Intensive Care Therapy Research Articles

Liver and COVID-19 - A Review and Clinical Approach

: Liver enzyme abnormalities occur frequently in patients diagnosed with Coronavirus disease 2019 (COVID-19). It has been suggested that patients with severe acute liver injury are more likely to be admitted to intensive care, require intubation or renal replacement therapy and their mortality rate is higher than patients without severe acute liver injury. This review article explores the possible aetiologies of liver dysfunction seen in patients with COVID-19 and also the effect of COVID-19 on patients with pre-existing liver disease. Finally, we suggest clinical approaches to treating a patient with liver enzyme disturbance and COVID-19 and also caring for patients who require liver transplantation in the COVID-19 era.

Intenzivna terapija u vreme pandemije 2020. i u budućnosti - akronimi nam mogu pomoći

In a busy working environment, with a shortage of healthcare workers and increased workloads since the beginning of the COVID-19 pandemic, the implementation of an easy-to-remember mnemonic can significantly help anesthesiologists and clinicians in conducting intensive therapy. One of the first mnemonics in critical care therapy was implemented by Jean-Louis Vincent in 2005. FAST HUG concept reminds clinicians of crucial moments in therapy - nutritional support(F-feeding), analgesia and sedation (A - analgesia, S - sedation), thrombosis prophylaxis (T - thrombolytic prophylaxis), head elevation in bed (H - head of the elevated bed), antiulcer therapy (U - stress ulcer prevention) and glycemic control (G - glucose control). This acronym has been modified and tested in several studies over the years for the treatment of different patient types. This concept is widely utilized in intensive care units, it is characterized with easy implementation, and proved to be useful in ventilator-associated pneumonia prevention. Therapy of critically ill patients with COVID-19 is based on elements of general intensive care therapy with some specific therapeutic guidelines. With the intention to ease and improve therapy of patients with COVID-19 in intensive care units, a new and comprehensive acronym is proposed: One Fast Hug Bids COVID.

Development and evaluation of the focused assessment of sonographic pathologies in the intensive care unit (FASP-ICU) protocol

BackgroundThe use of ultrasonography in the intensive care unit (ICU) is steadily increasing but is usually restricted to examinations of single organs or organ systems. In this study, we combine the ultrasound approaches the most relevant to ICU to design a whole-body ultrasound (WBU) protocol. Recommendations and training schemes for WBU are sparse and lack conclusive evidence. Our aim was therefore to define the range and prevalence of abnormalities detectable by WBU to develop a simple and fast bedside examination protocol, and to evaluate the value of routine surveillance WBU in ICU patients.MethodsA protocol for focused assessments of sonographic abnormalities of the ocular, vascular, pulmonary, cardiac and abdominal systems was developed to evaluate 99 predefined sonographic entities on the day of admission and on days 3, 6, 10 and 15 of the ICU admission. The study was a clinical prospective single-center trial in 111 consecutive patients admitted to the surgical ICUs of a tertiary university hospital.ResultsA total of 3003 abnormalities demonstrable by sonography were detected in 1275 individual scans of organ systems and 4395 individual single-organ examinations. The rate of previously undetected abnormalities ranged from 6.4 ± 4.2 on the day of admission to 2.9 ± 1.8 on day 15. Based on the sonographic findings, intensive care therapy was altered following 45.1% of examinations. Mean examination time was 18.7 ± 3.2 min, or 1.6 invested minutes per detected abnormality.ConclusionsPerforming the WBU protocol led to therapy changes in 45.1% of the time. Detected sonographic abnormalities showed a high rate of change in the course of the serial assessments, underlining the value of routine ultrasound examinations in the ICU.Trial registration The study was registered in the German Clinical Trials Register (DRKS, 7 April 2017; retrospectively registered) under the identifier DRKS00010428.

A service evaluation exploring perceptions of relatives of ICU patients and multidisciplinary team on patients’ experience of games based therapy

Purpose: Through the nature of emergency admissions to intensive care, patients experience sudden changes to their daily routines and surroundings. Worsened by sleep deprivation and disorientation this can lead to a lack of autonomy and frustration. Games based therapy (GBT) is utilized in other patient populations but is considered an emerging therapy in intensive care.

Factors Associated with Severe Acute Respiratory Infections Due to Rhinovirus/Enterovirus Complex in Children and Their Comparison with Those of Respiratory Syncytial Virus

Background: Acute respiratory tract infections (ARTIs) are one of the main causes of morbidity and mortality in children under the age of five worldwide. Objectives: The objective of this research was to describe the main characteristics of hospitalized patients with ARTI caused by the rhinovirus/enterovirus (RV/EV) complex and the risk factors associated with severe infection. Methods: This was a retrospective descriptive study in patients from one month to 18-years-old who had been hospitalized for ARTI between October 2015 and December 2019 at Fundación Cardioinfantil in Bogotá, Colombia, and had had an RT-PCR viral panel during their hospitalization. Rhinovirus/enterovirus infection was characterized to identify factors associated with disease severity as compared to respiratory syncytial virus (RSV). A multivariate analysis was performed, controlling for confounding factors, to identify groups at risk of developing associated acute respiratory distress syndrome (ARDS). Results: During the study period, 645 RT-PCRs were performed, with the two main etiological agents identified being RV/EV (n = 224) and RSV (n = 68). The median age of patients with the RV/EV complex was 27 months (IQR: 8 - 70), and seven months for those with RSV (IQR: 2 - 11). Severe RV/EV complex infections required more transfers to intensive care (47% vs. 11%), showed more viral coinfection (OR: 2.13, 95% CI: 1.42 - 4.64), and had less bacterial coinfection (OR: 0.55, 95% CI: 0.31 - 0.98) than RSV infections. The RV/EV group had a higher risk of developing ARDS (OR: 3.6, 95% CI: 1.07 - 12:18), especially in premature infants (P: 0.05; exp(B), 2.99; 95% CI = 1.01 - 8.82), those with heart disease (P: 0.047; exp(B), 2.99; 95% CI = 1.01 - 8.82), and those with inborn errors of metabolism (P: 0.032; exp(B), 5 - 01; 95% CI = 1.15 - 21.81). A total of 13 patients from both study groups died (4.5%), with no differences found between the groups (RV/EV 54% vs. RSV 46%; P = 0.3). Conclusions: Respiratory infection due to RV/EV in children can frequently be severe, requiring management with intensive care therapy. When compared to RSV, this complex is more frequently associated with the development of ARDS, especially in risk groups such as those with prematurity, heart disease, or inborn errors of metabolism.

Multidisciplinary team perception of games-based therapy in critical care: A service evaluation.

As survivorship following critical illness improves, there is greater focus on maximizing recovery. As well as physical effects, critical illness often results in cognitive impairments such as delirium, anxiety, or disorientation. In other populations, such as delirium, non-pharmacological approaches to manage these conditions are preferred, including re-orientation and ensuring personal care needs are met. Cognitive rehabilitation is also well documented for patients with neuropsychological deficits. Treatments include memory aids, compensation strategies, and functional execution. In other hospital populations, games and activities have been utilized to optimize patient engagement, stimulation, and aid recovery, but it is considered an emerging therapy in intensive care. This service evaluation aimed to gather multidisciplinary team members' perceptions of the use of games based therapy (GBT) in critical care, including patient engagement and acceptability in clinical practice. A UK-based single-centre qualitative service evaluation. Purposive sampling was used to identify interviewees within an adult intensive care who had experience of using a recently implemented GBT intervention. Qualitative data were collected through semi-structured interviews, which were recorded and transcribed verbatim. Data were analysed using thematic analysis. Eight staff members across the multidisciplinary team were interviewed. One overarching theme of humanizing health care was identified, with three sub-themes of enhancing recovery, non-physical components of care, and bespoke tailoring. In addition, further recommendations for development of the service were summarized. GBT was well received by staff in clinical practice. It was described as a supportive adjunct to traditional care and rehabilitation, enhancing staff-patient relationships. While it was recognized it may not suit all patients, GBT has the potential to enhance cognitive and physical recovery.

Economic considerations at the threshold of viability

Neonatal intensive care for infants born at 22–24 weeks has become more prevalent in the past three decades, but outcomes remain highly variable between centers, in part due to different approaches in management. With this increased frequency of intervention, there has been concern for a concurrent increase in costs of care for survivors. This article reviews the direct medical, direct non-medical, and indirect costs of care for periviable infants and their families, as well as the current limitations of published data. In addition, we highlight the cost-effectiveness of neonatal intensive care and various therapies offered to extremely preterm infants, while also considering the ethical dilemmas inherently tied to periviable decision-making. Strategies to improve the gaps in knowledge on the economic impact of the smallest infants are discussed.

Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence

HintergrundDie Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende.FragestellungEs existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen.MethodeDiese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt.ErgebnisseInsgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt.SchlussfolgerungenDie Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.

Strain Echocardiography and Myocardial Dysfunction in Critically Ill Children With Multisystem Inflammatory Syndrome Unrecognized by Conventional Echocardiography: A Retrospective Cohort Analysis.

OBJECTIVES:Multisystem inflammatory syndrome in children is a newly defined complication of severe acute respiratory syndrome coronavirus 2 infection that can result in cardiogenic shock in the pediatric population. Early detection of cardiac dysfunction is imperative in directing therapy and identifying patients at highest risk for deterioration. This study compares the strengths of conventional and strain echocardiography in identifying cardiac dysfunction in critically ill children with multisystem inflammatory syndrome in children and their association with ICU therapeutic needs and clinical outcomes.DESIGN:Retrospective, observational cohort study.SETTING:A large, quaternary care PICU.PATIENTS:Sixty-five pediatric patients admitted to the PICU with the diagnosis of multisystem inflammatory syndrome in children from March 2020 to March 2021.INTERVENTIONS:Global longitudinal strain four chamber was measured retrospectively by strain echocardiography and compared with conventional echocardiography. Cardiac dysfunction was defined by left ventricular ejection fraction less than 55% and global longitudinal strain four chamber greater than or equal to –17.2%. Clinical variables examined included cardiac biomarkers, immune therapies, and ICU interventions and outcomes.MEASUREMENTS AND MAIN RESULTS:Twenty-four patients (37%) had abnormal left ventricular ejection fraction and 56 (86%) had abnormal global longitudinal strain four chamber. Between patients with normal and abnormal left ventricular ejection fraction, we failed to identify a difference in cardiac biomarker levels, vasoactive use, respiratory support needs, or ICU length of stay. Global longitudinal strain four chamber was associated with maximum cardiac biomarker levels. Abnormal global longitudinal strain four chamber was associated with greater odds of any vasoactive use (odds ratio, 5.8; 95% CI, 1.3–25.3; z-statistic, 2.3; p = 0.021). The number of days of vasoactive infusion was correlated with global longitudinal strain four chamber (r = 0.400; 95% CI, 2.4–3.9; p < 0.001). Children with abnormal strain had longer ICU length of stay (4.5 d vs 2 d; p = 0.014).CONCLUSIONS:Our findings suggest strain echocardiography can detect abnormalities in cardiac function in multisystem inflammatory syndrome in children patients unrecognized by conventional echocardiography. These abnormalities are associated with increased use of intensive care therapies. Evaluation of these patients with strain echocardiography may better identify those with myocardial dysfunction and need for more intensive therapy.

Evaluation of Characteristics and Management of Influenza Patients in Relation to the STIKO Vaccination Recommendation During the 2017/2018 Season

Every year a large number of patients is suffering from influenza infection with often severe outcome. The influenza season 2017/2018 was characterized by a high number of cases (in Germany>346,000 laboratory-confirmed cases), but also by a high rate of hospitalizations with sometimes severe clinical outcome - also in the group of patients under 60 years. The aim of the present study was to find out whether patients not fullfilling the STIKO vaccination recommendation in the 2017/18 season were suffering from a worse outcome. All laboratory-confirmed influenza patients at Frankfurt University Hospital were retrospectively analyzed for disease severity with respect to the primary endpoint. Secondary endpoints were defined as demographic data, length of hospital stay, previous illnesses, intensive care therapy and its duration, drug therapy, and mortality. Fifty-one of 303 patients (16.8%) required intensive care treatments. Of these 51, 46 patients (90.2%) belonged to the group that should have been vaccinated according to the vaccination recommendations according to STIKO, 5 patients (9.8%) did not belong to this group (p=0.434). Of the 51 ICU patients, 16 (31.4%) died. All deceased were from the group with vaccination recommendation (p=0.120). Based on these data, it appears that severe disease progression occurs in both the group of patients with and without STIKO vaccination recommendation, but deaths occur only in the group of patients with recommendation.

Treating Patients Who Have Intermediate-Risk Acute Pulmonary Embolus

Although management of patients with acute pulmonary embolus is well defined for those at high risk (intensive care and reperfusion therapy) and low

Overview of Adverse Events Associated with Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy

Anti-CD19 chimeric antigen receptor (CAR) T-cells represent a novel immunotherapy that has shown remarkable success in the treatment of adult relapsed or refractory (R/R) B-cell non-Hodgkin's lymphoma, adult R/R mantle cell lymphoma, and R/R acute paediatric lymphoblastic leukaemia. One barrier to the widespread use of CAR T-cell therapy is toxicity, primarily cytokine release syndrome (CRS) with a variable grade of severity. The main manifestations of CRS are fever, hypotension, cytopenia, organ dysfunction among others. Neurological toxicities vary widely and range from headaches to encephalopathy. In addition, anti-CD19 CAR T-cell therapy provokes an array of less frequent events, such as coagulopathies, delayed cytopenia, and cardiovascular toxicities. In general, toxicities are usually reversible and resolve on their own in most cases, though severe cases may require intensive care and immunosuppressive therapy. Deaths due to CRS, neurologic toxicity and infectious complications have been reported, which highlights the gravity of these syndromes and the critical nature of appropriate intervention. In this paper, we look at all available FDA- and EMA-approved information about the pathophysiology, clinical manifestations, risk factor reviews of existing toxicity grading systems, current management strategies, and guidelines for anti-CD19 CAR T-cell toxicities. We also present new approaches, which are under investigation, to mitigate these adverse events.

Characteristics and outcomes of children receiving intensive care therapy within 12 hours following a medical emergency team event

Objectives: To describe characteristics and outcomes of children requiring intensive care therapy (ICT) within 12 hours following a medical emergency team (MET) event.Design: Retrospective cohort study.Setting: Quaternary paediatric hospital.Patients: Children experiencing a MET event.Measurements and main results: Between July 2017 and March 2019, 890 MET events occurred in 566 patients over 631 admissions. Admission to intensive care followed 183/890 (21%) MET events. 76/183 (42%) patients required ICT, defined as positive pressure ventilation or vasoactive support in intensive care, within 12 hours. Older children had a lower risk of requiring ICT than infants aged < 1 year (age 1–5 years [risk difference, –6.4%; 95% CI, –11% to –1.6%; P = 0.01] v age > 5 years [risk difference, –8.0%; 95% CI, –12% to –3.8%; P < 0.001]), while experiencing a critical event increased this risk (risk difference, 16%; 95% CI, 3.3–29%; P = 0.01). The duration of respiratory support and intensive care length of stay was approximately double in patients requiring ICT (ratio of geometric means, 2.0 [95% CI, 1.4–3.0] v 2.1 [95% CI, 1.5–2.8]; P < 0.001) and the intensive care mortality increased (risk difference, 9.6%; 95% CI, 2.4–17%; P = 0.01). Heart rate, oxygen saturation and respiratory rate were the most commonly measured vital signs in the 6 hours before the MET event.Conclusions: Approximately one-fifth of MET events resulted in intensive care admission and nearly half of these required ICT within 12 hours. This group had greater duration of respiratory support, intensive care and hospital length of stay, and higher mortality. Age < 1 year and a critical event increased the risk of ICT.

Rare Case of Traumatic Anterior Knee Dislocation of Total Knee Arthroplasty With a Serious Neurovascular Injury

Traumatic anterior dislocation of a total knee arthroplasty (TKA) is an extremely rare occurrence. There are only a few known cases of this type of dislocation which discuss the high risk of a neurovascular complication. This article describes a traumatic anterior dislocation of the TKA with a severe vascular lesion in a 75-year-old severely comorbid patient. Further complications led to the development of a compartment syndrome. Despite the repeated effort in performing a well-functioning anastomosis of the popliteal artery tear by the vascular surgeon, reperfusion of the lower extremity was not effective. Furthermore, multiorgan system failure due to the reperfusion syndrome evolved. This led to an above-knee amputation as a lifesaving procedure. Despite thorough intensive care therapy, the patient did not survive this complication. Presently there are no reported cases with such severe complications after the luxation of a previously well-functioning TKA leading to the death of the patient.

Geriatric patients in the intensive care unit

Der Anteil geriatrischer Patienten auf der Intensivstation an allen dort behandelten Patienten beträgt bis zu 30 %. Das Alter per se ist jedoch kein Prognosekriterium für das therapeutische Outcome einer intensivmedizinischen Behandlung. Prognostisch wichtiger sind der funktionelle Status und geriatrische Syndrome. Hierbei sind die Gebrechlichkeit (Frailty) und das Delir von zentraler Bedeutung. Zum jeweiligen Screening sollten Clinical Frailty Scale (CFS) bzw. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) zur Anwendung kommen. Darüber hinaus spielen altersphysiologische Organveränderungen sowie Multimorbidität und die damit assoziierte Polypharmazie eine wichtige Rolle. Letztere sollte bereits bei Aufnahme auf ihre absolute Notwendigkeit hin überprüft werden. Ein weiteres Ziel der intensivmedizinischen Behandlung von geriatrischen Patienten ist die Erhaltung und Verbesserung ihres Ernährungszustands. Zu seiner Erfassung sollte ein Screening mithilfe eines etablierten Tools (z. B. Nutritional Risk Screening [NRS] 2002) erfolgen. Bei der Behandlung von kritisch kranken geriatrischen Patienten mit Coronoaviruserkrankung 2019 (COVID-19) hat die Gebrechlichkeit ebenfalls eine entscheidende Bedeutung. Grundsätzlich ist bei jeder Therapieanwendung gerade auch bei geriatrischen Patienten die Frage nach der Sinnhaftigkeit der intensivmedizinischen Behandlung unter Beachtung des (mutmaßlichen) Patientenwillens und seiner Lebensperspektive zu klären. Dabei ist zu prüfen, ob ein angestrebtes Therapieziel erreicht werden kann und ob die Belastungen während der Behandlung gerechtfertigt ist. Weiterhin spielt bei der intensivmedizinischen Versorgung geriatrischer Patienten die sektorenübergreifende Zusammenarbeit eine wichtige Rolle.

Complete AV block in a neonatal foal suffering from nutritional myodegeneration

SummaryThis case report concerns a 1‐day‐old, full‐term Quarter Horse colt presented due to a progressive inability to rise and nurse. Besides the general weakness, a marked bradycardia was evident, which was caused by a third‐degree atrioventricular (AV) block. Subsequently, the diagnosis of acute nutritional myodegeneration (NMD) was made based on clinical signs, elevated muscle enzymes, ECG findings, as well as low serum selenium and vitamin E values. Despite intensive care and supportive therapy, the foal´s condition deteriorated, and euthanasia was elected. Necropsy confirmed the diagnosis of NMD and revealed diffuse necrosis and inflammatory infiltration of the skeletal and myocardial musculature, as well as the cardiac conduction system which might have resulted in complete AV block.

Neurosurgical treatment of cervical spine injuries

Injuries of the cervical spine are quite common with an incidence of more than 3% in trauma patients. The incidence is even higher in elderly patients. Cervical spine injuries might induce severe neurological deficits. Therefore, they must be quickly and adequately diagnosed and treated. Depending on the pattern of injury, conservative or surgical treatment is indicated. The authors describe the different surgical strategies and treatment options based on the pattern of injury. Typical surgical methods are illustrated by case presentations. Cervical spine injuries should be treated in atrauma centre with extensive expertise in spine surgery. The immobilisation and gentle transportation is important already at the scene of the accident. Nowadays, there are excellent surgical options and strategies available as well as excellent intensive care therapy. These possibilities lead to rapid and good stabilisation of cervical spine injuries and the posttraumatic morbidity and mortality can be reduced significantly especially in elderly patients.

Music therapy in neonatal intensive care: Influences of culture (Shoemark &amp; Ettenberger, Eds.)

This is a review of the book "Music therapy in neonatal intensive care: Influences of culture" edited by Helen Shoemark and Mark Ettenberger.&#x0D; Title: Music therapy in neonatal intensive care: Influences of culture Editors: Helen Shoemark &amp; Mark Ettenberger Publication year: 2020 Publisher: Barcelona Publishers Pages: 308 ISBN: 9781945411496

集中治療における理学療法：質保証と課題

集中治療における理学療法：質保証と課題

Influence of nurses on the experience of noninvasive ventilation

Noninvasive ventilation (NIV) is established as an integral part of intensive care therapy for respiratory insufficiency. However, it is associated with restrictions on patient autonomy and comfort. A successful course of therapy is largely dependent on the acceptance and adherence of the patients concerned. Intensive care nurses can have asignificant influence on the success of the therapy by dealing with the subjective experience of the patients and by maintaining close contact with them. The prerequisite for this is profound knowledge of the different technical aspects of therapy and equipment as well as positive and negative factors influencing NIV tolerance in order to be able to offer and implement an individual intervention.