Intensive Care Unit Research Articles

Relationship between age and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage requiring invasive mechanical ventilation: a secondary analysis

The association between age and delayed cerebral ischemia (DCI) has long been controversial. This study aimed to explore the relationship between age and DCI in patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring invasive mechanical ventilation (IMV). This study reanalyzed previously published data from a French university hospital. Chalard K et al. conducted a retrospective cohort study in the intensive care unit from 2010 to 2015. Univariate and multivariate logistic regression analyses were employed to identify risk factors for DCI. The non-linear relationship between age and DCI was estimated through a restricted cubic spline regression, and a two-piecewise linear regression model was further performed to calculate the threshold effect. The analysis included 222 patients with aSAH requiring IMV. Their median age was 56 years (range 19–84 years). Patients were equally divided into four groups: Q1 (19–45 years), Q2 (46–55 years), Q3 (56–63 years), and Q4 (64–84 years). The incidence of DCI was 27.48% (N = 61). After adjustment for potential confounders, patients in group Q2 were found to be more likely to develop DCI [odds ratio (OR), 4.91; 95% Confidence Interval (CI), 1.53–15.70] compared to those in group Q1. After adjusting for confounding variables, for patients aged < 53 years, the risk of DCI increased by 14% (OR, 1.14; 95% CI 1.05–1.23) for each 1-year increase in age. For patients aged 53 to 77 years, the risk of DCI decreased by 19% (OR, 0.81; 95% CI 0.73–0.88) for each 1-year increase. For patients aged > 77 years, the risk of DCI did not decrease with increasing age (OR, 1.42; 95% CI 0.47–4.34). Age was non-linearly associated with DCI in patients with aSAH requiring IMV.

The effect of GM-CSF and predictors of treatment outcome in pediatric septic shock patients

BackgroundPediatric septic shock is a critical condition associated with high mortality rates, largely due to sepsis-induced immunosuppression. Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been explored as a therapeutic intervention to counteract this immunosuppression. Despite its potential, the efficacy of GM-CSF in pediatric septic shock has not been clearly established. This study aims to investigate the impact of GM-CSF administration on survival rates and to identify key predictors of treatment outcomes in pediatric septic shock patients.MethodsWe conducted a retrospective cohort study at the Pediatric Intensive Care Unit (PICU) of Children’s Hospital of Fudan University, Shanghai, from January 1, 2019, to December 31, 2023. The study included pediatric patients diagnosed with septic shock, analyzing their demographic data, GM-CSF and adjunctive therapies, laboratory results, and clinical outcomes. We employed univariate and multivariate logistic regression models to assess the influence of GM-CSF on 28-day mortality and identify significant predictors of treatment outcomes.ResultsThe study included 200 pediatric patients, with 66 receiving GM-CSF treatment and 134 not treated with GM-CSF. The initial comparison showed a higher 28-day mortality in the GM-CSF group (59.1%) compared to the non-GM-CSF group (35.1%, P = 0.001). Notably, after adjustment for confounding factors, multivariate analysis revealed that the effect of GM-CSF treatment on 28-day mortality among pediatric septic shock patients did not reach statistical significance, with an odds ratio (OR) of 0.472 and a 95% confidence interval (CI) ranging from 0.153 to 1.457 (P = 0.192). However, the analysis indicated a potential trend suggesting that GM-CSF treatment may contribute to a reduction in 28-day mortality. In addition, significant predictors of treatment outcomes included hematopoietic stem cell transplantation (HSCT), lactic acid (LAC) levels, hospital-acquired septic shock (HASS), red blood cell (RBC) count, and platelet (PLT) count.ConclusionsGM-CSF treatment may benefit pediatric septic shock patients, especially those with higher lactic acid, and lower RBC and platelet counts. These factors, which are significant predictors of outcomes, should be monitored during therapy.

Caring Readiness Among Parents of Children Who Have Undergone Liver Transplantation and Are Transitioning From the Intensive Care Unit: A Cross-Sectional Study.

To investigate the status and influencing factors of caring readiness among parents of children undergoing liver transplantation transitioning from the intensive care unit, and to explore the associations between caring readiness and other variables. A cross-sectional study. A total of 126 parents of children who underwent liver transplantation at a tertiary hospital in China took a questionnaire survey via convenience sampling. Independent t-test, ANOVA and correlation analysis were conducted to analyse the data. Multivariable stepwise linear regression was used to analyse the influencing factors of caring readiness. The PROCESS macro (Model 4) was used to verify the mediating effect of caregiver burden between social support and caring readiness. The STROBE checklist was used as a guideline in this study. The mean score of caring readiness among parents of children who had undergone liver transplantation and were transitioning from the intensive care unit was 23.62 ± 5.34. Multivariable stepwise linear regression analysis indicated that experience with caregiving, intensive care unit length of stay, social support and caregiver burden were the factors associated with caring readiness, explaining 18.6% of the variance in caring readiness among parents. Caregiver burden partially moderated the relationship between social support and caring readiness (20.93%). The study shows caring readiness was moderate among parents of children who have undergone liver transplantation and are transitioning from the intensive care unit. It reveals that lack of caregiving experience and children's short intensive care unit length of stay should be emphasised, preventing inadequate readiness of parents. Furthermore, enhancing social support interventions and burden-reduction strategies are important for improving parents' caring readiness. The findings demonstrate that health care professionals should provide timely and appropriate intervention strategies to enhance parents' caring readiness, which could potentially be achieved by increasing social support and reducing caregiver burden. Parents of children who underwent liver transplantation participated in this study via a questionnaire survey.

Predicting the risk of invasive fungal infections in ICU sepsis population: the AMI risk assessment tool.

Invasive fungal infections (IFI) represent a significant contributor to mortality among sepsis patients in the Intensive Care Unit (ICU). Early diagnosis of IFI is challenging, and currently, there are no predictive tools for identifying sepsis patients who may develop IFI. Our study aims to develop a predictive scoring system to assess the risk of IFI in patients with sepsis admitted to the ICU. A retrospective collection of data from a total of 549 patients was conducted. Data-driven, clinically knowledge-driven, and decision tree models were used to identify predictive variables for risk of IFI in ICU patients with sepsis. Demographic data, vital signs, laboratory values, comorbidities, medication use, and clinical outcomes were all collected. The optimal model was selected based on model performance and clinical utility to establish a risk score. Among adult patients with sepsis admitted to the ICU, 127 patients (23.1%) developed IFI. The final data-driven model included four predictive factors, the clinically knowledge-driven model included three predictive factors, and the decision tree model included two. Based on the good performance and clinical utility of the clinically knowledge-driven model, it was chosen as the optimal risk scoring model (C-statistics: 0.79 (95% confidence interval (CI): 0.75-0.83); Hosmer-Lemeshow (H-L) test P = 0.884). The ICU sepsis patient invasive fungal infection risk (AMI) score, created based on the clinically knowledge-driven model, includes mechanical ventilation, application of immunosuppressants, and the types of antibiotics used. The C-statistics for this risk score was 0.79 (95% CI:0.75-0.84) with good calibration (H-L test P = 0.992 and see calibration curve: Fig.2). Moreover, in terms of clinical utility, the decision curve analysis for AMI showed a favorable net benefit. The application of the AMI score can effectively distinguish whether ICU sepsis patients will develop IFI, which is beneficial for clinicians to formulate targeted and timely preventive and treatment measures based on the risk of IFI.

Individualized drug therapy and survival prediction in ICU patients with acute kidney injury: construction and validation of a nomogram

BackgroundAcute kidney injury (AKI) is defined by a sharp decrease in the estimated glomerular filtration rate (eGFR). However, the impact of medication history on the survival of AKI patients has received little attention. Hence, it is necessary to investigate the potential of medication history as a predictor of survival outcomes among AKI patients in the intensive care unit (ICU).MethodsCritically ill AKI patients were sourced from the MIMIC-IV database. To ascertain significant, drug-related, independent predictors of survival, univariate Cox analysis and stepwise Cox regression were performed. Based on the identified predictor, a nomogram was developed to estimate the individualized survival probability for AKI patients. Additionally, to address potential confounders among patients with medications referenced in the nomogram, a propensity score matching procedure was applied. Ultimately, a comparative analysis was performed to elucidate the prognostic disparities among these patient subgroups.ResultsThis study enrolled 1,208 patients and developed a nomogram incorporating oxygen flow rate, respiratory frequency, continuous venovenous hemodiafiltration status, age, and medication use (including ibuprofen, epinephrine, cefazolin, warfarin, and vasopressin). The predictive model demonstrated diagnostic accuracy, with AUC values for 1-year, 3-year, and 5-year survival among AKI patients of 0.827, 0.799, and 0.777 in the training dataset, and 0.760, 0.743, and 0.740 in the internal validation dataset, respectively. Kaplan–Meier survival analyses revealed significant differences in survival outcomes among AKI patients based on their exposure to different medications.ConclusionsIn summary, the developed prediction model demonstrated accuracy for AKI patients in the ICU and helped clinical decision-making. However, future studies will require external validation to confirm these findings.

L-shaped association of body mass index with prognosis in individuals with sepsis: a multicenter cohort study

ObjectiveThe relationship between body mass index (BMI) and sepsis prognosis remains highly controversial and uncertain. This study investigated the association between BMI and prognosis in patients with sepsis.MethodsThis retrospective observational cohort study included adult patients admitted to the intensive care unit (ICU) with sepsis from Medical Information Mart for Intensive Care-IV version 2.2 (MIMIC-IV V2.2) and eICU Collaborative Research Database (eICU-CRD). The cut-off value of BMI was identified by the restricted cubic spline (RCS) curve and included patients were categorized into two groups: the low BMI group (< 28 kg/m2) and the high BMI group (≥ 28 kg/m2). The primary outcome was ICU mortality, and secondary outcomes were in-hospital and 28-day mortality. We performed the log-rank test to detect whether there is a difference in prognosis among different groups in two different cohorts. Multiple distinct models were used to validate the robustness of the results.ResultsThere were 18,385 and 38,713 patients in the MIMIC-IV 2.2 and eICU-CRD cohorts, respectively. An L-shaped relationship was observed between BMI and ICU mortality in the primary analysis from MIMIC-IV 2.2. Similar relationships were found in eICU-CRD. When BMI was less than the cut-point, the risk of ICU mortality increased rapidly with decreasing BMI. When BMI was greater than the cut-point, the risk of ICU mortality levelled off as BMI increased. Sepsis patients with higher BMI values exhibited decreased ICU all-cause mortality rates (MIMIC-IV cohort: HR: 0.81, 95% CI 0.75–0.88, p < 0.001; eICU-CRD cohort: HR: 0.75, 95% CI 0.71–0.80, p < 0.001). Consistent trends were observed for both in-hospital mortality and 28-day mortality rates. The results remained robust in multiple distinct models and subgroup analyses.ConclusionAn L-shaped relationship was observed between BMI and prognosis in septic patients, indicating that lower BMI values are significantly linked to increased mortality. Targeted nutritional interventions and close monitoring for patients with low BMI could potentially enhance their prognosis. Therefore, BMI can also be utilized to categorize the risk levels of patients with sepsis and effectively predict their prognosis.

A Retrospective Study Evaluating the Safety and Clinical Impact of High Dose (6.75grams) Piperacillin-Tazobactam Dosing in Critically Ill Obese Patients for Pneumonia.

Background: Piperacillin-tazobactam (PTZ) demonstrates time-dependent bactericidal activity, potentially increasing the need for higher dosing in obese and critically ill patients. However, limited information is available on the safety of higher dosing strategies. Objective: To evaluate the safety and clinical impact of high dose 6.75g IV PTZ for the treatment of pneumonia in critically ill, obese (≥120kg) patients vs standard dose 4.5g IV PTZ. Methods: Retrospective, cohort study, multicenter in health-system consisting of four acute-care teaching hospitals. Adult patients weighing at least 120kg on PTZ for pneumonia in the intensive care unit (ICU) from January 2013 to September 2018 were included. The primary outcome of the study was acute nephrotoxicity defined as initiation of renal replacement therapy and/or serum creatinine increase within 48hours of last PTZ dose. Secondary outcomes included thrombocytopenia, 14-day all-cause mortality, and ICU length of stay (LOS). Results: One hundred thirty-six patients were included with 52 and 84 in 4.5g PTZ and 6.75g PTZ respectively. The rate of acute nephrotoxicity was comparable between cohorts (50% 4.5g vs 40.5% 6.75g, P = 0.277). High dose PTZ was not independently associated with acute nephrotoxicity after control for selected confounders. All secondary outcomes were similar. Concomitant vancomycin and calculated supratherapeutic vancomycin area under curve were not independently associated with increased nephrotoxicity. Conclusions: High dose PTZ was not associated with increased acute nephrotoxicity, thrombocytopenia, 14-day all-cause mortality, or ICU LOS. Additionally, more robust trials are needed to fully assess the clinical impact of 6.75g PTZ dosing for critically ill, obese patients, for pneumonia.

Comparative analysis of malnutrition screening tools in predicting mortality in critically ill patients: SGA, GLIM, and mNutric Score.

Introduction: Malnutrition is prevalent among critically ill patients and is associated with increased mortality, prolonged hospital stays, and higher rates of complications. Several malnutrition screening tools are available, including the Subjective Global Assessment (SGA), the Global Leadership Initiative on Malnutrition (GLIM), and the modified Nutrition Risk in Critically Ill (mNutric) Score. This study aims to compare the predictive ability of these three tools in determining mortality among critically ill patients. Methods: A retrospective cohort study was conducted in the Intensive Care Unit (ICU) of RSUP Dr. Wahidin Sudirohusodo from April 2022 to March 2023. Patients aged 18 years and older were included. Nutritional status was assessed using SGA, GLIM, and mNutric Score. The primary outcome was mortality. Result: A total of 1,106 patients were included in the analysis. The overall ICU mortality rate was 23.1%. The mNutric Score was a significant independent predictor of mortality (OR = 6.601, 95% CI: 4.183–10.416, p &lt; 0.001), while neither SGA nor GLIM were significant after adjustment for confounders. Conclusion: The mNutric Score is a superior tool for predicting mortality in critically ill patients compared to SGA and GLIM. Its use should be considered in ICU settings to identify patients at nutritional risk and guide timely interventions.

The use of machine learning based models to predict the severity of community acquired pneumonia in hospitalised patients: A systematic review

Background: Community acquired pneumonia (CAP) is a common cause of hospital admission. CAP carries significant risk of adverse outcomes including organ dysfunction, intensive care unit (ICU) admission and death. Earlier admission to ICU for those with severe CAP is associated with better outcomes. Traditional prediction models are used in clinical practice to predict the severity of CAP. However, accuracy of predicting severity may be improved by using machine learning (ML) based models with added advantages of automation and speed. This systematic review evaluates the evidence base of ML-prediction tools in predicting CAP severity. Methods: MEDLINE, EMBASE and PubMed were systematically searched for studies that used ML-based models to predict mortality and/or ICU admission in CAP patients, where a performance metric was reported. Results: 11 papers including a total of 351,365 CAP patients were included. All papers predicted severity and four predicted ICU admission. Most papers applied multiple ML algorithms to datasets and derived area under the receiver operator characteristic curve (AUROC) of 0.98 at best performance and 0.57 at worst, with a mixed performance against traditional prediction tools. Conclusion: Although ML models showed good performance at predicting CAP severity, the variables selected for inclusion in each model varied significantly which limited comparisons between models and there was a lack of reproducible data, limiting validity. Future research should focus on validating ML predication models in multiple cohorts to derive robust, reproducible performance measures, and to demonstrate a benefit in terms of patient outcomes and resource use.

Nineteen years retrospective analysis of epidemiology, antifungal resistance and a nomogram model for 30-day mortality in nosocomial candidemia patients

BackgroundThe incidence of nosocomial candidemia has increased in recently years, however, the epidemiological data remain insufficient in China.MethodsA total of 234 candidemia patients were included from Xiamen University Zhong Shan hospital between January 2006 and October 2024. Incidence, species proportion, distribution, antifungal drug resistance of candidemia was analyzed. A nomogram model for 30-day morbidity of candidemia was determined using the least absolute shrinkage and logistic regression analysis.ResultsThe incidence of candidemia increased in recent years (2020: 0.025%, 2021: 0.029%, 2023:0.022%). The dominant species of candidemia were Candida albicans (n=99,42.31%), Candida parapsilosis (n=47,20.09%), Candida tropicalis (n=43,18.38%), Candida glabrata (n=31,13.25%). Departments with a higher detection of candidemia included intensive care unit (n=55), emergency department (n=24) and hepatobiliary surgery (n=22). Candida tropicalis performed the highest resistance to azole (fluconazole: 55.81%, voriconazole:55.00% and itraconazole:58.14%). The resistance of Candida albicans to fluconazole, voriconazole and itraconazole were 32.32%, 23.53% and 31.31%. The mortality rate of 30-day discharge for candidemia reached 52.99%. 205 cases of candidemia patients from January 2006 to December 2023 were included as the training set, while 29 cases of candidiasis patients from January to October 2004 were included as the validation set. Five independent factors included Candida albicans, decreased albumin, multiple organ dysfunction syndrome, solid tumor and septic shock were adopted in a nomogram for 30-days mortality of candidemia. In the training set, the area under curve was 0.866 (95%CI: 0.817-0.916), the optimal cutoff value was 0.617, the sensitivity was 80% and the specificity was 80.4%. In the validation set, the area under curve was 0.808 (95%CI:0.737-0.970), the optimal cutoff value was 0.543. The sensitivity was 72.7% and the specificity was 83.3%.ConclusionThe incidence of nosocomial candidemia has risen in recent years. Candida albicans remains the primary species, with the highest incidence is intensive care unit. Candida tropicalis exhibits the highest resistance rate to azole drugs. A nomogram predicting 30-day mortality discharge for candidemia patients has been constructed, and the independent risk factors including Candida albicans, multiple organ dysfunction syndrome, septic shock, solid tumors, and decreased albumin.

Moral sensitivity and attitudes towards patient safety among critical care nurses.

Patient safety is essential for healthcare quality and a global concern. The rapid advancement of medical technology presents ethical challenges for critical care nurses, who navigate complex decision-making processes. Given their close relationships with patients, nurses are uniquely positioned to address patient safety issues. Thus, enhancing nurses' moral sensitivity and ethical values is increasingly important. This study aims to explore the relationship between moral sensitivity and attitude towards patient safety in critical care nurses. This cross-sectional, descriptive-correlational study was conducted from June to September 2022 in three hospitals affiliated with Hamadan University of Medical Sciences in Iran. Participants were nurses in intensive care units (ICUs), selected via convenience sampling. A total of 382 nurses completed questionnaires assessing demographic information, moral sensitivity, and patient safety attitudes. Data analysis was performed using descriptive statistics, t-tests, ANOVA, Pearson's correlation, and multiple regression in SPSS 26.Ethical considerations: This research received ethical approval from the Ethics Committee of Hamadan University of Medical Sciences. Participants provided informed consent regarding the study's objectives, and their confidentiality was strictly upheld throughout the research. The nurses' average age and work experience were 38.6years and 12.4years, respectively. Mean scores for moral sensitivity and patient safety attitude were 81.65 ± 2.69 and 51.47 ± 2.21, indicating high levels and a significant positive correlation. Factors such as increasing age, work experience, fewer working hours, and completion of ethics training were linked to more positive attitudes towards patient safety (p < .05). Regression analysis showed that 42.8% of the variability in attitudes towards patient safety could be explained by moral sensitivity and demographic characteristics. This study highlights the relationship between moral sensitivity and patient safety attitudes among critical care nurses, emphasizing the importance of education, experience, and training in shaping ethical values. Enhancing moral sensitivity is vital for reducing risky behaviors and improving patient safety outcomes in critical care settings.

Clinical and economic assessment of nosocomial pneumonia antibacterial therapy in Moscow hospital

Objective: to conduct clinical and economic analysis of nosocomial pneumonia antibacterial therapy in a multidisciplinary hospital in Moscow.Material and methods. The medical records of patients admitted to Yudin City Clinical Hospital in Moscow in 2019–2021 were analyzed retrospectively. Pharmacoepidemiological analysis included the structure of prescriptions of antibacterial drugs (ABDs), features of empirical and etiotropic therapy, duration of using ABDa and other parameters. In total, 110 cases of severe nosocomial pneumonia caused by ESKAPE pathogens were selected for analysis. Direct medical costs and cost-effectiveness coefficients were calculated based on real world data.Results. It was established that nosocomial pneumonia is the most common complication among hospitalized patients in the intensive care unit (ICU). The etiology of nosocomial pneumonia was mostly presented by K. pneumoniae, A. Baumanii, and P. aeruginosa. The administered ABDs included 31 international nonproprietary names of the group J01 Systemic antibacterial drugs. The direct medical costs of empirical antibacterial therapy averaged for 9367 rubles (2118 rubles [1462; 3525]). Comparative cost-effectiveness analysis was performed based on surrogate and endpoints. It was found that direct medical costs associated with ESKAPE pathogens spend about 70% of the budget of established tariff to pay for medical care of the compulsory health insurance program for the patient's stay in the ICU.Conclusion. Antibacterial therapy costs for nosocomial pneumonia significantly increase the total cost of a patient's hospital stay. Сlinical and economic assessment of drug use help optimize therapy costs and develop a hospital formulary of antimicrobial drugs.

Effectiveness and safety of an emergency department-based rapid response system

Rapid Response Systems (RRSs) are designed to assist hospitalized patients who become unstable, aiming to address “failure to rescue” and prevent cardiac arrests. Despite global implementation, evidence of RRS effectiveness is controversial. This study evaluates the effectiveness and safety of an RRS at Maggiore Hospital in Lodi, Italy, focusing on the Medical Emergency Team (MET) organization. The RRS at Maggiore Hospital was established in 2017 using the National Early Warning Score (NEWS) for monitoring. The MET, consisting of an emergency physician and one nurse, operates from 8:00 PM to 8:00 AM. Data from 2014-2019, divided into PRE (2014-2016) and POST (2017-2019) periods, were analyzed. The primary outcomes were unplanned ICU transfers and in-hospital mortality. A difference-in-differences (DiD) design compared outcomes in MET and non-MET wards before and after RRS implementation. Hospitalizations were similar in the PRE and POST periods. A significant reduction in Intensive Care Unit (ICU) transfers was observed overall (0.26%, p=0.005), but not in mortality (0.10%, p=0.47). Both MET and non-MET wards showed reduced ICU transfers, but the decrease was statistically significant only in MET wards. DiD analysis showed no significant reductions in either ICU transfer (p=0.77) or mortality rates (p=0.15) between MET and non-MET wards. The RRS at Maggiore Hospital effectively reduced ICU transfers without increasing mortality, demonstrating its safety. The MET organization did not significantly impact ICU transfers compared to non-MET wards. Further studies should explore additional measures of clinical deterioration to fully assess the impact of RRS.

Are contemporary antifungal doses sufficient for critically ill patients? Outcomes from an international, multicenter pharmacokinetics study for Screening Antifungal Exposure in Intensive Care Units-the SAFE-ICU study.

Appropriate antifungal therapy is a major determinant of survival in critically ill patients with invasive fungal disease. We sought to describe whether contemporary dosing of antifungals achieves therapeutic exposures in critically ill patients. In a prospective, open-label, multicenter pharmacokinetic study, intensive care unit (ICU) patients prescribed azoles, echinocandins, or polyene antifungals for treatment or prophylaxis of invasive fungal disease were enrolled. Blood samples were collected on two occasions, with three samples taken during a single dosing interval on each occasion. Total concentrations were centrally measured using validated chromatographic methods. Pharmacokinetic parameters were estimated using noncompartmental methods. Antifungal dosing adequacy was assessed using predefined PK/PD targets. We included 339 patients from 30 ICUs across 12 countries. Median age 62 (interquartile range [IQR], 51-70) years, median APACHE II score 22 (IQR, 17-28), and 61% males. Antifungal therapy was primarily prescribed for treatment (80.8%). Fluconazole was the most frequently prescribed antifungal (40.7%). The most common indication for treatment was intra-abdominal infection (30.7%). Fungi were identified in 45% of patients, of which only 26% had a minimum inhibitory concentration available. Target attainment was higher for patients receiving prophylaxis (> 80% for most drugs). For patients receiving treatment, low target attainment was noted for voriconazole (57.1%), posaconazole (63.2%), micafungin (64.1%) and amphotericin B (41.7%). This study highlights the varying degrees of target attainment across antifungal agents in critically ill patients. While a significant proportion of patients achieved the predefined PK/PD targets, wide variability and subtherapeutic exposures persist. ClinicalTrials.gov Identifier: NCT03136926, 2017-04-21.

Real-world cost-effectiveness of nirmatrelvir-ritonavir as treatment for SARS-CoV-2 infection in the Belgian setting with omicron variant

BackgroundNirmatrelvir-ritonavir is an oral treatment for SARS-CoV-2 infection in patients who are at high risk of developing severe COVID-19 disease. This antiviral has proven to significantly reduce the risk of hospitalization and death compared to no anti-SARS-CoV-2 treatment in this target population. This paper aims to assess the cost-effectiveness of nirmatrelvir-ritonavir in Belgium using real-world evidence.MethodsA static decision tree model was developed to capture the health progression of patients infected with the SARS-CoV-2 virus. Outcomes were expressed in Quality Adjusted-Life Years (QALYs), hospitalizations, Intensive Care Unit (ICU) admissions, deaths and Long Covid cases, derived from epidemiological data over the first full year of the Omicron variant’s circulation (2022). Costs were calculated for the year 2023 from the healthcare payer’s perspective. Extensive sensitivity analyses were conducted to test the robustness of the cost-effectiveness results.ResultsIn a cohort of 1,000 patients, treatment with nirmatrelvir-ritonavir is projected to save 95 QALYs and €82,658 compared to no anti-SARS-CoV-2 treatment over a lifetime horizon. These savings primarily stem from the reduction in hospitalizations among vulnerable patients who typically require a longer recovery time. The analysis also indicates 5 fewer ICU admissions and 8 fewer premature deaths per 1,000 infected patients.ConclusionIn the context of Omicron SARS-CoV-2 infection, administering nirmatrelvir-ritonavir to patients at high risk of severe disease improves health outcomes and reduces costs. Nirmatrelvir-ritonavir is 100% likely to be cost-effective at a willingness to pay of €2,000 per QALY.

A model-based spectral directional approach reveals the long-term impact of COVID-19 on cardiorespiratory control and baroreflex

BackgroundCoronavirus disease 19 (COVID-19) patients might develop sequelae after apparent resolution of the infection. Autonomic dysfunction and baroreflex failure have been frequently reported. However, the long-term effect of COVID-19 on cardiorespiratory and cardiovascular neural controls has not been investigated with directional approaches able to open the closed-loop relationship between physiological variables.MethodsA model-based causal spectral approach, namely causal squared coherence (CK2), was applied to the beat-to-beat variability series of heart period (HP) and systolic arterial pressure (SAP), and to the respiratory signal (RESP) acquired at rest in supine position and during active standing (STAND) in COVID-19 survivors 9 months after their hospital discharge. Patients were categorized according to their need of ventilatory support during hospitalization as individuals that had no need of continuous positive airway pressure (noCPAP, n = 27), need of continuous positive airway pressure in sub-intensive care unit (CPAP, n = 14) and need of invasive mechanical ventilation in intensive care unit (IMV, n = 8).ResultsThe expected decrease of the strength of the HP-RESP dynamic interactions as well as the expected increase of the dependence of HP on SAP along baroreflex during STAND was not observed and this result held regardless of the severity of the disease, namely in noCPAP, CPAP and IMV cohorts. Regardless of the experimental condition, spectral causality markers did not vary across groups either.ConclusionsCK2 markers, in association with an orthostatic challenge, were able to characterize the impairment of cardiorespiratory control and baroreflex in COVID-19 patients long after acute infection resolution and could be exploited to monitor the evolution of the COVID-19 patients after hospital discharge.

Transfer of POCUS Skills of Anesthesia Trainees from the Simulation Laboratory to Clinical Practice: A Follow-Up Pilot Evaluation After ABC US Protocol Training

Background/objectives: Point-of-care ultrasound (POCUS) in the intensive care unit (ICU) has gained much attention in the last few years as an alternative to the classic ways of assessing and diagnosing life-threatening conditions in critical patients. During the COVID-19 pandemic, we proposed a POCUS protocol based on the airway, breathing, and circulation (ABC) approach to quickly evaluate and diagnose life-threatening diseases in critical patients with acute respiratory failure and shock, and later, we used it as a curriculum to teach POCUS to anesthesia and intensive care trainees. Methods: We developed an evaluation protocol where evaluators with experience in POCUS in critically ill patients had to assess the trainee’s ultrasound scan; this was based on the ABC protocol taught in the simulation laboratory and applied in a clinical setting at the bedside. Results: Statistically significant differences were observed in some categories evaluated regarding independence and diagnosis. Conclusion: Initial POCUS simulation-based training using an ABC POCUS protocol (that demonstrated good results in the simulation laboratory) is useful when transferring US skills to the bedside and is applicable in daily clinical practice with good results in terms of operator independence.

Advances in acute pancreatitis management: From guidelines to clinical practice

Objectives: This study aimed to evaluate current management strategies and early outcomes in patients with acute pancreatitis (AP) to provide insights into effective practices and contribute to the discourse on optimizing AP care. Methods: A retrospective observational study was conducted on 350 AP patients admitted to Kanuni Sultan Süleyman Training and Research Hospital between January 2015 and December 2022. Data were extracted from electronic medical records, including demographics, clinical presentation, laboratory findings, imaging results, treatment strategies, and outcomes. Patients were assessed for severity using the Revised Atlanta Classification and Bedside Index for Severity in Acute Pancreatitis (BISAP) scores, and management protocols included controlled fluid resuscitation, pain management, nutritional support, selective antibiotic use, and endoscopic interventions. Results: Of 350 patients (male: 54%, mean age: 50 years), 79.7% had mild AP, 14.9% moderately severe AP, and 5.4% severe AP. Goal-directed fluid resuscitation and early nutritional support were implemented, with early oral feeding initiated in 81.4% of cases. Antibiotics were used in 20% of patients with confirmed or suspected infections, and Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 24.6% of patients with biliary pancreatitis. The mean hospital stay was 7, 14, and 21 days for mild, moderately severe, and severe AP, respectively. Intensive care unit (ICU) admission was required for 8.6%, and in-hospital mortality was 2%. Recurrence within six months occurred in 9.1% of cases. Conclusions: management strategies adhering to current guidelines led to favorable early outcomes, including reduced complications and a high six-month survival rate (98%). Future multicenter studies are recommended to confirm these findings and assess long-term outcomes.

Correlation between traumatic brain injury, obesity and insulin-resistance – a case report

Introduction: Traumatic brain injury is a significant global health concern. It often results from high-velocity accidents and leads to diffuse axonal injury, causing consciousness disorders and potentially permanent cognitive and behavioural changes. Individuals with traumatic brain injury often exhibit weight gain, potentially leading to obesity. This weight increase is influenced by cognitive dysfunction, reduced physical activity and metabolic changes. Case report: A 23-year-old woman suffered a traumatic brain injury after a traffic accident, with an initial Glasgow Coma Scale score of 5/15. Positive neurological improvement was observed during her stay in the intensive care unit and the neurosurgical department. Subsequently, she was transferred to the rehabilitation department, where she faced significant challenges, including mood fluctuations, cognitive impairments and substantial weight gain. Her body mass index (BMI) increased from 23 kg/m2 pre-accident to a maximum of 36 kg/m2, despite interventions like medications and lifestyle changes. Blood tests revealed insulin-resistance and metformin initiated a successful weight reduction. Conclusion: Managing weight gain following traumatic brain injury requires effective interventions that acknowledge its complexity and multifaceted nature, including lifestyle modifications, behavioural therapy and potentially pharmacotherapy or bariatric surgery. Further research is essential to better understand underlying mechanisms and evaluate intervention effectiveness in this specific patient population.

Regional cerebral oxygen saturation during initial mobilization of critically ill patients is associated with clinical outcomes: a prospective observational study

BackgroundVital signs help determine the safety of early mobilization in critically ill patients in intensive care units. However, none of these variables directly assess cerebral circulation. Therefore, we aimed to investigate the relationship of regional cerebral oxygen saturation (rSO2) and vital signs with in-hospital death in critically ill patients.MethodsThis prospective study included critically ill patients admitted to the Uonuma Kikan Hospital Emergency Center who received physical therapy between June 2020 and December 2022. We continuously measured rSO2 during the initial mobilization using a wearable brain near-infrared spectroscopy device. With in-hospital death as the primary endpoint, the association between rSO2 and in-hospital death was assessed in Analysis 1 to determine the rSO2 cut-off value that predicts in-hospital death. In Analysis 2, patients were categorised into survival and non-survival groups to examine the temporal changes in vital signs and rSO2 associated with postural changes during mobilization.ResultsOf the 132 eligible patients, 98 were included in Analysis 1, and 70 were included in Analysis 2. Analysis 1 demonstrated that lower premobilization rSO2 was independently associated with in-hospital death (odds ratio 0.835, 95% confidence interval 0.724–0.961, p = 0.012). Receiver operating characteristic curve analysis identified an optimal rSO2 cut-off value of 57% for predicting in-hospital death (area under the curve 0.818, sensitivity 73%, specificity 83%). Analysis 2 showed that rSO2 changes during mobilization were unrelated to changes in vital signs, suggesting rSO2 as an independent prognostic marker.ConclusionsThe results suggest that rSO2 measured during initial mobilization is associated with in-hospital death in critically ill patients.