Category Archives: Original Research

Early lactate clearance as a determinant of survival in patients with sepsis: Findings from a low-resource country

DOI: 10.2478/jccm-2023-0005

Background: Single lactate measurements have been reported to have prognostic significance, however, there is a lack of data in local literature from Pakistan. This study was done to determine prognostic role of lactate clearance in sepsis patients being managed in our lower-middle income country.
Methods: This prospective cohort study was conducted from September 2019-February 2020 at the Aga Khan University Hospital, Karachi. Patients were enrolled using consecutive sampling and categorized based on their lactate clearance status. Lactate clearance was defined as decrease by 10% or greater in repeat lactate from the initial measurement (or both initial and repeat levels <=2.0 mmol/L).
Results: A total 198 patients were included in the study, 51% (101) were male. Multi-organ dysfunction was reported in 18.6% (37), 47.7% (94) had single organ dysfunction, and 33.8% (67) had no organ dysfunction. Around 83% (165) were discharged and 17% (33) died. There were missing data for 25.8% (51) of the patients for the lactate clearance, whereas 55% (108) patients had early lactate clearance and 19.7% (39) had delayed lactate clearance. On univariate analysis, mortality rate was higher in patients with delayed lactate clearance (38.4% vs 16.6%) and patients were 3.12 times (OR = 3.12; [95% CI: 1.37-7.09]) more likely to die as compared with early lactate clearance. Patients with delayed lactate clearance had higher organ dysfunction(79.4% vs 60.1%) and were 2.56 (OR = 2.56; [95% CI: 1.07-6.13]) times likely to have organ dysfunction . On multivariate analysis, after adjusting for age and co-morbids, patients with delayed lactate clearance were 8 times more likely to die than patients with early lactate clearance [aOR = 7.67; 95% CI:1.11-53.26], however, there was no statistically significant association between delayed lactate clearance [aOR = 2.18; 95% CI: 0.87-5.49)] and organ dysfunction. Conclusion: Lactate clearance is a better determinant of sepsis and septic shock effective management. Early lactate clearance is related to better outcomes in septic patients.

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Brain Tissue Oxygen Levels as a Perspective Therapeutic Target in Traumatic Brain Injury. Retrospective Cohort Study

DOI: 10.2478/jccm-2023-0001

Introduction: Management of traumatic brain injury (TBI) requires a multidisciplinary approach and represents a significant challenge for both neurosurgeons and intensivists. The role of brain tissue oxygenation (PbtO2) monitoring and its impact on posttraumatic outcomes remains a controversial topic.
Aim of the study: Our study aimed to evaluate the impact of PbtO2 monitoring on mortality, 30 days and 6 months neurological outcomes in patients with severe TBI compared with those resulting from standard intracranial pressure (ICP) monitoring.
Material and methods: In this retrospective cohort study, we analysed the outcomes of 77 patients with severe TBI who met the inclusion criteria. These patients were divided into two groups, including 37 patients who were managed with ICP and PbtO2 monitoring protocols and 40 patients who were managed using ICP protocols alone.
Results: There were no significant differences in demographic data between the two groups. We found no statistically significant differences in mortality or Glasgow Outcome Scale (GOS) scores one month after TBI. However, our results revealed that GOS scores at 6 months had improved significantly among patients managed with PbtO2; this finding was particularly notable for Glasgow Outcome Scale (GOS) scores of 4–5. Close monitoring and management of reductions in PbtO2, particularly by increasing the fraction of inspired oxygen, was associated with higher partial pressures of oxygen in this group.
Conclusions: Monitoring of PbtO2 may facilitate the appropriate evaluation and treatment of low PbtO2 and represents a promising tool for the management of patients with severe TBI. Additional studies will be needed to confirm these findings.

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Prevalence and Risk Factors of Venous Thromboembolism in Critically Ill Patients with Severe COVID-19 and the Association between the Dose of Anticoagulants and Outcomes

DOI: 10.2478/jccm-2022-0023

Introduction: COVID-19 is characterized by a procoagulant state that increases the risk of venous and arterial thrombosis. The dose of anticoagulants in patients with severe COVID-19 pneumonia without suspected or confirmed thrombosis has been debated.
Aim of the study: We evaluated the prevalence, predictors, and outcomes of venous thromboembolism (VTE) in critically ill COVID-19 patients and assessed the association between the dose of anticoagulants and outcomes.
Materials and methods: This retrospective cohort included patients with COVID-19 who were admitted to the ICU between March and July 2020. Patients with clinically suspected and confirmed VTE were compared to those not diagnosed to have VTE.
Results: The study enrolled 310 consecutive patients with severe COVID-19 pneumonia: age 60.0±15.1 years, 67.1% required mechanical ventilation and 44.7% vasopressors. Most (97.1%) patients received anticoagulants during ICU stay: prophylactic unfractionated heparin (N=106), standard-dose enoxaparin (N=104) and intermediate-dose enoxaparin (N=57). Limb Doppler ultrasound was performed for 49 (15.8%) patients and chest computed tomographic angiography for 62 (20%). VTE was diagnosed in 41 (13.2%) patients; 20 patients had deep vein thrombosis and 23 had acute pulmonary embolism. Patients with VTE had significantly higher D-dimer on ICU admission. On multivariable Cox regression analysis, intermediate-dose enoxaparin versus standard-dose unfractionated heparin or enoxaparin was associated with lower VTE risk (hazard ratio, 0.06; 95% confidence interval, 0.01-0.74) and lower risk of the composite outcome of VTE or hospital mortality (hazard ratio, 0.42; 95% confidence interval, 0.23-0.78; p=0.006). Major bleeding was not different between the intermediate- and prophylactic-dose heparin groups.
Conclusions: In our study, clinically suspected and confirmed VTE was diagnosed in 13.2% of critically ill patients with COVID-19. Intermediate-dose enoxaparin versus standard-dose unfractionated heparin or enoxaparin was associated with decreased risk of VTE or hospital mortality.

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Family Burden of ICU Survivors and Correlations with Patient Quality of Life and Psychometric Scores – A Pilot Study

DOI: 10.2478/jccm-2022-0027

Introduction: Post intensive care syndrome (PICS) affects an increasing number of critical illness survivors and their families, with serious physical and psychological sequelae. Since little is known about the burden of critical illness on ICU survivor families, we conducted a prospective observational study aiming to assess this, and investigate correlations of the patients’ psychometric and health-related quality of life (HRQOL) scores with family burden.
Materials and Methods: Twenty-nine patients were evaluated in the presence of a family member. Participants were assessed with the use of validated scales for anxiety, depression, post-traumatic stress disorder, cognitive decline, and the family burden scale (FBS).
Results: High burden was present in 27.6% of family members. Statistically significant correlations were observed between the FBS score and trait anxiety, depression, and the physical and psychological components of HRQOL.
Conclusions: Our results suggest that family burden following critical illness is common, suggesting that its assessment should be incorporated in the evaluation of PICS-family in large observational studies.

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Knowledge, Practice and Attitudes to the Management of Sepsis in Jamaica

DOI: 10.2478/jccm-2022-0024

Introduction: Sepsis is a life-threatening dysfunction resulting from the dysregulated host response to infection. The mortality of sepsis in Jamaica remains high amid the proven efficacy of the Surviving Sepsis Guidelines implementation in some countries.
Aim of study: To evaluate the inter-relationship of healthcare workers’ attitude towards, knowledge of and practice of sepsis management in Jamaica.
Material and methods: A survey was done using an anonymous self-administered validated questionnaire to healthcare workers across Jamaica. Questions on knowledge, attitude, and practice of sepsis within private and public hospitals were answered.
Results: A total of 616 healthcare workers were eligible for analysis. Most respondents agree that healthcare workers need more training on sepsis (93.7%) and that formal sepsis training modules should be implemented at their hospitals or practice (93.2%). Several signs of sepsis as outlined by qSOFA were correctly identified as such by most respondents (60.6% to 76.4%), with the exception of a low PaCO2 (34.9%), which was correctly identified by a minority of respondents. While a majority (69.3%) were able to correctly define sepsis, only 8.8% of respondents knew the annual sepsis mortality rate. Postgraduate training (p<0.01) and formal sepsis training (p<0.05) were both predictive of high correct knowledge and practice scores. Specialization in Anaesthesia/ Critical Care Medicine (p<0.05) or Emergency Medicine (p<0.05) was predictive of high knowledge scores and Internal Medicine predictive of high practice scores (p<0.01).
Conclusions: This study revealed that education for healthcare workers on sepsis and the implementation of SSC is needed in Jamaica.

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Burnout Syndrome During COVID-19 Second Wave on ICU Caregivers

DOI: 10.2478/jccm-2022-0026

Objective: The main objective of this article is to evaluate the prevalence of burnout syndrome (BOS) among the Intensive Care Unit (ICU) healthcare workers.
Methods: The COVID-impact study is a study conducted in 6 French intensive care units. Five units admitting COVID patient and one that doesn’t admit COVID patients. The survey was conducted between October 20th and November 20th, 2020, during the second wave in France. A total of 208 professionals responded (90% response rate). The Maslach Burnout Inventory scale, the Hospital Anxiety and Depression Scale and the Impact of Event Revisited Scale were used to study the psychological impact of the COVID-19 Every intensive care unit worker.
Results: The cohort includes 208 professionals, 52.4% are caregivers. Almost 20% of the respondents suffered from severe BOS. The professionals who are particularly affected by BOS are women, engaged people, nurses or reinforcement, not coming willingly to the intensive care unit and professionals with psychological disorders since COVID-19, those who are afraid of being infected, and people with anxiety, depression or post-traumatic stress disorder. Independent risk factors isolated were being engaged and being a reinforcement. Being a volunteer to come to work in ICU is protective. 19.7% of the team suffered from severe BOS during the COVID-19 pandemic in our ICU. The independent risk factors for BOS are: being engaged (OR = 3.61 (95% CI, 1.44; 9.09), don’t working in ICU when it’s not COVID-19 pandemic (reinforcement) (OR = 37.71 (95% CI, 3.13; 454.35), being a volunteer (OR = 0.10 (95% CI, 0.02; 0.46).
Conclusion: Our study demonstrates the value of assessing burnout in health care teams. Prevention could be achieved by training personnel to form a health reserve in the event of a pandemic.

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Variability of Steroid Prescription for COVID-19 Associated Pneumonia in Real-Life, Non-Trial Settings

DOI: 10.2478/jccm-2022-0025

The RECOVERY study documented lower 28-day mortality with the use of dexamethasone in hospitalized patients on invasive mechanical ventilation or oxygen with COVID-19 Pneumonia. We aimed to examine the practice patterns of steroids use, and their impact on mortality and length of stay in ICU. We retrospectively examined records of all patients with confirmed Covid 19 pneumonia admitted to the ICU of Dubai hospital from January 1st, 2020 – June 30th, 2020. We assigned patients to four groups (No steroids, low dose, medium dose, and high dose steroids). The primary clinical variable of interest was doses of steroids. Secondary outcomes were 28-day mortality and length of stay in ICU”. We found variability in doses of steroid treatment. The most frequently used dose was the high dose. Patients who survived were on significantly higher doses of steroids and had significantly longer stays in ICU. The prescription of steroids in Covid-19 ARDS is variable. The dose of steroids impacts mortality rate and length of stay in ICU, although patients treated with high dose steroids seem to stay more days in ICU.

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The use of metaraminol as a vasopressor in critically unwell patients: a narrative review and a survey of UK practice

DOI: 10.2478/jccm-2022-0017

Background: Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as second line medication for cardiovascular support.
Aim of the study: The aim of this study was to carry out a systematic review of metaraminol use for management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances.
Methods: A systematic review literature search was conducted. A short telephone survey consisting of 6 questions regarding metaraminol use was conducted across 30 UK critical care units which included a mix of tertiary and district general intensive care units.
Results: Twenty-six of thirty contacted centres responded to our survey. Metaraminol was used in 88% of them in various settings and circumstances (emergency department, theatres, medical emergencies on medical wards), with 67% reporting use of metaraminol infusions in the critical care setting. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use and the data was incomparable, hence we decided not to perform a meta-analysis.
Conclusions: Metaraminol is widely used as a vasopressor inside and outside of the critical care setting in the UK despite limited evidence supporting its safety and efficacy for treating shock. Further service evaluation, observational studies and prospective randomised controlled trials are warranted to validate the role and safety profile of metaraminol in the treatment of the critically unwell patient.

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Characteristics and risk factors for mortality in critically ill patients with COVID-19 receiving invasive mechanical ventilation: the experience of a private network in Sao Paulo, Brazil

DOI: 10.2478/jccm-2022-0015

Introduction: The use of invasive mechanical ventilation (IMV) in COVID-19 represents in an incremental burden to healthcare systems.
Aim of the study: We aimed to characterize patients hospitalized for COVID-19 who received IMV and identify risk factors for mortality in this population.
Material and Methods: A retrospective cohort study including consecutive adult patients admitted to a private network in Brazil who received IMV from March to October, 2020. A bidirectional stepwise logistic regression analysis was used to determine the risk factors for mortality.
Results: We included 215 patients, of which 96 died and 119 were discharged from ICU. The mean age was 62.7 ± 15.4 years and the most important comorbidities were hypertension (62.8%), obesity (50.7%) and diabetes (40%). Non-survivors had lower body mass index (BMI) (28.3 [25.5; 31.6] vs. 31.2 [28.3; 35], p<0.001, and a shorter duration from symptom onset to intubation (8.5 [6.0; 12] days vs. 10 [8.0; 12.5] days, p = 0.005). Multivariable regression analysis showed that the risk factors for mortality were age (OR: 1.07, 95% CI: 1.03 to 1.1, p < 0.001), creatinine level at the intubation date (OR: 3.28, 95% CI: 1.47 to 7.33, p = 0.004), BMI (OR: 0.91, 95% CI: 0.84 to 0.99, p = 0.033), lowest PF ratio within 48 hours post-intubation (OR: 0.988, 95% CI: 0.979 to 0.997, p = 0.011), barotrauma (OR: 5.18, 95% CI: 1.14 to 23.65, p = 0.034) and duration from symptom onset to intubation (OR: 0.76, 95% CI: 0.76 to 0.95, p = 0.006).
Conclusion: In our retrospective cohort we identified the main risk factors for mortality in COVID-19 patients receiving IMV: age, creatinine at the day of intubation, BMI, lowest PF ratio 48-hours post-intubation, barotrauma and duration from symptom onset to intubation.

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Predictive Value of Systemic Immune-inflammation Index in Determining Mortality in COVID-19 Patients

DOI: 10.2478/jccm-2022-0013

Aim: The aim of this study was to evaluate whether systemic immune-inflammation index (SII) could predict mortality in patients with novel coronavirus 2019 (COVID-19) disease.
Methods: This two-center, retrospective study included a total of 191 patients with confirmed diagnosis of COVID-19 via nucleic acid test (NAT). The SII was calculated based on the complete blood parameters (neutrophil × platelet/lymphocyte) during hospitalization. The relationship between the SII and other inflammatory markers and mortality was investigated.
Results: The mortality rate was 18.3%. The mean age was 54.32±17.95 years. The most common symptoms were fever (70.7%) and dry cough (61.3%), while 8 patients (4.2%) were asymptomatic. The most common comorbidities were hypertension (37.7%), diabetes (23.0%), chronic renal failure (14.7%), and heart failure (7.9%) which all significantly increased the mortality rate (p<0.001). There was a highly positive correlation between the SII and polymorphonuclear leukocyte (PNL), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) (r=0.754, p<0.001; r=0.812, p<0.001; r=0.841, p<0.001, respectively), while a moderate, positive correlation was found between the SII and C-reactive protein (CRP) (r=0.439, p<0.001). There was a significant correlation between the SII and mortality (U=1,357, p<0.001). The cut-off value of SII was 618.8 (area under the curve=0.751, p<0.001) with 80.0% sensitivity and 61.5% specificity. A cut-off value of >618.8 was associated with a 4.68-fold higher mortality.
Conclusion: Similar to NLR and PLR, the SII is a proinflammatory marker of systemic inflammation and can be effectively used in independent predicting COVID-19 mortality .

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