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Dbouk T, Roger F, Drikakis D, Ali S, Menu H, Wiel E. The impact of endotracheal intubation on oxygen delivery, trachea pressure and wall deformation. Comput Biol Med 2023; 164:107325. [PMID: 37586206 DOI: 10.1016/j.compbiomed.2023.107325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/15/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
This paper concerns improving endotracheal tube (ETT) insertion through advanced computational science modelling. The study aims to better understand endotracheal intubation (ETI) and reduce medical errors in intensive and critical care units since ETT insertion is unique for each patient, depending on age, gender, size, physiology, and underlying health conditions. We have employed computational fluid dynamics and biomechanics modelling to investigate the effect of ETT for three ventilation modes on (a) local oxygen delivery to the lungs, (b) air pressure and wall shear stress at the tracheal walls, and (c) oscillatory elastic deformation of the tracheal tissues and muscle. For the first time, we reveal how the ventilation mode and ETT insertion in the trachea may induce major complications, especially in long periods of ETT. We show that rotating the ETT or displacing it by 2 mm only can induce a significant rise in the tracheal pressure up to 177 cmH2O. This study, for the first time, shows the vital role of computers in biology and medicine to provide enhanced decision-making-support to clinicians and medical doctors dealing with ETI.
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Affiliation(s)
- T Dbouk
- CORIA, CNRS, UMR 6614, Rouen Normandy University, UNIROUEN, 76000 Rouen, France.
| | - F Roger
- IMT Nord Europe, Materials and processes Center, University of Lille, F-59000 Lille, France
| | - D Drikakis
- Institute for Advanced Modelling and Simulation, University of Nicosia, Nicosia, CY-2417, Cyprus
| | - S Ali
- Junia, ULR 4515 - LGCgE, Laboratoire de Génie Civil et géo-Environnement, F-59000 Lille, France
| | - H Menu
- Faculté des Sciences de la Santé et du Sport (UFR3S) - Médecine, CHU de Lille, ULR 2694, METRICS, 59000 Lille, France
| | - E Wiel
- Faculté des Sciences de la Santé et du Sport (UFR3S) - Médecine, CHU de Lille, ULR 2694, METRICS, 59000 Lille, France
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Malin A, Cassidy J. Head and neck positioning for out-of-theatre intubation during the COVID-19 pandemic. J Intensive Care Soc 2023; 24:335-337. [PMID: 37744081 PMCID: PMC8886308 DOI: 10.1177/17511437221079121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The COVID-19 pandemic has brought with it a large number of challenges for healthcare professionals including intubation safety in out-of-theatre environments. An important aspect of this topic is the optimisation of a patient's head and neck position prior to laryngoscopy which can be challenging when a pillow cannot be located. As a result, the authors compared how well the sniffing position (35o neck flexion and 15o head extension) could be reached using pillows or other novel head supports. The resulting data demonstrated that a 1-litre pressure bag and two 1-litre saline bags achieved the most accurate position.
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Affiliation(s)
- Alexander Malin
- Department of Intensive Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - James Cassidy
- Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Halaseh RM, Drescher GS, Al-Ahmad M, Masri IH, Alayon AL, Ghawanmeh M, Arar T, Mohammad SAD, Pavate R, Bakri MH, Al-Tarbsheh A, AlGhadir-AlKhalaileh M. Risk Factors and Outcomes Associated With Re-Intubation Secondary to Respiratory Failure in Patients With COVID-19 ARDS. Respir Care 2023; 69:respcare.10881. [PMID: 37438052 PMCID: PMC10753619 DOI: 10.4187/respcare.10881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS. METHODS We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student t test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables. RESULTS One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], P = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], P = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], P = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 ± 22.7 d vs 26.1 ± 12.1 d, P = .01) and ICU (29.6 ± 22.4 d vs 15.8 ± 10.4 d, P < .001) stays. More subjects died who failed extubation (49% vs 3%, P < .001). Age (OR 1.07 [95% CI 1.02-1.23], P = .005), male sex (OR 4.9 [95% CI 1.08-22.35], P = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], P = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], P < .001) were independently associated with death (area under the curve = 0.93). CONCLUSIONS Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.
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Affiliation(s)
- Ramez M Halaseh
- Pulmonary and Critical Care Department, Cleveland Clinic Florida, Weston, Florida.
| | - Gail S Drescher
- Respiratory Therapy Department, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Ma'amoon Al-Ahmad
- Internal Medicine Department, University of Florida Health, Gainesville, Florida
| | - Ihab H Masri
- Pulmonary and Critical Care Department, MedStar Washington Hospital Center, Washington, District of Columbia
| | | | - Malik Ghawanmeh
- Cardiology Department, George Washington University Hospital, Washington, District of Columbia
| | - Tareq Arar
- Internal Medicine Department, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Saad Al-Deen Mohammad
- Internal Medicine Department, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Rea Pavate
- Internal Medicine Department, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Mouaz Haj Bakri
- Internal Medicine Department, University of Florida Health, Gainesville, Florida
| | - Ali Al-Tarbsheh
- Pulmonary and Critical Care Department, Cleveland Clinic Florida, Weston, Florida
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Rola P, Daxon B. Airway Pressure Release Ventilation With Time-Controlled Adaptive Ventilation (TCAV™) in COVID-19: A Community Hospital's Experience. Front Physiol 2022; 13:787231. [PMID: 35480043 PMCID: PMC9037240 DOI: 10.3389/fphys.2022.787231] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/27/2022] [Indexed: 12/30/2022] Open
Abstract
Santa Cabrini Ospedale, a community hospital in Montreal, Canada, used the airway pressure release ventilation following a time-controlled adaptive ventilation (APRV-TCAV™) approach for several patients in the first wave of the coronavirus disease 2019 (COVID-19) outbreak in the spring of 2021. Based on favorable patient responses, it became the primary mode of invasive mechanical ventilation—from initiation through extubation—during the second and third waves of COVID-19. In this article, we describe our success with APRV-TCAV™ over more conventional modes and protocols and look at three cases that aptly demonstrate our experience. We then outline several risks with our approach and the lessons learned from our experience. While we generally saw improvement in patients’ clinical course with APRV-TCAV™, there are inherent risks with this approach that others must prepare for if they attempt to implement it in their practice.
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Affiliation(s)
- Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, QC, Canada
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AbuRuz S, Al-Azayzih A, ZainAlAbdin S, Beiram R, Al Hajjar M. Clinical characteristics and risk factors for mortality among COVID-19 hospitalized patients in UAE: Does ethnic origin have an impact. PLoS One 2022; 17:e0264547. [PMID: 35235580 PMCID: PMC8890645 DOI: 10.1371/journal.pone.0264547] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/12/2022] [Indexed: 01/08/2023] Open
Abstract
Background The relationship between COVID-19 patient’s clinical characteristics and disease manifestation remains incompletely understood. The impact of ethnicity on mortality of patients with COVID-19 infection is poorly addressed in the literature. Emerging evidence suggests that many risk factors are related to symptoms severity and mortality risk, emphasizing the necessity of fulfilling this knowledge gap that may help reducing mortality from COVID-19 infections through tackling the risk factors. Aims To explore epidemiological and demographic characteristics of hospitalized COVID-19 patients from different ethnic origins living in the UAE, compare them to findings reported across the globe and determine the impact of these characteristics and ethnicity on mortality during hospitalization. Methods A single center, retrospective chart review study of hospitalized COVID-19 patients was conducted in a large COVID-19 referral hospital in UAE. The following outcomes were assessed: patients’ clinical characteristics, disease symptoms and severity, and association of ethnicity and other risk factors on 30-day in hospital mortality. Results A total of 3296 patients were recruited in this study with an average age of 44.3±13.4 years old. Preliminary data analysis indicated that 78.3% (n = 2582) of cases were considered mild. Average duration of hospital stay was 6.0±7.3 days and 4.3% (n = 143) were admitted to ICU. The most frequently reported symptoms were cough (32.6%, n = 1075) and fever (22.2%, n = 731). The 30-day mortality rate during hospitalization was 2.7% (n = 90). Many risk factors were associated with mortality during hospitalization including: age, respiratory rate (RR), creatinine, and C-reactive protein, oxygen saturation (SaO2), hemoglobin, hematocrit, ferritin, creatinine, C-reactive protein, anemia, COPD, Chronic kidney disease, dyslipidemia, Vitamin-D Deficiency, and ethnic origin (p <0.05). Multiple logistic regression analysis showed that higher mortality rates during hospitalization was associated with anemia, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and Middle Eastern origin (p<0.05). Conclusion The results indicated that most COVID-19 cases were mild and morality rate was low compared to worldwide reported mortality. Mortality rate during hospitalization was higher in patients from Middle East origin with preexisting comorbidities especially anemia, COPD, and chronic kidney disease. Due to the relatively small number of mortality cases, other identified risk factors from univariate analysis such as age, respiratory rate, and Vitamin-D (VitD) deficiency should also be taken into consideration. It is crucial to stratify patients on admission based on these risk factors to help decide intensity and type of treatment which, possibly, will reduce the risk of death.
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Affiliation(s)
- Salah AbuRuz
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, The United Arab Emirates University, Al Ain, United Arab Emirates
- Department of Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
- * E-mail:
| | - Ahmad Al-Azayzih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Sham ZainAlAbdin
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, The United Arab Emirates University, Al Ain, United Arab Emirates
| | - Rami Beiram
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, The United Arab Emirates University, Al Ain, United Arab Emirates
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Mihajlovic S, Savic P, Potparevic N, Lackovic M. Outcomes of mechanical ventilation in COVID-19 pregnant patients. Hippokratia 2022; 26:32-37. [PMID: 37124279 PMCID: PMC10132392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Pregnancy poses a risk factor for respiratory infections due to hormonal changes, reduced tolerance to hypoxia, immunodeficiency, and increased susceptibility towards viral infections. Pregnant women might develop a broad spectrum of clinical conditions associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, from asymptomatic to potentially life-threatening complications. Critical respiratory failure associated with the progression of viral pneumonia is the most severe complication of the coronavirus disease (COVID-19). In some cases, it may require intubation and invasive mechanical ventilation. CASE SERIES In this case series, we evaluated the outcomes and clinical features of eight critically ill pregnant patients requiring invasive mechanical ventilation during treatment. The most commonly observed symptoms were fever at admission to the hospital, cough, difficulty breathing, and fatigue. Less frequently observed were sore throat and loss of smell and taste. All patients had anemia, and hypertension was the second most common comorbidity in pregnancy. Pregnant patients with lethal outcomes were older than those who recovered. They had higher body mass index values, more symptoms at admission, and higher C-reactive protein values and ferritin levels. Acute Respiratory Distress Syndrome (ARDS) was diagnosed in five cases, and none of these patients survived. CONCLUSION Obesity, maternal age, and diagnosis of ARDS were most commonly observed in our group of patients with lethal outcomes. Preventive measurements, counseling, and enlightenment of potential risk factors, such as obesity, advanced maternal age, and pregnancy-related comorbidities, should be the cornerstones in crises such as COVID-19 when medical care and resources are limited or restricted. HIPPOKRATIA 2022, 26 (1):32-37.
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Affiliation(s)
- S Mihajlovic
- Department of Obstetrics and Gynecology, University hospital "Dr. Dragisa Misovic", Belgrade, Serbia
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - P Savic
- Department of General Surgery, University hospital "Dr. Dragisa Misovic", Belgrade, Serbia
- Department of Surgery and Anesthesiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - N Potparevic
- Department of Obstetrics and Gynecology, University hospital "Dr. Dragisa Misovic", Belgrade, Serbia
| | - M Lackovic
- Department of Obstetrics and Gynecology, University hospital "Dr. Dragisa Misovic", Belgrade, Serbia
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Staibano P, Levin M, McHugh T, Gupta M, Sommer DD. Association of Tracheostomy With Outcomes in Patients With COVID-19 and SARS-CoV-2 Transmission Among Health Care Professionals: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:646-655. [PMID: 34042963 PMCID: PMC8160928 DOI: 10.1001/jamaoto.2021.0930] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
Importance Approximately 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV) and, at times, tracheostomy. Details regarding the safety and use of tracheostomy in treating COVID-19 continue to evolve. Objective To evaluate the association of tracheostomy with COVID-19 patient outcomes and the risk of SARS-CoV-2 transmission among health care professionals (HCPs). Data Sources EMBASE (Ovid), Medline (Ovid), and Web of Science from January 1, 2020, to March 4, 2021. Study Selection English-language studies investigating patients with COVID-19 who were receiving IMV and undergoing tracheostomy. Observational and randomized clinical trials were eligible (no randomized clinical trials were found in the search). All screening was performed by 2 reviewers (P.S. and M.L.). Overall, 156 studies underwent full-text review. Data Extraction and Synthesis We performed data extraction in accordance with Meta-analysis of Observational Studies in Epidemiology guidelines. We used a random-effects model, and ROBINS-I was used for the risk-of-bias analysis. Main Outcomes and Measures SARS-CoV-2 transmission between HCPs and levels of personal protective equipment, in addition to complications, time to decannulation, ventilation weaning, and intensive care unit (ICU) discharge in patients with COVID-19 who underwent tracheostomy. Results Of the 156 studies that underwent full-text review, only 69 were included in the qualitative synthesis, and 14 of these 69 studies (20.3%) were included in the meta-analysis. A total of 4669 patients were included in the 69 studies, and the mean (range) patient age across studies was 60.7 (49.1-68.8) years (43 studies [62.3%] with 1856 patients). We found that in all studies, 1854 patients (73.8%) were men and 658 (26.2%) were women. We found that 28 studies (40.6%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy. Overall, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was associated with tracheostomy. Studies did not consistently report the number of HCPs involved in tracheostomy. Among the patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days; 95% CI, -11.30 to -1.30), but no change in IMV weaning (mean difference, -2.99 days; 95% CI, -8.32 to 2.33) or decannulation (mean difference, -3.12 days; 95% CI, -7.35 to 1.12). There was no association between mortality or perioperative complications and type of tracheostomy. A risk-of-bias evaluation that used ROBINS-I demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was notable heterogeneity in study reporting. Conclusions and Relevance The findings of this systematic review and meta-analysis indicate that enhanced personal protective equipment is associated with low rates of SARS-CoV-2 transmission during tracheostomy. Early tracheostomy in patients with COVID-19 may reduce ICU stay, but this finding is limited by the observational nature of the included studies.
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Affiliation(s)
- Phillip Staibano
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Marc Levin
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tobial McHugh
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Michael Gupta
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Doron D. Sommer
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
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Yeates EO, Nahmias J, Chinn J, Sullivan B, Stopenski S, Amin AN, Nguyen NT. Improved outcomes over time for adult COVID-19 patients with acute respiratory distress syndrome or acute respiratory failure. PLoS One 2021; 16:e0253767. [PMID: 34170950 PMCID: PMC8232521 DOI: 10.1371/journal.pone.0253767] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/12/2021] [Indexed: 12/15/2022] Open
Abstract
Background COVID-19’s pulmonary manifestations are broad, ranging from pneumonia with no supplemental oxygen requirements to acute respiratory distress syndrome (ARDS) with acute respiratory failure (ARF). In response, new oxygenation strategies and therapeutics have been developed, but their large-scale effects on outcomes in severe COVID-19 patients remain unknown. Therefore, we aimed to examine the trends in mortality, mechanical ventilation, and cost over the first six months of the pandemic for adult COVID-19 patients in the US who developed ARDS or ARF. Methods and findings The Vizient Clinical Data Base, a national database comprised of administrative, clinical, and financial data from academic medical centers, was queried for patients ≥ 18-years-old with COVID-19 and either ARDS or ARF admitted between 3/2020-8/2020. Demographics, mechanical ventilation, length of stay, total cost, mortality, and discharge status were collected. Mann-Kendall tests were used to assess for significant monotonic trends in total cost, mechanical ventilation, and mortality over time. Chi-square tests were used to compare mortality rates between March-May and June-August. 110,223 adult patients with COVID-19 ARDS or ARF were identified. Mean length of stay was 12.1±13.3 days and mean total cost was $35,991±32,496. Mechanical ventilation rates were 34.1% and in-hospital mortality was 22.5%. Mean cost trended downward over time (p = 0.02) from $55,275 (March) to $18,211 (August). Mechanical ventilation rates trended down (p<0.01) from 53.8% (March) to 20.3% (August). Overall mortality rates also decreased (p<0.01) from 28.4% (March) to 13.7% (August). Mortality rates in mechanically ventilated patients were similar over time (p = 0.45), but mortality in patients not requiring mechanical ventilation decreased from March-May compared to June-July (13.5% vs 4.6%, p<0.01). Conclusions This study describes the outcomes of a large cohort with COVID-19 ARDS or ARF and the subsequent decrease in cost, mechanical ventilation, and mortality over the first 6 months of the pandemic in the US.
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Affiliation(s)
- Eric O. Yeates
- Department of Surgery, University of California Irvine, Orange, California, United States of America
- * E-mail:
| | - Jeffry Nahmias
- Department of Surgery, University of California Irvine, Orange, California, United States of America
| | - Justine Chinn
- Department of Surgery, University of California Irvine, Orange, California, United States of America
| | - Brittany Sullivan
- Department of Surgery, University of California Irvine, Orange, California, United States of America
| | - Stephen Stopenski
- Department of Surgery, University of California Irvine, Orange, California, United States of America
| | - Alpesh N. Amin
- Department of Medicine, University of California Irvine, Orange, California, United States of America
| | - Ninh T. Nguyen
- Department of Surgery, University of California Irvine, Orange, California, United States of America
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Crossman ME, Stobart-Gallagher M, Siegel M. Determining Goals of Care During the COVID-19 Pandemic: A Virtual Course for Emergency Medicine Residents. Cureus 2021; 13:e14558. [PMID: 34026375 PMCID: PMC8133506 DOI: 10.7759/cureus.14558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Patients' goals of care (GOC), which direct end-of-life clinical decision-making, should be established in conjunction with their primary physician when they are well. However, these discussions are often left for when critical intervention is needed in the Emergency Department, and this has been exacerbated in the new context of the current coronavirus disease 2019 pandemic. Establishing effective, formal training for Emergency Medicine (EM) residents to successfully carry out these conversations and potentially improve patient care is needed. Methodology A physician dual-certified in Emergency Medicine and Palliative Care developed a virtual course on best practices in determining GOC for EM residents. It occurred for one hour during resident didactic conference and all residents who attended were included. A survey was sent to all participants to assess the success of the course's content and method of delivery. Results Of the 39 residents who participated, 18 (46%) completed the survey. The majority (94%) agreed the course helped close knowledge gaps and increased comfort in carrying out these discussions and 100% planned to incorporate these learning points into practice. A smaller majority (61%) thought the virtual platform was an effective method of delivery and 61% felt the breakout rooms helped with learning retention. Open-ended comments reflected learners' desire for more of this content, suggestions to augment with simulation, as well as technical difficulties experienced. Conclusions This course helped EM residents identify and close knowledge gaps in determining patients' GOC who plan to incorporate what they learned into their clinical practice. Next steps in validating the course include seeking more pointed feedback of the virtual format and assessing its effects over broader audiences after making feedback-focused adjustments to its content and delivery.
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Affiliation(s)
- Megan E Crossman
- Emergency Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
| | | | - Mari Siegel
- Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
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Silva JM, Treml RE, Golinelli PC, Segundo MRDMG, Menezes PFL, Umada JDDA, Alves APS, Nabeshima RP, Carvalho ADS, Pereira TS, Sponton ES. Response of patients with acute respiratory failure caused by COVID-19 to awake-prone position outside the intensive care unit based on pulmonary involvement. Clinics (Sao Paulo) 2021; 76:e3368. [PMID: 34909912 PMCID: PMC8614624 DOI: 10.6061/clinics/2021/e3368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Since there are difficulties in establishing effective treatments for COVID-19, a vital way to reduce mortality is an early intervention to prevent disease progression. This study aimed to evaluate the performance of patients with COVID-19 with acute hypoxic respiratory failure according to pulmonary impairment in the awake-prone position, outside of the intensive care unit (ICU). METHODS A prospective observational cohort study was conducted on COVID-19 patients under noninvasive respiratory support. Clinical and laboratory data were obtained for each patient before the treatment and after they were placed in the awake-prone position. To identify responders and non-responders after the first prone maneuver, receiver operating characteristic curves with sensitivity and specificity of the PaO2/FiO2 and SpO2/FiO2 indices were analyzed. The maneuver was considered positive if the patient did not require endotracheal intubation for ventilatory assistance. RESULTS Forty-eight patients were included, and 64.6% were categorized as responders. The SpO2/FiO2 index was effective for predicting endotracheal intubation in COVID-19 patients regardless of lung parenchymal damage (area under the curve 0.84, cutoff point 165, sensitivity 85%, specificity 75%). Responders had better outcomes with lower hospital mortality (hazard ratio [HR]=0.107, 95% confidence interval [CI]: 0.012-0.93) and a shorter length of stay (median difference 6 days, HR=0.30, 95% CI: 0.13-0.66) after adjusting for age, body mass index, sex, and comorbidities. CONCLUSIONS The awake-prone position for COVID-19 patients outside the ICU can improve oxygenation and clinical outcomes regardless of the extent of pulmonary impairment. Furthermore, the SpO2/FiO2 index discriminates responders from non-responders to the prone maneuver predicting endotracheal intubation with a cutoff under or below 165.
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Affiliation(s)
- João Manoel Silva
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding Author: E-mail:
| | - Ricardo Esper Treml
- Department of Anesthesia, Critical Care and Pain Medicine, University of Jena, Jena, Germany
| | | | | | - Pedro Ferro L. Menezes
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | | | - Renata Peres Nabeshima
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - André dos Santos Carvalho
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Talison Silas Pereira
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Elaine Serafim Sponton
- Departamento de Enfermagem, Hospital do Servidor Publico Estadual (IAMPSE), Sao Paulo, SP, BR
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