The Ability of Critical Care Physicians to Identify Patient-Ventilator Asynchrony Using Waveform Analysis: A National Survey

BACKGROUND

Improved patient-ventilator asynchrony (PVA) identification using waveform analysis by critical care physicians (CCPs) may improve patient outcomes. This study aimed to assess the ability of CCPs to identify different types of PVAs using waveform analysis as well as factors related to this ability.

METHODS

We surveyed 12 university-affiliated medical ICUs (MICUs) in Tunisia. CCPs practicing in these MICUs were asked to visually identify 4 clinical cases, each corresponding to a different PVA. We collected the following characteristics regarding CCPs: scientific grade, years of experience, prior training in mechanical ventilation, prior exposure to waveform analysis, and the characteristics of the MICUs in which they practice. Respondents were categorized into 2 groups based on their ability to correctly identify PVAs (defined as the correct identification of at least 3 of the 4 PVA cases). Univariate analysis was performed to identify factors related to the correct identification of PVA.

RESULTS

Among 136 included CCPs, 72 (52.9%) responded to the present survey. The respondents comprised 59 (81.9%) residents, and 13 (18.1%) senior physicians. Further, 50 (69.4%) respondents had attended prior training in mechanical ventilation. Moreover, 21 (29.2%) of the respondents could correctly identify PVAs. Double-triggering was the most frequently identified PVA type, 43 (59.7%), followed by auto-triggering, 36 (50%); premature cycling, 28 (38.9%); and ineffective efforts, 25 (34.7%). Univariate analysis indicated that senior physicians had a better ability to correctly identify PVAs than residents (7 [53.8%] vs 14 [23.7%], P = .044).

CONCLUSIONS

The present study revealed a significant deficiency in the accurate visual identification of PVAs among CCPs in the MICUs. When compared to residents, senior physicians exhibited a notably superior aptitude for correctly recognizing PVAs.

Epidemiology and burden of Severe Acute Respiratory Infections (SARI) in the aftermath of COVID-19 pandemic: A prospective sentinel surveillance study in a Tunisian Medical ICU, 2022/2023

BACKGROUND

Severe Acute Respiratory Infections (SARI) caused by influenza and other respiratory viruses pose significant global health challenges, and the COVID-19 pandemic has further strained healthcare systems. As the focus shifts from the pandemic to other respiratory infections, assessing the epidemiology and burden of SARI is crucial for healthcare planning and resource allocation. Aim: to understand the impact of the post-pandemic period on the epidemiology of SARI cases, clinical outcomes, and healthcare resource utilization in Tunisia.

METHODS

This is a prospective study conducted in a Tunisian MICU part of a national sentinel surveillance system, focusing on enhanced SARI surveillance. SARI cases from week 39/2022, 26 September to week 19/2023, 13 May were included, according to a standardized case definition. Samples were collected for virological RT-PCR testing, and an electronic system ensured standardized and accurate data collection. Descriptive statistics were performed to assess epidemiology, trends, and outcomes of SARI cases, and univariate/multivariate analyses to assess factors associated with mortality.

RESULTS

Among 312 MICU patients, 164 SARI cases were identified during the study period. 64(39%) RT-PCR were returned positive for at least one pathogen, with influenza A and B strains accounting for 20.7% of cases at the early stages of the influenza season. The MICU experienced a significant peak in admissions during weeks 1-11/2023, leading to resource mobilization and the creation of a surge unit. SARI cases utilized 1664/3120 of the MICU-stay days and required 1157 mechanical ventilation days. The overall mortality rate among SARI cases was 22.6%. Age, non-COPD, and ARDS were identified as independent predictors of mortality.

CONCLUSIONS

The present study identified a relatively high rate of SARI cases, with 39% positivity for at least one respiratory virus, with influenza A and B strains occurring predominantly during the early stages of the influenza season. The findings shed light on the considerable resource utilization and mortality associated with these infections, underscoring the urgency for proactive management and efficient resource allocation strategies.

Clinical Features and Outcomes of Acute Kidney Injury in Critically Ill COVID-19 Patients: A Retrospective Observational Study

BACKGROUND

An alarming number of COVID-19 patients, especially in severe cases, have developed acute kidney injury (AKI).

AIM

The study aimed to assess the frequency, risk factors, and impact of AKI on mortality in critically ill COVID-19 patients.

METHODS

The study was a retrospective observational study conducted in the MICU. Univariate and multivariate analyses were performed to identify risk factors for AKI and clinical outcomes.

RESULTS

During the study period, 465 consecutive COVID-19 patients were admitted to the MICU. The patients' characteristics were median age, 64 [54-71] years; median SAPSII, 31 [24-38]; and invasive mechanical ventilation (IMV), 244 (52.5%). The overall ICU mortality rate was 49%. Two hundred twenty-nine (49.2%) patients developed AKI. The factors independently associated with AKI were positive fluid balance (OR, 2.78; 95%CI [1.88-4.11]; p < 0.001), right heart failure (OR, 2.15; 95%CI [1.25-3.67]; p = 0.005), and IMV use (OR, 1.55; 95%CI [1.01-2.40]; p = 0.044). Among the AKI patients, multivariate analysis identified the following factors as independently associated with ICU mortality: age (OR, 1.05; 95%CI [1.02-1.09]; p = 0.012), IMV use (OR, 48.23; 95%CI [18.05-128.89]; p < 0.001), and septic shock (OR, 3.65; 95%CI [1.32-10.10]; p = 0.012).

CONCLUSION

The present study revealed a high proportion of AKI among critically ill COVID-19 patients. This complication seems to be linked to a severe cardiopulmonary interaction and fluid balance management, thus accounting for a poor outcome.

Resource utilization and preparedness within the COVID-19 pandemic in Tunisian medical intensive care units: A nationwide retrospective multicentre observational study

BACKGROUND

The worldwide SARS-CoV-2 pandemic represents the most recent global healthcare crisis. While all healthcare systems suffered facing the immense burden of critically-ill COVID-19 patients, the levels of preparedness and adaptability differed highly between countries.

AIM

to describe resource mobilization throughout the COVID-19 waves in Tunisian University Medical Intensive Care Units (MICUs) and to identify discrepancies in preparedness between the provided and required resource.

METHODS

This is a longitudinal retrospective multicentre observational study conducted between March 2020 and May 2022 analyzing data from eight University MICUs. Data were collected at baseline and at each bed expansion period in relation to the nation's four COVID-19 waves. Data collected included epidemiological, organizational and management trends and outcomes of COVID-19 and non-COVID-19 admissions.

RESULTS

MICU-beds increased from 66 to a maximum of 117 beds. This was possible thanks to equipping pre-existing non-functional MICU beds (n = 20) and creating surge ICU-beds in medical wards (n = 24). MICU nurses increased from 53 to 200 of which 99 non-ICU nurses, by deployment from other departments and temporary recruitment. The nurse-to-MICU-bed ratio increased from 1:1 to around 1·8:1. Only 55% of beds were single rooms, 80% were equipped with ICU ventilators. These MICUs managed to admit a total of 3368 critically-ill patients (15% of hospital admissions). 33·2% of COVID-19-related intra-hospital deaths occurred within the MICUs.

CONCLUSION

Despite a substantial increase in resource mobilization during the COVID-19 pandemic, the current study identified significant persisting discrepancies between supplied and required resource, at least partially explaining the poor overall prognosis of critically-ill COVID-19 patients.

North-African doctors as second victims of medical errors: a cross sectional survey

INTRODUCTION

Physicians involved in medical errors (MEs) can experience loss of self-esteem and negative psychological experiences. They are called "second victims" of the ME.

AIMS

To i) describe the profile, the types and the severity of MEs, and ii) explore the psychological impact on "second victims" to better understand how they cope.

METHODS

It was a cross sectional retrospective study conducted from March to August 2018. All physicians working at Farhat Hached and Sahloul University hospitals were asked to complete a questionnaire about their possible MEs. The impact of MEs was evaluated using the Impact of Event Scale-Revised (IES-R) (scoring, 0-88) (subscales ranges; intrusion, (0-32); avoidance, (0-32); hyperarousal, (0-24)). The diagnosis of post-traumatic stress disorder (PTSD) was made when the total IES-R score exceeded 33. The coping strategies were evaluated using Ways of Coping Checklist Revised (WCC-R) scale (scoring, problem-focused, (10-40); emotion focused, (9-36); seeking social support, (8-32)).

RESULTS

Among 393 responders, 268(68.2%) reported MEs. Wrong diagnosis (40.5%), faulty treatment (34.6%), preventive errors (13.5%) and faulty communication (6.4%) were the main frequent types of MEs. The most common related causes of MEs were inexperience (47.3%) and job overload (40.2%). The physicians' median (range) score of the IES-R was 19(0-69). According to the IES-R score, the most frequent psychological impacts were median (range): intrusion, 7(0-28) and avoidance symptoms, 7(0-24). PTSD symptoms affected 23.5% of physicians. Female sex and serious MEs were identified as predictors of PTSD. On the WCC-R check list, coping was balanced between the three coping strategies median (range), problem focused, 28.5(10-40); emotion-focused, 24(9-36) and seeking social support 21(8-32).

CONCLUSION

There is a relatively high impact of ME within these North-African university hospital physicians. Coping was balanced within different three strategies as reported worldwide. Physicians adopted more likely constructive changes than defensive ones.

Psychological impact of pediatric cancer : a cross-sectional study among thirty parents

Introduction

The diagnosis of pediatric cancer is a traumatic event that is considered to be one of the most adverse situations the child and his family can experience. The psychological impact of this diagnosis on the parents has triggered a great scientific attention in these recent years.

Objectives

Estimate the prevalence of depression and post-traumatic stress among parents of children with cancer.

Methods

Our study was cross-sectional over a period of 1 month in the medical carcinology department at the Salah Azaeiz Institute. We used the Beck Depression Scale II and the Post Traumatic Stress Disorder Cheklist-Civilian assessements.

Results

Thirty parents participated in our study. Most of whom were mothers (73%). The educational level was primary in 63% of cases and socio-economic level was average in 60% of parents. 40% of parents were assessed within six months after diagnosis. Prevalence of depressive disorder and post-traumatic stress disorder were 73% and 57% respectively. The low educational level was correlated to the presence of these two disorders. Similarly, the low educational level was correlated to the presence of depressive disorders (p=0.008). The number of children in the family was also associated to the presence of post-traumatic stress disorder (p=0.029).

Conclusions

The prevalence of depressive and post-traumatic stress disorders was high among parents of children diagnosed with cancer. The low socio-economic and educational level and the large number of children in the family are risk factors for psychological distress. Psychosocial support should be offered to parents of children with cancer to optimize the management of this disease.

Disclosure

No significant relationships.

Characteristics and potential hemodynamic benefits of proning on the right ventricle in intensive care patients with SARS-CoV-2 ARDS

Funding Acknowledgements

Type of funding sources: None.

Introduction

One of the key challenges in treating COVID-19 ARDS patients is hemodynamic monitoring. Therapies proven to be effective in ARDS, such as protective ventilation, fluid restriction or high PEEP tend to alter right ventricular (RV) function and indicate a closer in-bed management, which is particularly difficult in prone position (PP) patients. Transthoracic echocardiography(TTE) enables a direct window for hemodynamic monitoring of RV performance.

Objective

To assess characteristics and potential hemodynamic benefits of proning on the RV in ICU patients with SARS-CoV-2 ARDS, using echocardiography.

Methods

This is an observational, cross-sectional study of SARS-CoV-2 ARDS in 11 patients hospitalized in a 12 bed ICU in Farhat Hached University hospital in December 2020. All patients were deeply sedated and curarized during the study.

After a stabilization period (MAP ≥ 65mmHg), TTE was performed first in the supine position before putting the patient on PP. Same measures were repeated during a second scan 4 to 8 hours after PP setting.

Norepinephrine infusion levels were not changed between the two scans. The average duration of a scan was 20 ± 10 minutes depending mostly on echogenicity. Several frequencies and harmonics were tested and we selected the ones that provided the best image quality.

PP ventilation (PPV) was performed continuously for 12 hours using the "swimmer position" that enabled affordable TTE views.

A quantitative study of the RV was performed using RV focused 4C view. A special view dedicated to the IVC was studied.

 Parameters measured were RV basal end diastolic diameter, S’ peak wave in TDI, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) and maximal trans tricuspid velocity (MTTV).

 Post hoc analysis was performed by two readers (one intensivist and one cardiologist). All parameters are expressed as a mean of two measurements.

Results

Twenty-four TTEs were performed in 11 patients respectively 40 ± 15mn before and 5.8 ± 1.1hrs after the PP setting. Patients were 71.0 ± 9.4yrs aged, 5(45%) obese, 7(63%) had diabetes mellitus, 4(36%) hypertension, 1(9%) coronary artery disease. All (100%) were on sinus rhythm. 7(63.6%) presented moderate ARDS and 3(27.3%) severe ARDS. None of the patients developed RV failure prior to the examination.

The PPV achieved a non-statistically significant improvement in RV function as assessed by the increase of S′, TAPSE, a decrease in RV basal diameter and an increase in FAC.

 A statistically significant decrease in MTTV (mean 3.20 ± 0.49 m/s before PP vs mean 2.47 ± 0.77m/s (p = 0.01)) was objectified.

Conclusions

PPV improves hemodynamic parameters of the RV.

TEE 4C view is sufficient in the assessment of RV function in PP.

SPAP monitoring could be the key parameter to quickly and reliably assess RV response to PPV.

Facteurs associés à la symptomatologie anxiodépressive chez des femmes tunisiennes atteintes d’un cancer du sein

Objectifs : L’étude avait pour objectif d’estimer la prévalence de la dépression et de l’anxiété dans une population de femmes tunisiennes suivies pour un cancer du sein et de relever les données sociodémographiques, cliniques et de vie de couple qui leur sont associées.

Matériels et méthodes : Une étude transversale auprès de 100 patientes suivies pour un cancer du sein a été réalisée. Un questionnaire portant sur les caractéristiques sociodémographiques, cliniques, thérapeutiques, sur la vie conjugale et sur la sexualité du couple a été administré. L’échelle HADS (Hospital Anxiety and Depression Scale) a été utilisée pour le dépistage des symptômes anxieux et dépressifs.

Résultats : Un score clinique a été retrouvé dans 48 % des cas pour l’anxiété et 37 % des cas pour la dépression. Les patientes qui ont vécu une réaction négative de leur conjoint face à leur maladie et dont la relation de couple et la relation sexuelle ont été altérées présentaient des scores significativement plus élevés de symptomatologie anxieuse et dépressive. Une relation sexuelle non altérée était retrouvée comme facteur protecteur de l’anxiété et de la dépression.

Conclusion : Les résultats de cette étude mettent en évidence l’importance de développer des mesures spécifiques pour améliorer la communication et promouvoir la santé sexuelle au sein du couple en Tunisie.

Compared efficacy and tolerance of the neuromuscular blockade induced by brand-name (Nimbex®) and generic (Cisatrex®) of cisatracurium in mechanically ventilated critically ill patients: a crossover double-blind randomized study

Introduction

use of generic drugs is common. However, there is still concern among patients and physicians that brand name drugs are more efficient. The aim of the study was to compare efficacy and tolerance between two forms of cisatracurium: brand name versus generic name.

Methods

it´s a crossover, randomized, double-blind physiological trial. Patients admitted for hypoxemic acute respiratory failure with PaO2/FIO2 < 200mmHg despite optimized ventilation and sedation thus requiring non-depolarizing neuromuscular blocking agents (NMBAs), were enrolled. Patients received consecutively, in a random order, cisatracurium brand name (Nimbex®) and generic (Cisatrex®) over two-hour period separated by one-hour washout period. Neuromuscular function was monitored by a calibrated train-of-four (TOF) stimulation device. Paralysis time delay to reach TOF of 2/4, recovery kinetics and tolerance were monitored. The number needed to demonstrate a significant difference in time delays to reach a TOF of 2/4 between the two forms of cisatracurium was estimated at 22 patients.

Results

twenty-two patients were included. Eight (36.4%) had acute respiratory distress syndrome; 8(36.4%), acute exacerbation of chronic obstructive pulmonary disease and 3(13.6%), status asthmaticus. Median [IQR] SAPS II at admission, 28.5 [22, 41]. PaO2/FIO2, 121 [81, 156] mmHg. Paralysis time delays were respectively, 80 [50, 112] vs. 87 [65, 115] minutes, in Nimbex® group and Cisatrex® group; (p=0.579). Within the recovery period, the between two-studied drugs´ difference in TOF was at 0.25±0.96; p=0.64. There were no significant hemodynamic differences.

Conclusion

the present study revealed no significant differences in efficacy nor in tolerance between cisatracurium brand name Nimbex® and generic name Cisatrex® in hypoxemic ventilated patients.

Very severe COVID-19 in the critically ill in Tunisia

INTRODUCTION

SARS-CoV-2 is an emerging health threat outbreak. It may cause severe viral pneumonia with Acute Respiratory Distress Syndrome requiring critical care. Aim: to describe clinical features and outcomes of critically ill patients with SARS-CoV-2 infection.

METHODS

it was a retrospective study carried out in the medical ICU of Farhat Hached teaching hospital between March 11 and May 7, 2020. All consecutive patients with RT-PCR confirmed COVID-19 were included. Clinical characteristics and outcomes were collected by reviewing medical records.

RESULTS

during the study period, 10 critically ill patients with COVID-19 were enrolled. Mean age, 51.8±6.3 years; 8(80%), male. The most common comorbidities were; diabetes mellitus, 6(60%), obesity 2(20%), chronic kidney disease 2(20%) and hypertension 1(10%). Mean SAPS II, 23.2±1.8. The mean arterial oxygen partial pressure to fractional inspired oxygen ratio at admission was 136.2±79.7. Noninvasive mechanical ventilation was used in 4(40%) patients and 7(70%) received invasive mechanical ventilation. Tidal volume and PEEP were set respectively within the median [IQR] of, 5.7[5.6-6.3]ml/Kg and 10.7[6.5-11.7]cm H2O. Plateau pressure was monitored in the median [IQR] of 27.9 [25.9-28.5] cm H2O. Four patients received hydroxychloroquine alone and five hydroxychloroquine associated with an antiviral. Five patients developed respectively hyperactive (n=2), hypoactive (n=2) and mixed delirium (n=1). Mortality rate was at 70%.

CONCLUSION

this study demonstrated a particular profile of COVID-19 in the critically ill as a severe presentation in aged males with comorbidities presenting with an ARDS-like and neurological impairment with poor prognosis. The only survivals seem to have benefited from noninvasive ventilatory support.

Rethinking aerosol-generating procedures in COVID-19

Dealing with COVID-19 pandemic raised several issues regarding aerosol generating procedures such High Flow Nasal Cannula (HFNC) and Non Invasive Ventilation (NIV). Adequately managing patients with COVID-19 pneumonia, while, ensuring caregivers' safety is of utmost importance. Recommendations regarding aerosol generating procedures are, certainly, required to guide therapeutic attitudes in this context. However, excessive fear of contamination could interfere with patients' management. The present paper discussesthe place of aerosol generating procedures such as HFNC and NIV in the management of COVID-19 and does fear of aerosolization, solely, justifies the avoidance of these methods.

Pulmonary Barotrauma Including Huge Pulmonary Interstitial Emphysema in an Adult with Status Asthmaticus: Diagnostic and Therapeutic Challenges

Introduction

Pulmonary interstitial emphysema is a rare finding defined as abnormal air collection inside the lung interstitial tissues. Described more frequently in ventilated new-borns, pulmonary interstitial emphysema is an uncommon barotrauma-related complication in adults. Management and clinical sequelae are poorly described.

Patient

We describe the case of a 64-year-old man who presented with huge pulmonary interstitial emphysema together with simultaneous pulmonary barotrauma in status asthmaticus requiring invasive ventilation.

Discussion

There are no guidelines for the management of such complications and their possible sequelae but conservative treatment seems to be effective. The treatment of our patient is described.

LEARNING POINTS

Two years survival of primary cardiac leiomyosarcoma managed by surgical and adjuvant therapy

BACKGROUND

Cardiac tumors are a very rare entity. Leiomyosarcoma represents less than 1% of cases.

CASE PRESENTATION

a 51-year-old woman diagnosed with primary left atrium leiomyosarcoma. She was treated by optimal surgery and adjuvant chemotherapy. She is still alive after a follow-up of 24 months without evidence of local or distant recurrence.

CONCLUSIONS

Cardiac leiomyosarcoma is a rare tumor with a dismal prognosis. Surgery is the mainstay of treatment. Adjuvant treatment is still controversial.