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Tahtabasi M, Hosbul T, Karaman E, Akin Y, Kilicaslan N, Gezer M, Sahiner F. Frequency of hepatic steatosis and its association with the pneumonia severity score on chest computed tomography in adult COVID-19 patients. World J Crit Care Med 2021; 10:47-57. [PMID: 34046310 PMCID: PMC8131933 DOI: 10.5492/wjccm.v10.i3.47] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/19/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent studies of the coronavirus disease 2019 (COVID-19) demonstrated that obesity is significantly associated with increased disease severity, clinical outcome, and mortality. The association between hepatic steatosis, which frequently accompanies obesity, and the pneumonia severity score (PSS) evaluated on computed tomography (CT), and the prevalence of steatosis in patients with COVID-19 remains to be elucidated.
AIM To assess the frequency of hepatic steatosis in the chest CT of COVID-19 patients and its association with the PSS.
METHODS The chest CT images of 485 patients who were admitted to the emergency department with suspected COVID-19 were retrospectively evaluated. The patients were divided into two groups as COVID-19-positive [CT- and reverse transcriptase-polymerase chain reaction (RT-PCR)-positive] and controls (CT- and RT-PCR-negative). The CT images of both groups were evaluated for PSS as the ratio of the volume of involved lung parenchyma to the total lung volume. Hepatic steatosis was defined as a liver attenuation value of ≤ 40 Hounsfield units (HU).
RESULTS Of the 485 patients, 56.5% (n = 274) were defined as the COVID-19-positive group and 43.5% (n = 211) as the control group. The average age of the COVID-19-positive group was significantly higher than that of the control group (50.9 ± 10.9 years vs 40.4 ± 12.3 years, P < 0.001). The frequency of hepatic steatosis in the positive group was significantly higher compared with the control group (40.9% vs 19.4%, P < 0.001). The average hepatic attenuation values were significantly lower in the positive group compared with the control group (45.7 ± 11.4 HU vs 53.9 ± 15.9 HU, P < 0.001). Logistic regression analysis showed that after adjusting for age, hypertension, diabetes mellitus, overweight, and obesity there was almost a 2.2 times greater odds of hepatic steatosis in the COVID-19-positive group than in the controls (odds ratio 2.187; 95% confidence interval: 1.336-3.580, P < 0.001).
CONCLUSION The prevalence of hepatic steatosis was significantly higher in COVID-19 patients compared with controls after adjustment for age and comorbidities. This finding can be easily assessed on chest CT images.
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Affiliation(s)
- Mehmet Tahtabasi
- Department of Radiology, University of Health Science, Mehmet Akif Inan Education and Research Hospital, Sanliurfa 63000, Turkey
| | - Tugrul Hosbul
- Department of Medical Microbiology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06100, Turkey
| | - Ergin Karaman
- Department of Radiology, University of Health Science, Mehmet Akif Inan Education and Research Hospital, Sanliurfa 63000, Turkey
| | - Yasin Akin
- Department of Radiology, University of Health Science, Mehmet Akif Inan Education and Research Hospital, Sanliurfa 63000, Turkey
| | - Nihat Kilicaslan
- Department of Radiology, University of Health Science, Mehmet Akif Inan Education and Research Hospital, Sanliurfa 63000, Turkey
| | - Mehmet Gezer
- Department of Radiology, University of Health Science, Mehmet Akif Inan Education and Research Hospital, Sanliurfa 63000, Turkey
| | - Fatih Sahiner
- Department of Medical Microbiology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06100, Turkey
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Alqahtani JS. Patient–ventilator asynchrony in Saudi Arabia: Where we stand? World J Crit Care Med 2021; 10:58-60. [PMID: 34046311 PMCID: PMC8131934 DOI: 10.5492/wjccm.v10.i3.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/13/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Patient–ventilator asynchrony in Saudi Arabia practices is common, and more emphasis on how to mitigate such a clinical problem is needed. This letter is intended to shed the light on the current national evidence of patient–ventilator asynchrony and how to step ahead for better patients' ventilation management.
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Affiliation(s)
- Jaber S Alqahtani
- UCL Respiratory, University College London, London WC1E 6BT, United Kingdom
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
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See KC. Acute cor pulmonale in patients with acute respiratory distress syndrome: A comprehensive review. World J Crit Care Med 2021; 10:35-42. [PMID: 33728264 PMCID: PMC7941786 DOI: 10.5492/wjccm.v10.i2.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/01/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS)-related acute cor pulmonale (ACP) is found in 8%-50% of all patients with ARDS, and is associated with adverse hemodynamic and survival outcomes. ARDS-related ACP is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia, which connote simultaneous diastolic (volume) and systolic (pressure) overload respectively. Risk factors include pneumonia, hypercapnia, hypoxemia, high airway pressures and concomitant pulmonary disease. Current evidence suggests that ARDS-related ACP is amenable to multimodal treatments including ventilator adjustment (aiming for arterial partial pressure of carbon dioxide < 60 mmHg, plateau pressure < 27 cmH2O, driving pressure < 17 cmH2O), prone positioning, fluid balance optimization and pharmacotherapy. Further research is required to elucidate the optimal frequency and duration of routine bedside echocardiography screening for ARDS-related ACP, to more clearly delineate the diagnostic role of transthoracic echocardiography relative to transesophageal echocardiography, and to validate current and novel therapies.
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Affiliation(s)
- Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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Omar AS, Hanoura S, Shouman Y, Sivadasan PC, Sudarsanan S, Osman H, Pattath AR, Singh R, AlKhulaifi A. Intensive care outcome of left main stem disease surgery: A single center three years’ experience. World J Crit Care Med 2021; 10:12-21. [PMID: 33505869 PMCID: PMC7805253 DOI: 10.5492/wjccm.v10.i1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/09/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring.
AIM To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome.
METHODS Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups.
RESULTS Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures.
CONCLUSION Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients’ care.
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Affiliation(s)
- Amr S Omar
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and Intensive Care Unit, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Medicine, Weill Cornell Medical College in Qatar, Doha 3050, DA, Qatar
- Department of Critical Care Medicine, Beni Suef University, Beni Suef 62511, Egypt
| | - Samy Hanoura
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Anesthesia, Alazhar University, Cairo 11651, Egypt
| | - Yasser Shouman
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Praveen C Sivadasan
- Department of Cardiothoracic Surgery/Intensive Care Unit Section, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Suraj Sudarsanan
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Hany Osman
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Anesthesia, Alazhar University, Cairo 11651, Egypt
| | - Abdul Rasheed Pattath
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Rajvir Singh
- Department of Medical Research, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Abdulaziz AlKhulaifi
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Cardiothoracic Surgery, Qatar University, Doha 3050, DA, Qatar
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Paul R, Sathe P, Kumar S, Prasad S, Aleem M, Sakhalvalkar P. Multicentered prospective investigator initiated study to evaluate the clinical outcomes with extracorporeal cytokine adsorption device (CytoSorb ®) in patients with sepsis and septic shock. World J Crit Care Med 2021; 10:22-34. [PMID: 33505870 PMCID: PMC7805252 DOI: 10.5492/wjccm.v10.i1.22] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/11/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sepsis is a severe clinical syndrome related to the host response to infection. The severity of infections is due to an activation cascade that will lead to an auto amplifying cytokine production: The cytokine storm. Hemoadsorption by CytoSorb® therapy is a new technology that helps to address the cytokine storm and to regain control over various inflammatory conditions.
AIM To evaluate prospectively CytoSorb® therapy used as an adjunctive therapy along with standard of care in septic patients admitted to intensive care unit (ICU).
METHODS This was a prospective, real time, investigator initiated, observational multicenter study conducted in patients admitted to the ICU with sepsis and septic shock. The improvement of mean arterial pressure and reduction of vasopressor needs were evaluated as primary outcome. The change in laboratory parameters, sepsis scores [acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA)] and vital parameters were considered as secondary outcome. The outcomes were also evaluated in the survivor and non-survivor group. Descriptive statistics were used; a P value < 0.05 was considered to be statistically significant.
RESULTS Overall, 45 patients aged ≥ 18 and ≤ 80 years were included; the majority were men (n = 31; 69.0%), with mean age 47.16 ± 14.11 years. Post CytoSorb® therapy, 26 patients survived and 3 patients were lost to follow-up. In the survivor group, the percentage dose reduction in vasopressor was norepinephrine (51.4%), epinephrine (69.4%) and vasopressin (13.9%). A reduction in interleukin-6 levels (52.3%) was observed in the survivor group. Platelet count improved to 30.1% (P = 0.2938), and total lung capacity count significantly reduced by 33% (P < 0.0001). Serum creatinine and serum lactate were reduced by 33.3% (P = 0.0190) and 39.4% (P = 0.0120), respectively. The mean APACHE II score was 25.46 ± 2.91 and SOFA scores was 12.90 ± 4.02 before initiation of CytoSorb® therapy, and they were reduced significantly post therapy (APACHE II 20.1 ± 2.47; P < 0.0001 and SOFA 9.04 ± 3.00; P = 0.0003) in the survivor group. The predicted mortality in our patient population before CytoSorb® therapy was 56.5%, and it was reduced to 48.8% (actual mortality) after CytoSorb® therapy. We reported 75% survival rate in patients given treatment in < 24 h of ICU admission and 68% survival rates in patients given treatment within 24-48 h of ICU admission. In the survivor group, the average number of days spent in the ICU was 4.44 ± 1.66 d; while in the non-survivor group, the average number of days spent in ICU was 8.5 ± 15.9 d. CytoSorb® therapy was safe and well tolerated with no adverse events reported.
CONCLUSION CytoSorb® might be an effective adjuvant therapy in stabilizing sepsis and septic shock patients. However, it is advisable to start the therapy at an early stage (preferably within 24 h after onset of septic shock).
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Affiliation(s)
- Rajib Paul
- Department of Internal Medicine and Critical Care, Apollo Health City, Hyderabad 500033, India
| | - Prachee Sathe
- Department of Critical Care Medicine, Ruby Hall Clinic, Pune 411001, India
| | - Senthil Kumar
- Department of Critical Care Medicine, Apollo Hospital, Chennai 600006, India
| | - Shiva Prasad
- Department of Anesthesiology and Critical Care, Narayana Institute of Cardiac Sciences, Bangaluru 560099, India
| | - Ma Aleem
- Department of Internal Medicine and Critical Care, Apollo Health City, Hyderabad 500033, India
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Kichloo A, Kumar A, Amir R, Aljadah M, Farooqi N, Albosta M, Singh J, Jamal S, El-Amir Z, Kichloo A, Lone N. Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic. World J Crit Care Med 2021; 10:1-11. [PMID: 33505868 PMCID: PMC7805254 DOI: 10.5492/wjccm.v10.i1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/07/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Akshay Kumar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15260, United States
| | - Rawan Amir
- Department of Internal Medicine, University of Maryland, Baltimore, MD 20742, United States
| | - Michael Aljadah
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Najiha Farooqi
- Department of Surgery, Central Michigan University, Saginaw, MI 48603, United States
| | - Michael Albosta
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Jagmeet Singh
- Department of Nephrology and Transplant Nephrology, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Shakeel Jamal
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Zain El-Amir
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Akif Kichloo
- Department of Anesthesiology and Critical Care, Saraswathi Institute of Medical Sciences, Uttar Pradesh 245304, India
| | - Nazir Lone
- Department of Pulmonology and Critical Care, Northwell Health, Riverhead, NY 11901, United States
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Webb AJ, Seisa MO, Nayfeh T, Wieruszewski PM, Nei SD, Smischney NJ. Vasopressin in vasoplegic shock: A systematic review. World J Crit Care Med 2020; 9:88-98. [PMID: 33384951 PMCID: PMC7754532 DOI: 10.5492/wjccm.v9.i5.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/10/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vasoplegic shock is a challenging complication of cardiac surgery and is often resistant to conventional therapies for shock. Norepinephrine and epinephrine are standards of care for vasoplegic shock, but vasopressin has increasingly been used as a primary pressor in vasoplegic shock because of its unique pharmacology and lack of inotropic activity. It remains unclear whether vasopressin has distinct benefits over standard of care for patients with vasoplegic shock.
AIM To summarize the available literature evaluating vasopressin vs non-vasopressin alternatives on the clinical and patient-centered outcomes of vasoplegic shock in adult intensive care unit (ICU) patients.
METHODS This was a systematic review of vasopressin in adults (≥ 18 years) with vasoplegic shock after cardiac surgery. Randomized controlled trials, prospective cohorts, and retrospective cohorts comparing vasopressin to norepinephrine, epinephrine, methylene blue, hydroxocobalamin, or other pressors were included. The primary outcomes of interest were 30-d mortality, atrial/ventricular arrhythmias, stroke, ICU length of stay, duration of vasopressor therapy, incidence of acute kidney injury stage II-III, and mechanical ventilation for greater than 48 h.
RESULTS A total of 1161 studies were screened for inclusion with 3 meeting inclusion criteria with a total of 708 patients. Two studies were randomized controlled trials and one was a retrospective cohort study. Primary outcomes of 30-d mortality, stroke, ventricular arrhythmias, and duration of mechanical ventilation were similar between groups. Conflicting results were observed for acute kidney injury stage II-III, atrial arrhythmias, duration of vasopressors, and ICU length of stay with higher certainty of evidence in favor of vasopressin serving a protective role for these outcomes.
CONCLUSION Vasopressin was not found to be superior to alternative pressor therapy for any of the included outcomes. Results are limited by mixed methodologies, small overall sample size, and heterogenous populations.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR 97239, United States
| | - Mohamed O Seisa
- Robert D and Patricia E Kern Center For The Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, United States
| | - Tarek Nayfeh
- Robert D and Patricia E Kern Center For The Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan J Smischney
- Department of Anesthesia, Mayo Clinic, Rochester, MN 55905, United States
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Abulebda K, Ahmed RA, Auerbach MA, Bona AM, Falvo LE, Hughes PG, Gross IT, Sarmiento EJ, Barach PR. National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic. World J Crit Care Med 2020; 9:74-87. [PMID: 33384950 PMCID: PMC7754533 DOI: 10.5492/wjccm.v9.i5.74] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections.
AIM To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide.
METHODS A cross-sectional multi-center national survey of PICU medical director(s) from children’s hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation.
RESULTS We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children’s hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives.
CONCLUSIONS A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves.
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Affiliation(s)
- Kamal Abulebda
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
| | - Rami A Ahmed
- Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, United States
| | - Marc A Auerbach
- Department of Pediatrics, Division of Pediatrics Emergency Medicine, Yale University School of Medicine, New Haven, CT 06504, United States
| | - Anna M Bona
- Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, United States
| | - Lauren E Falvo
- Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, United States
| | - Patrick G Hughes
- Department of Integrated Medical Science, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Isabel T Gross
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT 06504, United States
| | - Elisa J Sarmiento
- Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, United States
| | - Paul R Barach
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48202, Jefferson College of Population Health, Philadelphia, PA, 19107, United States
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Rodrigues AT, Rodrigues JT, Rodrigues CT, Volpe CMDO, Rocha-Silva F, Nogueira-Machado JA, Alberti LR. Association between thrombomodulin and high mobility group box 1 in sepsis patients. World J Crit Care Med 2020; 9:63-73. [PMID: 33134112 PMCID: PMC7579433 DOI: 10.5492/wjccm.v9.i4.63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND High mobility group box 1 (HMGB1) has been studied as a molecule associated with severe outcomes in sepsis and thrombomodulin (TM) seems to decrease HMGB1 activity.
AIM To investigate the role of the thrombomodulin/high mobility group box 1 (T/H) ratio in patients with sepsis and their association with their clinic, testing the hypothesis that higher ratios are associated with better outcomes.
METHODS Twenty patients diagnosed with sepsis or septic shock, according to the 2016 criteria sepsis and septic shock (Sepsis-3), were studied. Patients were followed until they left the intensive care unit or until they achieved 28 d of hospitalization (D28). The following clinical outcomes were observed: Sequential Organ Failure Assessment (SOFA) score; Need for mechanical pulmonary ventilation; Presence of septic shock; Occurrence of sepsis-induced coagulopathy; Need for renal replacement therapy (RRT); and Death.
RESULTS The results showed that patients with SOFA scores greater than or equal to 12 points had higher serum levels of TM: 76.41 ± 29.21 pg/mL vs 37.41 ± 22.55 pg/mL among those whose SOFA scores were less than 12 points, P = 0.003. The T/H ratio was also higher in patients whose SOFA scores were greater than or equal to 12 points, P = 0.001. The T/H ratio was, on average, three times higher in patients in need of RRT (0.38 ± 0.14 vs 0.11 ± 0.09), P < 0.001.
CONCLUSION Higher serum levels of TM and, therefore, higher T/H ratio in the first 24 h after the diagnosis of sepsis were associated with more severe disease and the need for renal replacement therapy, while those with better clinical outcomes and those who were discharged before D28 showed a tendency for lower T/H ratio values.
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Affiliation(s)
- Adriana Teixeira Rodrigues
- Department of Pediatrics, School of Medicine, Federal University of Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Graduation Program in Medicine/Biomedicine - Santa Casa Hospital - Education and Research, Belo Horizonte 30150-240, Minas Gerais, Brazil
| | - Julia Teixeira Rodrigues
- Department of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Minas Gerais, Brazil
| | | | - Caroline Maria de Oliveira Volpe
- Department of Immunology, Graduation Program in Medicine/Biomedicine - Santa Casa Hospital - Education and Research, Belo Horizonte 30150-240, Minas Gerais, Brazil
| | - Fabiana Rocha-Silva
- Clinical Laboratory, Graduation Program in Medicine/Biomedicine - Santa Casa Hospital - Education and Research, Belo Horizonte 30150-240, Minas Gerais, Brazil
| | - Jose Augusto Nogueira-Machado
- Department of Immunology, Graduation Program in Medicine/Biomedicine - Santa Casa Hospital - Education and Research, Belo Horizonte 30150-240, Minas Gerais, Brazil
| | - Luiz Ronaldo Alberti
- Graduation Program in Medicine/Biomedicine - Santa Casa Hospital - Education and Research, Belo Horizonte 30150-240, Minas Gerais, Brazil
- Department of Surgery, School of Medicine, Federal University of Minas Gerais, Belo Horizonte 30220-000, Minas Gerais, Brazil
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Cornejo-Juárez P, González-Oros I, Mota-Castañeda P, Vilar-Compte D, Volkow-Fernández P. Ventilator-associated pneumonia in patients with cancer: Impact of multidrug resistant bacteria. World J Crit Care Med 2020; 9:43-53. [PMID: 32844090 PMCID: PMC7416360 DOI: 10.5492/wjccm.v9.i3.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 05/22/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with cancer have several risk factors for developing respiratory failure requiring mechanical ventilation (MV). The emergence of multidrug resistant bacteria (MDRB) has become a public health problem, creating a new burden on medical care in hospitals, particularly for patients admitted to the intensive care unit (ICU).
AIM To describe risk factors for ventilator-acquired pneumonia (VAP) in patients with cancer and to evaluate the impact of MDRB.
METHODS A retrospective study was performed from January 2016 to December 2018 at a cancer referral center in Mexico City, which included all patients who were admitted to the ICU and required MV ≥ 48 h. They were classified as those who developed VAP versus those who did not; pathogens isolated, including MDRB. Clinical evolution at 60-d was assessed. Descriptive analysis was carried out; comparison was performed between VAP vs non-VAP and MDRB vs non-MDRB.
RESULTS Two hundred sixty-three patients were included in the study; mean age was 51.9 years; 52.1% were male; 68.4% had solid tumors. There were 32 episodes of VAP with a rate of 12.2%; 11.5 episodes/1000 ventilation-days. The most frequent bacteria isolated were the following: Klebsiella spp. [n = 9, four were Extended-Spectrum Beta-Lactamase (ESBL) producers, one was Carbapenem-resistant (CR)]; Escherichia coli (n = 5, one was ESBL), and Pseudomonas aeruginosa (n = 8, two were CR). One Methicillin-susceptible Staphylococcus aureus was identified. In multivariate analysis, the sole risk factor associated for VAP was length of ICU stay (OR = 1.1; 95%CI: 1.03-1.17; P = 0.003). Sixty-day mortality was 53% in VAP and 43% without VAP (P = 0.342). There was not higher mortality in those patients with MDRB.
CONCLUSION This study highlights the high percentage of Gram-negative bacteria, which allows the initiation of empiric antibiotic coverage for these pathogens. In this retrospective, single center, observational study, MDRB VAP was not directly linked to increased mortality at 60 days.
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Affiliation(s)
- Patricia Cornejo-Juárez
- Infectious Diseases Department, Instituto Nacional de Cancerología (INCan), Mexico City 14080, Mexico
| | - Ivan González-Oros
- Infectious Diseases Department, Instituto Nacional de Cancerología (INCan), Mexico City 14080, Mexico
| | - Paola Mota-Castañeda
- Infectious Diseases Department, Instituto Nacional de Cancerología (INCan), Mexico City 14080, Mexico
| | - Diana Vilar-Compte
- Infectious Diseases Department, Instituto Nacional de Cancerología (INCan), Mexico City 14080, Mexico
| | - Patricia Volkow-Fernández
- Infectious Diseases Department, Instituto Nacional de Cancerología (INCan), Mexico City 14080, Mexico
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Gouda AS, Khattab AM, Mégarbane B. Lessons from a methanol poisoning outbreak in Egypt: Six case reports. World J Crit Care Med 2020; 9:54-62. [PMID: 32844091 PMCID: PMC7416361 DOI: 10.5492/wjccm.v9.i3.54] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/08/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mass methanol poisonings are challenging, especially in regions with no preparedness, management guidelines and available antidotes.
CASE SUMMARY Six Ukrainian patients were referred to our emergency department in Cairo, Egypt several hours after drinking an alcoholic beverage made of 70%-ethanol disinfectant bought from a local pharmacy. All patients presented with severe metabolic acidosis and visual impairments. Two were comatose. Management was based on the clinical features and chemistry tests due to deficient resources for methanol leveling. No antidote was administered due to fomepizole unavailability and the difficulties expected to obtain ethanol and safely administer it without concentration monitoring. One patient died from multiorgan failure, another developed blindness and the four other patients rapidly improved.
CONCLUSION This methanol poisoning outbreak strongly highlights the lack of safety from hazardous pharmaceuticals sold in pharmacies and limitations due to the lack of diagnostic testing, antidote availability and staff training in countries with limited-resources such as Egypt.
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Affiliation(s)
- Ahmed S Gouda
- National Egyptian Center of Environmental and Toxicological Research, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Amr M Khattab
- Department of Forensic Medicine and clinical Toxicology, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris 75010, France
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Lal A, Pinevich Y, Gajic O, Herasevich V, Pickering B. Artificial intelligence and computer simulation models in critical illness. World J Crit Care Med 2020; 9:13-19. [PMID: 32577412 PMCID: PMC7298588 DOI: 10.5492/wjccm.v9.i2.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Widespread implementation of electronic health records has led to the increased use of artificial intelligence (AI) and computer modeling in clinical medicine. The early recognition and treatment of critical illness are central to good outcomes but are made difficult by, among other things, the complexity of the environment and the often non-specific nature of the clinical presentation. Increasingly, AI applications are being proposed as decision supports for busy or distracted clinicians, to address this challenge. Data driven "associative" AI models are built from retrospective data registries with missing data and imprecise timing. Associative AI models lack transparency, often ignore causal mechanisms, and, while potentially useful in improved prognostication, have thus far had limited clinical applicability. To be clinically useful, AI tools need to provide bedside clinicians with actionable knowledge. Explicitly addressing causal mechanisms not only increases validity and replicability of the model, but also adds transparency and helps gain trust from the bedside clinicians for real world use of AI models in teaching and patient care.
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Affiliation(s)
- Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rochester, Mayo Clinic, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
| | - Yuliya Pinevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rochester, Mayo Clinic, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
| | - Vitaly Herasevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN 55905, United States
| | - Brian Pickering
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN 55905, United States
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Cengic S, Zuberi M, Bansal V, Ratzlaff R, Rodrigues E, Festic E. Hypotension after intensive care unit drop-off in adult cardiac surgery patients. World J Crit Care Med 2020; 9:20-30. [PMID: 32577413 PMCID: PMC7298587 DOI: 10.5492/wjccm.v9.i2.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension is a frequent complication in the intensive care unit (ICU) after adult cardiac surgery.
AIM To describe frequency of hypotension in the ICU following adult cardiac surgery and its relation to the hospital outcomes.
METHODS A retrospective study of post-cardiac adult surgical patients at a tertiary academic medical center in a two-year period. We abstracted baseline demographics, comorbidities, and all pertinent clinical variables. The primary predictor variable was the development of hypotension within the first 30 min upon arrival to the ICU from the operating room (OR). The primary outcome was hospital mortality, and other outcomes included duration of mechanical ventilation (MV) in hours, and ICU and hospital length of stay in days.
RESULTS Of 417 patients, more than half (54%) experienced hypotension within 30 min upon arrival to the ICU. Presence of OR hypotension immediately prior to ICU transfer was significantly associated with ICU hypotension (odds ratio = 1.9; 95% confidence interval: 1.21-2.98; P < 0.006). ICU hypotensive patients had longer MV, 5 (interquartile ranges 3, 15) vs 4 h (interquartile ranges 3, 6), P = 0.012. The patients who received vasopressor boluses (n = 212) were more likely to experience ICU drop-off hypotension (odds ratio = 1.45, 95% confidence interval: 0.98-2.13; P = 0.062), and they experienced longer MV, ICU and hospital length of stay (P < 0.001, for all).
CONCLUSION Hypotension upon anesthesia-to-ICU drop-off is more frequent than previously reported and may be associated with adverse clinical outcomes.
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Affiliation(s)
- Sabina Cengic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of General Surgery, Stadtspital Triemli, Zurich 8063, Switzerland
| | - Muhammad Zuberi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Robert Ratzlaff
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Eduardo Rodrigues
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Emir Festic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
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Kashyap R, Vashistha K, Saini C, Dutt T, Raman D, Bansal V, Singh H, Bhandari G, Ramakrishnan N, Seth H, Sharma D, Seshadri P, Daga MK, Gurjar M, Javeri Y, Surani S, Varon J. Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018). World J Crit Care Med 2020; 9:31-42. [PMID: 32577414 PMCID: PMC7298589 DOI: 10.5492/wjccm.v9.i2.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 04/27/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels.
AIM To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions.
METHODS The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23rd-August 25th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.
RESULTS There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability.
CONCLUSION In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.
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Affiliation(s)
- Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Kirtivardhan Vashistha
- Department of Infectious Disease, Mayo Clinic, Rochester, MN 55905, United States
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA 15212, United States
| | - Chetan Saini
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, United States
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 14061, United States
| | - Taru Dutt
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, United States and Department of Psychiatry, Hennepin County Medical Center, Minneapolis, MN 55415, United States
| | - Dileep Raman
- Department of Medicine, Cloud Physician Healthcare, Bangalore 560038, India
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Harpreet Singh
- Department of Internal Medicine, Maulana Azad Medical College & Associated Hospitals, New Delhi, Delhi 110002, India
| | - Geeta Bhandari
- Department of Anesthesiology, Government Medical College, Haldwani, Nainital 263129, India
| | | | - Harshit Seth
- Department of Hospitalist Medicine, Allegany Clinic, Allegany Health Network, Pittsburgh, PA 15222, United States
| | - Divya Sharma
- Department of Medicine, MAAGF Healthcare, Chennai 600024, India
| | | | - Mradul Kumar Daga
- Department of Internal Medicine and Center for Occupational and Environment Health, Maulana Azad Medical College, New Delhi, Delhi 110002, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Yash Javeri
- Department of Critical Care Medicine, Regency Super Speciality Hospital, Lucknow 208005, India
- Nayati Healthcare, New Delhi, Delhi 110065, India
| | - Salim Surani
- Department of Pulmonary and Critical Care Medicine, Texas A&M University, College Station, TX 77843, United States
| | - Joseph Varon
- Department of Critical Care, United Memorial Medical Center, Houston, TX 77091, United States
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Mehta Y, Mehta C, Kumar A, George JV, Gupta A, Nanda S, Kochhar G, Raizada A. Experience with hemoadsorption (CytoSorb ®) in the management of septic shock patients. World J Crit Care Med 2020; 9:1-12. [PMID: 32104647 PMCID: PMC7031623 DOI: 10.5492/wjccm.v9.i1.1] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/23/2019] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cytokines and inflammatory mediators are the hallmarks of sepsis. Extracorporeal cytokine hemoadsorption devices are the newer clinical support system to overcome the cytokine storm during sepsis.
AIM To retrospectively evaluate the clinical outcomes of patients admitted in intensive care unit with septic shock with different etiologies.
METHODS The laboratory parameters including biomarkers such as procalcitonin, serum lactate and C-reactive protein; and the hemodynamic parameters; mean arterial pressure, vasopressor doses, sepsis scores, cytokine levels and other vital parameters were evaluated. We evaluated these outcomes among survivors and non-survivors.
RESULTS Of 100 patients evaluated, 40 patients survived. Post treatment, the vasopressors dosage remarkably decreased though it was not statistically different; 34.15% (P = 0.0816) for epinephrine, 20.5 % for norepinephrine (P = 0.3099) and 51% (P = 0.0678) for vasopressin. In the survivor group, a remarkable reduction of biomarkers levels; procalcitonin (65%, P = 0.5859), C-reactive protein (27%, P = 0.659), serum lactate (27%, P = 0.0159) and bilirubin (43.11%; P = 0.0565) were observed from baseline after CytoSorb® therapy. A significant reduction in inflammatory markers; interleukin 6 and interleukin 10; (87% and 92%, P < 0.0001) and in tumour necrosis factor (24%, P = 0.0003) was also seen. Overall, 28 (28%) patients who were given CytoSorb® therapy less than 48 h after onset of septic shock survived and the maximum duration of stay for 70% of these patients in intensive care unit was less than 15 d.
CONCLUSION CytoSorb® is a safe and well tolerated rescue therapy option in patients with septic shock. However, early (preferably within < 48 h after onset of septic shock) initiation could result in better clinical outcomes. Further randomized trials are needed to define the potential benefits of this new treatment modality.
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Affiliation(s)
- Yatin Mehta
- Medanta The Medicity, Gurgaon 122001, Haryana, India
| | - Chitra Mehta
- Medanta The Medicity, Gurgaon 122001, Haryana, India
| | - Ashish Kumar
- Medanta The Medicity, Gurgaon 122001, Haryana, India
| | | | - Aditi Gupta
- Medanta The Medicity, Gurgaon 122001, Haryana, India
| | - Saurabh Nanda
- Medanta The Medicity, Gurgaon 122001, Haryana, India
| | | | - Arun Raizada
- Medanta The Medicity, Gurgaon 122001, Haryana, India
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Capoccia M, Maybauer MO. Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review. World J Crit Care Med 2019; 8:135-147. [PMID: 31942440 PMCID: PMC6957356 DOI: 10.5492/wjccm.v8.i8.135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation (ECMO) for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.
AIM To review the available literature to determine if there was any evidence.
METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.
RESULTS The search resulted in 29 publications relevant to the subject: 1 brief communication, 1 surgical technique report, 1 invited commentary, 1 retrospective case review, 1 observational study, 4 retrospective reviews, 13 case reports and 7 conference abstracts. A total of 194 patients were included in these publications of whom 77 survived.
CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection, it is enough to justify its use in this patient population despite current adverse attitude.
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Affiliation(s)
- Massimo Capoccia
- Department of Aortic and Cardiac Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, United Kingdom
| | - Marc O Maybauer
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Anaesthesiology and Intensive Care Medicine, Phillips University, Marburg 35037, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane QLD 4032, Queensland, Australia
- Advanced Critical Care and Transplant Institute, Integris Baptist Medical Centre, Oklahoma City, OK 73112, United States
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Kumar R, Shah TH, Hadda V, Tiwari P, Mittal S, Madan K, Khan MA, Mohan A. Assessment of quadriceps muscle thickness using bedside ultrasonography by nurses and physicians in the intensive care unit: Intra- and inter-operator agreement. World J Crit Care Med 2019; 8:127-134. [PMID: 31853448 PMCID: PMC6918044 DOI: 10.5492/wjccm.v8.i7.127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 08/29/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Data regarding the agreement among multiple operators for measurement of quadriceps muscle thickness by bedside ultrasonography (USG) are sparse.
AIM To statistically assess the agreement among 5 operators for measurement of quadriceps muscle thickness on bedside USG.
METHODS This was a cross-sectional observational study. The 5 operators of varied experience (comprised of 1 critical care consultant, 2 fellows, and 2 nurses) independently measured quadriceps muscle thickness in triplicate for 45 critically ill patients each, using USG. Intra- and interrater agreement rates among the 5 operators were assessed using intraclass correlation coefficient (ICC) and expressed with 95% confidence interval (CI).
RESULTS The 5 operators produced a total of 135 readings and 675 observations for ICC calculations to determine the intraoperator and interoperator variations respectively. For intraoperator agreement, the overall ICC (95%CI) was 0.998 (0.997, 0.999) for operator 1, 0.998 (0.997, 0.999) for operator 2, 0.997 (0.995, 0.999) for operator 3, 0.999 (0.998, 0.999) for operator 4, and 0.998 (0.997, 0.999) for operator 5. For interoperator agreement, the overall ICC (95%CI) was 0.977 (0.965, 0.986; P < 0.001) for reading 1, 0.974 (0.960, 0.984; P < 0.001) for reading 2, and 0.975 (0.961, 0.985; P < 0.001) for reading 3.
CONCLUSION USG measurement of quadriceps muscle thickness was not dependent on clinical experience, supporting training for nurses in it.
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Affiliation(s)
- Rohit Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Tajamul Hussain Shah
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
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Janata A, Magnet IAM, Schreiber KL, Wilson CD, Stezoski JP, Janesko-Feldman K, Kochanek PM, Drabek T. Minocycline fails to improve neurologic and histologic outcome after ventricular fibrillation cardiac arrest in rats. World J Crit Care Med 2019; 8:106-119. [PMID: 31853446 PMCID: PMC6918046 DOI: 10.5492/wjccm.v8.i7.106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/17/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prolonged cardiac arrest (CA) produces extensive neuronal death and microglial proliferation and activation resulting in neuro-cognitive disabilities. Among other potential mechanisms, microglia have been implicated as triggers of neuronal death after hypoxic-ischemic insults. Minocycline is neuroprotective in some brain ischemia models, either by blunting the microglial response or by a direct effect on neurons.
AIM To improve survival, attenuate neurologic deficits, neuroinflammation, and histological damage after ventricular fibrillation (VF) CA in rats.
METHODS Adult male isoflurane-anesthetized rats were subjected to 6 min VF CA followed by 2 min resuscitation including chest compression, epinephrine, bicarbonate, and defibrillation. After return of spontaneous circulation (ROSC), rats were randomized to two groups: (1) Minocycline 90 mg/kg intraperitoneally (i.p.) at 15 min ROSC, followed by 22.5 mg/kg i.p. every 12 h for 72 h; and (2) Controls, receiving the same volume of vehicle (phosphate-buffered saline). The rats were kept normothermic during the postoperative course. Neurologic injury was assessed daily using Overall Performance Category (OPC; 1 = normal, 5 = dead) and Neurologic Deficit Score (NDS; 0% = normal, 100% = dead). Rats were sacrificed at 72 h. Neuronal degeneration (Fluoro-Jade C staining) and microglia proliferation (anti-Iba-1 staining) were quantified in four selectively vulnerable brain regions (hippocampus, striatum, cerebellum, cortex) by three independent reviewers masked to the group assignment.
RESULTS In the minocycline group, 8 out of 14 rats survived to 72 h compared to 8 out of 19 rats in the control group (P = 0.46). The degree of neurologic deficit at 72 h [median, (interquartile range)] was not different between survivors in minocycline vs controls: OPC 1.5 (1-2.75) vs 2 (1.25-3), P = 0.442; NDS 12 (2-20) vs 17 (7-51), P = 0.328) or between all studied rats. The number of degenerating neurons (minocycline vs controls, mean ± SEM: Hippocampus 58 ± 8 vs 76 ± 8; striatum 121 ± 43 vs 153 ± 32; cerebellum 20 ± 7 vs 22 ± 8; cortex 0 ± 0 vs 0 ± 0) or proliferating microglia (hippocampus 157 ± 15 vs 193 cortex 0 ± 0 vs 0 ± 0; 16; striatum 150 ± 22 vs 161 ± 23; cerebellum 20 ± 7 vs 22 ± 8; cortex 26 ± 6 vs 31 ± 7) was not different between groups in any region (all P > 0.05). Numerically, there were approximately 20% less degenerating neurons and proliferating microglia in the hippocampus and striatum in the minocycline group, with a consistent pattern of histological damage across the individual regions of interest.
CONCLUSION Minocycline did not improve survival and failed to confer substantial benefits on neurologic function, neuronal loss or microglial proliferation across multiple brain regions in our model of rat VF CA.
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Affiliation(s)
- Andreas Janata
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
- Emergency Department, KA Rudolfstiftung, Vienna 1030, Austria
| | - Ingrid AM Magnet
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Emergency Medicine, Vienna General Hospital, Medical University of Vienna, Vienna 1090, Austria
| | - Kristin L Schreiber
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Caleb D Wilson
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Wyoming Otolaryngology, Wyoming Medical Center, Casper, WY 82604, United States
| | - Jason P Stezoski
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Tomas Drabek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
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Dhungana P, Serafim LP, Ruiz AL, Bruns D, Weister TJ, Smischney NJ, Kashyap R. Machine learning in data abstraction: A computable phenotype for sepsis and septic shock diagnosis in the intensive care unit. World J Crit Care Med 2019; 8:120-126. [PMID: 31853447 PMCID: PMC6918045 DOI: 10.5492/wjccm.v8.i7.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/21/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With the recent change in the definition (Sepsis-3 Definition) of sepsis and septic shock, an electronic search algorithm was required to identify the cases for data automation. This supervised machine learning method would help screen a large amount of electronic medical records (EMR) for efficient research purposes.
AIM To develop and validate a computable phenotype via supervised machine learning method for retrospectively identifying sepsis and septic shock in critical care patients.
METHODS A supervised machine learning method was developed based on culture orders, Sequential Organ Failure Assessment (SOFA) scores, serum lactate levels and vasopressor use in the intensive care units (ICUs). The computable phenotype was derived from a retrospective analysis of a random cohort of 100 patients admitted to the medical ICU. This was then validated in an independent cohort of 100 patients. We compared the results from computable phenotype to a gold standard by manual review of EMR by 2 blinded reviewers. Disagreement was resolved by a critical care clinician. A SOFA score ≥ 2 during the ICU stay with a culture 72 h before or after the time of admission was identified. Sepsis versions as V1 was defined as blood cultures with SOFA ≥ 2 and Sepsis V2 was defined as any culture with SOFA score ≥ 2. A serum lactate level ≥ 2 mmol/L from 24 h before admission till their stay in the ICU and vasopressor use with Sepsis-1 and-2 were identified as Septic Shock-V1 and-V2 respectively.
RESULTS In the derivation subset of 100 random patients, the final machine learning strategy achieved a sensitivity-specificity of 100% and 84% for Sepsis-1, 100% and 95% for Sepsis-2, 78% and 80% for Septic Shock-1, and 80% and 90% for Septic Shock-2. An overall percent of agreement between two blinded reviewers had a k = 0.86 and 0.90 for Sepsis 2 and Septic shock 2 respectively. In validation of the algorithm through a separate 100 random patient subset, the reported sensitivity and specificity for all 4 diagnoses were 100%-100% each.
CONCLUSION Supervised machine learning for identification of sepsis and septic shock is reliable and an efficient alternative to manual chart review.
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Affiliation(s)
- Prabij Dhungana
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN 55905, United States
| | - Laura Piccolo Serafim
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN 55905, United States
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Arnaldo Lopez Ruiz
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN 55905, United States
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Danette Bruns
- Anesthesia Clinical Research Unit, Mayo Clinic, MN 55905, United States
| | - Timothy J Weister
- Anesthesia Clinical Research Unit, Mayo Clinic, MN 55905, United States
| | - Nathan Jerome Smischney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN 55905, United States
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN 55905, United States
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Maillet F, Bonnet N, Billard-Pomares T, El Alaoui Magdoud F, Tandjaoui-Lambiotte Y. Fatal Legionella pneumophila serogroup 1 pleural empyema: A case report. World J Crit Care Med 2019; 8:99-105. [PMID: 31750087 PMCID: PMC6854392 DOI: 10.5492/wjccm.v8.i6.99] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Legionella pneumophila (L. pneumophila) is a gram-negative intracellular bacillus composed of sixteen different serogroups. It is mostly known to cause pneumonia in individuals with known risk factors as immunocompromised status, tobacco use, chronic organ failure or age older than 50 years. Although parapneumonic pleural effusion is frequent in legionellosis, pleural empyema is very uncommon. In this study, we report a case of fatal pleural empyema caused by L. pneumophila serogroup 1 in an 81-year-old man with multiple risk factors.
CASE SUMMARY An 81-year-old man presented to the emergency with a 3 wk dyspnea, fever and left chest pain. His previous medical conditions were chronic lymphocytic leukemia, diabetes mellitus, chronic kidney failure, hypertension and hyperlipidemia, without tobacco use. Chest X-ray and comouted tomography-scan confirmed a large left pleural effusion, which puncture showed a citrine exudate with negative standard bacterial cultures. Despite intravenous cefotaxime antibiotherapy, patient’s worsening condition after 10 d led to thoracocentesis and evacuation of 2 liters of pus. The patient progressively developed severe hypoxemia and multiorgan failure occurred. The patient was treated by antibiotherapy with cefepime and amikacin and with adequate symptomatic shock treatment, but died of uncontrolled sepsis. The next day, cultures of the surgical pleural liquid samples yielded L. pneumophila serogroup 1, consistent with the diagnosis of pleural legionellosis.
CONCLUSION L. pneumophila should be considered in patients with multiple risk factors and undiagnosed pleural empyema unresponsive to conventional antibiotherapy.
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Affiliation(s)
- François Maillet
- Intensive Care Unit, Avicenne Hospital, Assistance Publique – Hôpitaux de Paris, Bobigny 93000, France
| | - Nicolas Bonnet
- Intensive Care Unit, Avicenne Hospital, Assistance Publique – Hôpitaux de Paris, Bobigny 93000, France
- Paris XIII University, Bobigny 93000, France
| | - Typhaine Billard-Pomares
- Microbiology Department, Avicenne Hospital, Assistance Publique – Hôpitaux de Paris, Bobigny 93000, France
| | - Fatma El Alaoui Magdoud
- Microbiology Department, Jean Verdier Hospital, Assistance Publique–Hôpitaux de Paris, Bondy 93140, France
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Burstein B, Wieruszewski PM, Zhao YJ, Smischney N. Anticoagulation with direct thrombin inhibitors during extracorporeal membrane oxygenation. World J Crit Care Med 2019; 8:87-98. [PMID: 31750086 PMCID: PMC6854393 DOI: 10.5492/wjccm.v8.i6.87] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 08/13/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
Use of extracorporeal membrane oxygenation to support patients with critical cardiorespiratory illness is increasing. Systemic anticoagulation is an essential element in the care of extracorporeal membrane oxygenation patients. While unfractionated heparin is the most commonly used agent, unfractionated heparin is associated with several unique complications that can be catastrophic in critically ill patients, including heparin-induced thrombocytopenia and acquired antithrombin deficiency. These complications can result in thrombotic events and subtherapeutic anticoagulation. Direct thrombin inhibitors (DTIs) are emerging as alternative anticoagulants in patients supported by extracorporeal membrane oxygenation. Increasing evidence supports DTIs use as safe and effective in extracorporeal membrane oxygenation patients with and without heparin-induced thrombocytopenia. This review outlines the pharmacology, dosing strategies and available protocols, monitoring parameters, and special use considerations for all available DTIs in extracorporeal membrane oxygenation patients. The advantages and disadvantages of DTIs in extracorporeal membrane oxygenation relative to unfractionated heparin will be described.
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Affiliation(s)
- Barry Burstein
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Yan-Jun Zhao
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan Smischney
- Department of Anesthesia, Mayo Clinic, Rochester, MN 55905, United States
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122
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Mishra R, Patel HK, Singasani R, Vakde T. Tuberculosis septic shock, an elusive pathophysiology and hurdles in management: A case report and review of literature. World J Crit Care Med 2019; 8:72-81. [PMID: 31559146 PMCID: PMC6753395 DOI: 10.5492/wjccm.v8.i5.72] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is a rare etiology of the septic shock. Timely administration of the anti-microbial agents has shown mortality benefit. Prompt diagnosis and a high index of suspicion are crucial to the management. We present three cases of TBSS with poor outcome in the majority despite timely and susceptible antibiotic administration. CASE SUMMARY Sixty-seven-year-old woman with latent TB presented with fever, cough, and shortness of breath. She was promptly diagnosed with active TB and started on the appropriate anti-microbial regimen; she had a worsening clinical course with septic shock and multi-organ failure after initiation of antibiotics. Thirty-three-year-old man immunocompromised with acquired immune deficiency syndrome presented with fever, anorexia and weight loss. He had no respiratory symptoms, and first chest X-ray was normal. He had enlarged liver, spleen and lymph nodes suspicious for lymphoma. Despite broad-spectrum antibiotics, he succumbed to refractory septic shock and multi-organ failure. It was shortly before his death that anti-TB antimicrobials were initiated based on pathology reports of bone marrow and lymph node biopsies. Forty-nine-year-old woman with asthma and latent TB admitted with cough and shortness of breath. Although Initial sputum analysis was negative, a subsequent broncho-alveolar lavage turned out to be positive for acid fast bacilli followed by initiation of susceptible ant-TB regimen. She had a downward spiral clinical course with shock, multi-organ failure and finally death. CONCLUSION Worse outcome despite timely initiation of appropriate antibiotics raises suspicion of TB immune reconstitution as a possible pathogenesis for TB septic shock.
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Affiliation(s)
- Rashmi Mishra
- Pulmonary and Critical Care, Penn Highlands Healthcare, Dubois, PA 15801, United States
| | - Harish K Patel
- Division of Gastroenterology, Department of Medicine, Bronx Care Health system, Bronx, NY 10457, United States
| | - Rakesh Singasani
- Department of Medicine, SBH Health System, Bronx, NY 10457, United States
| | - Trupti Vakde
- Division of Pulmonary and Critical Care, Department of Medicine, Bronx Care Health System, Bronx, NY 10457, United States
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123
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Muñoz-Bermúdez R, Abella E, Zuccarino F, Masclans JR, Nolla-Salas J. Successfully non-surgical management of flail chest as first manifestation of multiple myeloma: A case report. World J Crit Care Med 2019; 8:82-86. [PMID: 31559147 PMCID: PMC6753394 DOI: 10.5492/wjccm.v8.i5.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/23/2019] [Accepted: 08/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multiple myeloma is a malignant neoplasm of the bone marrow characterized by neoplastic proliferation of monoclonal plasma cells with a high relationship with destructive bone disease. We present a case of a patient diagnosed with multiple myeloma and sternal fracture in association with multiple bilateral rib fractures and thoracic kyphosis, who developed a severe acute respiratory failure, thus complicating the initial presentation of multiple myeloma. We discuss the therapeutic implications of this uncommon presentation.
CASE SUMMARY A 56-year-old man presented to Hematological Department after he had been experiencing worsening back pain over the last five months, with easy fatigability and progressive weight loss. He had no history of previous trauma. The chemical blood tests were compatible with a diagnosis of multiple myeloma. A radiographic bone survey of all major bones revealed, in addition to multiple bilateral rib fractures, a sternal fracture and compression fracture at T9, T10, T11 and L1 vertebrae. Subcutaneous fat biopsy was positive for amyloid. We started treatment with bortezomib and dexamethasone. After 24 h of treatment, he presented dyspnea secondary to flail chest. He required urgent intubation and ventilatory support being transferred to intensive care unit for further management. The patient remained connected to mechanical ventilation (positive pressure) as treatment which stabilized the thorax. A second cycle of bortezomib plus dexamethasone was started and analgesia was optimized. The condition of the patient improved, as evidenced by callus formation on successive computed tomography scans. The patient was taken off the ventilator one month later, and he was extubated successfully, being able to breathe unaided without paradoxical motion.
CONCLUSION This case highlights the importance of combination between bortezomib and dexamethasone to induce remission of multiple myeloma and the initiation of positive airway pressure with mechanical ventilation to stabilize chest wall to solve the respiratory failure. This combined approach allowed to obtain a quick and complete resolution of the clinical situation.
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Affiliation(s)
| | - Eugenia Abella
- Department of Hematology, Hospital del Mar, Barcelona 08003, Spain
| | - Flavio Zuccarino
- Department of Radiology, Hospital del Mar, Barcelona 08003, Spain
| | | | - Juan Nolla-Salas
- Department of Critical Care, Hospital del Mar, Barcelona 08003, Spain
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Chalmers S, Khawaja A, Wieruszewski PM, Gajic O, Odeyemi Y. Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers. World J Crit Care Med 2019; 8:59-71. [PMID: 31559145 PMCID: PMC6753396 DOI: 10.5492/wjccm.v8.i5.59] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/02/2019] [Accepted: 08/06/2019] [Indexed: 02/06/2023] Open
Abstract
Pneumonia and acute respiratory distress syndrome are common and important causes of respiratory failure in the intensive care unit with a significant impact on morbidity, mortality and health care utilization despite early antimicrobial therapy and lung protective mechanical ventilation. Both clinical entities are characterized by acute pulmonary inflammation in response to direct or indirect lung injury. Adjunct anti-inflammatory treatment with corticosteroids is increasingly used, although the evidence for benefit is limited. The treatment decisions are based on radiographic, clinical and physiological variables without regards to inflammatory state. Current evidence suggests a role of biomarkers for the assessment of severity, and distinguishing sub-phenotypes (hyper-inflammatory versus hypo-inflammatory) with important prognostic and therapeutic implications. Although many inflammatory biomarkers have been studied the most common and of interest are C-reactive protein, procalcitonin, and pro-inflammatory cytokines including interleukin 6. While extensively studied as prognostic tools (prognostic enrichment), limited data are available for the role of biomarkers in determining appropriate initiation, timing and dosing of adjunct anti-inflammatory treatment (predictive enrichment).
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Affiliation(s)
- Sarah Chalmers
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Ali Khawaja
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Patrick M Wieruszewski
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Yewande Odeyemi
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Berg S, Bittner EA, Berra L, Kacmarek RM, Sonny A. Independent lung ventilation: Implementation strategies and review of literature. World J Crit Care Med 2019; 8:49-58. [PMID: 31667133 PMCID: PMC6817931 DOI: 10.5492/wjccm.v8.i4.49] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023] Open
Abstract
Independent lung ventilation, though infrequently used in the critical care setting, has been reported as a rescue strategy for patients in respiratory failure resulting from severe unilateral lung pathology. This involves isolating and ventilating the right and left lung differently, using separate ventilators. Here, we describe our experience with independent lung ventilation in a patient with unilateral diffuse alveolar hemorrhage, who presented with severe hypoxemic respiratory failure despite maximal ventilatory support. Conventional ventilation in this scenario leads to preferential distribution of tidal volume to the non-diseased lung causing over distension and inadvertent volume trauma. Since each lung has a different compliance and respiratory mechanics, instituting separate ventilation strategies to each lung could potentially minimize lung injury. Based on review of literature, we provide a detailed description of indications and procedures for establishing independent lung ventilation, and also provide an algorithm for management and weaning a patient from independent lung ventilation.
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Affiliation(s)
- Sheri Berg
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Lorenzo Berra
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Abraham Sonny
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
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Pena-Hernandez C, Nugent K. One approach to circulation and blood flow in the critical care unit. World J Crit Care Med 2019; 8:36-48. [PMID: 31667132 PMCID: PMC6817932 DOI: 10.5492/wjccm.v8.i4.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/24/2019] [Accepted: 06/12/2019] [Indexed: 02/06/2023] Open
Abstract
Evaluating and managing circulatory failure is one of the most challenging tasks for medical practitioners involved in critical care medicine. Understanding the applicability of some of the basic but, at the same time, complex physiological processes occurring during a state of illness is sometimes neglected and/or presented to the practitioners as point-of-care protocols to follow. Furthermore, managing hemodynamic shock has shown us that the human body is designed to fight to sustain life and that the compensatory mechanisms within organ systems are extraordinary. In this review article, we have created a minimalistic guide to the clinical information relevant when assessing critically ill patients with failing circulation. Measures such as organ blood flow, circulating volume, and hemodynamic biomarkers of shock are described. In addition, we will describe historical scientific events that led to some of our current medical practices and its validation for clinical decision making, and we present clinical advice for patient care and medical training.
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Affiliation(s)
- Camilo Pena-Hernandez
- Department of Internal Medicine, Division of Nephrology and Hypertension, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
| | - Kenneth Nugent
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
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Cascella M, Fiore M, Leone S, Carbone D, Di Napoli R. Current controversies and future perspectives on treatment of intensive care unit delirium in adults. World J Crit Care Med 2019; 8:18-27. [PMID: 31240172 PMCID: PMC6582227 DOI: 10.5492/wjccm.v8.i3.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/19/2019] [Accepted: 05/05/2019] [Indexed: 02/06/2023] Open
Abstract
Delirium is the most frequent manifestation of acute brain dysfunction in intensive care unit (ICU). Although antipsychotics are widely used to treat this serious complication, recent evidence has emphasized that these agents did not reduce ICU delirium (ICU-D) prevalence and did not improve survival, length of ICU or hospital stay after its occurrence. Of note, no pharmacological strategy to prevent or treat delirium has been identified, so far. In this scenario, new scientific evidences are urgently needed. Investigations on specific ICU-D subgroups, or focused on different clinical settings, and studies on medications other than antipsychotics, such as dexmedetomidine or melatonin, may represent interesting fields of research. In the meantime, because there is some evidence that ICU-D can be effectively prevented, the literature suggests strengthening all the strategies aimed at prevention through no-pharmacological approaches mostly focused on the correction of risk factors. The more appropriate strategy useful to treat established delirium remains the use of antipsychotics managed by choosing the right doses after a careful case-by-case analysis. While the evidence regarding the use of dexmedetomidine is still conflicting and sparse, this drug offers interesting perspectives for both ICU-D prevention and treatment. This paper aims to provide an overview of current pharmacological approaches of evidence-based medicine practice. The state of the art of the on-going clinical research on the topic and perspectives for future research are also addressed.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples 80049, Italy
| | - Marco Fiore
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
| | - Sebastiano Leone
- Division of Infectious Diseases, “San Giuseppe Moscati” Hospital, Avellino 83100, Italy
| | - Domenico Carbone
- Department of Emergency Medicine, Umberto I Hospital, Nocera Inferiore, Salerno 84014, Italy
| | - Raffaela Di Napoli
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles 1000, Belgium
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Serena G, Corredor C, Fletcher N, Sanfilippo F. Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study. World J Crit Care Med 2019; 8:28-35. [PMID: 31240173 PMCID: PMC6582226 DOI: 10.5492/wjccm.v8.i3.28] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/31/2019] [Accepted: 05/22/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time.
AIM To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour.
METHODS A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared “standard practice” and “intervention” periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24th postoperative hour.
RESULTS Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period).
CONCLUSION The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.
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Affiliation(s)
- Giovanni Serena
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
| | - Carlos Corredor
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
| | - Nick Fletcher
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
| | - Filippo Sanfilippo
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
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Patel VH, Vendittelli P, Garg R, Szpunar S, LaLonde T, Lee J, Rosman H, Mehta RH, Othman H. Neutrophil-lymphocyte ratio: A prognostic tool in patients with in-hospital cardiac arrest. World J Crit Care Med 2019; 8:9-17. [PMID: 30815378 PMCID: PMC6388309 DOI: 10.5492/wjccm.v8.i2.9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/24/2019] [Accepted: 01/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) portends a poor prognosis and survival to discharge rate. Prognostic markers such as interleukin-6, S-100 protein and high sensitivity C reactive protein have been studied as predictors of adverse outcomes after return of spontaneous circulation (ROSC); however; these variables are not routine laboratory tests and incur additional cost making them difficult to incorporate and less attractive in assessing patient’s prognosis. The neutrophil-lymphocyte ratio (NLR) is a marker of adverse prognosis for many cardiovascular conditions and certain types of cancers and sepsis. We hypothesize that an elevated NLR is associated with poor outcomes including mortality at discharge in patients with IHCA.
AIM To determine the prognostic significance of NLR in patients suffering IHCA who achieve ROSC.
METHODS A retrospective study was performed on all patients who had IHCA with the advanced cardiac life support protocol administered in a large urban community United States hospital over a one-year period. Patients were divided into two groups based on their NLR value (NLR < 4.5 or NLR ≥ 4.5). This cutpoint was derived from receiving operator characteristic curve analysis (area under the curve = 0.66) and provided 73% positive predictive value, 82% sensitivity and 42% specificity for predicting in-hospital death after IHCA. The primary outcome was death or discharge at 30 d, whichever came first.
RESULTS We reviewed 153 patients with a mean age of 66.1 ± 16.3 years; 48% were female. In-hospital mortality occurred in 65%. The median NLR in survivors was 4.9 (range 0.6-46.5) compared with 8.9 (0.28-96) in non-survivors (P = 0.001). A multivariable logistic regression model demonstrated that an NLR above 4.55 [odds ratio (OR) = 5.20, confidence interval (CI): 1.5-18.3, P = 0.01], older age (OR = 1.03, CI: 1.00-1.07, P = 0.05), and elevated serum lactate level (OR = 1.20, CI: 1.03-1.40, P = 0.02) were independent predictors of death.
CONCLUSION An NLR ≥ 4.5 may be a useful marker of increased risk of death in patients with IHCA.
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Affiliation(s)
- Vishal H Patel
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Philip Vendittelli
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Rajat Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44915, United States
| | - Susan Szpunar
- Department of Biomedical Investigations and Research, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Thomas LaLonde
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - John Lee
- Department of Critical Care Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Howard Rosman
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 22705, United States
| | - Hussein Othman
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
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Koutsoukou A, Pecchiari M. Expiratory flow-limitation in mechanically ventilated patients: A risk for ventilator-induced lung injury? World J Crit Care Med 2019; 8:1-8. [PMID: 30697515 PMCID: PMC6347666 DOI: 10.5492/wjccm.v8.i1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/24/2018] [Accepted: 10/17/2018] [Indexed: 02/06/2023] Open
Abstract
Expiratory flow limitation (EFL), that is the inability of expiratory flow to increase in spite of an increase of the driving pressure, is a common and unrecognized occurrence during mechanical ventilation in a variety of intensive care unit conditions. Recent evidence suggests that the presence of EFL is associated with an increase in mortality, at least in acute respiratory distress syndrome (ARDS) patients, and in pulmonary complications in patients undergoing surgery. EFL is a major cause of intrinsic positive end-expiratory pressure (PEEPi), which in ARDS patients is heterogeneously distributed, with a consequent increase of ventilation/perfusion mismatch and reduction of arterial oxygenation. Airway collapse is frequently concomitant to the presence of EFL. When airways close and reopen during tidal ventilation, abnormally high stresses are generated that can damage the bronchiolar epithelium and uncouple small airways from the alveolar septa, possibly generating the small airways abnormalities detected at autopsy in ARDS. Finally, the high stresses and airway distortion generated downstream the choke points may contribute to parenchymal injury, but this possibility is still unproven. PEEP application can abolish EFL, decrease PEEPi heterogeneity, and limit recruitment/derecruitment. Whether increasing PEEP up to EFL disappearance is a useful criterion for PEEP titration can only be determined by future studies.
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Affiliation(s)
- Antonia Koutsoukou
- ICU, 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens Medical School, Athens 11527, Greece
| | - Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan 20133, Italy
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131
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Kapoor S, Morgan CK, Siddique MA, Guntupalli KK. Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases. World J Crit Care Med 2018; 7:73-83. [PMID: 30596029 PMCID: PMC6305525 DOI: 10.5492/wjccm.v7.i6.73] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/21/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU).
METHODS We performed a retrospective observational study of adult patients with the diagnosis of “HLH” admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.
RESULTS Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.
CONCLUSION HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.
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Affiliation(s)
- Sumit Kapoor
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
| | - Christopher K Morgan
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
| | - Muhammad Asim Siddique
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
| | - Kalpalatha K Guntupalli
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
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132
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Wieruszewski PM, Herasevich S, Gajic O, Yadav H. Respiratory failure in the hematopoietic stem cell transplant recipient. World J Crit Care Med 2018; 7:62-72. [PMID: 30370228 PMCID: PMC6201323 DOI: 10.5492/wjccm.v7.i5.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/04/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023] Open
Abstract
The number of patients receiving hematopoietic stem cell transplantation (HSCT) is rapidly rising worldwide. Despite substantial improvements in peri-transplant care, pulmonary complications resulting in respiratory failure remain a major contributor to morbidity and mortality in the post-transplant period, and represent a major barrier to the overall success of HSCT. Infectious complications include pneumonia due to bacteria, viruses, and fungi, and most commonly occur during neutropenia in the early post-transplant period. Non-infectious complications include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary veno-occlusive disease, delayed pulmonary toxicity syndrome, cryptogenic organizing pneumonia, bronchiolitis obliterans syndrome, and post-transplant lymphoproliferative disorder. These complications have distinct clinical features and risk factors, occur at differing times following transplant, and contribute to morbidity and mortality.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
| | - Svetlana Herasevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Hemang Yadav
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Abstract
Ascorbic acid (vitamin C) elicits pleiotropic effects in the body. Among its functions, it serves as a potent anti-oxidant, a co-factor in collagen and catecholamine synthesis, and a modulator of immune cell biology. Furthermore, an increasing body of evidence suggests that high-dose vitamin C administration improves hemodynamics, end-organ function, and may improve survival in critically ill patients. This article reviews studies that evaluate vitamin C in pre-clinical models and clinical trials with respect to its therapeutic potential.
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Affiliation(s)
- Christoph S Nabzdyk
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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134
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Wang BC, Pei T, Lin CB, Guo R, Elashoff D, Lin JA, Pineda C. Clinical characteristics and outcomes associated with nasal intermittent mandatory ventilation in acute pediatric respiratory failure. World J Crit Care Med 2018; 7:46-51. [PMID: 30211019 PMCID: PMC6134265 DOI: 10.5492/wjccm.v7.i4.46] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/25/2018] [Accepted: 08/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize the clinical course and outcomes of nasal intermittent mandatory ventilation (NIMV) use in acute pediatric respiratory failure.
METHODS We identified all patients treated with NIMV in the pediatric intensive care unit (PICU) or inpatient general pediatrics between January 2013 and December 2015 at two academic centers. Patients who utilized NIMV with other modes of noninvasive ventilation during the same admission were included. Data included demographics, vital signs on admission and prior to initiation of NIMV, pediatric risk of mortality III (PRISM-III) scores, complications, respiratory support characteristics, PICU and hospital length of stays, duration of respiratory support, and complications. Patients who did not require escalation to mechanical ventilation were defined as NIMV responders; those who required escalation to mechanical ventilation (MV) were defined as NIMV non-responders. NIMV responders were compared to NIMV non-responders.
RESULTS Forty-two patients met study criteria. Six (14%) failed treatment and required MV. The majority of the patients (74%) had a primary diagnosis of bronchiolitis. The median age of these 42 patients was 4 mo (range 0.5-28.1 mo, IQR 7, P = 0.69). No significant difference was measured in other baseline demographics and vitals on initiation of NIMV; these included age, temperature, respiratory rate, O2 saturation, heart rate, systolic blood pressure, diastolic blood pressure, and PRISM-III scores. The duration of NIMV was shorter in the NIMV non-responder vs NIMV responder group (6.5 h vs 65 h, P < 0.0005). Otherwise, NIMV failure was not associated with significant differences in PICU length of stay (LOS), hospital LOS, or total duration of respiratory support. No patients had aspiration pneumonia, pneumothorax, or skin breakdown.
CONCLUSION Most of our patients responded to NIMV. NIMV failure is not associated with differences in hospital LOS, PICU LOS, or duration of respiratory support.
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Affiliation(s)
- Billy C Wang
- Department of Pediatrics, Division of Critical Care Medicine, Loma Linda University Children’s Hospital, Loma Linda, CA 92354, United States
| | - Theodore Pei
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
| | - Cheryl B Lin
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
| | - Rong Guo
- Department of Medicine, Biostatistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - David Elashoff
- Department of Medicine, Biostatistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - James A Lin
- Department of Pediatrics, Mattel Children’s Hospital at UCLA, Los Angeles, CA 90095, United States
| | - Carol Pineda
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
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135
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Plate JDJ, Peelen LM, Leenen LPH, Hietbrink F. Validation of the VitalPAC Early Warning Score at the Intermediate Care Unit. World J Crit Care Med 2018; 7:39-45. [PMID: 30090705 PMCID: PMC6081388 DOI: 10.5492/wjccm.v7.i3.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/19/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the performance and clinical relevance of the Early Warning Scoring (EWS) system at the Intermediate Care Unit (IMCU).
METHODS This cohort study used all the VitalPAC EWS (ViEWS) scores collected during each nursing shift from 2014 through 2016 at the mixed surgical IMCU of an academic teaching hospital. Clinical deterioration defined as transfer to the Intensive Care Unit (ICU) or mortality within 24 h was the primary outcome of interest.
RESULTS A total of 9113 aggregated ViEWS scores were obtained from 2113 admissions. The incidence of the combined outcome was 272 (3.0%). The area under the curve of the ViEWS was 0.72 (CI: 0.69-0.75). Using a threshold value of six, the sensitivity was 68% with a positive predictive value of 5% and a number needed to trigger (e.g., false alarms) of 19%.
CONCLUSION The ViEWS at the IMCU has a discriminative performance that is considerably lower than at the hospital ward. The number of false alarms is high, which may result in alarm fatigue. Therefore, use of the ViEWS in its current form at the IMCU should be reconsidered.
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Affiliation(s)
- Joost DJ Plate
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Linda M Peelen
- Julius Center for Health Sciences, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
- Departments of Anaesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Luke PH Leenen
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Falco Hietbrink
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
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Morparia K, Berg J, Basu S. Confidence level of pediatric trainees in management of shock states. World J Crit Care Med 2018; 7:31-38. [PMID: 29736378 PMCID: PMC5934529 DOI: 10.5492/wjccm.v7.i2.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/12/2018] [Accepted: 04/22/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess overall confidence level of trainees in assessing and treating shock, we sought to improve awareness of recurrent biases in clinical decision-making to help address appropriate educational interventions.
METHODS Pediatric trainees on a national listserv were offered the opportunity to complete an electronic survey anonymously. Four commonly occurring clinical scenarios were presented, and respondents were asked to choose whether or not they would give fluid, rank factors utilized in decision-making, and comment on confidence level in their decision.
RESULTS Pediatric trainees have a very low confidence level for assessment and treatment of shock. Highest confidence level is for initial assessment and treatment of shock involving American College of Critical Care Medicine/Pediatric Advanced Life Support recommendations. Children with preexisting cardiac comorbidities are at high risk of under-resuscitation.
CONCLUSION Pediatric trainees nationwide have low confidence in managing various shock states, and would benefit from guidance and teaching around certain common clinical situations.
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Affiliation(s)
- Kavita Morparia
- Department of Pediatric Critical Care, Children’s Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, NJ 07112, United States
| | - Julie Berg
- Department of Emergency Medicine, Children’s National Health System, Washington, DC 20010, United States
| | - Sonali Basu
- Department of Critical Care Medicine, George Washington University, Children’s National Health System, Washington, DC 20010, United States
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137
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Kock KDS, Maurici R. Respiratory mechanics, ventilator-associated pneumonia and outcomes in intensive care unit. World J Crit Care Med 2018; 7:24-30. [PMID: 29430405 PMCID: PMC5797973 DOI: 10.5492/wjccm.v7.i1.24] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/05/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the predictive capability of respiratory mechanics for the development of ventilator-associated pneumonia (VAP) and mortality in the intensive care unit (ICU) of a hospital in southern Brazil.
METHODS A cohort study was conducted between, involving a sample of 120 individuals. Static measurements of compliance and resistance of the respiratory system in pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) modes in the 1st and 5th days of hospitalization were performed to monitor respiratory mechanics. The severity of the patients’ illness was quantified by the Acute Physiology and Chronic Health Evaluation II (APACHE II). The diagnosis of VAP was made based on clinical, radiological and laboratory parameters.
RESULTS The significant associations found for the development of VAP were APACHE II scores above the average (P = 0.016), duration of MV (P = 0.001) and ICU length of stay above the average (P = 0.003), male gender (P = 0.004), and worsening of respiratory resistance in PCV mode (P = 0.010). Age above the average (P < 0.001), low level of oxygenation on day 1 (P = 0.003) and day 5 (P = 0.004) and low lung compliance during VCV on day 1 (P = 0.032) were associated with death as the outcome.
CONCLUSION The worsening of airway resistance in PCV mode indicated the possibility of early diagnosis of VAP. Low lung compliance during VCV and low oxygenation index were death-related prognostic indicators.
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Affiliation(s)
- Kelser de Souza Kock
- Department of Physiotherapy, University of South of Santa Catarina, Tubarão, SC 88704-001, Brazil
| | - Rosemeri Maurici
- Graduate Program in Medical Sciences, Federal University of Santa Catarina, Florianópolis, SC 88700-000, Brazil
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Molina FJ, Rivera PT, Cardona A, Restrepo DC, Monroy O, Rodas D, Barrientos JG. Adverse events in critical care: Search and active detection through the Trigger Tool. World J Crit Care Med 2018; 7:9-15. [PMID: 29430403 PMCID: PMC5797974 DOI: 10.5492/wjccm.v7.i1.9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/17/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the incidence of disadvantageous events by using the Global Trigger Tool in an intensive care unit (ICU).
METHODS A retrospective descriptive study was performed in a 12-bed university ICU in the city of Medellin, Colombia. Clinical charts of hospitalized patients were reviewed, between January 1 and December 31, 2016, with the following inclusion criteria: subjects aged over 18 years, with at least 24 h of hospitalization and who had a complete medical history that could be accessed. Interventions: Trained reviewers conducted a retrospective examination of medical charts searching for clue events that elicit investigation, in order to detect an unfavorable event. Measurements: Information was processed through SPSS software version 21; for numerical variables, the mean was reported with standard deviation (SD). Percentages were calculated for qualitative variables.
RESULTS Two hundred and forty-four triggers occurred, with 82.4% of subjects having presented with at least one and an average of 3.37 (SD 3.47). A total of 178 adverse events (AEs) took place in 48 individuals, with an incidence of 52.1%. On average, four events per patient were recorded, and for each unfortunate event, 1.98 triggers were presented. The most frequent displeasing issues were: pressure ulcers (17.6%), followed by complications or reactions to medical devices (4.3%), and lacerations or skin defects (3.7%); the least frequent was delayed diagnosis or treatment (0.56%). Thirty-eight point four percent of mishap events caused temporary damage that required intervention, and 48.9% of AEs were preventable. Comparison between AEs and admission diagnoses found that hypertension and sepsis were the only diagnoses that had statistical significance (P = 0.042 and 0.022, respectively).
CONCLUSION Almost half of the unfavorable issues were classified as avoidable, which leaves a very wide field of work in terms of preventative activities.
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Affiliation(s)
- Francisco J Molina
- Clínica Universitaria Bolivariana, School of Medicine, Universidad Pontificia Bolivariana, Medellín 050034, Colombia
| | - Paula T Rivera
- Faculty of Nursing, Universidad de Caldas, Manizales 170004, Colombia
| | - Alejandro Cardona
- School of Medicine, Universidad Pontificia Bolivariana, Medellín 050034, Colombia
| | - Diana C Restrepo
- School of Medicine, Universidad Pontificia Bolivariana, Medellín 050034, Colombia
| | - Oralia Monroy
- Clínica Universitaria Bolivariana, Medellín 050034, Colombia
| | - Daniel Rodas
- Clínica Universitaria Bolivariana, School of Medicine, Universidad Pontificia Bolivariana, Medellín 050034, Colombia
| | - Juan G Barrientos
- Clínica Universitaria Bolivariana, School of Medicine, Universidad Pontificia Bolivariana, Medellín 050034, Colombia
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Karthik G, Sudarsan TI, Peter JV, Sudarsanam T, Varghese GM, Kundavaram P, Sathyendra S, Iyyadurai R, Pichamuthu K. Spectrum of cardiac manifestations and its relationship to outcomes in patients admitted with scrub typhus infection. World J Crit Care Med 2018; 7:16-23. [PMID: 29430404 PMCID: PMC5797972 DOI: 10.5492/wjccm.v7.i1.16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/08/2017] [Accepted: 12/28/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To study the spectrum of cardiac manifestations in scrub typhus infection and assess its relationship to outcomes.
METHODS Demographic data, electrocardiographic (ECG) changes, left ventricular (LV) systolic and diastolic function, myocardial injury (defined as troponin T > 14 pg/mL), and pericardial effusion were documented. Myocarditis was diagnosed when myocardial injury was associated with global LV systolic dysfunction. The relationship between myocarditis and outcomes was assessed using logistic regression analysis and expressed as odds ratio (OR) with 95%CI.
RESULTS The cohort (n = 81; 35 males) aged 49.4 ± 16.1 years (mean, SD) presented 8.1 ± 3.1 d after symptom onset. The APACHE-II score was 15.7 ± 7.0. Forty-eight (59%) patients were ventilated, and 46 (56%) required vasoactive agents. Mortality was 9.9%. ECG changes were non-specific; sinus tachycardia was the most common finding. Myocardial injury was evident in 61.7% of patients and LV systolic dysfunction in 30.9%. A diagnosis of myocarditis was made in 12.3%. In addition, seven patients with regional wall motion abnormalities had LV systolic dysfunction and elevated cardiac enzymes. Mild diastolic dysfunction was observed in 18 (22%) patients. Mild to moderate pericardial effusion was seen in 51%. On multivariate logistic regression analysis, patients with myocarditis tended to be older (OR = 1.04, 95%CI: 0.99-1.09), had shorter symptom duration (OR = 0.69, 95%CI: 0.49-0.98), and tended to stay longer in hospital (OR = 1.17, 95%CI: 0.98-1.40). Myocarditis was not associated with increased mortality.
CONCLUSION In scrub typhus infection, cardiac manifestations are frequent and associated with increased morbidity but not mortality.
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Affiliation(s)
| | | | - John Victor Peter
- Medical Intensive Care Unit, Christian Medical College, Vellore 632004, India
| | - Thambu Sudarsanam
- Department of Medicine, Christian Medical College, Vellore 632004, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore 632004, India
| | - Paul Kundavaram
- Department of Medicine, Christian Medical College, Vellore 632004, India
| | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College, Vellore 632004, India
| | - Ramya Iyyadurai
- Department of Medicine, Christian Medical College, Vellore 632004, India
| | - Kishore Pichamuthu
- Medical Intensive Care Unit, Christian Medical College, Vellore 632004, India
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Yamamoto K, Yamamoto T, Takamura M, Usui S, Murai H, Kaneko S, Taniguchi T. Effects of mineralocorticoid receptor antagonists on responses to hemorrhagic shock in rats. World J Crit Care Med 2018; 7:1-8. [PMID: 29430402 PMCID: PMC5797971 DOI: 10.5492/wjccm.v7.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/03/2017] [Accepted: 12/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effects of mineralocorticoid receptor (MR) antagonists on mortality and inflammatory responses after hemorrhagic shock (HS) in rats.
METHODS One hundred and two male Sprague–Dawley rats were randomly assigned to one of the following three groups: Control, spironolactone (SPL), and eplerenone (EP) groups. HS was induced by the removal of blood. One half of rats were evaluated to determine mortality, hemodynamics, plasma tumor necrosis factor-alpha (TNF-α) concentrations, and arterial blood gas at 8 h after HS recovery. In the remainder of rats, the expression levels of genes encoding cytokines were evaluated in liver tissue samples at 1 h after HS recovery.
RESULTS The survival rates 8 h after HS recovery were 71%, 94%, and 82% in the control, SPL, and EP groups, respectively. There were no significant differences in survival rates among the three groups (P = 0.219). Furthermore, there were no significant differences in gene expression levels in the liver or plasma TNF-α concentrations among the three groups (P = 0.888).
CONCLUSION Pretreatment with MR antagonists did not improve mortality or cytokine responses in the liver after HS recovery in rats.
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Affiliation(s)
- Kanako Yamamoto
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Takashi Yamamoto
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Masayuki Takamura
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Soichiro Usui
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hisayoshi Murai
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Shuichi Kaneko
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
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Abulebda K, Abu-Sultaneh S, Ahmed SS, Moser EAS, McKinney RC, Lutfi R. Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy. World J Crit Care Med 2017; 6:179-184. [PMID: 29152464 PMCID: PMC5680344 DOI: 10.5492/wjccm.v6.i4.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 06/30/2017] [Accepted: 09/04/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the safety and efficacy of sedating pediatric patients for outpatient flexible bronchoscopy.
METHODS A retrospective chart review was conducted for all children, age 17 years or under who underwent flexible bronchoscopy under deep sedation in an outpatient hospital-based setting. Two sedation regimens were used; propofol only or ketamine prior to propofol. Patients were divided into three age groups; infants (less than 12 mo), toddlers (1-3 years) and children (4-17 years). Demographics, indication for bronchoscopy, sedative dosing, sedation and recovery time and adverse events were reviewed.
RESULTS Of the total 458 bronchoscopies performed, propofol only regimen was used in 337 (74%) while propofol and ketamine was used in 121 (26%). About 99% of the procedures were successfully completed. Children in the propofol + ketamine group tend to be younger and have lower weight compared to the propofol only group. Adverse events including transient hypoxemia and hypotension occurred in 8% and 24% respectively. Median procedure time was 10 min while the median discharge time was 35 min. There were no differences in the indication of the procedure, propofol dose, procedure or recovery time in either sedative regimen. When compared to other age groups, infants had a higher incidence of hypoxemia.
CONCLUSION Children can be effectively sedated for outpatient flexible bronchoscopy with high rate of success. This procedure should be performed under vigilance of highly trained providers.
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Affiliation(s)
- Kamal Abulebda
- Department of Pediatrics, Section of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
| | - Samer Abu-Sultaneh
- Department of Pediatrics, Section of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
| | - Sheikh Sohail Ahmed
- Department of Pediatrics, Section of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
| | - Elizabeth A S Moser
- Department of Biostatistics, Indiana University School of Medicine and Richard M Fairbanks School of Public Health, Indianapolis, IN 46202, United States
| | - Renee C McKinney
- Department of Pediatrics, Section of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
| | - Riad Lutfi
- Department of Pediatrics, Section of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
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Dhungana A, Khilnani G, Hadda V, Guleria R. Reproducibility of diaphragm thickness measurements by ultrasonography in patients on mechanical ventilation. World J Crit Care Med 2017; 6:185-189. [PMID: 29152465 PMCID: PMC5680345 DOI: 10.5492/wjccm.v6.i4.185] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/26/2017] [Accepted: 09/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To prospectively evaluate the reproducibility of diaphragm thickness measurement by ultrasonography at the bedside by critical care physicians in patients on invasive mechanical ventilation.
METHODS In a prospective observational study of 64 invasively ventilated patients, diaphragmatic thickness measurement was taken by 2 different observers at the same site. Three measurements were taken by each observer and averaged. The intraobserver and interobserver variability was assessed by estimation of intraclass correlation coefficient. The limits of agreement were plotted as the difference between two observations against the average of the two observations in Bland and Altman analysis.
RESULTS The mean diaphragm thickness at the functional residual capacity was 2.29 ± 0.4 mm and the lower limit of the normal, i.e., the 5th percentile was 1.7 mm (95%CI: 1.6-1.8). The intraclass correlation coefficient for intraobserver variability was 0.986 (95%CI: 0.979-0.991) with a P value of < 0.001. The intraclass correlation coefficient for interobserver variability was 0.987 (95%CI: 0.949-0.997) with a P value of < 0.001. In Bland and Altman analysis, both intraobserver and interobserver measurements showed high limits of agreement.
CONCLUSION Our study demonstrates that the measurement of diaphragm thickness by ultrasound can be accurately performed by critical care physicians with high degree of reproducibility in patients on mechanical ventilation.
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Affiliation(s)
- Ashesh Dhungana
- Department of Medicine, National Academy of Medical Sciences, Pulmonary Medicine, Kantipath, Kathmandu 44600, Nepal
| | - Gopi Khilnani
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi 110029, India
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143
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Heil LBB, Silva PL, Pelosi P, Rocco PRM. Immunomodulatory effects of anesthetics in obese patients. World J Crit Care Med 2017; 6:140-152. [PMID: 28828299 PMCID: PMC5547428 DOI: 10.5492/wjccm.v6.i3.140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/27/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
Anesthesia and surgery have an impact on inflammatory responses, which influences perioperative homeostasis. Inhalational and intravenous anesthesia can alter immune-system homeostasis through multiple processes that include activation of immune cells (such as monocytes, neutrophils, and specific tissue macrophages) with release of pro- or anti-inflammatory interleukins, upregulation of cell adhesion molecules, and overproduction of oxidative radicals. The response depends on the timing of anesthesia, anesthetic agents used, and mechanisms involved in the development of inflammation or immunosuppression. Obese patients are at increased risk for chronic diseases and may have the metabolic syndrome, which features insulin resistance and chronic low-grade inflammation. Evidence has shown that obesity has adverse impacts on surgical outcome, and that immune cells play an important role in this process. Understanding the effects of anesthetics on immune-system cells in obese patients is important to support proper selection of anesthetic agents, which may affect postoperative outcomes. This review article aims to integrate current knowledge regarding the effects of commonly used anesthetic agents on the lungs and immune response with the underlying immunology of obesity. Additionally, it identifies knowledge gaps for future research to guide optimal selection of anesthetic agents for obese patients from an immunomodulatory standpoint.
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144
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Fernandez-Restrepo L, Shaffer L, Amalakuhan B, Restrepo MI, Peters J, Restrepo R. Effects of intrapulmonary percussive ventilation on airway mucus clearance: A bench model. World J Crit Care Med 2017; 6:164-171. [PMID: 28828301 PMCID: PMC5547430 DOI: 10.5492/wjccm.v6.i3.164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/01/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the ability of intrapulmonary percussive ventilation (IPV) to promote airway clearance in spontaneously breathing patients and those on mechanical ventilation.
METHODS An artificial lung was used to simulate a spontaneously breathing patient (Group 1), and was then connected to a mechanical ventilator to simulate a patient on mechanical ventilation (Group 2). An 8.5 mm endotracheal tube (ETT) connected to the test lung, simulated the patient airway. Artificial mucus was instilled into the mid-portion of the ETT. A filter was attached at both ends of the ETT to collect the mucus displaced proximally (mouth-piece filter) and distally (lung filter). The IPV machine was attached to the proximal end of the ETT and was applied for 10-min each to Group 1 and 2. After each experiment, the weight of the various circuit components were determined and compared to their dry weights to calculate the weight of the displaced mucus.
RESULTS In Group 1 (spontaneously breathing model), 26.8% ± 3.1% of the simulated mucus was displaced proximally, compared to 0% in Group 2 (the mechanically ventilated model) with a P-value of < 0.01. In fact, 17% ± 1.5% of the mucus in Group 2 remained in the mid-portion of the ETT where it was initially instilled and 80% ± 4.2% was displaced distally back towards the lung (P < 0.01). There was an overall statistically significant amount of mucus movement proximally towards the mouth-piece in the spontaneously breathing (SB) patient. There was also an overall statistically significant amount of mucus movement distally back towards the lung in the mechanically ventilated (MV) model. In the mechanically ventilated model, no mucus was observed to move towards the proximal/mouth piece section of the ETT.
CONCLUSION This bench model suggests that IPV is associated with displacement of mucus towards the proximal mouthpiece in the SB patient, and distally in the MV model.
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Weiss M, Marx G, Iber T. Generalizable items and modular structure for computerised physician staffing calculation on intensive care units. World J Crit Care Med 2017; 6:153-163. [PMID: 28828300 PMCID: PMC5547429 DOI: 10.5492/wjccm.v6.i3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 02/23/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
Intensive care medicine remains one of the most cost-driving areas within hospitals with high personnel costs. Under the scope of limited budgets and reimbursement, realistic needs are essential to justify personnel staffing. Unfortunately, all existing staffing models are top-down calculations with a high variability in results. We present a workload-oriented model, integrating quality of care, efficiency of processes, legal, educational, controlling, local, organisational and economic aspects. In our model, the physician's workload solely related to the intensive care unit depends on three tasks: Patient-oriented tasks, divided in basic tasks (performed in every patient) and additional tasks (necessary in patients with specific diagnostic and therapeutic requirements depending on their specific illness, only), and non patient-oriented tasks. All three tasks have to be taken into account for calculating the required number of physicians. The calculation tool further allows to determine minimal personnel staffing, distribution of calculated personnel demand regarding type of employee due to working hours per year, shift work or standby duty. This model was introduced and described first by the German Board of Anesthesiologists and the German Society of Anesthesiology and Intensive Care Medicine in 2008 and since has been implemented and updated 2012 in Germany. The modular, flexible nature of the Excel-based calculation tool should allow adaption to the respective legal and organizational demands of different countries. After 8 years of experience with this calculation, we report the generalizable key aspects which may help physicians all around the world to justify realistic workload-oriented personnel staffing needs.
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Peter J, Klingert W, Klingert K, Thiel K, Wulff D, Königsrainer A, Rosenstiel W, Schenk M. Algorithm-based arterial blood sampling recognition increasing safety in point-of-care diagnostics. World J Crit Care Med 2017; 6:172-178. [PMID: 28828302 PMCID: PMC5547431 DOI: 10.5492/wjccm.v6.i3.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/02/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To detect blood withdrawal for patients with arterial blood pressure monitoring to increase patient safety and provide better sample dating.
METHODS Blood pressure information obtained from a patient monitor was fed as a real-time data stream to an experimental medical framework. This framework was connected to an analytical application which observes changes in systolic, diastolic and mean pressure to determine anomalies in the continuous data stream. Detection was based on an increased mean blood pressure caused by the closing of the withdrawal three-way tap and an absence of systolic and diastolic measurements during this manipulation. For evaluation of the proposed algorithm, measured data from animal studies in healthy pigs were used.
RESULTS Using this novel approach for processing real-time measurement data of arterial pressure monitoring, the exact time of blood withdrawal could be successfully detected retrospectively and in real-time. The algorithm was able to detect 422 of 434 (97%) blood withdrawals for blood gas analysis in the retrospective analysis of 7 study trials. Additionally, 64 sampling events for other procedures like laboratory and activated clotting time analyses were detected. The proposed algorithm achieved a sensitivity of 0.97, a precision of 0.96 and an F1 score of 0.97.
CONCLUSION Arterial blood pressure monitoring data can be used to perform an accurate identification of individual blood samplings in order to reduce sample mix-ups and thereby increase patient safety.
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147
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Weiss M, Rossaint R, Iber T. Generalizable items of quantitative and qualitative cornerstones for personnel requirement of physicians in anesthesia. World J Crit Care Med 2017; 6:91-98. [PMID: 28529910 PMCID: PMC5415854 DOI: 10.5492/wjccm.v6.i2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 12/07/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023] Open
Abstract
Anesthesiologists perform a broad spectrum of tasks. However, in many countries, there is no legal basis for personnel staffing of physicians in anesthesia. Also, the German diagnosis related groups system for refunding does not deliver such a basis. Thus, in 2006 a new calculation base for the personnel requirement that included an Excel calculation sheet was introduced by the German Board of Anesthesiologists (BDA) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI), and updated in 2009 and 2015. Oriented primarily to organizational needs, in 2015, BDA/DGAI defined quantitative and qualitative cornerstones for personnel requirement of physicians in anesthesia, especially reflecting recent laws governing physician’s working conditions and competence in the field of anesthesia, as well as demands of strengthened legal rights of patients, patient care and safety. We present a workload-oriented model, integrating core working hours, shift work or standby duty, quality of care, efficiency of processes, legal, educational, controlling, local, organizational and economic aspects for calculating personnel demands. Auxiliary tables enable physicians to calculate personnel demands due to differing employee workload, non-patient oriented tasks and reimbursement of full-equivalents due to parental leave, prohibition of employment, or long-term illness. After 10 years of experience with the first calculation tool, we report the generalizable key aspects and items of a necessary calculation tool which may help physicians to justify realistic workload-oriented personnel staffing demands in anesthesia. A modular, flexible nature of a calculation tool should allow adaption to the respective legal and organizational demands of different countries.
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148
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Llompart-Pou JA, Pérez-Bárcena J, Chico-Fernández M, Sánchez-Casado M, Raurich JM. Severe trauma in the geriatric population. World J Crit Care Med 2017; 6:99-106. [PMID: 28529911 PMCID: PMC5415855 DOI: 10.5492/wjccm.v6.i2.99] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.
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Herrup EA, Wieczorek B, Kudchadkar SR. Characteristics of postintensive care syndrome in survivors of pediatric critical illness: A systematic review. World J Crit Care Med 2017; 6:124-134. [PMID: 28529914 PMCID: PMC5415852 DOI: 10.5492/wjccm.v6.i2.124] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 02/25/2017] [Accepted: 03/24/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To synthesize the available evidence focusing on morbidities in pediatric survivors of critical illness that fall within the defined construct of postintensive care syndrome (PICS) in adults, including physical, neurocognitive and psychological morbidities.
METHODS A comprehensive search was conducted in MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and CINAHL using controlled vocabulary and key word terms to identify studies reporting characteristics of PICS in pediatric intensive care unit (PICU) patients. Two reviewers independently screened all titles and abstracts and performed data extraction. From the 3176 articles identified in the search, 252 abstracts were identified for full text review and nineteen were identified for inclusion in the review. All studies reporting characteristics of PICS in PICU patients were included in the final synthesis.
RESULTS Nineteen studies meeting inclusion criteria published between 1995 and 2016 were identified and categorized into studies reporting morbidities in each of three categories-physical, neurocognitive and psychological. The majority of included articles reported prospective cohort studies, and there was significant variability in the outcome measures utilized. A synthesis of the studies indicate that morbidities encompassing PICS are well-described in children who have survived critical illness, often resolving over time. Risk factors for development of these morbidities include younger age, lower socioeconomic status, increased number of invasive procedures or interventions, type of illness, and increased benzodiazepine and narcotic administration.
CONCLUSION PICS-related morbidities impact a significant proportion of children discharged from PICUs. In order to further define PICS in children, more research is needed using standardized tools to better understand the scope and natural history of morbidities after hospital discharge. Improving our understanding of physical, neurocognitive, and psychological morbidities after critical illness in the pediatric population is imperative for designing interventions to improve long-term outcomes in PICU patients.
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Kapoor S, Bassily-Marcus A, Alba Yunen R, Tabrizian P, Semoin S, Blankush J, Labow D, Oropello J, Manasia A, Kohli-Seth R. Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. World J Crit Care Med 2017; 6:116-123. [PMID: 28529913 PMCID: PMC5415851 DOI: 10.5492/wjccm.v6.i2.116] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/14/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).
METHODS Our study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics.
RESULTS Of the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission.
CONCLUSION Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.
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