Intensive Care Unit Department Research Articles

Sustainment of a patient flow intervention in an intensive care unit in a regional hospital in Australia: a mixed-method, 5-year follow-up study

ObjectiveIn 2014, an escalation plan and morning handover meetings were implemented in an intensive care unit (ICU) to reduce access block for post-operative care. In this study, the improvement intervention...

Value of radiographic assessment of lung edema score in evaluating the severity and prognosis of patients with acute respiratory distress syndrome

To explore the value of radiographic assessment of lung edema (RALE) score in evaluating the severity and prognosis of patients with acute respiratory distress syndrome (ARDS). A retrospective study was conducted. Patients with ARDS admitted to the department of intensive care unit (ICU) of Affiliated Nantong Third Hospital of Nantong University from January 2016 to November 2020 were enrolled. Clinical data of those patients were collected, and two senior radiologists who did not know the outcome of the patients independently scored each chest radiograph, the mean value of which was taken as the RALE score. The patients were divided into death group and survival group according to the 28-day prognosis. The differences of the basic data, PaO2/FiO2, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II) score and RALE score between groups were analyzed. ARDS patients were classified according to the Berlin standard and RALE scores were compared between groups. Then, the correlations between RALE score and PaO2/FiO2, SOFA score, APACHE II score were analyzed. The prognostic capacity of RALE score for 28-day prognosis of ARDS patients were analyzed by Kaplan-Meier survival curve. Of the 98 ARDS patients, 62 were included in the final analysis, 39 patients survived and 23 patients died. The 28-day mortality was 37.1%. Compared with the survival group, patients in the death group were older (years old: 72.83±12.21 vs. 64.44±14.68), had lower PaO2/FiO2 [mmHg (1 mmHg = 0.133 kPa): 122.66±48.32 vs. 150.26±50.40], and higher SOFA score and greater difference of RALE score between the third day and the first day after admission (D3-D1 RALE score) (SOFA score: 11.26±3.91 vs. 9.04±3.72, D3-D1 RALE score: 1.35±6.42 vs. -2.74±7.35), with statistically significant differences (all P < 0.05). However, there were no significant differences in gender, cause of ARDS, APACHE II score, and RALE scores on the first and the third day of admission (D1 RALE, D3 RALE) between the two groups. Among the 62 patients, there were 11 mild cases (17.7%), 36 moderate cases (58.1%), and 15 severe cases (24.2%). The D1 RALE score of patients with mild and moderate ARDS were lower than those of patients with severe ARDS (19.09±3.65, 22.58±6.79 vs. 27.07±5.23, both P < 0.05). Correlation analysis showed that D1 RALE score was negatively correlated with PaO2/FiO2 (r = -0.385, P = 0.002), and positively correlated with SOFA score and APACHE II score (r1 = 0.433, r2 = 0.442, both P < 0.001). Kaplan-Meier survival curve analysis showed that the 28-day survival rate of ARDS patients in D3-D1 RALE score ≥ -1 group was significantly higher than that in D3-D1 RALE score < -1 group (73.08% vs. 55.56%; log-rank test: χ2 = 3.979, P = 0.046). The RALE score is a simple and reliable non-invasive evaluation index, which can be used to evaluate the severity of ARDS patients. The difference of RALE score in early stage is helpful to identify ARDS patients with poor prognosis.

Effects of treatment based on different target mean arterial pressure on gastrointestinal function in septic shock patients with hypertension

To investigate the effect of fluid resuscitation and circulatory support, directed by different target mean arterial pressure (MAP), on abdominal blood flow, gastrointestinal function and inflammatory response in septic shock patients with hypertension. A prospective randomized controlled study was conducted. Hypertensive patients with septic shock admitted to the department of intensive care unit (ICU) of Liuzhou People's Hospital from January 1, 2019 to May 31, 2020 were enrolled. Patients were randomly divided into the low MAP groups (low standard group, LS group) or high MAP group (high standard group, HS group). According to the Surviving Sepsis Campaign Guidelines in 2016 and the updated guideline in 2018, all patients were given treatment of primary disease, fluid resuscitation, supportive management. The target MAP was 65-70 mmHg (1 mmHg = 0.133 kPa) in LS group, and was 75-80 mmHg in HS group. Acute gastrointestinal function injury (AGI) classification was performed on the 1st, 3rd and 7th day. The mean flow rate (Vm) and resistance index (RI) of superior mesenteric artery were evaluated using ultrasound, and the gastrointestinal function was dynamically evaluated using the modified single section ultrasonic gastric antrum method. The gastric antrum movement index (MI) and gastric empaging time (GET) were recorded. The levels of inflammatory markers in serum were detected by enzyme linked immunosorbent assay (ELISA), such as tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), procalcitonin (PCT) and vascular endothelial growth factor (VEGF). The target MAP, the days of use of vasopressors and the amount of fluid resuscitation were recorded. A total of 208 hypertensive patients with septic shock were enrolled, including 109 in the LS group and 99 in the HS group. There were no significant differences in gender, age, acute physiology and chronic health evaluation II (APACHE II) score and sequential organ failure assessment (SOFA) score between the two groups when diagnosed. After treatment, there was no significant difference in AGI classification between the LS group and HS group on the 1st day. On the 3rd and 7th day, there were statistical differences between the two groups (3rd day: proportion of I, II, III, IV grades were 25.69%, 56.88%, 11.93%, 5.50% in LS group, 15.15%, 54.55%, 25.25%, 5.05% in HS group, respectively, χ2 = 7.900, P = 0.048; 7rd day: proportion of I, II, III, IV grades were 44.96%, 49.54%, 3.67%, 1.83% in LS group, 31.31%, 52.53%, 11.11%, 5.05% in HS group, respectively, χ2 = 8.178, P = 0.042). The Vm of superior mesenteric artery was higher and the RI was lower in the LS group than those in the HS group on day 1, 3 and 7 [Vm (cm/s): 21.72±3.02 vs. 19.50±2.83, 20.42±2.62 vs. 17.02±1.99, 26.52±2.70 vs. 22.47±4.03; RI: 0.86±0.05 vs. 0.92±0.04, 0.87±0.05 vs. 0.95±0.05, 0.81±0.03 vs. 0.85±0.03, all P < 0.01]. The MI was higher and the GET was shorter in the LS group than those in the HS group on day 3 and day 7 [MI: 3.00±0.33 vs. 2.60±0.29, 4.50±0.51 vs. 3.90±0.33; GET (minutes): 86.01±19.78 vs. 100.99±25.01, 71.00±16.37 vs. 84.98±20.18, all P < 0.01]. In addition, the levels of serum TNF-α, IL-6, PCT, VEGF were lower in the LS group than those in the HS group after 3 days of treatment [TNF-α (ng/L): 147.05±28.32 vs. 256.99±27.04, IL-6 (ng/L): 762.99±57.83 vs. 1 112.30±118.32, PCT (μg/L): 37.00±5.58 vs. 56.00±12.36, VEGF (ng/L): 123.00±19.78 vs. 167.01±21.55, all P < 0.05]. The target MAP was maintained at (68.02±4.71) mmHg in LS group, and (79.04±3.04) mmHg in HS group. The difference between the two groups was statistically significant (P < 0.01). Compared with the HS group, the days of using vasopressors was shorter in LS group (days: 3.50±1.27 vs. 4.55±1.47), and the amountof fluid was reduced significantly (mL: 1 602.29±275.49 vs. 2 000.30±272.59, both P < 0.01). Maintaining a low target mean arterial pressure (65-70 mmHg) in hypertensive patients with septic shock can improve blood supply of superior mesenteric artery, protect the gastrointestinal function, reduce the level of inflammatory factors, and diminish the duration of using vasopressors and the amount of fluid.

Application of extracorporeal membrane oxygenation in critically ill pregnant women

To investigate the safety and effectiveness of extracorporeal membrane oxygenation (ECMO) in emergency treatment of critically ill pregnant women. Clinical data of 8 pregnant women with severe cardiopulmonary dysfunction during the perinatal period treated by ECMO in the department of intensive care unit (ICU) of Nanjing Drum Tower Hospital, the Affiliated Hospital to Nanjing University Medical School from September 2017 to November 2020 were retrospectively analyzed. For the 8 pregnant women, the mean age was (32.5±6.3) years old. Body weight was (73.5±8.1) kg. Gestational age was (31.0±4.4) weeks. Acute physiology and chronic health evaluation II (APACHE II) score was 13.0±6.6, and sequential organ failure assessment (SOFA) score was 8.3±3.8. Among them, 5 pregnant women suffered from severe pneumonia and were treated with venous-venous ECMO (VV-ECMO). Another 3 pregnant women with heart failure underwent venous-arterial ECMO (VA-ECMO). The initial ECMO flow rate was set to 2.0-3.0 L/min. Then the highest flow rate was (3.1±0.6) L/min, and the average ECMO running time was (174±36) hours. The length of ICU stay was (16.0±5.4) days. Six pregnant women (5 with severe pneumonia and 1 with peripartum cardiomyopathy) successfully evacuated from ECMO and survived. Two pregnant women with pulmonary hypertension showed poor prognosis. In total, seven babies survived. Two of them were delivered after ECMO evacution, and one underwent emergency cesarean section with ECMO support. In another case, the fetus could not be delivered due to under-gestational weeks. During this period, there were no serious bleeding complications. One pregnant woman developed heparin-induced thrombocytopenia and thrombosis (HITT), then she received another anticoagulant treatment. One pregnant woman got sequential anticoagulation therapy for 3 months on account of thrombosis in the puncture vessel. ECMO has played an active role in the rescue of critically ill pregnant women. For those with reversible severe cardiopulmonary dysfunction, it is necessary to evaluate the application of ECMO as early as possible to improve the survival rate of mothers and infants.

Influencing factors of weaning outcome of intensive care unit patients with planned extubation

To determine the risk factors of extubation failure and its effect on the prognosis of patients who had successfully passed a spontaneous breathing trial (SBT). The clinical data of patients with mechanical ventilation more than 24 hours who passed SBT admitted to department of intensive care unit (ICU) of First Hospital of Qinhuangdao from November 2018 to November 2019 were retrospectively analyzed. According to the outcome of weaning within 48 hours after weaning, patients were divided into weaning success group and weaning failure group. The baseline data, the presence of basic cardiopulmonary diseases, B-type natriuretic peptide (BNP), fluid balance, albumin and hemoglobin within 24 hours before weaning, the time of mechanical ventilation before weaning, rapid shallow breathing index (RSBI) during SBT, oxygenation index, cough peak flow at the end of SBT, and prognostic indicators were collected. The outcome of weaning was taken as the dependent variable, and the observation factors were taken as the independent variable for univariate analysis. The factors with statistical significance in univariate analysis were analyzed by binary Logistic regression to determine the influencing factors of weaning failure. Of the 204 patients, 167 (81.9%) were successfully weaned, and 37 (18.1%) failed. Compared with the weaning success group, the total duration of mechanical ventilation and the length of ICU stay in the weaning failure group were significantly longer [days: 13.0 (7.5, 23.5) vs. 5.0 (3.0, 8.0), 17.0 (12.5, 31.0) vs. 10.0 (6.0, 15.0), both P < 0.01], and the tracheotomy rate and mortality were significantly higher (32.4% vs. 0%, 51.4% vs. 0%, both P < 0.01). Univariate analysis showed that there were significant differences in age, proportion of patients with cardiopulmonary diseases, BNP and cough peak flow between weaning failure group and weaning success group [age (years old): 70.65±15.78 vs. 62.69±15.82, cardiopulmonary diseases: 62.2% vs. 24.6%, BNP (ng/L): 416.87 (32.70, 1 225.80) vs. 45.36 (10.00, 273.60), cough peak flow (L/min): 59.89±9.06 vs. 83.84±16.52, all P < 0.01]. However, there were no significant differences in gender, acute physiology and chronic health evaluation II (APACHE II) at admission, mechanical ventilation time before weaning, albumin, hemoglobin, oxygenation index, RSBI and fluid balance 24 hours before weaning between weaning failure group and weaning success group [male: 51.4% vs. 68.3%, APACHE II: 16.70±6.65 vs. 15.67±6.28, mechanical ventilation time before weaning (days): 6.0 (2.5, 11.0) vs. 5.0 (3.0, 8.0), albumin (g/L): 27.78±4.15 vs. 27.76±4.46, hemoglobin (g/L): 102.43±15.80 vs. 100.61±17.19, oxygenation index (mmHg, 1 mmHg = 0.133 kPa): 359.33±79.83 vs. 365.75±78.23, RSBI (times×L-1×min-1): 50.73±24.97 vs. 46.76±15.53, positive fluid balance: 70.3% vs. 69.5%, all P > 0.05]. The results of binary Logistic regression analysis showed that age ≥ 75 years old [odds ratio (OR) = 3.099, 95% confidence interval (95%CI) was 1.003-9.574, P = 0.049], presence of cardiopulmonary diseases (OR = 3.599, 95%CI was 1.126-11.498, P = 0.031), BNP within 24 hours before weaning (OR = 1.002, 95%CI was 1.000-1.003, P = 0.005) were the risk factors of extubation failure, while cough peak flow at the end of SBT was the protective factor (OR = 0.869, 95%CI was 0.823-0.917, P = 0.000). For patients who had successfully passed SBT, age ≥ 75 years old, the presence of cardiopulmonary diseases and an increased level of BNP within 24 hours were the risk factors of extubation failure. In addition, the higher the cough peak flow at the end of SBT, the lower the risk of weaning failure will be.

Decreased T Cell Levels in Critically Ill Coronavirus Patients: Single-Center, Prospective and Observational Study.

BackgroundSince Dec. 2019, the COVID-19 pandemic has been an outbreak. T cells play an important role in dealing with various disease-causing pathogens. However, the role of T cells played in COVID-19 patients is still unknown. Our study aimed to describe the immunologic state of the critically ill COVID-19 patients.MethodsA total of 63 patients with confirmed COVID-19 pneumonia were admitted to the Department of Intensive Care Unit of the First Affiliated Hospital of Harbin Medical University. The immunologic characteristics (lymphocyte apoptosis, the expression of PD-1 and HLA-DR in T cells, T cell subset levels, redistribution and the production of inflammatory factors) as well as their laboratory parameters were compared between severe group and critical group.ResultsThe level of T cells in peripheral blood was decreased in critical patients compared with that in severe patients, but the expression levels of PD-1 (CD4+: 24.71% VS 30.56%; CD8+: 33.05% VS 32.38%) and HLA-DR (T cells: 36.28% VS 27.44%; monocytes: 20.58% VS 23.83%) in T cells were not significantly changed, and apoptosis and necrosis were not different in lymphocytes (apoptosis: 1.04% VS 1.27%; necrosis: 0.67% VS 1.11%), granulocytes, or monocytes between those two groups.ConclusionThere is severe immunosuppression in critically ill COVID-19 patients. Redistribution of T cells might be the main reason for lymphocytic decline. Decreasing the infiltration of T lymphocytes in the lung may be beneficial for the treatment of COVID-19.

Strengthening and supporting nurses' communication with mechanically ventilated patients in the intensive care unit: Development of a communication intervention.

Nurse-patient communication in intensive care units is challenged by the fact that patients are voiceless due to intubation and mechanical ventilation. Difficult communication affects nurses negatively, and it requires knowledge and expertise to facilitate communication in this complex and technologically tense setting. Augmentative and alternative communication has been suggested as a way of optimising communication; several approaches can be combined in a multi-component intervention. Also, a communication algorithm has been proposed as a way of providing structure in patient communication. To enhance transparency and avoid poorly reported interventions, this paper describes the process, rationale and reflections behind developing a communication intervention called the ICU-COM. To present the development process of a communication intervention prototype that aims to support and strengthen nurses' communication with mechanically ventilated patients in an intensive care unit. The Medical Research Council's framework for developing complex interventions in health was applied. The approach was target-population centred. The intervention was developed and tailored to four intensive care unit departments at Aarhus University Hospital in Denmark. Intensive care nurses and various experts, namely, speech-language pathologists, graphic designers, a software company, the local Centre for E-learning and nurse specialists were involved in its development. An intervention consisting of: 1) a multi-component communication bundle, 2) delivery of the bundle via a teaching session and 3) initial implementation via nurse communication guides was developed. The communication bundle contained: 1) a communication strategy with a BASIS framework and algorithm, 2) a nurse education programme and 3) low-tech and high-tech communication tools. A systematic approach was applied in the development process. However, the acceptability and feasibility of the intervention is at present unknown.

Continuous prone position ventilation in patients with severe acute respiratory distress syndrome at high altitude

To investigate the therapeutic effect of different prone position ventilation (PPV) on patients with severe acute respiratory distress syndrome (ARDS) at high altitude. The severe ARDS patients who met the Berlin standard admitted to the department of intensive care unit (ICU) of Qinghai Provincial People's Hospital from January 2017 to January 2020 were enrolled. The patients with classic PPV treatment (i.e. alternate prone supine position, about 16 hours per day) were included in the discontinuous PPV group; the patients with modified PPV treatment (i.e. alternate left and right prone positions 20 degree angle-30 degree angle, every 4 hours and continuous treatment for 24 hours per day) were included in the continuous PPV group. The oxygenation index (PaO2/FiO2), mechanics of breathing, ventilator parameters before treatment and 72 hours after treatment, and mechanical ventilation time, the length of ICU stay, and related complications between the two groups were analyzed. Eighteen cases were treated with continuous PPV and 20 cases were treated with discontinuous PPV. There were no significant differences in gender, age, acute physiology and chronic health evaluation II (APACHE II), PaO2/FiO2, lung compliance, driving pressure (ΔP) and positive end expiratory pressure (PEEP) before treatment between the two groups. Compared with before treatment, PaO2/FiO2 in discontinuous PPV group and continuous PPV group was increased significantly after 72-hour treatment [mmHg (1 mmHg = 0.133 kPa): 99.7±15.4 vs. 55.5±6.3, 121.8±25.3 vs. 55.1±7.1, both P < 0.05], lung compliance was improved significantly (mL/cmH2O: 36.8±2.4 vs. 28.0±2.0, 43.4±6.7 vs. 27.7±2.1, both P < 0.05), and ΔP was decreased significantly [cmH2O (1 cmH2O = 0.098 kPa): 10.5 (10.0, 12.0) vs. 13.0 (12.3, 14.0), 10.0 (8.0, 12.0) vs. 13.0 (12.0, 14.0), both P < 0.05], PEEP was also decreased [cmH2O: 12 (12, 14) vs. 14 (13, 14), 10 (8, 10) vs. 14 (12, 15), both P < 0.05], and the indexes in continuous PPV group were improved more significantly than those in discontinuous PPV group [PaO2/FiO2 (mmHg): 121.8±25.3 vs. 99.7±15.4, lung compliance (mL/cmH2O): 43.4±6.7 vs. 36.8±2.4, ΔP (cmH2O): 10.0 (8.0, 12.0) vs. 10.5 (10.0, 12.0), PEEP (cmH2O): 10 (8, 10) vs. 12 (12, 14), all P < 0.05]. The duration of mechanical ventilation and the length of ICU stay in the continuous PPV group were significantly shorter than those in the intermittent PPV group [days: 6.0 (5.0, 7.3) vs. 8.0 (7.0, 9.0), 9.7±1.5 vs. 12.1±2.2, both P < 0.01]. During the PPV treatment, there were 3 cases of cheek skin damage and 2 cases of ear skin damage in the continuous PPV group, and 3 cases of facial skin damage in the intermittent PPV group. There was no significant difference in the incidence of complications between the two groups (χ2 = 0.321, P = 0.571). All patients were repaired normally after PPV, without adverse consequences. Continuous PPV is more effective than discontinuous PPV in the treatment of severe ARDS patients at high altitude, and the related complications are did not increased in prolonged time of PPV.

Risk factors for citrate accumulation in patients with liver failure undergoing continuous renal replacement therapy with regional citrate anticoagulation

To investigate the risk factors of citrate accumulation in patients with liver failure treated with regional citrate anticoagulated continuous renal replacement therapy (RCA-CRRT). The clinical data of liver failure patients with RCA-CRRT admitted to department of intensive care unit (ICU) of Nantong Third People's Hospital from January 2017 to June 2020 were retrospectively analyzed. The selected patients were divided into citrate accumulation group and control group according to whether there was citrate accumulation (serum total calcium/free calcium ratio ≥ 2.4) during CRRT. The age, acute physiology and chronic health evaluation II (APACHE II), mean arterial pressure (MAP), norepinephrine (NE) dose, blood lactic acid (Lac) concentration, liver function status, citrate dose, filter time and prognosis of the patients were compared between the two groups. Unconditional Logistic regression was used to analyze the risk factors for citrate accumulation. Among 48 patients with RCA-CRRT and liver failure, 20 patients had citrate accumulation (accumulation group), and a total of 96 CRRTs were performed; the remaining 28 patients did not have citrate accumulation (control group), a total of 106 CRRTs were performed. There were no significant differences in age and APACHE II score between the two groups. Compared with the control group, the MAP in the accumulation group was lower [mmHg (1 mmHg = 0.133 kPa): 66.9±13.6 vs. 86.4±8.3, P = 0.032], and the dosage of NE (μg/min: 16.3±8.4 vs. 5.9±2.8, P = 0.015) and lactic acid level (mmol/L: 4.89±1.45 vs. 2.98±0.87, P = 0.004) were higher, the damage of liver function was more serious [total bilirubin (TBil, μmol/L): 220.4±45.2 vs. 163.4±43.8, P = 0.012; Child-Pugh score: 12.0±2.5 vs. 8.8±1.4, P = 0.029; model for end-stage liver disease (MELD) score: 31.30±8.22 vs. 21.78±6.40, P = 0.041], hourly citric acid dosage (mmol/h: 27.4±6.9 vs. 19.3±4.9, P = 0.032) and total citric acid dosage (mmol: 3 393±809 vs. 1 819±502, P = 0.039) were higher. Although there were no significant differences in the length of ICU stay, total length of hospitalization stay and cost of hospitalization between the two groups, the 28-day mortality of the accumulation group was higher than that of the control group (60.0% vs. 28.6%, P = 0.039). Unconditional Logistic regression analysis showed that MAP [odds ratio (OR) = 2.901, 95% confidence interval (95%CI) was 0.921-19.493, P = 0.019], NE dosage (OR = 2.098, 95%CI was 1.923-12.342, P = 0.002), Lac level (OR = 5.201, 95%CI was 3.211-9.433, P = 0.012), Child-Pugh score (OR = 1.843, 95%CI was 0.437-7.420, P = 0.018), MELD score (OR = 3.012, 95%CI was 0.384-12.843, P = 0.031), hourly citric acid dosage (OR = 4.254, 95%CI was 1.734-11.839, P = 0.011) and total citric acid dosage (OR = 4.109, 95%CI was 1.283-18.343, P = 0.001) were risk factors for citrate accumulation. In patients with tissue hypoperfusion and severe liver function damage, citrate anticoagulation should be avoided or the dosage of citric acid should be reduced, in order to avoid citrate accumulation.

Is COVID-19 infection more severe in kidney transplant recipients?

There are no studies which have compared the risk of severe COVID‐19 and related mortality between transplant recipients and nontransplant patients. We enrolled two groups of patients hospitalized for COVID‐19, that is, kidney transplant recipients (KTR) from the French Registry of Solid Organ Transplant (n = 306) and a single‐center cohort of nontransplant patients (n = 795). An analysis was performed among subgroups matched for age and risk factors for severe COVID‐19 or mortality. Severe COVID‐19 was defined as admission (or transfer) to an intensive care unit, need for mechanical ventilation, or death. Transplant recipients were younger and had more comorbidities compared to nontransplant patients. They presented with higher creatinine levels and developed more episodes of acute kidney injury. After matching, the 30‐day cumulative incidence of severe COVID‐19 did not differ between KTR and nontransplant patients; however, 30‐day COVID‐19‐related mortality was significantly higher in KTR (17.9% vs 11.4%, respectively, p = .038). Age >60 years, cardiovascular disease, dyspnea, fever, lymphopenia, and C‐reactive protein (CRP) were associated with severe COVID‐19 in univariate analysis, whereas transplant status and serum creatinine levels were not. Age >60 years, hypertension, cardiovascular disease, diabetes, CRP >60 mg/L, lymphopenia, kidney transplant status (HR = 1.55), and creatinine level >115 µmol/L (HR = 2.32) were associated with COVID‐19‐related mortality in univariate analysis. In multivariable analysis, cardiovascular disease, dyspnea, and fever were associated with severe disease, whereas age >60 years, cardiovascular disease, dyspnea, fever, and creatinine level>115 µmol/L retained their independent associations with mortality. KTR had a higher COVID‐19‐related mortality compared to nontransplant hospitalized patients.

Rapid deployment of an emergency department-intensive care unit for the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume. This paper describes one institution’s emergency department (ED) innovation at the center of the COVID-19 crisis, including the creation of a temporary ED–intensive care unit (ICU) and development of interdisciplinary COVID-19–specific care delivery models to care for critically ill patients. Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently rescue due to its size and lack of negative pressure rooms. Within 1 week, the ED-based observation unit, which has four negative pressure rooms, was quickly converted into a COVID-19–specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit. An increase in staffing for physicians, physician assistants, nurses, respiratory therapists, and medical technicians, as well as training in critical care protocols and procedures, was needed to ensure appropriate patient care. The transition of the ED to a COVID-19–specific unit with the inclusion of a temporary expanded ED-ICU at the beginning of the COVID-19 pandemic was a proactive solution to the growing challenges of surging patients, complexity, and extended boarding of critically ill patients in the ED. This pandemic underscores the importance of ED design innovation with flexible spacing, interdisciplinary collaborations on structure and services, and NP ventilation systems which will remain important moving forward.

Demographic and clinical profile with early outcome of critically ill COVID-19 patients admitted in an ICU of a tertiary care hospital in Dhaka, Bangladesh

Background: First outbreak of corona virus disease (COVID-19) started in Wuhan, China at December 2019 and since then, it spread globally but information about critically ill patients with COVID-19 is still limited. So, it is important to know the demographic profile and overall outcome of COVID-19 patients. We aimed to describe the clinic-demographic characteristics and outcome of critically ill COVID-19 patients admitted in our intensive care unit.&#x0D; Methods: This prospective observational study was carried out in the intensive care unit of department of Critical Care Medicine of BIRDEM General Hospital, Dhaka, Bangladesh from 11th June to 31st October, 2020. Out of 382 suspected cases, 86 patients were found to be RT-PCR for COVID-19 positive and were included in this study. After admission in ICU, all patients were resuscitated according to ICU protocol. Length of ICU stay were recorded and patient outcomes were mentioned as survival (transferred or discharged) or death.&#x0D; Results: A total of 86 patients (male 53, female 33, mean age 63.6 ± 12.8 years) with RT-PCR for COVID-19 positive were enrolled in this study. Regarding COVID related symptoms, Ninety six percent(83) had respiratory distress, 93.02 % (n=80) had cough, 84.9% (n=73) had history of fever,11.6 % (n=10) had loose motion and 7% (n=6), had anosmia. Diabetes mellitus (DM) was the most common co morbidity (91.9%).For improvement of oxygenation of COVID patient, we treated 7% of patients (n=6) by nasal Cannula, 24.4% (n=21) by Face Mask, 20.9% (n=18) by Non Rebreather Mask, 22.1% (n= 19) by High Flow Nasal Cannula (HFNC) and 25.6% (n= 22) by Mechanical Ventilation. Mean length of ICU stay were 6.9 ± 3.6 days and range of icu stay were 1-20 days. Among 86 COVID patient, 51.16% (n=44) were transferred to the isolation ward or discharged at home and 48.8% (n=42) were died.&#x0D; Conclusion: This study showed the overall demographic and clinical features of critically ill COVID-19 patients, admitted in an icu of a tertiary care hospital. As it is a single centered study, we need more study with multi center approach to know the detail demographic profile and outcome of COVID-19 patients.&#x0D; Birdem Med J 2020; 10, COVID Supplement: 51-55

Reference ranges for M-mode echocardiographic measurements within seven days after birth in preterm infants

Objective: To establish reference ranges for M-mode echocardiography in preterm infants within 7 days after birth based on different gestational age (GA) and birth weight. Methods: This retrospective study analyzed M-mode echocardiographic values of 489 premature infants, who were admitted to the neonatal intensive care unit of Department of Pediatrics, Peking University Third Hospital from March 2017 to February 2020. These infants were divided into four groups according to GA:<28 weeks, 28-31+6weeks, 32-33+6weeks and 34-36+6weeks; and five groups according to birth weight:<1 000 g, 1 000-1 499 g, 1 500-1 999 g, 2 000-2 499 g and ≥2 500 g. The M-mode values among groups were compared by independent sample K-W test, and based on which, the 95% confidence interval (CI) and the Z-value reference ranges were established. Results: The gestational age of these infants was 32.0 (24.0-36.7) weeks, and the birth weight was 1 700 (650-3 180) g. The interventricular septum end-diastolic thickness (IVSd), left ventricular posterior wall end-diastolic thickness (LVPWd), left atrial diameter (LAD), left ventricular end-diastolic diameter (LVED), left ventricular end-systolic diameter (LVES), right ventricular outflow tract (RVOT) and the right ventricular end-diastolic diameter (RVED), were all correlated with GA and birth weight (r = 0.209, 0.216, 0.430, 0.608, 0.495, 0.464, 0.447; r = 0.275, 0.288, 0.445, 0.609, 0.496, 0.499, 0.464;all P<0.01). While the left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) had no correlation with GA or birth weight (all P<0.05). Within the first 7 days after birth, the greater the GA and birth weight, the greater the inner diameters of the heart chambers, and the thicker the ventricular wall. The LVEF and LVFS maintained a high and stable level within the first week of life (95%CI: 67%-69%, 34%-36%). Conclusions: According to different GA and birth weight, the reference ranges for chamber diameters, interventricular septal thickness and left ventricular wall thickness within 7 days were established. The 95% CI and Z score ranges for M-mode echocardiographic measurements established based on gestational age and birth weight can provide a reliable reference for preterm infants aged 0-7 days.

Cardiac murmur in a neonate: how significant is it?

Background: There is a popular belief that cardiac murmurs are common in neonate and most are innocent or physiological. However, a cardiac murmur may be the first sign of a serious structural cardiac disease in neonate. Objective of study was conducted to determine the clinical significance of cardiac murmur as a sole clinical sign in neonate.Methods: 100 neonates having cardiac murmur were selected from neonatal intensive care unit of department of pediatrics BJMC Ahmedabad from June to November 2019. Murmurs were clinically classified as innocent or significant murmur. Echocardiography was done at UN Mehta institute of cardiology for confirmation of the diagnosis and then patients were reclassified as innocent murmur and structural heart defect. structural heart defects were further subdivided into physiological variant or significant heart defect.Results: Amongst 100 neonates studied, sixty two percent cases with murmur were found to have structural heart defect and 38% had innocent murmur. Among the cases with structural heart defect. 65.3% were found to have significant heart defect and 34.7% were physiological variant. Clinical suspicion was able to differentiate innocent murmur or structural heart defect (p&lt;0.05) as well as physiological variant versus significant heart defect (p&lt;0.05).Conclusions: Confident diagnosis of heart disease in the newborn period on clinical examination is probably possible by pediatricians or neonatologists. However, for confirmation of diagnosis, early echocardiographic evaluation is necessary.

Design and implementation of a temporary emergency department-intensive care unit patient care model during the COVID-19 pandemic surge.

The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID‐19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID‐19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary “emergency department‐intensive care unit” (ED‐ICU) patient care service. Critical care‐trained emergency physicians took call and came into the hospital overnight/on weekends to provide bedside treatment to admitted ICU patients boarding for prolonged periods in our ED. In this manuscript, we describe the creation and execution of the ED‐ICU service and the characteristics and management of the patients who received care under this model.

Current Practice in FFP Preparation and Use in Greece: A National Survey

Objective:Fresh frozen plasma (FFP) transfusion is widely used in modern clinical settings. Practices regarding its use vary due to lack of guidelines from randomized trials. The aim of this study was to assess both the current practices regarding FFP production, use, and wastage and the implementation of quality control (QC), female donor plasma production policies, and use of pharmaceutical hemostatic agents in Greece.Materials and Methods:The study was conducted during February-April 2018. For the first part of the study, data including FFP transfusion indication, hospital department, diagnosis, FFP units/transfusion episode, ABO compatibility, blood donor’s sex, and reasons for discarding were collected. For the second part, questionnaire data were analyzed.Results:According to data from 20 Greek hospitals, 12655 FFP units were transfused to 2700 patients during 5069 transfusion episodes in the studied period of time. Most patients were hospitalized in internal medicine, general surgery, and intensive care unit departments. Each patient received on average 4.69 units (2.5 units/episode). Transfusion requests were in accordance with international guidelines in 63.44% of cases and 99.04% of the units were given to ABO-identical patients. Main reasons for discarding included failure to meet quality requirements (30.06%), female donors (22.17%), and other causes (27.26%). Among 96.9% of all transfusion services across the country, 28.26% perform QC according to the directions of the European Directorate for the Quality of Medicines & Health Care and 68.83% discard plasma from female donors. Pharmaceutic hemostatic agents are used in 37.23% of the hospitals.Conclusion:This is the first national survey regarding FFP production and transfusion in Greece. Staff of internal medicine, general surgery, and ICU departments, where most FFP-transfused patients are hospitalized, should be regularly involved in training on contemporary transfusion guidelines. Upcoming centralization of FFP production and inventory management could help in homogenizing practices regarding FFP use and improve product quality. Strengthening the use of pharmaceutic hemostatic agents could improve patients’ management.

Refining Blood Products Utilization: Every One (unit) Matters. Post-Intervention Study

INTRODUCTION: Transfusion of red blood cells (RBCs) is a balance between providing benefits for patients while avoiding risks of transfusion. Meta-analyses of randomized controlled trials (RCT) comparing restricted versus liberal blood transfusion showed that there was no significant difference in terms of morbidity, mortality, or risk of myocardial infarction. In fact, the restrictive strategy had a significantly lower risk of all-cause mortality in patients with gastrointestinal bleeding. It also resulted in a significantly lower number of transfused units and a lower number of patients needing a transfusion. Examining the extent of adherence to the American Association of Blood Banks (AABB) transfusion guidelines in our VA medical center showed that the average transfused units were 1.4 units per person. The Average pre-transfusion hemoglobin (Hgb) was 7.6. 54% received 2 units, whereas 46% received 1 unit. AIM OF THE WORK: To improve the blood transfusion practice in our VA medical center to better comply with the (AABB) transfusion guidelines and to establish a culture of change to improve patient safety, minimize risks of transfusion reaction and reduce the cost. METHODOLOGY: This is a prospective analysis of transfused patients in the period of November 2019 to April 2020 (n=228) as a continuation of the prior retrospective analysis of randomly selected patients in 2018 (n=162). The data was retrieved from an electronic medical record database, which included patient gender, age, co-morbidities, mean baseline Hgb, pre- and post-transfusion Hgb, hemodynamic status, ordering division, and the number of units transfused. INTERVENTIONS We implemented a two-tier auditing system, based on a low and high priority, which reflects the timeline to address non-compliant transfusion orders. Low priority orders were evaluated during the periodic meeting of the transfusion committee, and high priority orders were addressed within a few hours of the transfusion order. All transfusion orders of Hgb &amp;gt; 7-8 g/dL were flagged with low priority, whereas those with Hgb &amp;gt; 8 g/dL and/or with orders exceeding one unit were flagged with high priority. The appropriate approval was obtained through the institutional review board (IRB), patients' consents for enrollment, and anonymity was maintained all through the study. RESULTS: The total number of transfused PRBC units was 386 units with a mean of 1.6 units per patient compared to 1.7 units in the pre-intervention group (p=0.056). The average Hgb before transfusion was 7.7 mg/dL compared to 7.5 mg/dL in the pre- versus the post-intervention group (p=0.659). Comparing the pre-transfusion Hgb values in both groups per ordering division showed that the average Hgb values were lower after the intervention among all divisions except for the hematology/oncology department. This difference was statistically significant in the Intensive Care Unit (ICU). In terms of the number of transfused units, overall, there was a decrease in the number of transfused units, however, this was not statistically significant.(table 1) The department with the highest number of transfused units was internal medicine. DISCUSSION: Our study showed that the application of an auditing system within the electronic medical system resulted in significant improvement in the transfusion practice in the ICU department. The lack of significant effects among other departments can be attributed to the lower number of cases in the pre- versus post-intervention cohorts, e.g. 22 versus 50 in the Hematology/Oncology department and 6 versus 26 in the Emergency Department. Besides, it was difficult to gauge the reasoning for blood transfusion among the different departments whether it was for objectively significant blood loss despite the stable hemodynamics, or due to symptomatic anemia. The overall acceptance of the new system should be further investigated through a qualitative study e.g. individual interviewing or group discussions to explore reasons for possible resistance to change. CONCLUSION: Changing the transfusion order can help in improving the transfusion practice in healthcare facilities. However, this strategy alone may not be effective, and further investigations into the root causes of the non-significant change in some departments are needed. Enforcing the electronic auditing system along with staff development workshops may result in better outcomes. Disclosures No relevant conflicts of interest to declare.

Study on mechanical ventilation pressure under continuous cuff pressure monitoring in critical patients

To explore the effective pressure range under continuous cuff pressure monitoring in critical patients with mechanical ventilation, so as to achieve the goal of ensuring ventilation quality and reducing mucosal injury without increasing the incidence of endotracheal catheter displacement and aspiration. Ninety critically ill patients with non-pulmonary diseases admitted to the department of intensive care unit (ICU) of Airport Hospital of Tianjin Medical University from June 2017 to June 2019 were enrolled, and divided into three groups according to the random number table, with 30 patients in each group. For all patients in the three groups , the head of the bed was raised by 30 degree angleand the balloon was measured continuously. Cuff pressure in the three groups were maintained at 20, 25 and 30 cmH2O (1 cmH2O = 0.098 kPa) respectively. The patient's air leakage, oxygen saturation, tracheal tube displacement of each group were recorded every hour when the patients were calm. Fiberbronchoscope was used to aspirate sputum during extubation to check for mucosal damage. Chest X-ray examination was used to evaluate pulmonary infection and sputum bacteria culture examination was conducted at the same time. There was no significant difference in gender, age and critical condition among the three groups. The number of patients with airway mucosal injury in the 30 cmH2O group was significantly higher than that in the 20 cmH2O group (cases: 8 vs. 4, P < 0.05). There was no significant difference in airway mucosal injury between Group 20 cmH2O and Group 25, Group 25 cmH2O and Group 30 cmH2O. When the balloon pressure was 20, 25, and 30 cmH2O, there was no significant difference in air bag leakage (cases: 14, 10, 12), trachea catheter displacement (cases: 18, 11, 16), ventilator-associated pneumonia (cases: 3, 4, 3), all P > 0.05, and there was no significant difference in mechanical ventilation time and the hospitalization time [mechanical ventilation time (hours): 77.07±65.34, 80.80±70.20, 77.60±65.23; the length of ICU stay (days): 5.70±3.74, 5.30±4.57, 6.23±3.51, all P > 0.05]. The cuff pressure of 20 cmH2O will not increase the mechanical ventilation time and hospitalization time of patients, while 20 cmH2O is much safer in airway mucosal injury.

The prognostic role of the programmed death-1 expression on T lymphocytes in septic patients

Objective: To investigate the value of programmed death-1（PD-1） expression on the T lymphocytes for the prognosis of septic patients. Methods: From September 2017 to May 2019, septic patients were included in Department of Intensive Care Unit at 6 hospitals. The PD-1 expression on T cells were measured by flow cytometry. Logistic regression was conducted to analyze independent risk factors related to death within 28 days，and receiver operating characteristic curve(ROC) was conducted to evaluate the prognostic value of PD-1 expression on T cells in septic patients. Results: A total of 64 septic patients were enrolled to this study，including 32 survivors and 32 deaths. The PD-1 expression on T cells in the death group was significantly higher than that in the surviving group (P<0.05). Correlation analysis showed that the percentages of PD-1+/CD3+T cells and PD-1+/CD8+T cells were positively correlated with procalciton in (r=0.313, P =0.015；r=0.375, P=0.003), logistic regression analysis showed that the percentages of PD-1+/CD3+，PD-1+/CD4+，PD-1+/CD8+T cells were independent risk factors for the death of sepsis patients. The percentage of PD-1+/CD3+T cell was 3.63%, with AUC 0.842, sensitivity to predict the mortality 96.43% and specificity 59.38%, (P<0.000 1). The percentage of PD-1+/CD4+T cell was 4.65%, with AUC 0.847, sensitivity 96.43%, specificity 62.50%，(P<0.000 1). The percentage of PD-1+/CD8+T cell was 3.91%, with AUC 0.771, sensitivity 64.29%, specificity 81.25%，(P=0.000 3). Conclusions: The T cell PD-1 expression is an independent risk factor to predict the 28-day mortality in septic patients. Combining the proportions of PD-1+/CD3+, PD-1+/CD4+and PD-1+/CD8+T cells may further enhance the predictive value for death.

Study on the effect of sedation strategy guided by driving pressure on prognosis of patients with mechanical ventilation

To evaluate the effect of airway driving pressure (ΔP) guided sedation strategy on the prognosis of patients with mechanical ventilation. Patients who needed invasive mechanical ventilation and admitted to the department of intensive care unit (ICU) of Jiangxi Provincial People's Hospital from January 2017 to December 2018 were enrolled. The patients were divided into study group and control group according to the random number table. After informed consent of patients or their families, both groups received routine treatment in ICU. The control group was treated with light sedation strategy, the Richmond agitation sedation score (RASS) was performed every 4 hours, and the target was RASS > -3. ΔP in the study group was measured once a day, and the sedative target of patients with low driving pressure (ΔP ≤ 14 cmH2O, 1 cmH2O = 0.098 kPa) was RASS > -3, while the patients with high driving pressure (ΔP > 14 cmH2O) was RASS ≤ -3. The evaluation was conducted at 28 days after admission to ICU, and the patients were followed up to 60 days. The main outcome was days without mechanical ventilation in 28 days. The secondary outcomes were the rate of extubation, discharge outcome, incidence of ventilator associated pneumonia (VAP) and delirium, and 60-day survival rate. A total of 60 patients with respiratory failure due to various reasons were recruited, 30 in each group. There was no significant difference in gender, age, primary disease, severity of disease or ΔP between the two groups. The days without mechanical ventilation within 28 days in the study group were significantly more than that in the control group [days: 20 (0, 23) vs. 12 (0, 16), P = 0.018], and the incidences of VAP (3.3% vs. 16.7%, P = 0.045) and delirium (0% vs. 10.0%, P = 0.038) were significantly lower than that in the control group. There were no significant differences in the rate of extubation (73.3% vs. 66.7%, P = 0.273), discharge outcome [improvement (cases): 24 vs. 21, unhealed (cases): 2 vs. 5, deaths (cases): 4 vs. 4, P = 0.506] and 60-day survival rate (83.3% vs. 76.7%, P = 0.519) between the study group and control group. Compared with light sedation strategy, ΔP directed sedation strategy can effectively shorten the duration of mechanical ventilation and reduce the incidence of VAP and delirium in the ICU patients.