2 vs 3.3 days, P<0.001) and ICU complications such as pulmonary embolism (PE) and pneumonia (10 vs 4 days; p <0.001) significantly increased the ICU LoS. Successful reperfusion significantly reduced ICU LoS (4.2 vs 5.8 days, p=0.015). After adjusting for age, sex, baseline NIHSS and ASPECTS, both the procedure time (b= 0.03, P=0.02) and final TICI score (b= -0.76, P=0.001) were independently associated with prolonged ICU LoS (R2=0.1, F=4, P<0.001). Conclusion: Pre-procedural factors such as poor ASPECTS (< 7), procedural factors such as the use of GA, prolonged procedure time, and TICI 0-2b reperfusion, and ICU complications such as pneumonia and PE are associated with prolonged ICU LoS.

Abstract 18832: Early Leadless Pacemaker Implantation in a Case of Severe Cervical Spinal Cord Injury

Introduction: Bradycardia is a frequent cause of morbidity and mortality in spinal cord injury (SCI) patients and optimal timing of permanent pacemaker implant is unclear. Case Summary: A 67-year-old female with no cardiac history was admitted for fall of uncertain etiology complicated by severe cervical SCI and neurogenic shock. Despite emergent surgical decompression, the injury resulted in quadriplegia. Post-operatively, bradycardic arrest occurred requiring resuscitation and dependence on dopamine infusion. Rhythm strip from showed p-p slowing followed by high grade atrioventricular block with multiple blocked p waves. A decision was made for early intervention with implantation of a Micra leadless pacemaker (LPM) (Medtronic, Minneapolis, MN) for both hemodynamically significant bradycardia and backup to prevent bradycardic arrest. A LPM was successfully implanted without complication on hospital day 8. The pacemaker was set to VVI 60. Post operatively, the patient required intermittent pacing and tolerated dopamine weaning. Discussion: Bradycardia in SCI patients, especially those with high cervical and complete SCI, occurs due to unopposed parasympathetic activity, resulting in baseline sinus bradycardia. Even more concerning is the risk for sudden and unpredictable sinus arrest and/or AV block, which is a leading cause of mortality in the first year after SCI. While initial management of bradyarrhythmia in SCI patients may respond to pharmacologic intervention, temporary and/or permanent pacing may be indicated. Acute SCI patients may not be ideal candidates for traditional pacemakers since ICU and infectious complications are common in this cohort, but LPMs have extremely low risk of implant site and infectious complications and can be utilized earlier in the hospital course. Our case showcases this strategy of early leadless pacemaker implantation. Further study is needed to better evaluate the safety and efficacy of this strategy.

Impact of frailty on hiatal hernia repair: a nationwide analysis of in-hospital clinical and healthcare utilization outcomes.

Previous studies recommend a watch-and-wait approach to paraesophageal hernia (PEH) repair due to an increased risk for mortality. While contemporary studies suggest that elective surgery is safe and effective, many patients presenting with PEH are elderly. Therefore, we assessed the impact of frailty on in-hospital outcomes and healthcare utilization among patients receiving PEH repair. This retrospective population-based cohort study assessed patients from the National Inpatient Sample database who received PEH repair between October 2015 to December 2019. Demographic and perioperative data were gathered, and frailty was measured using the 11-item modified frailty index. The outcomes measured were in-hospital mortality, complications, discharge disposition, and healthcare utilization. Overall, 10,716 patients receiving PEH repair were identified, including 1442 frail patients. Frail patients were less often female and were more often in the lowest income quartile compared to robust patients. Frail patients were at greater odds for in-hospital mortality [odds ratio (OR) 2.83 (95% CI 1.65-4.83); P < 0.001], postoperative ICU admissions [OR 2.07 (95% CI 1.55-2.78); P < 0.001], any complications [OR 2.18 (95% CI 1.55-2.78); P < 0.001], hospital length of stay [mean difference (MD) 1.75days (95% CI 1.30-2.210; P < 0.001], and total admission costs [MD $5631.65 (95% CI $3300.06-$7.963.24); P < 0.001] relative to their robust patients. While PEH repair in elderly patients is safe and effective, frail patients have an increased rate of in-hospital mortality, postoperative ICU admissions, complications, and total admission costs. Clinicians should consider patient frailty when identifying the most appropriate surgical candidates for PEH repair.

Incidence of Airway Complications in ICU.

To show the incidence of airway complications in ICU. Endotracheal intubation is an essential skill performed by multiple medical specialists to secure a patient's airway as well as provide oxygenation and ventilation through the oral route or nose. The goal of endotracheal intubation in the emergency setting is to secure the patient's airway and obtain first-pass success. There are many indications for endotracheal intubation, including poor respiratory drive, questionable airway patency, hypoxia, and Hypercapnia. These indications are assessed by evaluating the patient's mental status, conditions that may compromise the airway, level of consciousness, respiratory rate, respiratory acidosis, and level of oxygenation. In the setting of trauma, a Glasgow Coma Scale of 8 or less is generally an indication for intubation. There are many different complications of intubation as hoarseness of voice, dental injuries, arytenoid dislocation, laryngeal stenosis, tracheal stenosis and tracheomalacia. . 150 patients who were sat in the ICU that developed certain complications. 86 patients (57.3%) were sitting in the ICU develoed certain complications. Liver diseases were the main cause of ICU admission 34 (22.7%) patients then shock 32 (21.3%) patients. Blockage of endotracheal tube was the main ICU complications 18 (12%) patients then sinusitis 16 (10.7%) patients. Endotracheal intubation is a lifesaving procedure and its complications are significant problems in ICUs. A successful procedure of intubation avoids complications. Skilled endotracheal intubation in the ICU decreases the complications.

Adverse outcomes and maternal complications in pregnant women with severe-critical COVID-19: atertiary center experience.

This study aimed to present perinatal outcomes, clinical challenges, and basic ICU management in pregnant women with severe-critical COVID-19 at our tertiary referral center. In this prospective cohort study, patients were divided into two groups, whether they survived or not. Clinical characteristics, obstetric and neonatal outcomes, initial laboratory test results and radiologic imaging findings, arterial blood gas parameters at ICU admission, and ICU complications and interventions were compared between groups. 157 of the patients survived, and 34 of the patients died. Asthma was the leading health problem among the non-survivors. Fifty-eight patients were intubated, and 24 of them were weaned off and discharged healthfully. Of the10 patients who underwent ECMO, only 1 survived (p<0.001). Preterm labor was the most common pregnancy complication. Maternal deterioration was the most common indication for a cesarean section. Higher neutrophil-to-lymphocyte-ratio (NLR) values, the need for prone positioning, and the occurrence of an ICU complication were important parameters that influenced maternal mortality (p<0.05). Overweight pregnant women and pregnant women with comorbidities, especially asthma, may have a higher risk of mortality related to COVID-19. A worsening maternal health condition can lead to increased rates of cesarean delivery and iatrogenic prematurity.

Evaluation of critical care burden following traumatic injury from two randomized controlled trials

Trauma resuscitation practices have continued to improve with new advances targeting prehospital interventions. The critical care burden associated with severely injured patients at risk of hemorrhage has been poorly characterized. We aim to describe the individual and additive effects of multiorgan failure (MOF) and nosocomial infection (NI) on delayed mortality and resource utilization. A secondary analysis of harmonized data from two large prehospital randomized controlled trials (Prehospital Air Medical Plasma (PAMPer) Trial and Study of Tranexamic Acid during Air and Ground Medical Prehospital Transport (STAAMP) Trial) was conducted. Only those patients who survived beyond the first 24 hours post-injury and spent at least one day in the ICU were included. Patients were stratified by development of MOF only, NI only, both, or neither and diagnosis of early (≤ 3 days) versus late MOF (> 3 days). Risk factors of NI and MOF, time course of these ICU complications, associated mortality, and hospital resource utilization were evaluated. Of the 869 patients who were enrolled in PAMPer and STAAMP and who met study criteria, 27.4% developed MOF only (n = 238), 10.9% developed NI only (n = 95), and 15.3% were diagnosed with both MOF and NI (n = 133). Patients developing NI and/or MOF compared to those who had an uncomplicated ICU course had greater injury severity, lower GCS, and greater shock indexes. Early MOF occurred in isolation, while late MOF more often followed NI. MOF was associated with 65% higher independent risk of 30-day mortality when adjusting for cofounders (OR 1.65; 95% CI 1.04–2.6; p = 0.03), however NI did not significantly affect odds of mortality. NI was individually associated with longer mechanical ventilation, ICU stay, hospital stay, and rehabilitation requirements, and the addition of MOF further increased the burden of inpatient and post-discharge care. MOF and NI remain common complications for those who survive traumatic injury. MOF is a robust independent predictor of mortality following injury in this cohort, and NI is associated with higher resource utilization. Timing of these ICU complications may reveal differences in pathophysiology and offer targets for continued advancements in treatment.

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study.

Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality. This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables. Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery. Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

1284: OUTCOMES FROM THE GIFT OF LIFE INTERNATIONAL SURGERY REGISTRY

Introduction: Of the 1.3 million children born with congenital heart disease annually, over 90% do not have access to cardiac care. Since 2020, Gift of Life International (GOLI) has collaborated with CEDIMAT Hospital in the Dominican Republic to perform pediatric cardiac surgery. With limited access to care and delayed surgical repair, this population is data rich in epidemiology, natural history, and clinical management strategies. There is limited research evaluating the outcomes of pediatric cardiac surgery in this middle-income country. Prior studies have raised concerns of limited published data and the need for an international database with better accountability and communication between charities being imperative for patient safety. Since 2021, GOLI has been collecting data for internal quality review. We hope this study will serve as a beacon for charitable organizations to provide quality cardiac surgery to children with limited access. Methods: Combined retrospective and prospective observational analysis of the GOLI Surgical Registry was performed. The registry was developed by GOLI team members, using definitions shared by the PC4 and STS databases for generalizability. All patients who underwent cardiac surgery with the GOLI team at CEDIMAT Hospital since March 2021 to date were included. Results: 55 subjects were identified. They were predominantly Hispanic females (55%) with a mean age at diagnosis of 1.9 years, and mean age at repair of 3.5 years. Primary diagnosis included ASD (9%), VSD (32%), PDA (11%), AV Canal (9%), Tetralogy of Fallot (16%), Single Ventricle (13%), and Coarctation (7%). Most common intraoperative complications were bleeding requiring transfusion (14%) and multiple CPB runs (7%). ICU complications included arrhythmias (17%), cardiac arrest (7%), LCOS (5%), and effusions requiring chest tube (5%). Mean duration of intubation was 17.8 hours with 2 reintubations. Mortality was 7.1%. Conclusions: Globally, there is limited access to cardiac care for children with CHD. While many organizations have tried to close this gap, there is little published data on the surgical outcomes in low/middle-income countries. This study demonstrates that emerging countries can safely perform cardiac surgery and track quality metrics in children with congenital heart disease.

Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality

BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery “step-up” approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the “step-up” approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).ConclusionSPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a “step-up” approach. Larger, prospective studies to compare indications and outcomes for “step up” versus open SPN are warranted.

Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score

PurposeTo develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments. MethodsWe analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009–5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration. ResultsThe MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161). ConclusionsCertain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.

Base Excess or Hyperlactatemia: Identifying the Superior Risk Factor for Increased Morbidity and Mortality in Cardiac Surgery

Objective: Cardiopulmonary bypass in cardiac surgery is often associated with metabolic changes. So, we conducted this study in order to find the supremacy between two risk factors base excess and hyperlactatemia in early prediction of morbidity and mortality in ICU after cardiac surgery. Material and Methods: Intraoperative data of total of 100 patients who had cardiac surgery was recorded. Intraoperative and postoperative data of base excess and lactate levels were recorded at 1st, 6th, 12th and 24th hour in ICU. Two perioperative groups for B.E(Group 1 B.E &lt; +/-2.5 mmol: Group 2 B.E &gt;+/- 2.5 mmol) and lactate (Group 1 Lactate &lt; 3 mmol: Group 2 Lactate&gt;mmol ) were created, Two post-operative groups for B.E(Group 1 B.E &lt; +/-5.0 mmol: Group 2 B.E &gt;+/- 5.0 mmol) and lactate( Group 1 Lactate &lt;5mmol: Group 2 Lactate&gt;5mmol )were created to find their correlation with early postoperative complications. Results: In our study ICU morbidity and mortality was more related to the lactate and base excess values in the early 24 hours. Progressive Hyperlactatemia and constant negative base excess values were both significantly associated with ICU complications. In the CPB period subgroup negative base excess was more superior in predicting ICU prognosis than Lactate. (P-value 0.001) similarly patients divided in subgroup BE &gt;+/- 5mmol/l had demonstrated superiority in making such prediction. Both CPB (0.013) and X.C (0.036) time were associated independently with ICU prognosis. .Longer ventilation times were also associated with bad ICU prognosis. Conclusion: Our study found negative base excess values in the early postoperative period to be superior in predicting ICU morbidity and mortality when studied at subgroup level both peri-operatively and postoperatively.

Clinical and microbiological impact of syndromic pneumonia molecular testing in intensive care: A before and after study

• Molecular testing for respiratory pathogens provided quicker diagnosis in intensive care. • No effect was seen on length of stay. • A non significant reduction in all antibiotic use, with a significant decrease in macrolide usage was seen. Pneumonia is one of the most common diagnoses in ICU and carries high mortality rates, as well as significant healthcare costs. Microbiological diagnosis allows targeting of antimicrobial therapy, which is known to improve patient outcomes. Standard culture of sputum samples has limitations due to time required to obtain results. BioFire offers a syndromic panel of multiplex PCR to identify pathogens rapidly. This study evaluated patient outcomes relating to ICU admission, antimicrobial management and complications. The study analysed admission details of radiologically confirmed pneumonia patients admitted to ICUs in Hull Hospitals between 1st August and 31st December 2018 and 2019, before and after the introduction of BioFire testing. The review identified 139 and 120 patients in 2018 and 2019 periods respectively, who had radiologically confirmed pneumonia and sputum samples sent to the laboratory. No statistical difference was seen in the length of ITU admission or the duration of mechanical ventilation between the cohorts as a whole. However, sub-group analysis revealed a decrease in length of stay of 5.6 days in hospital and ventilator acquired pneumonias. We observed a reduction in time to change of antibiotics of 1.81 days (p < 0.001) after introduction of BioFire. Furthermore, we identified discrepancies when using BioFire, allowing for identification of additional pathogens in 23 patients not seen on standard culture. Rapid molecular diagnostics allow for a timelier antimicrobial therapy adjustment as well as ensuring appropriate infection control measures. Syndromic PCR-based testing shows potential for improving patient outcomes in pneumonia patients requiring ICU admission.

Clinical impact on treatment and prognosis of advanced cardiac imaging with echocardiography in the acute setting of a COVID-19 infection

Abstract Background and objectives Despite myocardial injury being related to excess mortality in acute COVID-19 infection, its impact on imaging findings remains unclear. This study aimed to characterize transthoracic echocardiographic (TTE) findings in patients admitted with COVID-19 infections and its impact on management and prognosis. Methods A prospective observational cohort study was performed among 66 COVID-19 patients who were admitted to a tertiary center between March 1 and May 25, 2020 and underwent TTE. High-sensitivity troponin I (hs-cTnI) data, echocardiographic assessment of right and left ventricular (LV) functional parameters, strain, and myocardial work analysis were obtained. Results 2025 patients were admitted with COVID-19 and in 200 a complete TTE study was performed. Due to poor image quality, only 66 studies were included in the final analysis. The median age was 62 years (IQR, 55–70) and 59.1% of patients were males. The most common comorbidity was hypertension (47%), followed by smoking history (30.3%), atrial fibrillation (9.1%), and chronic obstructive pulmonary disease (7.9%). More than half of the patients (39, 59%) were admitted to the ICU, and half of them (33, 50%) required invasive mechanical ventilation. TTE was mainly indicated because of concerns for systemic conditions (50%) and evaluation of hemodynamic assessment (30%). Thirty-six patients (54.5%) had an abnormal TTE result and 57% had elevated hs-cTnI levels. The most common cardiac abnormality was LV diastolic dysfunction in 33% of the patients, followed by right ventricular dysfunction (12%) and LV dysfunction (6%) (Figure 1). LV GLS was reduced in 48.5% of the cases. Myocardial work performance indices were all reduced in patients with an abnormal TTE (GWI 30%, GCW 30%, GWW 40%, and GWE 40%), although differences were not significant (P&amp;gt;0.2 for all parameters). Patients with an abnormal TTE were older and presented a higher cardiovascular risk profile. There were no significant differences in the levels of D-dimer, NTproBNP, and hs-cTnI between patients with and without diastolic dysfunction, RV, or LV dysfunction (P&amp;gt;0.3 for all parameters). Using Spearman rank correlation, there was an inverse relationship between hs-cTnI and LV strain and myocardial work analysis. TTE results impacted clinical management in 60 patients, mainly de-escalation of medical treatment (Figure 2). Abnormal TTE results did not impact in-hospital outcomes. Conclusions Severe echocardiographic abnormalities are uncommon in hospitalized patients with COVID-19 infections, presenting mostly with subclinical myocardial changes, such as diastolic dysfunction, reduced LV GLS, and myocardial work indices, both associated with high-sensitivity troponin I elevation. An echocardiographic study should be limited to rule out long-term ICU complications or to evaluate hemodynamic instability. Although TTE was a valuable tool for guiding management, it had no significant impact on prognosis. Funding Acknowledgement Type of funding sources: None. Figure 1. Findings on TTE studies.Figure 2. Changes in management.

A GLOBAL REMOTE QUALITY IMPROVEMENT INITIATIVE: NEEDS ASSESSMENT FROM INTERPROFESSIONAL CRITICAL CARE PROVIDERS FROM BOSNIA AND HERZEGOVINA

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: The need for swift international collaboration alongside rapidly deployable remote medical knowledge transition and implementation programs has been highlighted during the ongoing COVID-19 pandemic. Virtual programs have emerged as cost-effective alternatives to in-person education to spread best practices to resource-limited locations and garner purposeful learner engagement. Understanding local practice needs is paramount to the development of an effective quality improvement initiative. This study aimed to gain insight into the interests, clinical challenges, and attitudes of a group of interprofessional critical care providers from Bosnia and Herzegovina in preparation for a longitudinal remote education and quality improvement program. METHODS: A novel learning needs assessment tool was implemented in a cohort of critical care professionals from four hospitals in Bosnia and Herzegovina. A sequential explanatory design was employed, and a mixed-method assessment was conducted in three phases. 1) Utilizing the Delphi method, twenty statements containing common critical care entrustable professional activities (EPAs) were developed by a board of intensivists and medical education specialists. 2) Local learners used Q Sort methodology to rank-order EPAs based on self-perceived learning priorities, with subsequent by-person factor analysis. 3) Learners were invited for focus-group interviews to gather details of the rationale behind their rankings. RESULTS: Forty nine out of 105 participants completed the rank-order survey (response rate 47%). Factor analysis categorized the participants into two main groups based on the typology of their opinions, 22 participants into factor 1 and 9 participants into factor 2. The highest-ranked EPAs amongst the two factors were “evaluation and management of the patients with shock, stabilization, and resuscitation of critically ill patients” and “evaluation and management of ARDS,” respectively. Statements regarding common ICU complications and procedures were regarded as neutral. The lowest rank amongst factor 1 was “patient-centered care, communication skills, and interprofessional collaboration.” Participants in factor 2 ranked “preoperative evaluation and management” and “common hematologic and oncologic complications” the lowest. The rationale behind rank orders focused on the current patient population and perceived EPA importance to critical care practice. Participants in factor 1 displayed pessimistic attitudes toward patient-centered care and interprofessional collaboration due to cultural and healthcare system constraints. Interviewees in both factors described local challenges and expressed a need for change. CONCLUSIONS: We conducted a remote needs assessment in an international, interprofessional group of critical care providers. In addition to building trust with learners, the acquired knowledge of cultural differences, needs, and barriers to implementation will guide an ongoing remote education and quality improvement initiative. CLINICAL IMPLICATIONS: This investigation will shape a critical care best practices quality improvement initiative and remote education program in a country with limited resources. DISCLOSURES: No relevant relationships by Marija Bogojevic, source=Web Response No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty no disclosure on file for Pedja Kovacevic; No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Aida Mujakovic, source=Web Response No relevant relationships by Alexander Niven, source=Web Response No relevant relationships by Manja Spahalic, source=Web Response no disclosure on file for Slavenka Straus; No relevant relationships by Simon Zec, source=Web Response

Diaphragm echodensity in mechanically ventilated patients: a description of technique and outcomes.

BackgroundAcute increases in muscle sonographic echodensity reflect muscle injury. Diaphragm echodensity has not been measured in mechanically ventilated patients. We undertook to develop a technique to characterize changes in diaphragm echodensity during mechanical ventilation and to assess whether these changes are correlated with prolonged mechanical ventilation.MethodsDiaphragm ultrasound images were prospectively collected in mechanically ventilated patients and in 10 young healthy subjects. Echodensity was quantified based on the right-skewed distribution of grayscale values (50th percentile, ED50; 85th percentile, ED85). Intra- and inter-analyzer measurement reproducibility was determined. Outcomes recorded included duration of ventilation and ICU complications (including reintubation, tracheostomy, prolonged ventilation, or death).ResultsEchodensity measurements were obtained serially in 34 patients comprising a total of 104 images. Baseline (admission) diaphragm ED85 was increased in mechanically ventilated patients compared to younger healthy subjects (median 56, interquartile range (IQR) 42–84, vs. 39, IQR 36–52, p = 0.04). Patients with an initial increase in median echodensity over time (≥ + 10 in ED50 from baseline) had fewer ventilator-free days to day 60 (n = 13, median 46, IQR 0–52) compared to patients without this increase (n = 21, median 53 days, IQR 49–56, unadjusted p = 0.03). Both decreases and increases in diaphragm thickness during mechanical ventilation were associated with increases in ED50 over time (adjusted p = 0.03, conditional R2 = 0.80) and the association between increase in ED50 and outcomes persisted after adjusting for changes in diaphragm thickness.ConclusionsMany patients exhibit increased diaphragm echodensity at the outset of mechanical ventilation. Increases in diaphragm echodensity during the early course of mechanical ventilation are associated with prolonged mechanical ventilation. Both decreases and increases in diaphragm thickness during mechanical ventilation are associated with increased echodensity.

Characteristics and outcome determinants in patients with pulmonary tuberculosis in ICU

Background Severe tuberculosis requiring intensive care unit care is rare but commonly known to be of bad prognosis. The acute respiratory failure due to pulmonary infections is a common cause for ICU admission. However, despite their high mortality rate, the TB-related critical conditions are rarely reported. Most studies on critical care TB cases were not conducted in high TB burden areas and were retrospective in nature. Objective To identify potential prognostic factors and determinants of patient outcome in cases with pulmonary TB admitted to ICU. Subjects and methods This was a prospective observational study conducted on 51 patients with active pulmonary TB who required ICU admission for at least 24 h in ICU unit of Abbassia Chest Hospital during the period from January 1, 2018 till December 31, 2018. All patients were subjected to history and clinical examination, radiological and laboratory workup, and APACHI II score. Patients were diagnosed and managed according to National TB Control Guidelines in Egypt. Hospital course, complications and ICU stay period were monitored and were correlated to the outcome. Results Mean age of all studied patients was 42.9±16.4 years, 35 male (68.6%) and 16 females. There was Statistically significant correlation between patient outcome, and APACHE II score, arterial blood gases, duration of mechanical ventilation and the total ICU stay in days respectively. ICU complications occurred in 72.5% of patients and they were significantly correlated with patient outcome. Conclusion Pulmonary TB requiring ICU is rare but markedly of bad prognosis. Patients commonly admitted to ICU due to respiratory failure, sepsis, multi organ failure, ARDS and massive hemoptysis. Bad prognosis was related to respiratory failure, high APACHE II score, need for mechanical ventilation and its duration, ICU stay and related complications. Mechanical ventilation and APACHE II score were found to be predictors of mortality.

Value of prognostic scores in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis patients in intensive care unit: a multicenter retrospective cohort study from Turkey

Background/aimThere is a need for a scoring system for predicting ICU prognosis of patients with ANCA-associated vasculitis (AAV), but there are limited data on it in the literature. Therefore, we aimed to determine the scores that can estimate the prognosis of patients with AAV during intensive care follow up.Materials and methodsAll adult patients admitted to the medical ICUs of 4 reference university hospitals in Turkey due to AAV activation and/or disease/treatment complications in the last 10 years were included in this study. Demographic data, treatments before ICU, the Birmingham Vasculitis Activity Score (BVAS) score at the time of vasculitis diagnosis, and BVAS, APACHE II, SOFA, and SAPS II scores at the ICU admission, treatments, procedures, and complications during ICU stay were recorded for all AAV patients.ResultsThirty-four patients were included in the study. The median age of the patients was 60 (42–70) years, and 64.7% were male. Twenty-five patients were diagnosed with Granulomatosis with polyangiitis, and 9 were diagnosed with Microscopic polyangiitis. The most common ICU admission causes were hemorrhage (85.3%) and sepsis/septic shock (67.6%). Twenty patients (58.8%) died in the ICU follow up. There were significant differences in APACHE II (P = 0.004) and SAPS II (P = 0.044) scores between survivors and nonsurvivors, while there were no significant differences in BVAS (during diagnosis P = 0.089 and ICU admission P = 0.539) and SOFA (P = 0.097) scores. APACHE II score was found to be an independent risk factor for ICU mortality (OR = 1.231, CI 95% = 1.011–1.498, P = 0.038) according to logistic regression analysis. An APACHE II score of greater than 20.5 predicted ICU mortality with 80% sensitivity and 70% specificity (AUC = 0.8, P = 0.004, Likelihood ratio = 2.6) according to the ROC curve analysis.Conclusion APACHE II score can be used for the prediction of ICU mortality in AAV patients.

Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults.

Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA). A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest. The present study involved 160 patients with a mean age of 50.71years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5days (75th percentile: 7days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results. The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.