Designing drug regimens for special intensive care unit populations

This review is intended to help clinicians design drug regimens for special populations of critically ill patients with extremes of body size, habitus and composition that make drug choice or dosing particularly challenging due to the lack of high-level evidence on which to make well-informed clinical decisions. The data sources included a literature search of MEDLINE and EMBASE with reviews of reference lists of retrieved articles. Abstracts of original research investigations and review papers were reviewed for their relevance to drug choice or dosing in the following special critically ill populations: patients with more severe forms of bodyweight or height, patients with amputations or missing limbs, pregnant patients, and patients undergoing extracorporeal membrane oxygenation or plasma exchange. Relevant papers were retrieved and evaluated, and their associated reference lists were reviewed for citations that may have been missed through the electronic search strategy. Relevant original research investigations and review papers that could be used to formulate general principles for drug choice or dosing in special populations of critically ill patients were extracted. Randomized studies with clinically relevant endpoints were not available for performing quantitative analyses. Critically ill patients with changes in body size, habitus and composition require special consideration when designing medication regimens, but there is a paucity of literature on which to make drug-specific, high-level evidence-based recommendations. Based on the evidence that is available, general recommendations are provided for drug choice or dosing in special critically ill populations.

Intravenous glutamine for severe acute pancreatitis: A meta-analysis

AIM: To evaluate the efficacy of intravenous glutamine on the patients with severe acute pancreatitis (SAP).

METHODS: The Cochrane Library, PubMed, EMBASE, and EBM review databases were searched up to June 2012. Randomized controlled trials (RCTs) that compared non-glutamine nutrition with intravenous glutamine supplemented nutrition in patients with SAP were included. A method recommended by the Cochrane Collaboration was used to perform a meta-analysis of those RCTs.

RESULTS: Four RCTs involving a total of 190 participants were included. Analysis of these RCTs revealed the presence of statistical homogeneity among them. Results showed that glutamine dipeptide has a positive effect in reducing the mortality rate (OR = 0.26, 95%CI: 0.09-0.73, P = 0.01), length of hospital stay (weighted mean difference = -4.85, 95%CI: 6.67--3.03, P < 0.001), and the rate of complications (OR = 0.41, 95%CI: 0.22-0.78, P = 0.006). No serious adverse effects were found.

CONCLUSION: Current best evidence demonstrates that glutamine is effective for SAP. Further high quality trials are required and parameters of nutritional condition and hospital cost should be considered in future RCTs with sufficient size and rigorous design.

Current controversies and future perspectives on treatment of intensive care unit delirium in adults

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.

Independent lung ventilation: Implementation strategies and review of literature

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.

Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums

Thrombocytopenia is often noted in critically ill patients. While there are many reasons for thrombocytopenia, the use of heparin and its derivatives is increasingly noted to be associated with thrombocytopenia. Heparin induced thrombocytopenia syndrome (HITS) is a distinct entity that is characterised by the occurrence of thrombocytopenia in conjunction with thrombotic manifestations after exposure to unfractionated heparin or low molecular weight heparin. HITS is an immunologic disorder mediated by antibodies to heparin-platelet factor 4 (PF4) complex. HITS is an uncommon cause of thrombocytopenia. Reported incidence of HITS in patients exposed to heparin varies from 0.2% to up to 5%. HITS is rare in ICU populations, with estimates varying from 0.39%-0.48%. It is a complex problem which may cause diagnostic dilemmas and management conundrum. The diagnosis of HITS centers around detection of antibodies against PF4-heparin complexes. Immunoassays performed by most pathology laboratories detect the presence of antibodies, but do not reveal whether the antibodies are pathological. Platelet activation assays demonstrate the presence of clinically relevant antibodies, but only a minority of laboratories conduct them. Several anticoagulants are used in management of HITS. In this review we discuss the incidence, pathogenesis, diagnosis and management of HITS.

Physician staffing pattern in intensive care units: Have we cracked the code?

Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a "turf" war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.

Preemptive mechanical ventilation can block progressive acute lung injury

Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.

Sepsis: Evidence-based pathogenesis and treatment

Sepsis can develop during the body’s response to a critical illness leading to multiple organ failure, irreversible shock, and death. Sepsis has been vexing health care providers for centuries due to its insidious onset, generalized metabolic dysfunction, and lack of specific therapy. A common factor underlying sepsis is the characteristic hypermetabolic response as the body ramps up every physiological system in its fight against the underlying critical illness. A hypermetabolic response requires supraphysiological amounts of energy, which is mostly supplied via oxidative phosphorylation generated ATP. A by-product of oxidative phosphorylation is hydrogen peroxide (H₂O₂), a toxic, membrane-permeable oxidizing agent that is produced in far greater amounts during a hypermetabolic state. Continued production of mitochondrial H₂O₂ can overwhelm cellular reductive (antioxidant) capacity leading to a build-up within cells and eventual diffusion into the bloodstream. H₂O₂ is a metabolic poison that can inhibit enzyme systems leading to organ failure, microangiopathic dysfunction, and irreversible septic shock. The toxic effects of H₂O₂ mirror the clinical and laboratory abnormalities observed in sepsis, and toxic levels of blood H₂O₂ have been reported in patients with septic shock. This review provides evidence to support a causal role for H₂O₂ in the pathogenesis of sepsis, and an evidence-based therapeutic intervention to reduce H₂O₂ levels in the body and restore redox homeostasis, which is necessary for normal organ function and vascular responsiveness.

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic

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.

Validation of the VitalPAC Early Warning Score at the Intermediate Care Unit

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.

Prognostic categorization of intensive care septic patients

Sepsis is one of the leading worldwide causes of morbidity and mortality in critically-ill patients. Prediction of outcome in patients with sepsis requires repeated clinical interpretation of the patients’ conditions, clinical assessment of tissue hypoxia and the use of severity scoring systems, because the prognostic categorization accuracy of severity scoring indices alone, is relatively poor. Generally, such categorization depends on the severity of the septic state, ranging from systemic inflammatory response to septic shock. Now, there is no gold standard for the clinical assessment of tissue hypoxia which can be achieved by both global and regional oxygen extractabilities, added to prognostic pro-inflammatory mediators. Because the technology used to identify the genetic make-up of the human being is rapidly advancing, the structure of 30 000 genes which make-up the human DNA bank is now known. This would allow easy prognostic categorization of critically-ill patients including those suffering from sepsis. The present review spots lights on the main severity scoring systems used for outcome prediction in septic patients. For morbidity prediction, it discusses the Multiple Organ Dysfunction score, the sequential organ failure assessment score, and the logistic organ dysfunction score. For mortality/survival prediction, it discusses the Acute Physiology and Chronic Health Evaluation scores, the Therapeutic Intervention Scoring System, the Simplified acute physiology score and the Mortality Probability Models. An ideal severity scoring system for prognostic categorization of patients with systemic sepsis is far from being reached. Scoring systems should be used with repeated clinical interpretation of the patients’ conditions, and the assessment of tissue hypoxia in order to attain satisfactory discriminative performance and calibration power.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018)

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 23^rd-August 25^th, 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.

Expiratory flow-limitation in mechanically ventilated patients: A risk for ventilator-induced lung injury?

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.

Lessons from a methanol poisoning outbreak in Egypt: Six case reports

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.

Critical care practices in the world: Results of the global intensive care unit need assessment survey 2020

BACKGROUND

There is variability in intensive care unit (ICU) resources and staffing worldwide. This may reflect variation in practice and outcomes across all health systems.

AIM

To improve research and quality improvement measures administrative leaders can create long-term strategies by understanding the nature of ICU practices on a global scale.

METHODS

The Global ICU Needs Assessment Research Group was formed on the basis of diversified skill sets. We aimed to survey sites regarding ICU type, availability of staffing, and adherence to critical care protocols. An international survey 'Global ICU Needs Assessment' was created using Google Forms, and this was distributed from February 17th, 2020 till September 23rd, 2020. The survey was shared with ICU providers in 34 countries. Various approaches to motivating healthcare providers were implemented in securing submissions, including use of emails, phone calls, social media applications, and WhatsApp™. By completing this survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were a total 121 adult/adult-pediatrics ICU responses from 34 countries in 76 cities. A majority of the ICUs were mixed medical-surgical [92 (76%)]. 108 (89%) were adult-only ICUs. Total 36 respondents (29.8%) were 31-40 years of age, with 79 (65%) male and 41 (35%) female participants. 89 were consultants (74%). A total of 71 (59%) respondents reported having a 24-h in-house intensivist. A total of 87 (72%) ICUs were reported to have either a 2:1 or ≥ 2:1 patient/nurse ratio. About 44% of the ICUs were open and 76% were mixed type (medical-surgical). Protocols followed regularly by the ICUs included sepsis care (82%), ventilator-associated pneumonia (79%); nutrition (76%), deep vein thrombosis prophylaxis (84%), stress ulcer prophylaxis (84%), and glycemic control (89%).

CONCLUSION

Based on the findings of this international, multi-dimensional, needs-assessment survey, there is a need for increased recruitment and staffing in critical care facilities, along with improved patient-to-nurse ratios. Future research is warranted in this field with focus on implementing appropriate health standards, protocols and resources for optimal efficiency in critical care worldwide.

Automatic quality improvement reports in the intensive care unit: One step closer toward meaningful use

AIM: To examine the feasibility and validity of electronic generation of quality metrics in the intensive care unit (ICU).

METHODS: This minimal risk observational study was performed at an academic tertiary hospital. The Critical Care Independent Multidisciplinary Program at Mayo Clinic identified and defined 11 key quality metrics. These metrics were automatically calculated using ICU DataMart, a near-real time copy of all ICU electronic medical record (EMR) data. The automatic report was compared with data from a comprehensive EMR review by a trained investigator. Data was collected for 93 randomly selected patients admitted to the ICU during April 2012 (10% of admitted adult population). This study was approved by the Mayo Clinic Institution Review Board.

RESULTS: All types of variables needed for metric calculations were found to be available for manual and electronic abstraction, except information for availability of free beds for patient-specific time-frames. There was 100% agreement between electronic and manual data abstraction for ICU admission source, admission service, and discharge disposition. The agreement between electronic and manual data abstraction of the time of ICU admission and discharge were 99% and 89%. The time of hospital admission and discharge were similar for both the electronically and manually abstracted datasets. The specificity of the electronically-generated report was 93% and 94% for invasive and non-invasive ventilation use in the ICU. One false-positive result for each type of ventilation was present. The specificity for ICU and in-hospital mortality was 100%. Sensitivity was 100% for all metrics.

CONCLUSION: Our study demonstrates excellent accuracy of electronically-generated key ICU quality metrics. This validates the feasibility of automatic metric generation.

Determination of functional prognosis in hospitalized patients following an intensive care admission

AIM

To investigate the factors associated with the functional progress of hospitalized patients following an intensive care admission.

METHODS

Retrospective study including data from a cohort of 198 hospitalized patients following an intensive care admission and not requiring mechanical ventilation in a single tertiary referral hospital. A generalized linear model was used to identify the main effects of clinical and demographic variables on the outcomes of functionality (KATZ Index of Independence in Activities of Daily Living) and muscle strength (MRC Scale). The covariates identified as independent predictors were analysed using the receiver operating characteristic curves. The analysis differentiated the periods in the intensive care unit (ICU), in the Ward (WARD) and the total time of hospital stay (TOT).

RESULTS

Considering the functional outcome (ΔKATZ), the variables that significantly contributed to the model (P < 0.05) were the KATZ and MRC on admission, age, sepsis (no), and total length of stay (TLS). Regarding the muscle strength outcome model (ΔMRC), the predictors were MRC on admission, Simplified Acute Physiology Score III, previous stroke, TLS, and sex (female). The variable age (AUC = 0.664) discriminated the ΔKATZ_ICU. The variables age (AUC = 0.712), KATZ in ICU (AUC = 0.590) and on ward admission (AUC = 0.746), and MRC on ward admission (AUC = 0.721) were discriminative for ΔKATZ_WARD. For ΔKATZ_TOT the variables KATZ on ICU admission (AUC = 0.621) and TLS (AUC = 0.617) were discriminative. For ΔMRC_ICU the variables SAPSIII (AUC = 0.661) and MRC on ICU admission (AUC = 0.653) were discriminative. MRC on ICU (AUC = 0.681) and ward admission (AUC = 0.553) were discriminative for ΔMRC_WARD. TLS (AUC = 0.649) and MRC on ward admission (AUC = 0.696) discriminative for the ΔMRC_TOT.

CONCLUSION

Specific functional, clinical and demographical variables at ICU admission are associated with the functional prognosis during the hospitalization period.

Spectrum of cardiac manifestations and its relationship to outcomes in patients admitted with scrub typhus infection

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.

Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

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.

Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients

BACKGROUND

Patients leaving the intensive care unit (ICU) often experience gaps in care due to deficiencies in discharge communication, leaving them vulnerable to increased stress, adverse events, readmission to ICU, and death. To facilitate discharge communication, written summaries have been implemented to provide patients and their families with information on medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and who to call if there are questions. While written discharge summaries for patients and their families are utilized frequently in surgical, rehabilitation, and pediatric settings, few have been utilized in ICU settings.

AIM

To develop an ICU specific patient-oriented discharge summary tool (PODS-ICU), and pilot test the tool to determine acceptability and feasibility.

METHODS

Patient-partners (i.e., individuals with lived experience as an ICU patient or family member of an ICU patient), ICU clinicians (i.e., physicians, nurses), and researchers met to discuss ICU patients' specific informational needs and design the PODS-ICU through several cycles of discussion and iterative revisions. Research team nurses piloted the PODS-ICU with patient and family participants in two ICUs in Calgary, Canada. Follow-up surveys on the PODS-ICU and its impact on discharge were administered to patients, family participants, and ICU nurses.

RESULTS

Most participants felt that their discharge from the ICU was good or better (n = 13; 87.0%), and some (n = 9; 60.0%) participants reported a good understanding of why the patient was in ICU. Most participants (n = 12; 80.0%) reported that they understood ICU events and impacts on the patient's health. While many patients and family participants indicated the PODS-ICU was informative and useful, ICU nurses reported that the PODS-ICU was "not reasonable" in their daily clinical workflow due to "time constraint".

CONCLUSION

The PODS-ICU tool provides patients and their families with essential information as they discharge from the ICU. This tool has the potential to engage and empower patients and their families in ensuring continuity of care beyond ICU discharge. However, the PODS-ICU requires pairing with earlier discharge practices and integration with electronic clinical information systems to fit better into the clinical workflow for ICU nurses. Further refinement and testing of the PODS-ICU tool in diverse critical care settings is needed to better assess its feasibility and its effects on patient health outcomes.

Tuberculosis septic shock, an elusive pathophysiology and hurdles in management: A case report and review of literature

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.

Nutrient stimulation of mesenteric blood flow - implications for older critically ill patients

Nutrient ingestion induces a substantial increase in mesenteric blood flow. In older persons (aged ≥ 65 years), particularly those with chronic medical conditions, the cardiovascular compensatory response may be inadequate to maintain systemic blood pressure during mesenteric blood pooling, leading to postprandial hypotension. In older ambulatory persons, postprandial hypotension is an important pathophysiological condition associated with an increased propensity for syncope, falls, coronary vascular events, stroke and death. In older critically ill patients, the administration of enteral nutrition acutely increases mesenteric blood flow, but whether this pathophysiological response is protective, or precipitates mesenteric ischaemia, is unknown. There are an increasing number of older patients surviving admission to intensive care units, who are likely to be at increased risk of postprandial hypotension, both during, and after, their stay in hospital. In this review, we describe the prevalence, impact and mechanisms of postprandial hypotension in older people and provide an overview of the impact of postprandial hypotension on feeding prescriptions in older critically ill patients. Finally, we provide evidence that postprandial hypotension is likely to be an unrecognised problem in older survivors of critical illness and discuss potential options for management.

Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review

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.

Predictive modeling in neurocritical care using causal artificial intelligence

Artificial intelligence (AI) and digital twin models of various systems have long been used in industry to test products quickly and efficiently. Use of digital twins in clinical medicine caught attention with the development of Archimedes, an AI model of diabetes, in 2003. More recently, AI models have been applied to the fields of cardiology, endocrinology, and undergraduate medical education. The use of digital twins and AI thus far has focused mainly on chronic disease management, their application in the field of critical care medicine remains much less explored. In neurocritical care, current AI technology focuses on interpreting electroencephalography, monitoring intracranial pressure, and prognosticating outcomes. AI models have been developed to interpret electroencephalograms by helping to annotate the tracings, detecting seizures, and identifying brain activation in unresponsive patients. In this mini-review we describe the challenges and opportunities in building an actionable AI model pertinent to neurocritical care that can be used to educate the newer generation of clinicians and augment clinical decision making.

Biomarkers in sepsis-looking for the Holy Grail or chasing a mirage!

Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated host response to infection. It is a complex syndrome and is characterized by physiologic, pathologic and biochemical abnormalities in response to an infection. Diagnosis of sepsis is based on history, physical examination and other investigations (including biomarkers) which may help to increase the certainty of diagnosis. Biomarkers have been evaluated in the past for many diseases and have been evaluated for sepsis as well. Biomarkers may find a possible role in diagnosis, prognostication, therapeutic monitoring and anti-microbial stewardship in sepsis. Since the pathophysiology of sepsis is quite complex and is incompletely understood, a single biomarker that may be robust enough to provide all information has not been found as of yet. However, many biomarkers have been studied and some of them have applications at the bedside and guide clinical decision-making. We evaluated the PubMed database to search for sepsis biomarkers for diagnosis, prognosis and possible role in antibiotic escalation and de-escalation. Clinical trials, meta-analyses, systematic reviews and randomized controlled trials were included. Commonly studied biomarkers such as procalcitonin, Soluble urokinase-type plasminogen activator (Supar), presepsin, soluble triggering receptor expressed on myeloid cells 1, interleukin 6, C-reactive protein, etc., have been described for their possible applications as biomarkers in septic patients. The sepsis biomarkers are still an area of active research with newer evidence adding to the knowledge base continuously. For patients presenting with sepsis, early diagnosis and prompt resuscitation and early administration of anti-microbials (preferably within 1 h) and source control are desired goals. Biomarkers may help us in the diagnosis, prognosis and therapeutic monitoring of septic patients. The marker redefining our view on sepsis is yet a mirage that clinicians and researchers continue to chase.