Treatment Of Critical Patients Research Articles

Modern aspects of infusion therapy: review

The infusion therapy is a routine procedure of the nowadays perioperative period and critical patient treatment. But there are controversial questions about the quantity, quality, start and duration of infusion therapy, which are under discussion. Modern infusion therapy includes intravenous administration of crystalloid solutions and more rarely colloid solutions. The type, amount and rate of infusion fluid depends on the indication for infusion therapy and the specific requirements of the patient. Nowadays colloidal solutions have limited indications. Crystalloid solutions are used for infusion therapy of patients with hypovolemia or dehydration, correction of free water deficiency, correction of electrolyte disorders, replenishment of ongoing fluid losses and replacement for patients who unable to drink water orally. All patients should be monitored with combination of clinical parameters and laboratory tests. Therapeutic endpoints should be determined. The moment these endpoints are achieved fluid therapy should be appropriately de-escalated in order to avoid overhydration.

Application of immunosuppressive agents in crtical coronavirus disease

The outbreak of novel coronavirus (SARS-CoV-2) infection has brought great harm to people's life and social development. Although SARS-CoV-2 infection is more common in mild patients at present, considering the characteristics of crtical disease, rapid progress and high mortality, the treatment of critical patients are the focus of clinical attention. Immune imbalance which is characterized by cytokine storm plays a vital role in SARS-CoV-2 induced acute respiratory distress syndrome (ARDS), extrapulmonary multiple organ failure and even death. Therefore, the application of immunosuppressive agent in crtical coronavirus disease patients has a promising prospect. In this paper, different immunosuppressive agents and their application in crtical SARS-CoV-2 infection are reviewed, so as to provide reference for crtical coronavirus disease therapy.

Specific Changes in Hemostasis System Parameters during Extracorporeal Membrane Oxygenation in Patients with a Novel Coronavirus Infection

Extracorporeal membrane oxygenation (ECMO) is a method that makes it possible to compensate for critical changes caused by acute respiratory failure, with the ineffectiveness of treatment with rigid modes of artificial lung ventilation (ventilator) in patients with acute respiratory distress syndrome in intensive care units. The search for the optimal state of the hemostasis system is one of the main tasks in the treatment of critical patients in ECMO conditions.The objective: to study changes in hemostatic parameters in patients with COVID-19 undergoing ECMO and determine the need for their correction.Subjects and Methods. According to the inclusion and exclusion criteria, 100 patients were included in the study: 72 men and 28 women aged 26 to 75 years old, the median age made 55 years [47; 60]. VV-ECMO was performed in all observations. In 100% of cases, the cause of respiratory failure which required VV-ECMO was COVID-19-associated pneumonia.Results. 49 episodes of hemorrhagic complications and 76 episodes of thrombotic complications were recorded from the 1st to the 7th day from the moment of ECMO initiation. We found that the chance of developing thrombosis decreased by an average of 0.3% with an increase in the activity of antithrombin-3 by 1%. A statistically significant association of thrombosis risk was also found for prothrombin and prothrombin time.Conclusion. During the first 7 days of ECMO, patients with COVID-19 demonstrate the increase in APTT, prothrombin time and a decrease in the number of platelets, prothrombin activity, and fibrinogen concentration. The risk of thrombosis in this group of patients significantly decreases with the increasing activity of antithrombin-3 and prothrombin and increases with rising need of the higher dose of unfractionated heparin. The tactics of restrictive anticoagulant therapy when using unfractionated heparin can be taken into account as a way to reduce the risk of thrombosis and requires further research.

The exogenous surfactant pre-treatment attenuates ventilator-induced lung injury in adult rats

Mechanical ventilation is an essential supportive therapy in the treatment of critical patients, and it aims to maintain adequate gas exchange; however, it can also contribute to inflammation and oxidative stress, thus leading to lung injury. We tested the hypothesis that exogenous surfactant administration will be protective against ventilator-induced lung injury in adult healthy Wistar rats both because of its anti-inflammatory properties as well as its role in preventing alveolar collapse at end-expiration. Thus, the effect of intranasal instillation of a bovine exogenous surfactant was tested in Wistar rats submitted to mechanical ventilation. The animals were divided into four groups: (1) CONTROL; (2) SURFACTANT; (3) Mechanical ventilation (MV); (4) MV with pre-treatment with surfactant (MVSURFACTANT). The MV and MVSURFACTANT were submitted to MV with high tidal volume (12 mL/kg) for 1 h. After the experimental protocol, all animals were euthanized and the arterial blood, bronchoalveolar lavage fluid and lungs were collected for biochemical, immunoenzymatic assay, arterial blood gases, and morphometric analyzes. The Wistar rats that received exogenous surfactant (Survanta®) by intranasal instillation before MV demonstrated reduced levels of leukocytes, inflammatory biomarkers such as CCL2, IL-1, IL-6 and TNF-α. Furthermore, it prevented oxidative damage by reducing lipid peroxidation and protein carbonylation as well as histological pattern changes of pulmonary parenchyma. Our data indicate that exogenous surfactant attenuated lung inflammation and redox imbalance induced by mechanical ventilation in healthy adult rats suggesting a preventive effect on ventilator-induced lung injury.

Glycemic Control in Neurological Intensive Care Unit Patients

Critically ill patients often develop hyperglycemia because of the metabolic response to trauma and stress. In response to any form of damage to the organism, it reacts by increasing its own glucose production which subsequently causes hyperglycemia. This adaptive reaction of the organism is directed to aid in the rapid restoration after the damage. Therefore, glucose is an indispensable substrate in the critically ill which aids the reparation process. Severe and persistent hyperglycemia is associated with unfavorable outcomes and is considered to be an independent predictor of in-hospital mortality. The discussion remains on whether hyperglycemia is just a marker of increased stress which makes it a surrogate indicator of disease severity or if it is the reason for the unfavorable outcome. A few years ago, several published articles suggested that a tight glycemic control within the normal range improves treatment outcome. Over time, researchers have changed their point of view and currently there is a discussion on this matter in the scientific literatures. At the same time, the question of what glycemic level should be maintained for patients in the Neurological Intensive Care Unit is a matter of discussion. In this review, the authors analyzed the latest guidelines on treatment of critical patients with neurosurgical and neurological pathologies, specifically the glycemic control in this category of patients.

Progress in pathophysiology and integrated traditional Chinese and Western medicine of post-intensive care syndrome

With the continuous improvement of treatment ability in intensive care unit (ICU), many critically ill and complex patients have survived due to the development of technology. However, most of them suffer from the psychological and physiological problems of post-intensive care syndrome (PICS). Therefore, the early identification and prevention of PICS is particularly critical. We should understand the pathophysiological mechanism of PICS, strictly implement ABCDEFG bundle management measures [including airway management (A), breath (B), reasonable analgesia and sedation treatment (C), prevention of delirium (D), early rehabilitation (E), family engagement (F), good communication (G)] during ICU hospitalization, and pay attention to reasonable nutritional support, optimizing blood glucose management, providing positive psychological intervention and support to patients through family members' encouragement and accompanying, ICU diary and other forms, following up the health status of patients transferred out/discharged from ICU, providing multi-disciplinary and professional continuing medical services, finding the entry point and timing of traditional Chinese medicine intervention, and giving full play to the advantages of integrated traditional Chinese and Western medicine treatment, which can improve the quality of life of patients. This article reviews the pathophysiological mechanism, risk factors, prevention and management measures, traditional Chinese medicine syndrome differentiation and treatment of PICS, in order to improve the early identification, diagnosis and treatment of critical patients with PICS, and improve the prognosis of patients.

Association between severity score, inflammatory levels and DNA damage in intensive care patients

Background and Objectives: The Intensive Care Unit (ICU) is responsible for the treatment of critical patients and monitoring it continuously can improve the quality of care provided. This study aims to associate the Simplified Acute Physiology Score (SAPS 3) with inflammatory levels and genomic damage in patients admitted to the ICU of a hospital in Vale do Taquari, Rio Grande do Sul, Brazil. Methods: This is a cross-sectional study conducted with 22 patients from an adult ICU,between January and June 2016. The SAPS 3 was scored by the medical staff at the admission of patients and blood samples were obtained after 24 and 72 hours of hospitalization for C-Reactive Protein (CRP) dosing and DNA damage. Results: The SAPS 3 score was not associated with 24-and 72-hours CRP. However, the SAPS 3 score was significantly associated with the index and frequency of DNA damage, only after 72 hours of hospitalization. Conclusion: The severity score was not associated with CRP levels, but with DNA damage only after 72 hours of admission. Critical Care. Simplified Acute Physiology Score. Polymerase Chain Reaction. DNA damage.

Gemtuzumab Ozogamicin in the Treatment of Critical Patients with Refractory Acute Myeloid Leukemia (3 Case Reports)

The treatment of refractory acute myeloid leukemia (AML) patients presents considerable challenges. They are often critically ill. The critical conditions of these patients are mainly associated with severe infectious complications resulting in sepsis as well as with the extramedullary lesions with organ dysfunctions. So far, the obtained data demonstrated the successful use of gemtuzumab ozogamicin, the mechanism of which is likely to be based not only on depletion of CD33-positive tumor cells but also on its immunomodulatory effect. The present article focuses on the fast-effect mechanisms of gemtuzumab ozogamicin and deals with clinical experience of successful use of this drug combined with hypomethylating agents in patients with refractory AML whose condition is critical by the time therapy begins. The use of this drug combination results in fast stabilization of health status, recovery of internal organs, and apyrexia with the decreasing systemic inflammatory response within the first days of therapy. All this together with significantly lower blast count in blood and in bone marrow can bring critically ill patients to recovery.

Update and recommendations in decision making referred to limitation of advanced life support treatment

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients.The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Update and recommendations in decision making referred to limitation of advanced life support treatment.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Resistance analysis of pathogenic bacteria in chronic obstructive pulmonary disease patients with mechanical ventilation

Objective To investigate the constitution and drug resistance status of the major pathogens in mechanically ventilated patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), so as to provide evidences for clinical treatment. Methods From patients with AECOPD undergoing mechanical ventilation in EICU or ICU of the Second Affiliated Hospital of Wenzhou Medical University from January 2016 to December 2017, various specimens were collected for identification and drug susceptibility testing of pathogens; the clinical data and test results were analyzed. Results A total of 104 patients were included in the study. Total of 163 strains of pathogens were isolated from the specimens, of which gram-negative pathogens were the most common, accounting for 74.8% of any pathogens. Drug resistance analysis showed that gram-negative pathogens were severely resistant to third generation cephalosporins, and were more sensitive to Sulperazon and carbapenems; gram-positive cocci were more sensitive to vancomycin and linezolid. Fungi were more sensitive to amphotericin B and 5-fluorocytosine. Most of the pathogens were multi-resistant. Conclusions In selecting antibiotics for the treatment of critical patients with AECOPD, emphasis should be placed on bacterial culture and drug susceptibility testing, so as to reduce irrational drug use and the emergence of drug-resistant strains or superinfection. Key words: Chronic obstructive pulmonary disease; Mechanical ventilation; Pathogens; Drug resistance

Advantage of B-ultrasound Guidance in Indwelling Needle Puncture of External Jugular Vein for Patients in General ICU

The paper aims to investigate the advantage of B-ultrasound guidance in indwelling needle puncture of external jugular vein in the emergency treatment for critical patients with microcirculation failure. We included 70 microcirculation failure patients induced by different factors and with unclear external jugular veins that were admitted to the general ICU from September 2018 to June 2019 and performed indwelling needle puncture on them. We used random number table to divide the patients into control group and observation group with 35 patients in each group. The control group received traditional indwelling needle puncture and the observation group was given B-ultrasound guided indwelling needle puncture. The success rate, time and cost of indwelling needle puncture of two groups were compared. In the control group, 31 out of 35 cases of indwelling needle puncture were successful. The success rate was 88.6% and the average time consumed in each case was (9.09±2.35) min; in the observation group, 35 out of 35 cases of indwelling needle puncture were successful. The success rate was 100% and the average time consumed in each case was (2.13±0.52) minutes. Statistically, the results of observation group were significantly better than those of the control group (P<0.01). In the emergency treatment for critical patients with microcirculation failure, compared with the doctor-guided central venous catheterization, B-ultrasound guided indwelling needle puncture of the external jugular vein has the advantages of high success rate and time efficiency so as to open the vein access for critical patients quickly and help them take the medicine timely, which reduces the pressure of nurses and is well worth clinical application.

Second-line therapy in paediatric warm autoimmune haemolytic anaemia. Guidelines from the Associazione Italiana Onco-Ematologia Pediatrica (AIEOP).

Autoimmune haemolytic anaemia (AIHA) is a rare condition in children caused by the presence of auto-antibodies directed against red blood cell surface antigens, leading to premature red cell destruction1,2. It is classified as warm, cold, including cold haemagglutinin disease and paroxysmal cold haemoglobinuria, or mixed, according to the thermal range of the auto-antibody. AIHA can be idiopathic or secondary. The overall annual incidence is reported to be 1–3 cases/100,000 people and approximately 0.2 cases/1,000,000 individuals less than 20 years of age3–7. AIHA constitutes an important issue for many paediatricians who often have to deal with the diagnosis and treatment of critical patients in the absence of consistent support from the literature. This is particularly true for the second-line therapy. Indeed, while there is an established common practice about management of the acute phase of the disease, including diagnostic work-up and first-line therapy8,9, second-line therapy is more debated. On the basis of these considerations, the Red Cell Working Group of the AIEOP (Associazione Italiana di Ematologia ed Oncologia Pediatrica) developed this consensus paper with the objective of providing shared recommendations to paediatricians.

Nursing of three children patients receiving extracorporeal membrane oxygenation support during long-distance transfer

Objective To summarize the experience of nursing three critical children patients with extracorporeal membrane oxygenation (ECMO) during long-distance transfer. Methods Before the transfer, a sound contingency plan was made in case of problems that might happen during the transfer; during the transfer, the patients' vital signs and ECMO parameters were closely monitored, and their complications were identified and managed; when transferred in the ward, they were handed over and nursed carefully. Results The first patient's transfer time and distance were 8h and 700km, the second's 14 h and 1200 km, and the third's 15 h and 1700 km. After successfully transferred, two patients left hospital thanks to treatment, while the other one, who suffered from Nephrotic Syndrome complicated by pneumocystis carinii pneumonia, died in hospital. Conclusions ECMO support for children patients during long-distance transfer is a specialized and systematic process that requires multidisciplinary coordination. The aid of ECMO makes the transfer of severe children patients with Cardiopulmonary Failure possible and safe, and saves valuable time for the treatment of critical patients. Key words: Nursing; Extracorporeal membrane oxygenation; Critical children patients; Long-distance transfer

Discussion on clinical application and nursing experience of percutaneous dilational tracheostomy in critical patients of ICU

Objective To explore the clinical effect and nursing methods of percutaneous dilational tracheostomy in critical patients of ICU. Methods A total of 76 cases of critical patients of ICU from January 2014 to January 2015 were randomly collected as the research objects.All of the patients were divided into two groups according to the surgical methods, 38 patients underwent traditional open tracheotomy were as the control group, while 38 patients underwent percutaneous dilational tracheostomy were as the observation group.The patients of the two groups all received appropriate nursing measures throughout the perioperative period.The operation effect indexes included operative time, peri-operative bleeding, length of incision, wound healing time, etc.of the two groups were observed and compared, and the postoperative complications were compared. Results The operative time, peri-operative bleeding, length of incision and wound healing time of the observation group were significantly better than that of the control group, and the differences were statistical significance (P<0.05). The postoperative complication rate of the observation group (5.26%) was significantly lower than that of the control group, and the difference was statistical significance (P<0.05). Conclusions Percutaneous dilational tracheostomy for the treatment of critical patients of ICU can significantly shorten the operation time, and when combined with careful and meticulous nursing can reduce the intraoperative blood loss and promote the wound healing, and has good security, it is worthy of clinical application. Key words: ICU; Critical patients; Percutaneous dilational tracheotomy; Nursing strategy

Dropped calls, Turnaround time and Document Retention Time: Crucial parameters to monitor the effective implementation of laboratory Critical alert policy for critically ill patients

Context: Critical alert policy adopted under laboratory accreditation guidelines [1] and under the National Patient Safety Goals (NPSGs) has prioritized safe and timely communication of critical alert [2] so that immediate treatment can be done as soon as the sample showing critical value is communicated by the laboratory. Laboratories are burdened with the analysis of samples not only from emergency and intensive care units but also from outdoor and wards; require to frame a policy, which meets the need of the critical patients. Most of the studies conducted to analyze the effective implementation of the critical alert policy look at the tip of iceberg as the percentage of critical alerts reported by laboratory and the turn- around time. Aim: The present study was conducted to analyze the various components of critical alert policy framed by the laboratory under study. Setting and Design: Study was conducted at a tertiary care hospital in a NABL accreditation of laboratory running since 3 years. We assessed not only the policy and procedure documented and followed by the laboratory under study as laid down under the guidelines [1],[2] but also certain issue (Dropped calls), which are encountered during implementation of the critical alert policy and procedure. Statistical Analysis: Study was a retrospective, cross-sectional. Results: The outcome of the study highlighted the hidden component of the iceberg causing obstacle in implementation of the critical alert policy as increased dropped calls, the turnaround time of which till the writing of the manuscript was infinite. Moreover, short storage time of the document maintained by a laboratory as evidence of communication of critical alert to the caretaker by the hospital-based laboratory leaves the hospital with no evidence if required later on. Conclusions: Detecting and correcting hidden components of critical alert policy can lead to immediate attention and treatment of critical patients and prevent mortality and mortality on one hand and on the other hand the hospital that implements this system can be prevented from the burden of medico legal cases to an extent.

Sequential blood purification therapy for critical patients with hyperlipidemic severe acute pancreatitis.

To evaluate the efficacy of sequential blood purification therapy in the treatment of critical patients with hyperlipidemic severe acute pancreatitis. Thirty-one intensive care unit (ICU) patients with hyperlipidemic severe acute pancreatitis treated at the Second Affiliated Hospital of Harbin Medical University were divided into either a study group (n = 15; July 1, 2012 to June 30, 2014) or a control group (n = 16; July 1, 2010 to June 30, 2012) based on the implementation of sequential blood purification therapy. The control group received continuous venous-venous hemofiltration (CVVH) on the basis of conventional treatments, and the therapeutic dose of CVVH was 30 mL/kg per hour. The study group received sequential plasma exchange and CVVH on the basis of conventional treatments. The anticoagulation regimen of CVVH is the regional citrate anticoagulation. Mortality rate on day 28, rates of systemic and local complications, duration of ICU, and time to target serum lipid level, as well as physiologic and laboratory indices were compared between the two groups. The mortality rate on day 28 was significantly lower in the study group than in the control group (13.33% vs 37.50%; P < 0.05). The duration of ICU stay was significantly shorter in the study group than in the control group (7.4 ± 1.35 d vs 9.19 ± 2.99 d, P < 0.05). The time to target serum lipid level was significantly shorter in the study group than in the control group (3.47 ± 0.52 d vs 7.90 ± 1.14 d, P < 0.01). There were no significant differences in the rates of systemic complications and local complications between the two groups (60% vs 50% and 80% vs 81%, respectively). In the comparisons of physiologic and laboratory indices, serum albumin and C-reactive protein were significantly better in the study group than in the control group after treatment (37.8 ± 4.6 g/L vs 38.9 ± 5.7 g/L, and 20.5 ± 6.4 mg/L vs 28.5 ± 7.1 mg/L, respectively, both P < 0.05). With the exception of plateletcrit, no other indices showed significant differences between the two groups. Sequential blood purification therapy is effective in the treatment of ICU patients with hyperlipidemic severe acute pancreatitis and can improve patient prognosis.

P005: Effect of improvement activity for decreasing catheter related bloodstream infection

Insertion of central venous catheter is essential procedure for treatment of critical patient, but if this procedure is increased, bloodstream infection (BSI) can be increased. But through fulfillment of practice guideline, Catheter related Bloodstream Infection (CRBSI) can be fully prevented, and many hospitals try to decrease BSI like “0” percent.

The iOSC3 System: Using Ontologies and SWRL Rules for Intelligent Supervision and Care of Patients with Acute Cardiac Disorders

Physicians in the Intensive Care Unit (ICU) are specially trained to deal constantly with very large and complex quantities of clinical data and make quick decisions as they face complications. However, the amount of information generated and the way the data are presented may overload the cognitive skills of even experienced professionals and lead to inaccurate or erroneous actions that put patients' lives at risk. In this paper, we present the design, development, and validation of iOSC3, an ontology-based system for intelligent supervision and treatment of critical patients with acute cardiac disorders. The system analyzes the patient's condition and provides a recommendation about the treatment that should be administered to achieve the fastest possible recovery. If the recommendation is accepted by the doctor, the system automatically modifies the quantity of drugs that are being delivered to the patient. The knowledge base is constituted by an OWL ontology and a set of SWRL rules that represent the expert's knowledge. iOSC3 has been developed in collaboration with experts from the Cardiac Intensive Care Unit (CICU) of the Meixoeiro Hospital, one of the most significant hospitals in the northwest region of Spain.

Comparison of immunohistochemistry (IHC) and quantitative RT-PCR: ER, PR, and HER2 receptor status.

47 Background: IHC is the present standard for measuring estrogen (ER) and progesterone receptor (PR) expression for breast cancer. However, the lack of concordance between testing laboratories and the critical patient treatment decisions made with results prompted ASCO/CAP to recommend guidelines and proficiency testing requirements to ensure accuracy. Quantitative RT-PCR (qRT-PCR) is an alternative method for ER and PR testing and while concordance with IHC has been reported, additional testing is merited. This study compares ER, PR and HER2 status determined by IHC and qRT-PCR. Methods: FFPE tissues of ER(+) tumors collected and tested at the Blumenthal Cancer Center were studied. Expression levels of ESR1, PGR, and ERBB2 were determined by a multiplex qRT-PCR TaqMan assay and by the Oncotype Dx assay. Pre-established cutpoints were used to determine positivity. Only samples with qRT-PCR and corresponding IHC data were used, resulting in 144 ER, 128 PR, and 107 HER2 comparisons. ESR1 and PGR expression levels determined by the two qRT-PCR assays were also compared. Results: Of the144 IHC ER(+) samples, 142 were positive and 2 were negative by both qRT-PCR assays. All 120 IHC PR(+) samples were positive by both qRT-PCR assays. Of the 8 IHC PR(-) samples, 5 were negative and 3 were positive by both qRT-PCR assays. Of the 107 IHC HER2(-) samples, all but 2 were negative by qRT-PCR. One sample was positive by both qRT-PCR assays; one was positive by Oncotype Dx only. The expression levels determined by the qRT-PCR assays showed good correlation for ESR1 (r=0.85) and PGR (r=0.9). Conclusions: Concordance between qRT-PCR and IHC was 98.6% for ER and 97.7% for PR. Except for a single HER2 determination, there was 100% concordance between the two qRT-PCR assays. The discordant sample was HER2 (+) by multiplex qRT-PCR and “equivocal” by Oncotype Dx. Excellent correlation was also observed in the mRNA expression levels. The absence of HER2(+) and ER(-) samples are limitations of this study. These results suggest that qRT-PCR is a promising alternative method to IHC for determining hormone receptor status. Additional testing of samples with endocrine therapy outcomes including ER(-) samples would be beneficial.