Category Archives: Original Research

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

Lina Grauslyte1, Nathalie Bolding2, Mandeep Phull3, Tomas Jovaisa3

1 Barts Health NHS Trust, London, UK
2 Royal Free Hampstead NHS Trust, London, UK
3 Barking Havering and Redbridge Hospitals NHS Trust, London, UK

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

Eduardo Atsushi Osawa, Alexandre Toledo Maciel

Imed Group, Research Department, Sao Paulo, Brazil; Adult Intensive Care Unit, São Camilo Hospital, 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

Tahsin Karaaslan1, Esra Karaaslan2

1 Medeniyet University Göztepe Training and Research Hospital, Istanbul, Turkey
2 Istanbul Medipol University, Istanbul, Turkey

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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Occupational Stress and Quality of Life among Health Professionals during the COVID-19 Pandemic

Efstratios Vamvakas1, Ioanna Kontogeorgou1, Aggeliki Ntaountaki1, Georgia Karkouli1, Eleni Pisimisi1, Eirini Karampekiou1, Efstathios Politis1, Iordana Moskofi1, Dimitrios Konitopoulos1, Eleni Dokoutsidou2, Maria Grigoropoulou3, Maria Theodorakopoulou1, Apostolos Armaganidis1,4

1 Attikon General University Hospital, Athens, Greece
2 University of West Attika, Athens, Greece
3 Second Health Centre, Peristeri, Greece
4 Department of Medicine, National and Kapodistrian University of Athens, Greece

DOI: 10.2478/jccm-2022-0012

Introduction: Healthcare professionals, due to the nature of their work, have always experienced occupational stress, depression and low quality of life, which have been aggravated during the COVID-19 pandemic.
Aim: A large-scale cross-sectional descriptive correlational study aimed to investigate the impact of the COVID-19 pandemic on Greek healthcare professionals’ psychological status and quality of life.
Material and Methods: The study was conducted at “Attikon” General University Hospital and the 2nd Health Region in Athens, Greece. An assessment of anxiety and depression was carried out using the Zung’s Self-Rating Anxiety and Depression Scale (SAS/SDS). To assess the participants’ Quality of Life (QoL) the Short Form Survey-36 (SF-36) was used.
Results: 147 healthcare professionals were enrolled in the study. 70.7% experienced normal stress levels, 23.8% mild, 4.8% moderate and 0.7% severe. Mild depression was experienced by 34.7%, moderate by 10.2% and severe by 1.4%, with a 53.7% showing no depressive symptoms. Women experienced higher levels of anxiety and depression (p=0.001 & 0.001 respectively), and were 5.4 times more at risk to develop anxiety [Odds Ratio (OR) 5.357, 95% Confidence Interval (CI), 1.95-14.72: p=0.001] and 3.4 depression (OR, 3.365, 95% CI, 1.59- 7.12: p=0.002). Nurses and other professionals experienced higher stress and depression levels (p=0.004 & 0.040 respectively) than doctors. Participants reporting more exhaustion exhibited higher anxiety and depression levels (p=0.001). Compared to the pre-COVID-19 era, women (p=0.001), other health professionals (p=0.001) and those experiencing more physical burnout during COVID-19 (p=0.005) reported worse physical health. Anxiety and depression were negatively correlated with most sub scales of SF-36 except social functioning and bodily pain (p=0.001).
Conclusions: Healthcare professionals’ QoL has been affected by the COVID-19 pandemic and they experience higher levels of anxiety and depression. There is a need to develop strategies to address the negative psychological impact of this pandemic on healthcare professionals.

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Effective Outcome of HBOT as an Adjuvant Therapy in Patients Diagnosed with COVID-19 in a Tertiary Care Hospital – A Preliminary Study

Thiruppathy Palaniappan, Asif Shaikh, Navamani Kirthika

Medway Hospital, Chennai, India

DOI: 10.2478/jccm-2022-0008

Introduction: Hyperbaricoxygen therapy (HBOT) is breathing100% oxygen in pressurised chamber. This therapy ensures quick oxygen delivery to the bloodstream. In patients with severe COVID-19 pneumonia, progressive hypoxemia occurs. Oxygen therapy hasa significant role in its management.
Aim of the study: The objective was to study the efficacy of hyperbaric oxygen therapy (HBOT) as adjuvant therapy for reducing the requirement of additional oxygen supplementationin patients with moderate to severe ARDS diagnosed with COVID-19.
Methods: A single-centre prospective pilot cohort study was conducted ata tertiary care hospital from December 2020 to February 2021 over two months. Fifty patients with COVID-19 needingoxygen, satisfying the selection criteria, were included. Hyperbaricoxygen therapy wasgiven to all patients. The patient received30-45 minutes of hyperbaric oxygen with 15 minutes of pressurizing and depressurizing at 2.0 atmosphere absolute (ATA) with or without airbrakesas per the critical care team. Oxygen requirement, PaO2, andcondition at discharge were considered as primary outcome variables.
Results: Among the 50 participants studied, the mean age was 53.64±13.26 years. Out of 50 participants, 49(98.00%) had PaO2≤80 mmHg, and one (2.00%) had >80 PaO2. All the participants 50(100%) had PaO2 as 90 mmHg after three sittings.
Conclusion: This studyshows promising results in using HBOT to overcome respiratory failure in COVID-19. HBOT reduced the need for oxygen by improving the oxygen saturation levels.

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Impact of Palliative Care on Interhospital Transfers to the Intensive Care Unit

Safanah Tabassum Siddiqui1, Emily Xiao2, Sonika Patel3, Kiran Motwani1, Keneil Shah1, Xinyuan Ning4, Kathryn S. Robinett1

1 University of Maryland School of Medicine, Baltimore, MD, USA
2 University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
4 The University of Chicago Pritzker School of Medicine, Chicago, IL, USA

DOI: 10.2478/jccm-2022-0009

Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.

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Renal Manifestations and their Association with Mortality and Length of Stay in COVID-19 Patients at a Safety-net Hospital

Sandra Gomez-Paz1, Eric Lam2, Luis Gonzalez-Mosquera2, Diana Cardenas-Maldonado2, Joshua Fogel3, Ellen Gabrielle Kagan2, Sofia Rubinstein1

1 Division of Nephrology and Hypertension, Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA
2 Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA
3 Department of Business Management, Brooklyn College, Brooklyn, New York, USA

DOI: 10.2478/jccm-2022-0010

Background: Renal involvement in COVID-19 leads to severe disease and higher mortality. We study renal parameters in COVID-19 patients and their association with mortality and length of stay in hospital. Methods: A retrospective study (n=340) of confirmed COVID-19 patients with renal involvement determined by the presence of acute kidney injury. Multivariate analyses of logistic regression for mortality and linear regression for length of stay (LOS) adjusted for relevant demographic, comorbidity, disease severity, and treatment covariates. Results: Mortality was 54.4% and mean LOS was 12.9 days. For mortality, creatinine peak (OR:35.27, 95% CI:2.81, 442.06, p<0.01) and persistent renal involvement at discharge (OR:4.47, 95% CI:1.99,10.06, p<0.001) were each significantly associated with increased odds for mortality. Increased blood urea nitrogen peak (OR:0.98, 95%CI:0.97,0.996, p<0.05) was significantly associated with decreased odds for mortality. For LOS, increased blood urea nitrogen peak (B:0.001, SE:<0.001, p<0.01), renal replacement therapy (B:0.19, SE:0.06, p<0.01), and increased days to acute kidney injury (B:0.19, SE:0.05, p<0.001) were each significantly associated with increased length of stay. Conclusion: Our study emphasizes the importance in identifying renal involvement parameters in COVID-19 patients. These parameters are associated with LOS and mortality, and may assist clinicians to prognosticate COVID-19 patients with renal involvement.

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Early Empirical Anidulafungin Reduces the Prevalence of Invasive Candidiasis in Critically Ill Patients: A Case-control Study

Md Jahidul Hasan1, Sharmind Neelotpol2, Raihan Rabbani3

1 Clinical Pharmacy Service, Department of Pharmacy, Square Hospitals Ltd, Dhaka, Bangladesh
2 Department of Pharmacy, BRAC University, Dhaka, Bangladesh
3 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh

DOI: 10.2478/jccm-2022-0006

Introduction: Invasive candidiasis (IC) in critically ill patients is a serious infection with high rate of mortality. As an empirical therapy, like antibiotics, the use of antifungals is not common in intensive care units (ICUs) worldwide. The empirical use of echinocandins including anidulafungin is a recent trend.
Aim of the study: The objective of this study was to assess the impact of empirical anidulafungin in the development of invasive candidiasis in critically ill patients in ICU.
Methods: This retrospective case-control study was conducted on 149 patients with sepsis with/without septic shock and bacterial pneumonia. All the patients were divided into two groups. The ‘control group’ termed as ‘NEAT group’ received no empirical anidulafungin therapy and the ‘treated group’ termed as ‘EAT group’ received empirical anidulafungin therapy in early hospitalization hours.
Results: Seventy-two and 77 patients were divided into the control and the treated group, respectively. Patients in EAT group showed less incidences of IC (5.19%) than that of the NEAT group (29.17%) (p = 0.001). Here, the relative risk (RR) was 0.175 (95% CI, 0.064-0.493) and the risk difference (RD) rate was 24% (95% CI, 12.36%-35.58%). The 30-day all-cause mortality rate in NEAT group was higher (19.44%) than that of in EAT group (10.39%) (p = 0.04). Within the first 10-ICU-day, patients in the EAT group left ICU in higher rate (62.34%) than that in the NEAT group (54.17%).
Conclusion: Early empirical anidulafungin within 6 h of ICU admission reduced the risk of invasive candidiasis, 30-day all cause mortality rate and increased ICU leaving rate within 10-day of ICU admission in critically ill patients.

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Using Machine Learning Techniques to Predict Hospital Admission at the Emergency Department

Georgios Feretzakis1,3, George Karlis2, Evangelos Loupelis1, Dimitris Kalles3, Rea Chatzikyriakou1, Nikolaos Trakas1, Eugenia Karakou1, Aikaterini Sakagianni1, Lazaros Tzelves1, Stavroula Petropoulou1, Aikaterini Tika1, Ilias Dalainas1, Vasileios Kaldis1

1 Sismanogleio General Hospital, Athens, Greece
2 Sotiria General Hospital of Chest Diseases of Athens, Athens, Greece
3 Hellenic Open University, Patras, Greece

DOI: 10.2478/jccm-2022-0003

Introduction: One of the most important tasks in the Emergency Department (ED) is to promptly identify the patients who will benefit from hospital admission. Machine Learning (ML) techniques show promise as diagnostic aids in healthcare.
Aim of the study: Our objective was to find an algorithm using ML techniques to assist clinical decision-making in the emergency setting.
Material and methods: We assessed the following features seeking to investigate their performance in predicting hospital admission: serum levels of Urea, Creatinine, Lactate Dehydrogenase, Creatine Kinase, C-Reactive Protein, Complete Blood Count with differential, Activated Partial Thromboplastin Time, DDimer, International Normalized Ratio, age, gender, triage disposition to ED unit and ambulance utilization. A total of 3,204 ED visits were analyzed.
Results: The proposed algorithms generated models which demonstrated acceptable performance in predicting hospital admission of ED patients. The range of F-measure and ROC Area values of all eight evaluated algorithms were [0.679-0.708] and [0.734-0.774], respectively. The main advantages of this tool include easy access, availability, yes/no result, and low cost. The clinical implications of our approach might facilitate a shift from traditional clinical decision-making to a more sophisticated model.
Conclusions: Developing robust prognostic models with the utilization of common biomarkers is a project that might shape the future of emergency medicine. Our findings warrant confirmation with implementation in pragmatic ED trials.

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Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country

Taymmia Ejaz, Fazal Rehman, Arslan Ahmed, Safia Akhlaq, Sheema Saadia, Adil Aziz, Erfan Hussain

The Aga Khan University Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2021-0044

Background: Covid-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources.
Methods: A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23.
Results: Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5).
Conclusion: There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

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