Critical care "normality": individualized versus protocolized care

Challenges faced in establishing a dedicated 250 bed COVID-19 intensive care unit in a temporary structure

An Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. While this availability of trained manpower and specialized equipment makes it possible to care for critically ill patients, it also presents singular challenges in the form of man and material management, design concerns, budgetary concerns, and protocolization of treatment. Consequently, the establishment of an ICU requires rigorous design and planning, a process that can take months to years. However, the Coronavirus disease-19 (COVID-19) epidemic has required the significant capacity building to accommodate the increased number of critically ill patients. At the peak of the pandemic, many countries were forced to resort to the building of temporary structures to house critically ill patients, to help tide over the crisis. This narrative review describes the challenges and lessons learned while establishing a 250 bedded ICU in a temporary structure and achieving functionality within a period of a fortnight.

Intraoperative Blood Pressure Variability Predicts Postoperative Mortality in Non-Cardiac Surgery-A Prospective Observational Cohort Study

Little is known about the clinical importance of blood pressure variability (BPV) during anesthesia in non-cardiac surgery. We sought to investigate the impact of intraoperative BPV on postoperative mortality in non-cardiac surgery subjects, taking into account patient- and procedure-related variables. This prospective observational study covered 835 randomly selected patients who underwent gastrointestinal (n = 221), gynecological (n = 368) and neurosurgical (n = 246) procedures. Patient’s and procedure’s risks were assessed according to the validated tools and guidelines. Blood pressure (systolic, SBP, and diastolic, DBP) was recorded in five-minute intervals during anesthesia. Mean arterial pressure (MAP) was assessed. Individual coefficients of variation (Cv) were calculated. Postoperative 30-day mortality was considered the outcome. Median SBP_Cv was 11.2% (IQR 8.4–14.6), DBP_Cv was 12.7% (IQR 9.8–16.3) and MAP_Cv was 10.96% (IQR 8.26–13.86). Mortality was 2%. High SBP_Cv (i.e., ≥11.9%) was associated with increased mortality by 4.5 times (OR = 4.55; 95% CI 1.48–13.93; p = 0.008). High DBP_Cv (i.e., ≥22.4%) was associated with increased mortality by nearly 10 times (OR = 9.73; 95% CI 3.26–28.99; p < 0.001). High MAP_Cv (i.e., ≥13.6%) was associated with increased mortality by 3.5 times (OR = 3.44; 95% CI 1.34–8.83; p = 0.01). In logistic regression, it was confirmed that the outcome was dependent on both SBPV and DBPV, after adjustment for perioperative variables, with AUCSBP_Cv = 0.884 (95% CI 0.859–0.906; p < 0.001) and AUCDBP_Cv = 0.897 (95% CI 0.873–0.918; p < 0.001). Therefore, intraoperative BPV may be considered a prognostic factor for the postoperative mortality in non-cardiac surgery, and DBPV seems more accurate in outcome prediction than SBPV.

Safest Time to Resume Oral Anticoagulation in Patients with Traumatic Brain Injury

OBJECTIVE

 There is no standard protocol to guide the optimal time to resume anti-clotting agents after traumatic brain injury (TBI) in patients with a continued indication for anticoagulation/antiplatelet therapy (AAT). This study develops baseline data supporting a future prospective cohort study. We predict that there will be significantly decreased adverse events when AAT is started on or after Day 7.

METHODS

 A retrospective chart review of 256 patients was performed. Patients admitted to a level I trauma center in West Texas between January 1, 2009, and December 31, 2012, on anti-clotting agents (specifically acetylsalicylic acid, coumadin, and/or clopidogrel) and who suffered a TBI were included. Patient metrics included admission coagulation studies, type of TBI and treatment, and time to continuation of AAT. Outcomes were assessed using follow-up appointment data. The primary outcome was death (mortality). Secondary outcomes included myocardial infarction, stroke, re-bleed, venous thromboembolism, and pneumonia.

RESULTS

A total of 256 patients met the inclusion criteria. However, only 85 patients on AAT presented for the six-month follow-up. Time to AAT resumption varied from immediate to 31 days. Out of the 85 patients, 32 patients never resumed AAT, 32 patients were restarted on AAT medication in less than seven days, 10 patients restarted medication between seven and 14 days, and 11 patients restarted AAT in more than 14 days. Adverse events occurred most infrequently in the AAT group resuming therapy between seven and 14 days (10%). Adverse events were most prevalent in the AAT group that never resumed therapy (68.8%).

CONCLUSION

 While most studies suggest that the safest time for resuming AAT lies between three and 10 days, our study revealed that adverse events were minimized in patients on AAT between seven and 9.5 days.

Outcomes of patients with severe sepsis after the first 6 hours of resuscitation at a regional referral hospital in Uganda

INTRODUCTION

The optimal resuscitation strategy for patients with severe sepsis in resource-limited settings is unknown. Therefore, we determined the association between intravenous fluids, changes in vital signs and lactate after the first 6 hours of resuscitation from severe sepsis, and in-hospital mortality at a hospital in Uganda.

MATERIALS AND METHODS

We enrolled patients admitted with severe sepsis to Mbarara Regional Referral Hospital and obtained vital signs and point-of-care blood lactate concentration at admission and after 6 hours of resuscitation. We used logistic regression to determine predictors of in-hospital mortality.

RESULTS

We enrolled 218 patients and had 6 hour postresuscitation data for 202 patients. The median (interquartile range) age was 35 (26-50) years, 49% of patients were female, and 57% were HIV infected. The in-hospital mortality was 32% and was associated with admission Glasgow Coma Score (adjusted odds ratio [aOR], 0.749; 95% confidence interval [CI], 0.642-0.875; P < .001), mid-upper arm circumference (aOR, 0.876; 95% CI, 0.797-0.964; P = .007), and 6-hour systolic blood pressure (aOR, 0.979; 95% CI, 0.963-0.995; P = .009) but not lactate clearance of 10% or greater (aOR, 1.2; 95% CI, 0.46-3.10; P = .73).

CONCLUSIONS

In patients with severe sepsis in Uganda, obtundation and wasting were more closely associated with in-hospital mortality than lactate clearance of 10% or greater.

Refinement of animal models of sepsis and septic shock

This report aims to facilitate the implementation of the Three Rs (replacement, reduction, and refinement) in the use of animal models or procedures involving sepsis and septic shock, an area where there is the potential of high levels of suffering for animals. The emphasis is on refinement because this has the greatest potential for immediate implementation. Specific welfare issues are identified and discussed, and practical measures are proposed to reduce animal use and suffering as well as reducing experimental variability and increasing translatability. The report is based on discussions and submissions from a nonregulatory expert working group consisting of veterinarians, animal technologists, and scientists with expert knowledge relevant to the field.

Surgical inflammatory stress: the embryo takes hold of the reins again

The surgical inflammatory response can be a type of high-grade acute stress response associated with an increasingly complex trophic functional system for using oxygen. This systemic neuro-immune-endocrine response seems to induce the re-expression of 2 extraembryonic-like functional axes, i.e. coelomic-amniotic and trophoblastic-yolk-sac-related, within injured tissues and organs, thus favoring their re-development. Accordingly, through the up-regulation of two systemic inflammatory phenotypes, i.e. neurogenic and immune-related, a gestational-like response using embryonic functions would be induced in the patient's injured tissues and organs, which would therefore result in their repair. Here we establish a comparison between the pathophysiological mechanisms that are produced during the inflammatory response and the physiological mechanisms that are expressed during early embryonic development. In this way, surgical inflammation could be a high-grade stress response whose pathophysiological mechanisms would be based on the recapitulation of ontogenic and phylogenetic-related functions. Thus, the ultimate objective of surgical inflammation, as a gestational process, is creating new tissues/organs for repairing the injured ones. Since surgical inflammation and early embryonic development share common production mechanisms, the factors that hamper the wound healing reaction in surgical patients could be similar to those that impair the gestational process.

The impact of clinical protocols in the management of severe sepsis: a prospective cohort study

This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality. In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.

Nourishing the dysfunctional gut and whey protein

PURPOSE OF REVIEW

This review discusses the mechanisms of the dysfunctional gut during the critical illness and the possibility that an immunonutrient such as whey protein can play a role in better tolerance of enteral nutrition, also decreasing inflammation and increasing anti-inflammatory defenses.

RECENT FINDINGS

Impaired gastric motor function and associated feed intolerance are common issues in critically ill patients. Some studies have been published with enteral nutrition enriched with whey protein as a dietary protein supplement that provides antimicrobial activity, immune modulation, improving muscle strength and body composition, and preventing cardiovascular disease and osteoporosis.

SUMMARY

Early enteral feeding will enhance patient recovery and the use of enteral diets enriched with whey protein may play a role in these patients.

Interrogating a clinical database to study treatment of hypotension in the critically ill

OBJECTIVE

In intensive care, it is imperative to resolve hypotensive episodes (HEs) in a timely manner to minimise end-organ damage. Clinical practice guidelines generally recommend initial treatment with fluid resuscitation followed by vasoactive agent administration if patients remain hypotensive. However, the impact of such interventions on patient outcomes has not been clearly established. Hence, the objective of this study was to investigate the relationship between fluid and vasoactive agent interventions and patient outcomes, while highlighting the utility of electronic medical records in clinical research.

DESIGN

Retrospective cohort study.

SETTING

Intensive care units (ICUs) at a large, academic, tertiary medical center.

PARTICIPANTS

Patients in Multi-parameter Intelligent Monitoring in Intensive Care II (a large electronic ICU database) who experienced a single HE during their ICU stay. 2332 patients had complete data.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of interest was inhospital mortality. Secondary outcomes were ICU length of stay (LOS), HE duration, Hypotension Severity Index (defined as the mean arterial pressure curve area below 60 mm Hg during the HE) and rise in serum creatinine.

RESULTS

Fluid resuscitation was associated with significantly shorter ICU LOS among ICU survivors (p=0.007). Vasoactive agent administration significantly decreased HE duration (p<0.001) and Hypotension Severity Index (p=0.002) but was associated with increased inhospital mortality risk (p<0.001), prolonged ICU LOS among ICU survivors (p=0.04) and rise in serum creatinine (p=0.002) after adjustment for confounders. Propensity score analyses as well as sensitivity analyses in treatment-, diagnosis- and ICU service-specific subpopulations corroborated the relationship between vasoactive agents and increased inhospital mortality.

CONCLUSIONS

An adverse relationship between vasoactive agents and inhospital mortality was found in patients with hypotension. This study has implications for the care of critically ill patients with hypotension and illustrates the utility of electronic medical records in research when randomised controlled trials are difficult to conduct.

Physiological modeling, tight glycemic control, and the ICU clinician: what are models and how can they affect practice?

Critically ill patients are highly variable in their response to care and treatment. This variability and the search for improved outcomes have led to a significant increase in the use of protocolized care to reduce variability in care. However, protocolized care does not address the variability of outcome due to inter- and intra-patient variability, both in physiological state, and the response to disease and treatment. This lack of patient-specificity defines the opportunity for patient-specific approaches to diagnosis, care, and patient management, which are complementary to, and fit within, protocolized approaches.Computational models of human physiology offer the potential, with clinical data, to create patient-specific models that capture a patient's physiological status. Such models can provide new insights into patient condition by turning a series of sometimes confusing clinical data into a clear physiological picture. More directly, they can track patient-specific conditions and thus provide new means of diagnosis and opportunities for optimising therapy.This article presents the concept of model-based therapeutics, the use of computational models in clinical medicine and critical care in specific, as well as its potential clinical advantages, in a format designed for the clinical perspective. The review is presented in terms of a series of questions and answers. These aspects directly address questions concerning what makes a model, how it is made patient-specific, what it can be used for, its limitations and, importantly, what constitutes sufficient validation.To provide a concrete foundation, the concepts are presented broadly, but the details are given in terms of a specific case example. Specifically, tight glycemic control (TGC) is an area where inter- and intra-patient variability can dominate the quality of care control and care received from any given protocol. The overall review clearly shows the concept and significant clinical potential of using computational models in critical care medicine.