Anastasios Tzenalis1, Helen Papaemmanuel2, George Kipourgos2, George Elesnitsalis2
1 University Of Patras, Patra, Greece
2 General Hospital of Thessaloniki Papageorgiou, Greece
Introduction: Professionals in Intensive Care Units face death, shifting their role from therapists to caregivers in end-of-life management. The nursing attitude and response to death has been shown to affect the quality of palliative care and end-of-life services that are interrelated services. Aim of the study: The aim of this research was to evaluate the professional attitude of nurses towards the care of the families of critically ill patients in the ICU, leading to the emergence of specific attitudes, relating them to their demographic and professional characteristics, with the aim of drawing conclusions for the improvement of quality in end-of-life care. Material and Methods: The sample of the study was 81 nurses from a large tertiary hospital. Participants completed the “Nurse Activities for Communicating with Families” (NACF) questionnaire. The questions are about ways in which nurses can help the patient’s family during the patient’s stay in the ICU. Results: The results revealed that the nurses took actions related to the information and psychological support of the patient’s family. On the contrary, they did not focus on the spiritual / religious needs of the patient and the needs of the family based on their cultural background. Conclusions: The professional treatment of staff is characterized by compassion and empathy, but it is necessary to train them on important issues related to diversity, including the religious, spiritual values and beliefs of patients and their relatives.
Md Jahidul Hasan1, Chandra Datta Sumi2, Shihan Mahmud Redwanul Huq3, Ahmad Mursel Anam4, Raihan Rabbani3
1 University of New South Wales, Sydney, NSW, Australia
2 The University of Queensland, Brisbane, Australia
3 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh.
4 High Dependency Unit, Square Hospitals Ltd., Dhaka, Bangladesh
Background: Pandrug-resistant Klebsiella pneumoniae ventilator associated pneumonia (VAP) is associated with high rate of mortality in intensive care unit (ICU) and has been recognized as a difficult-to-treat infection worldwide. Polymyxin B or colistin-based combination therapies are frequently used worldwide though microbial eradication rate is not promising. Aim: The aim of this study is to compare the clinical outcome of intravenous with aerosolized polymyxin B versus colistin in the treatment of pandrug-resistant K. pneumoniae VAP. Methods: This retrospective cohort study was conducted on 222 mechanically ventilated patients admitted from May 11, 2019 to October 19, 2020. K. pneumoniae isolates were resistant to all available antibiotics, including polymyxins in culture sensitivity tests. As treatment, polymyxin B and colistin was administered in intravenous and aerosolized form concurrently twice daily in 106 patients and 116 patients in PMB and CLN group, respectively for 14 days. Survival rate, safety, and clinical outcomes were compared among the groups. The Cox proportional-hazard model was performed to calculate hazard ratio (HR) with 95% confidence intervals (CI). Results: Patients in PMB group showed more microbial eradication than the patients CLN group [68.1% (n=116)/83% (n=106), respectively; P <0.05). The median day of intubation and ICU stay in PMB group was shorter than that in CLN group [10 (IQR: 9-12.25) vs. 14 (IQR: 11-19), P <0.05; 12 (IQR: 10-14) vs. 15 (IQR: 9-18.5), P=0.072, respectively] with reduced 60-day all-cause mortality rate [15% (n=106) vs. 21.55% (n=116)]. Polymyxin B improved survival compared to colistin (multivariate HR: 0.662; 95% CI=0.359- 1.222, P=0.195). Conclusions: Concurrent administration of intravenous and aerosolized polymyxin B in patients with pandrug-resistant K. pneumoniae-associated VAP revealed better microbial eradication, reduced the length of intubation and ICU stay, and improved survival rate compared to colistin.
1 Faculty of Medicine, University of Porto, Portugal
2 Faculty of Mathematics, University of Porto, Portugal
3 Centre of Mathematics of the University of Porto, Porto, Portugal
4 University Hospital Centre São João, Porto Portugal
Introduction: Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications. Aim of the study: We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome. Methods and results: Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO2/FiO2) was 305±88 and driving pressure 15.9±3.5cmH2O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found. Conclusion: Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.
Fazal Rehman1, Saad Bin Zafar1, Adil Aziz1, Abdul Aziz1, Pirbhat Shams Memon1, Taymmia Ejaz1, Summaira Aziz2
1 Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan 2 Department of Community Health Sciences, The Aga Khan University Hospital, Karachi, Pakistan
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.
All India Institute of Medical Science – Bhopal, Madhya Pradesh, India
Introduction: Lung ultrasound when used in isolation, usually misses out metabolic causes of dyspnoea and differentiating acute exacerbation of COPD from pneumonia and pulmonary embolism is difficult, hence we thought of combining critical care ultrasonography (CCUS) with arterial blood gas analysis (ABG). Aim of the study: The objective of this study was to estimate accuracy of Critical Care Ultrasonography (CCUS) plus Arterial blood gas (ABG) based algorithm in diagnosing aetiology of dyspnoea. Accuracy of traditional Chest X-ray (CxR) based algorithm was also validated in the following setting. Methods : It was a facility based comparative study, where 174 dyspneic patients were subjected to CCUS plus ABG and CxR based algorithms on admission to ICU. The patients were classified into one of five pathophysiological diagnosis 1) Alveolar( Lung-pneumonia)disorder ; 2) Alveolar (Cardiac-pulmonary edema) disorder; 3) Ventilation with Alveolar defect (COPD) disorder ;4) Perfusion disorder; and 5) Metabolic disorder. We calculated diagnostic test properties of CCUS plus ABG and CXR based algorithm in relation to composite diagnosis and correlated these algorithms for each of the defined pathophysiological diagnosis. Results: The sensitivity of CCUS and ABG based algorithm was 0.85 (95% CI-75.03-92.03) for alveolar (lung) ; 0.94 (95% CI-85.15-98.13) for alveolar (cardiac); 0.83 (95% CI-60.78-94.16) for ventilation with alveolar defect; 0.66 (95% CI-30-90.32) for perfusion defect; 0.63 (95% CI-45.25-77.07) for metabolic disorders.Cohn’s kappa correlation coefficient of CCUS plus ABG based algorithm in relation to composite diagnosis was 0.7 for alveolar (lung), 0.85 for alveolar (cardiac), 0.78 for ventilation with alveolar defect, 0.79 for perfusion defect and 0.69 for metabolic disorders. Conclusion: CCUS plus ABG algorithm is highly sensitive and it’s agreement with composite diagnosis is far superior. It is a first of it’s kind study, where authors have attempted combining two point of care tests and creating an algorithmic approach for timely diagnosis and intervention.
Gal Roman1, Ondrej Hrdy1, Kamil Vrbica1, Jan Hudec1, Andrej Mrlian2, Martin Smrcka2
1 Department of Anaesthesiology and Intensive Care Medicine, Masaryk University and University Hospital Brno, Brno, Czech Republic 2 Department of Neurosurgery, Masaryk University and University Hospital Brno, Brno, Czech Republic
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.
Hasan M. Al-Dorzi, Muhannad Q. Alqirnas, Mohamed M. Hegazy, Abdullah S. Alghamdi, Mohammed T. Alotaibi, Mohammed T. Albogami, Mohammed M. Alhafi, Salem Alwadani, Ashraf Elsharkawi, Yaseen M. Arabi
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, and Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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.
Vassiliki Mantziou, Charikleia S. Vrettou, Alice G. Vassiliou, Stylianos E. Orfanos, Anastasia Kotanidou, Ioanna Dimopoulou
1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens (NKUA), “Evangelismos” Hospital, Athens, Greece
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.
Karen Roye-Green1, Rohan Willis2, Sharon R. Priestley3, Ivan Vickers1
1 The University of the West Indies Mona Campus, Department of Microbiology, Kingston, Jamaica 2 The University of Texas Medical Branch at Galveston Department of Internal Medicine, TX, USA 3 The University of the West Indies Mona Campus, Department of Sociology, Psychology and Social Work, Kingston, Jamaica
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.
1 Hospices Civils de Lyon, Hospital center Lyon-Sud, ICU, F-69310, Pierre-Bénite, France 2 Biostatistics-Bioinformatics Department, Public Health Unit, Hospices Civils de Lyon, Lyon, France 3 CIRI, International Center for Research in Infectiology (Emerging Pathogens Laboratory Team), Inserm, U1111, Claude Bernard Lyon 1 University, CNRS, UMR5308, Lyon, France 4 University Claude Bernard, Lyon1, Lyon, France 5 Lyon university, VetAgro Sup, Lyon veterinary campus, UPSP 2016.A101, Pulmonary and Cardiovascular Agression in Sepsis, F-69280, Marcy l’Étoile, France
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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