Intensive Care Society Research Articles

P0305 / #534: INTEGRATION OF A PEDIATRIC CRITICAL CARE DATABASE INTO AN ADULT DATABASE.

Aims & Objectives: As database construction is the cornerstone of quality improvement and research promotion in critical care, we have implemented a new multicenter Japanese Intensive Care Patient Database (JIPAD), which attempts to cover both children and adults. This is an initiative of the Japanese Society of Intensive Care Medicine and was started in 2015. We report the process by which we have integrated pediatric and adult databases and the trajectory of the pediatric data. Methods: JIPAD initially provided the same format for adults and children, including baseline profiles, background comorbidities and admission diagnoses associated with APACHE scoring, treatment modalities, and outcomes. In 2018, we introduced the top 100 pediatric-specific diagnostic codes from the pediatric intensive care registry courteously provided by the Australia & New Zealand Intensive Care Society. Results: The number of annual registered cases increased from 5,908 in 2015 to 37,268 in 2018 as participating centers increased from 9 to 46. Overall, 5% were children, and 70% of them were admitted for post-operative care. Cardiovascular diagnoses were most common, followed by respiratory and then neurological. In 2018, crude ICU and hospital mortality rates were 2.3% and 4.3%, respectively, which were half of those in adults. The median ICU and hospital lengths of stay were equivalent to those in adults at 1.9 days [IQR 0.8–4.9]) and 19 days [IQR 11–46], respectively. Conclusions: Most of the database format can be shared for critically ill children, adolescents, and adults. It efficiently captures all relevant data, enabling comprehensive evaluation of critical care in Japan.

Annual prevalence, characteristics, and outcomes of intensive care patients with skin or soft tissue infections in Australia and New Zealand: A retrospective cohort study between 2006-2017

BackgroundThere are limited published data on the epidemiology of skin and soft tissue infections (SSTIs) requiring intensive care unit (ICU) admission. This study intended to describe the annual prevalence, characteristics, and outcomes of critically ill adult patients admitted to the ICU for an SSTI. MethodsThis was a registry-based retrospective cohort study, using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database for all admissions with SSTI between 2006 and 2017. The inclusion criteria were as follows: primary diagnosis of SSTI and age ≥16 years. The exclusion criteria were as follows: ICU readmissions (during the same hospital admission) and transfers from ICUs from other hospitals. The primary outcome was in-hospital mortality, and the secondary outcomes were ICU mortality and length of stay (LOS) in the ICU and hospital with independent predictors of outcomes. ResultsAdmissions due to SSTI accounted for 10 962 (0.7%) of 1 470 197 ICU admissions between 2006 and 2017. Comorbidities were present in 25.2% of the study sample. The in-hospital mortality was 9% (991/10 962), and SSTI necessitating ICU admission accounted for 0.07% of in-hospital mortality of all ICU admissions between 2006 and 2017. Annual prevalence of ICU admissions for SSTI increased from 0.4% to 0.9% during the study period, but in-hospital mortality decreased from 16.1% to 6.8%. The median ICU LOS was 2.1 days (interquartile range = 3.4), and the median hospital LOS was 12.1 days (interquartile range = 20.6). ICU LOS remained stable between 2006 and 2017 (2.0–2.1 days), whereas hospital LOS decreased from 15.7 to 11.2 days. Predictors for in-hospital mortality included Australian and New Zealand Risk of Death scores [odds ratio (OR): 1.07; confidence interval (CI) (1.05, 1.09); p < 0.001], any comorbidity except diabetes [OR: 2.00; CI (1.05, 3.79); p = 0.035], and admission through an emergency response call [OR: 2.07; CI (1.03, 4.16); p = 0.041]. ConclusionsSSTIs are uncommon as primary ICU admission diagnosis. Although the annual prevalence of ICU admissions for SSTI has increased, in-hospital mortality and hospital LOS have decreased over the last decade.

The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients.

OBJECTIVE:Expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.DATA SOURCES:Original article, literature search.STUDY SELECTION:Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy.DATA EXTRACTION:None.DATA SYNTHESIS:None.CONCLUSION:In the second of a series of manuscripts subsequent to the original article, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.

Device-related pressure injuries in adult intensive care unit patients: An Australian and New Zealand point prevalence study

BackgroundDevice-related pressure injuries (DRPIs) are an ongoing iatrogenic problem evident in intensive care unit (ICU) settings. Critically ill patients are at high risk of developing pressure injuries caused by devices. ObjectiveThe aim of the study was to determine the prevalence of DRPI in critically ill patients in intensive care and the location, stage, and attributable device of DRPI and describe the products and processes of care used to prevent these injuries. MethodsThis was a prospective, multicentre, cross-sectional point prevalence study of patients aged more than 16 years in Australian and New Zealand ICUs. The study was part of the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program coordinated by The George Institute for Global Health. Main outcome measureIdentification of DRPI on the study day was the main outcome measure. ResultsOf the 624 patients included from 44 participating ICUs, 27 were found to have 35 identified DRPIs, giving a point prevalence DRPI rate of 4.3% (27/624). Study patients had a mean age of 59 years, and 60.3% were men. Patients with DRPI compared with patients without DRPI were significantly heavier (median: 92 kg versus 80 kg, respectively, p = 0.027), were less likely to survive the ICU (63.0% versus 85.9%, respectively, p = 0.015), had higher Acute Physiology and Chronic Health Evaluation II scores at admission to the ICU (median: 20 versus 16, respectively, p = 0.001), received mechanical ventilation more often (88.9% versus 43.5%, respectively, p < 0.001), and were more frequently diagnosed with respiratory conditions (37.0% versus 18.6%, respectively, p = 0.022). Processes of care activities were surveyed in 42 ICUs. Most DRPIs were attributed to endotracheal tubes and other respiratory devices. Forty-two ICUs reported processes of care to prevent DRPI, and just more than half of the participating sites (54.8%, 23/44) reported a dedicated ICU-based protocol for prevention of DRPI. ConclusionDRPIs pose a burden on patients in the ICU. Our study showed a DRPI prevalence comparable with other studies. Prevention strategies targeting DRPI should be included in ICU-specific pressure injury prevention guidelines or protocols.

The Surviving Sepsis Campaign: Research Priorities for Coronavirus Disease 2019 in Critical Illness.

To identify research priorities in the management, pathophysiology, and host response of coronavirus disease 2019 in critically ill patients. The Surviving Sepsis Research Committee, a multiprofessional group of 17 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine, was virtually convened during the coronavirus disease 2019 pandemic. The committee iteratively developed the recommendations and subsequent document. Each committee member submitted a list of what they believed were the most important priorities for coronavirus disease 2019 research. The entire committee voted on 58 submitted questions to determine top priorities for coronavirus disease 2019 research. The Surviving Sepsis Research Committee provides 13 priorities for coronavirus disease 2019. Of these, the top six priorities were identified and include the following questions: 1) Should the approach to ventilator management differ from the standard approach in patients with acute hypoxic respiratory failure?, 2) Can the host response be modulated for therapeutic benefit?, 3) What specific cells are directly targeted by severe acute respiratory syndrome coronavirus 2, and how do these cells respond?, 4) Can early data be used to predict outcomes of coronavirus disease 2019 and, by extension, to guide therapies?, 5) What is the role of prone positioning and noninvasive ventilation in nonventilated patients with coronavirus disease?, and 6) Which interventions are best to use for viral load modulation and when should they be given? Although knowledge of both biology and treatment has increased exponentially in the first year of the coronavirus disease 2019 pandemic, significant knowledge gaps remain. The research priorities identified represent a roadmap for investigation in coronavirus disease 2019.

Validation of the pediatric refractory septic shock definition: post hoc analysis of a controlled trial

BackgroundThe European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bedside SSS (bSSS) and computed SSS (cSSS) were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India.MethodsPost hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single-center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality.ResultsIn this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 h. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR = 60.9 [95% CI: 10.5–676.2], p < 0.001 with a median delay from sepsis onset of 3 days [1.0–6.7]. Among patients diagnosed with RSS, the mortality was not significantly different according to vasopressors randomization. Diagnosis of RSS with bSSS and cSSS had a high discrimination for death with an area under the receiver operating curve of 0.916 [95% CI: 0.843–0.990] and 0.925 [95% CI: 0.845–1.000], respectively. High prognostic accuracy of the bSSS was found in the first hours following intensive care admission. The best interval of prognostication occurs after the 12th hour following treatment initiation (AUC 0.973 [95% CI: 0.925–1.000]).ConclusionsThe ESPNIC refractory septic shock definition accurately identifies, within the first 6 h of septic shock management, children with lethal outcome.

Linkage of Australian national registry data using a statistical linkage key

BackgroundData from clinical registries may be linked to gain additional insights into disease processes, risk factors and outcomes. Identifying information varies from full names, addresses and unique identification codes to statistical linkage keys to no direct identifying information at all. A number of databases in Australia contain the statistical linkage key 581 (SLK-581). Our aim was to investigate the ability to link data using SLK-581 between two national databases, and to compare this linkage to that achieved with direct identifiers or other non-identifying variables.MethodsThe Australian and New Zealand Society of Cardiothoracic Surgeons database (ANZSCTS-CSD) contains fully identified data. The Australian and New Zealand Intensive Care Society database (ANZICS-APD) contains non-identified data together with SLK-581. Identifying data is removed at participating hospitals prior to central collation and storage. We used the local hospital ANZICS-APD data at a large single tertiary centre prior to deidentification and linked this to ANZSCTS-CSD data. We compared linkage using SLK-581 to linkage using non-identifying variables (dates of admission and discharge, age and sex) and linkage using a complete set of unique identifiers. We compared the rate of match, rate of mismatch and clinical characteristics between unmatched patients using the different methods.ResultsThere were 1283 patients eligible for matching in the ANZSCTS-CSD. 1242 were matched using unique identifiers. Using non-identifying variables 1151/1242 (92.6%) patients were matched. Using SLK-581, 1202/1242 (96.7%) patients were matched. The addition of non-identifying data to SLK-581 provided few additional patients (1211/1242, 97.5%). Patients who did not match were younger, had a higher mortality risk and more non-standard procedures vs matched patients. The differences between unmatched patients using different matching strategies were small.ConclusionAll strategies provided an acceptable linkage. SLK-581 improved the linkage compared to non-identifying variables, but was not as successful as direct identifiers. SLK-581 may be used to improve linkage between national registries where identifying information is not available or cannot be released.

Recomendaciones de la Sociedad Uruguaya de Medicina Intensiva sobre los aspectos bioéticos en la pandemia Covid-19

Introduction: the pandemic caused by SARS-CoV2 constitutes a significant challenge for the health system, and especially for Critical Care Units, so we need to prepare in many aspects. Likewise, we need to consider there could be an extraordinary demand for beds in critical care units, what would lead to an imbalance between clinical needs and the effective availability of health resources. Objectives: the study aims to perform a bioethical analysis that could provide guidelines for the assistance of patients in critical care. Specific objectives: 1) to analyse the main bioethical principles in this context, 2) to support clinicians in the making of difficult decisions, 3) to make the resource allocation criteria specific, 4) to define action lines upon a potential “health’s disastrous” scenarioMethod: the Uruguayan Society of Intensive Care has generated a space for collective work based on discussion processes. Documents include a bibliographic review and the existing protocols. Results: the study presents a theoretical analysis that is backed up by the bioethical principles involved in the pandemic context on the scenarios of demand for assistance and, by the arguments calling for a change in the ethical criteria upon the saturation of the health system. Conclusion: practical recommendations are made: 1) for the making of decisions about admission and discharge in a controlled demand. 2) to define action criteria upon an increase in demand, clearly defining the different scenarios, 3) to apply upon the saturation of the health system.

Timing of VV‐ECMO therapy implementation influences prognosis of COVID‐19 patients

IntroductionCurrent knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID‐19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID‐19 patients.MethodsA cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID‐19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV‐ECMO from March 14 to May 31. The VV‐ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine.ResultsOut of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m2, and SAPS II score 56 ± 3) were put on VV‐ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non‐survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died.ConclusionThe present results suggest that VV‐ECMO can be safely utilized in appropriately selected COVID‐19 patients with refractory hypoxemia. The main information for clinicians is that late VV‐ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile.

Practical strategies to implement the ESPNIC Nutrition Clinical recommendations into PICU practice.

The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) published 32 clinical recommendations around supporting nutrition in critically ill children following an extensive review of the literature online in January 2020. The challenge now is to engage with paediatric intensive care unit teams to implement these into their practice. This practical implementation guide uses a recognised implementation model to guide pediatric intensive care professionals to implement these evidence-based clinical recommendations into clinical practice. We use the Pronovost implementation of evidence into practice model to provide a practical framework with associated documents to facilitate PICU healthcare professional's implementation of these clinical recommendations into PICU practice. The paper is structured around the four steps in this model: summarising the evidence, identifying local barriers to implementation, measuring performance and ensuring all patients receive the intervention and useful checklists for implementation and compliance monitoring are provided, in addition to tables outlining key professional roles and responsibilities around nutrition in the paediatric Intensive care Unit.

Pneumothorax in Coronavirus Disease-19 Patients: A Retrospective Case Series

Objective: Pneumothorax may develop secondary to alveolar damage and barotrauma in Covid- 19 patients. In this study, in the light of the literature. we aimed to present Covid-19 patients who developed pneumothorax among whom we followed up in the intensive care unit. Methods: Eleven patients among 2680 patients tested positive for Covid-19 in the PCR test and developed pneumothorax in the radiologic examination were included in the study. The data were obtsined from patient follow-up forms and electronic medical records. Demographic data, blood and biochemical parameters, blood culture results, time and location of development of pneumothorax, modality, and duration of pneumothorax treatment, and mortality data were recorded. Results: The frequency of development of pneumothorax was found to be 0.41%. The most common complaint was dyspnea. Comorbidiites were observed in 9 (81.8%) patients and the most common comorbidity was hypertension. It was determined that 3 (27.2%) patients did not smoke, 4 patients(36.3%) were active smokers, and 4 (36.3%) patients were ex-smokers. The mean age was 69±14.8 years, the APACHE II score were 18.8±8.7, the female/male ratio was 3/8, and the the time to pneumothorax development was 10.7±11.8 days. Pneumothorax developed in 3 (27.27%) patients on noninvasive mechanical ventilation and 8 (72.7%) patients on invasive mechanical ventilation. The mean length of stay in the intensive care unit was 21.6±26.5 days. It was found that 10 (90.9%) patients died and the mean time to mortality was 19.5±27.0 days. Conclusion: In Covid-19 infection, lung protective ventilation strategies should be adopted and it should be known that the development of pneumothorax is a late complication that increases mortality and morbidity. (English) [ABSTRACT FROM AUTHOR] Amac: Covid-19 hastalarinda alveolar hasar ve barotravmaya sekonder pnomotoraks gelisebilir. Bu calismada, yogun bakim unitesinde takip ettigimiz Covid-19 hastalarindan pnomotoraks gelisenlerini literatur esliginde sunmayi amacladik. Yontem: Calismaya PCR testi pozitif oldugu saptanan 2.680 hastadan radyolojik olarak pnomotoraks gelistigi belirlenen 11 hasta dahil edildi. Veriler hasta takip formlari ve elektronik tibbi kayitlardan alindi. Demografik veriler, tam kan ve biyokimyasalparametreleri, kan kultur sonuclari, pnomotoraks gelisim zamani ve lokasyonu, pnomotoraks tedavi sekli, mortalite ve suresi kaydedildi. Bulgular: Pnomotoraks gelisme sikligi %0,41 bulundu. En sik basvuru yakinmasinin dispne oldugu saptandi. Dokuz (%81.8)hastada comorbidite oldugu ve en sik gozlenen comorbiditenin hipertansiyon oldugu goruldu. Uc (%27,2) hastanin sigara kullanmadigi, 4(%36,3) hastanin aktif sigara icicisi oldugu ve 4 (%36.3) hastanin sigarayi biraktigi saptandi. Hastalarin yas ortalamalari 69±14,8 yil, APACHE II skor ortalamalari 18,8±8,7, kadin/erkek orani 3/8 ve pnomotoraks gelisene 10,7±11,8 gun bulundu. Uc hastada (%27.27) noninvaziv mekanik ventilasyonda ve 8 hastada (%72,7) invaziv mekanik ventilasyondayken pnomotoraks gelistigi saptandi. Yogun bakim unitesinde ortalama kalma suresi 21,6±26,5 gundu. On (%90,9) hastanin eks oldugu ve eks olana kadar ortalama 19,5±27,0 gun gectigi saptandi. Sonuc: Covid-19 infeksiyonu sirasinda hipoksemi tedavi edilirken, akciger koruyucu ventilasyon stratejileri benimsenmeli ve pnomotoraks gelisiminin mortalite ve morbiditeyi arttiran gec donem komplikasyon oldugu bilinmelidir. (Turkish) [ABSTRACT FROM AUTHOR] Copyright of Journal of the Society of Thoracic Carido-Vascular Anaesthesia & Intensive Care is the property of Gogus Kalp Damar Anestezi ve Yogun Bakim Dernegi and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

INTENSIVE CARE UNIT PRESCRIPTIONS MUST FIT RISK FACTORS TO PREVENT STRESS ULCER BLEEDING.

ABSTRACT Background:The physiological stress of critically ill patients can trigger several complications, including digestive bleeding due to stress ulcers (DBSU). The use of acid secretion suppressants to reduce their incidence has become widely used, but with the current understanding of the risks of these drugs, their use, as prophylaxis in critically ill patients, is limited to the patients with established risk factors. Aim:To determine the appropriateness of the use of prophylaxis for stress ulcer bleeding in acutely ill patients admitted to intensive care units and to analyze the association of risk factors with adherence to the prophylaxis guideline. Methods:Retrospective, analytical study carried out in three general adult intensive care units. Electronic medical records were analyzed for epidemiological data, risk factors for DBSU, use of stress ulcer prophylaxis, occurrence of any digestive bleeding and confirmed DBSU. The daily analysis of risk factors and prophylaxis use were in accordance with criteria based on the Guidelines of the Portuguese Society of Intensive Care for stress ulcer prophylaxis. Results:One hundred and five patients were included. Of the patient days with the opportunity to prescribe prophylaxis, compliance was observed in 95.1%. Of the prescription days, 82.35% were considered to be of appropriate use. Overt digestive bleeding occurred in 3.81% of those included. The occurrence of confirmed DBSU was identified at 0.95%. Multivariate analysis by logistic regression did not identify risk factors independently associated with adherence to the guideline, but identified risk factors with a negative association, which were spinal cord injury (OR 0.02 p <0.01) and shock (OR 0.36 p=0.024). Conclusion:The present study showed a high rate of adherence to stress ulcer prophylaxis, but with inappropriate use still significant. In the indication of prophylaxis, attention should be paid to patients with spinal cord injury and in shock.

Portuguese Society of Intensive Care Score for Predicting SARS-CoV-2 Infection Applied to Inpatients with Pneumonia: A Reliable Tool?

Objectives: Early identification of patients with the novel coronavirus induced-disease 2019 (COVID-19) and pneumonia is currently challenging. Few data are available on validated scores predictive of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. The Portuguese Society of Intensive Care (PSIC) proposed a risk score whose main goals were to predict a higher probability of COVID-19 and optimize hospital resources, adjusting patients’ intervention. This study aimed to validate the PSIC risk score applied to inpatients with pneumonia. Methods: A retrospective analysis of 207 patients with pneumonia admitted to a suspected/confirmed SARS-CoV-2 infection specialized ward (20/03 to 20/05/2020) was performed. Score variables were analyzed to determine the significance of the independent predictive variables on the probability of a positive SARS-CoV-2 rRT-PCR test. The binary logistic regression modeling approach was selected. The best cut-off value was obtained with the Receiver Operating Characteristic (ROC) curve together with the evaluation of the discriminatory power through the Area Under the Curve (AUC). Results: The validation cohort included 145 patients. Typical chest computed-tomography features (OR, 12.16; 95% CI, 3.32 - 44.50) and contact with a positive SARS-CoV-2 patient (OR, 6.56; 95% CI, 1.33 - 32.30) were the most significant independent predictive variables. A score ≥ 10 increased suspicion for SARS-CoV-2 pneumonia. The AUC was 0.82 (95% CI, 0.73 - 0.91) demonstrating the good discriminating power for COVID-19 probability stratification in inpatients with pneumonia. Conclusions: The application of the PSIC score to inpatients with pneumonia may be of value in predicting the risk of COVID-19. Further studies from other centers are needed to validate this score widely.

Quality Assurance in Intensive Care Medicine: Peer Reviews and Quality Indicators

Goal-oriented quality management in health care is an essential tool to provide good medical practice and treatment. It aims at a patient-centred case management with high transparency of structural and clinical process aspects, as well as patient outcome. An objective and comprehensive description of clinical care includes the use of quality indicators. However, the appliance of those indicators falls short, when the evaluation of quality is not followed by recommendations for improvement.As a highly specified area in health care provided in hospitals, intensive care medicine is characterized by complex interprofessional and multidisciplinary approaches. In addition, critical care units are an expensive resource. In order to provide an economic and yet high quality patient care, treatments should be evidence-based, and cost-drivers must be analysed for their effectiveness on patient-outcome.Various methods of quality assurance allow for a formative evaluation of intensive care units by peer reviews, including the use of quality indicators. This article focuses on peer review systems currently applied in German hospitals, and particularly describes quality indicators that have been established by DIVI (German Interdisciplinary Society of Intensive Care and Emergency Medicine). It also addresses the need for a professional dialogue between equal partners. This has to accompany each peer review that aims at an improvement in quality of critical patient care.

Nutritional risk and clinical outcomes in critically ill adult patients with COVID-19.

Introduction: the COVID-19 pandemic put the world's population at risk. As the relationship between nutritional risk and clinical outcomes in critically ill patients with COVID-19 is still poorly understood, a multidisciplinary research team of the Argentine Society of Intensive Care (SATI) conducted a multicenter study aimed to define nutritional features, and to evaluate the relationship between nutritional risk and relevant clinical outcomes for COVID-19 patients in an intensive care unit (ICU). Methods: a multicenter, prospective, observational study including twelve Argentinian ICUs was conducted between March and October 2020. Inclusion criteria were: adult patients older than 18 years who were admitted to the ICU with a COVID-19 diagnosis were included. Clinical data included comorbidities scores, and nutritional screening tools such as the Subjective Global Assessment (SGA), the Nutritional Risk Screening (NRS) 2002, and the modified NUTRIC score (mNUTRIC SCORE) were used. In addition, clinical outcomes including overall mortality, mechanical ventilation (MV) days, and ICU and hospital length of stay (LOS) were recorded. Results: a total of 285 ICU patients met our inclusion criteria. Mean age was 61.24 (SD = 14.6) years; APACHE-II, 14.2 (SD = 6.6); Charlson Comorbidity Index (CCI), 2.3 (SD = 2.3). Most patients were admitted from the emergency room to the ICU. Hypertension, obesity, and diabetes were the most common comorbidities. Nutritional assessment showed that 36.9 % were SGA B+C, and 46 % were obese. Mean ICU LOS was 22.2 (SD = 19.5), and hospital LOS was 28.1 (SD = 21.9) days. Of all patients, 90.2 % underwent MV, and MV days were 20.6 (SD = 15.6). The univariate and multivariate analyses showed that risk factors for COVID-19 mortality were (odds ratio [95 % confidence interval]): SGA score of B or C: 2.13 [1.11-4.06], and NRS 2002 ≥ 3: 2.25 [1.01-5.01]. Conclusions: in the present study, nutritional status (SGA) and NRS 2002 were major mortality risk factors for CODIV-19 patients in the ICU.

Triage in emergenza pandemica: sui rischi di una carrellologia

Tra i temi più discussi durante l’emergenza pandemica da Sars-CoV-2 c’è quello che riguarda l’accesso (o l’eventuale sospensione) a trattamenti intensivi (specificatamente i supporti ventilatori), nel caso di forte squilibrio tra necessità cliniche e risorse disponibili. Particolare clamore ha suscitato in Italia la pubblicazione il 6 marzo 2020, dunque in una delle fasi più gravi dell’emergenza, del documento Raccomandazioni di etica clinica per l’ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili ad opera della Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), per aver prospettato la possibilità di utilizzare l’età come criterio di accesso ai supporti ventilatori. Obiettivo del presente contributo è discutere l’impostazione teorica di fondo che SIAARTI ha adottato, e il criterio specifico che ha proposto per stabilire la priorità di trattamento dei pazienti intensivi nel contesto dell’emergenza. A ciò farà seguito un breve approfondimento della questione in chiave egualitarista.

European Society of Intensive Care Medicine и Society of Critical Care Medicine: 6 key provisions for management of sepsis patients. Where do we go next?

The objective: to analyze the validity of recommendations of the special research committee of the European Society of Intensive Care Medicine ( ESICM ) and Society of Critical Care Medicine ( SCCM ) concerning the most important provisions for the management of patients with sepsis and septic shock identifying predictors of lon g-t erm need for medical care and lethality. Subjects and methods. The article analyses the publications based on which experts in sepsis management identified the key provisions of the above recommendations. Results . Attention is focused on six issues: empirical combined antibiotic therapy, individual infusion volume, express diagnosis of infection, assessment of organ and systemic dysfunction, identification of predictors of lon g-t erm need for medical care and lethality, and implementation attempts and prospects of precis e/p ersonalized medicine. It has been shown that the values of SOFA score, heart rate, syst. blood pressure, lactate and albumin levels should reflect the balance of the groups in these parameters. Molecular classification of patients with sepsis providing different endotypes allows better patients enrollment in clinical trials.

Research Priorities for U.K. Pediatric Critical Care in 2019: Healthcare Professionals' and Parents' Perspectives.

The Paediatric Intensive Care Society Study Group conducted a research prioritization exercise with the aim to identify and agree research priorities in Pediatric Critical Care in the United Kingdom both from a healthcare professional and parent/caregiver perspective. A modified three-round e-Delphi survey, followed by a survey of parents of the top 20 healthcare professional priorities. U.K. PICUs. U.K. PICU healthcare professionals who are members of the professional society and parents and family members of children, with experience of a U.K. PICU admission. None. Forty-nine healthcare professional submitted topics in round 1, 98 participated in round 2, and 102 in round 3. These topics were categorized into eight broad domain areas, and within these, there were 73 specific topics in round 2. At round 3, 18 topics had a mean score less than 5.5 and were removed, leaving 55 topics for ranking in round 3. Ninety-five parents and family members completed the surveys from at least 17 U.K. PICUs. Both parents and healthcare professional prioritized research topics associated with the PICU workforce. Healthcare professional research priorities reflected issues that impacted on day-to-day management and practice. Parents' prioritized research addressing acute situations such as infection identification of and sepsis management or research addressing long-term outcomes for children and parents after critical illness. Parents prioritized research into longer term outcomes more than healthcare professional. Parental responses showed clear support for the concept of research in PICU, but few novel research questions were proposed. This is the first research prioritization exercise within U.K. PICU setting to include parents' and families' perspectives and compare these with healthcare professional. Results will guide both funders and future researchers.

Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons

The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.

Risks of and risk factors for COVID-19 disease in people with diabetes: a cohort study of the total population of Scotland

BackgroundWe aimed to ascertain the cumulative risk of fatal or critical care unit-treated COVID-19 in people with diabetes and compare it with that of people without diabetes, and to investigate risk factors for and build a cross-validated predictive model of fatal or critical care unit-treated COVID-19 among people with diabetes.MethodsIn this cohort study, we captured the data encompassing the first wave of the pandemic in Scotland, from March 1, 2020, when the first case was identified, to July 31, 2020, when infection rates had dropped sufficiently that shielding measures were officially terminated. The participants were the total population of Scotland, including all people with diabetes who were alive 3 weeks before the start of the pandemic in Scotland (estimated Feb 7, 2020). We ascertained how many people developed fatal or critical care unit-treated COVID-19 in this period from the Electronic Communication of Surveillance in Scotland database (on virology), the RAPID database of daily hospitalisations, the Scottish Morbidity Records-01 of hospital discharges, the National Records of Scotland death registrations data, and the Scottish Intensive Care Society and Audit Group database (on critical care). Among people with fatal or critical care unit-treated COVID-19, diabetes status was ascertained by linkage to the national diabetes register, Scottish Care Information Diabetes. We compared the cumulative incidence of fatal or critical care unit-treated COVID-19 in people with and without diabetes using logistic regression. For people with diabetes, we obtained data on potential risk factors for fatal or critical care unit-treated COVID-19 from the national diabetes register and other linked health administrative databases. We tested the association of these factors with fatal or critical care unit-treated COVID-19 in people with diabetes, and constructed a prediction model using stepwise regression and 20-fold cross-validation.FindingsOf the total Scottish population on March 1, 2020 (n=5 463 300), the population with diabetes was 319 349 (5·8%), 1082 (0·3%) of whom developed fatal or critical care unit-treated COVID-19 by July 31, 2020, of whom 972 (89·8%) were aged 60 years or older. In the population without diabetes, 4081 (0·1%) of 5 143 951 people developed fatal or critical care unit-treated COVID-19. As of July 31, the overall odds ratio (OR) for diabetes, adjusted for age and sex, was 1·395 (95% CI 1·304–1·494; p<0·0001, compared with the risk in those without diabetes. The OR was 2·396 (1·815–3·163; p<0·0001) in type 1 diabetes and 1·369 (1·276–1·468; p<0·0001) in type 2 diabetes. Among people with diabetes, adjusted for age, sex, and diabetes duration and type, those who developed fatal or critical care unit-treated COVID-19 were more likely to be male, live in residential care or a more deprived area, have a COVID-19 risk condition, retinopathy, reduced renal function, or worse glycaemic control, have had a diabetic ketoacidosis or hypoglycaemia hospitalisation in the past 5 years, be on more anti-diabetic and other medication (all p<0·0001), and have been a smoker (p=0·0011). The cross-validated predictive model of fatal or critical care unit-treated COVID-19 in people with diabetes had a C-statistic of 0·85 (0·83–0·86).InterpretationOverall risks of fatal or critical care unit-treated COVID-19 were substantially elevated in those with type 1 and type 2 diabetes compared with the background population. The risk of fatal or critical care unit-treated COVID-19, and therefore the need for special protective measures, varies widely among those with diabetes but can be predicted reasonably well using previous clinical history.FundingNone.