Category Archives: JCCM 2023

End-of-life Care in the Intesive Care Unit and Nursing Roles in Communicating with Families

Anastasios Tzenalis1, Helen Papaemmanuel2, George Kipourgos2, George Elesnitsalis2

1 University Of Patras, Patra, Greece
2 General Hospital of Thessaloniki Papageorgiou, Greece

DOI: 10.2478/jccm-2023-0013

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.

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Therapeutic Hypothermia Following Cardiopulmonary Arrest: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Robert Maclaren1, Sterling Torian2, Tyree Kiser1, Scott Mueller3, Paul Reynolds4

1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
2 Department of Pharmacy, TriStar Centennial Medical Center, Nashville, Tennessee, USA
3 Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA
4 Department of Pharmacy, VA Eastern Colorado Health Care System, Aurora, Colorado, USA

DOI: 10.2478/jccm-2023-0015

Introduction: The risk-benefit profile of therapeutic hypothermia is controversial with several randomized controlled trials providing conflicting results. Aim of Study: The purpose of this systematic review and meta-analysis was to determine if therapeutic hypothermia provides beneficial neurologic outcomes relative to adverse effects.
Material and Methods: MEDLINE and EMBASE databases were searched for randomized controlled trials of post-cardiac arrest patients comparing therapeutic hypothermia (~33 degrees Celsius) to normothermia or the standard of care (36 – 38 degrees Celsius). Data were collected using the Covidence systematic review software. Statistical analysis was performed by Review Manager software. Risk of bias, sensitivity, and heterogeneity were analyzed using the Cochran’s Collaboration tool, trial sequential analysis (TSA) software, and I2 statistic respectively.
Results: A total of 1825 studies were screened and 5 studies (n=3614) were included. No significant differences existed between the hypothermia group and normothermia for favorable neurologic outcome (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.97 to 1.41) or all-cause mortality (RR 0.97, 95% CI 0.89 to 1.05). When compared to normothermia, the hypothermia group had greater risk of adverse effects (RR 1.16, 95% CI 1.04 to 1.28), which was driven by the onset of arrhythmias. Subgroup analyses revealed that therapeutic hypothermia provided greater neurologic benefit in trials with a higher percentage of subjects with shockable rhythms (RR 0.73, 95% CI 0.6 to 0.88). Trial sequential analysis revealed statistical futility for therapeutic hypothermia and favorable neurologic outcome, mortality, and adverse effects.
Conclusions: Therapeutic hypothermia does not provide consistent benefit in neurologic outcome or mortality in the general cardiac arrest population. Patients with shockable rhythms may show favorable neurologic outcome with therapeutic hypothermia and further investigation in this population is warranted. Any potential benefit associated with therapeutic hypothermia must be weighed against the increased risk of adverse effects, particularly the onset of arrhythmias.

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Aerosolized Plus Intravenous Polymyxin B Versus Colistin in the Treatment of Pandrug-Resistant Klebsiella Pneumonia-mediated Ventilator-Associated Pneumonia: A Retrospective Cohort Study in Bangladesh

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

DOI: 10.2478/jccm-2023-0012

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.

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Post Hospital Discharge Functional Recovery of Critical Illness Survivors. Systematic Review

Irini Patsaki1, Georgia Bachou2, Georgios Sidiras3, Serafim Nanas3, Christina Routsi3, Eleftherios Karatzanos3

1 University of West Attica, Athens, Greece
2 National and Kapodistrian University of Athens, Greece
3 Clinical Ergospirometry, Exercise and Rehabilitation Laboratory, 1st Critical Care Department, Evangelismos Hospital, School of Medicine, National & Kapodistrian University of Athens, Greece

DOI: 10.2478/jccm-2023-0011

Background: Millions of people face critical illnesses and need to be hospitalized in an Intensive Care Unit (ICU) annually worldwide. Despite the fact that survival rates of these patients have increased, they develop various cognitive, psychological and functional impairments. This study aims to investigate the significance of the recovery interventions following intensive care unit discharge, the effectiveness of the rehabilitative protocols and their possible deficits.
Methods: MEDLINE (PubMed) and Physiotherapy Evidence Database (PEDro) were searched for studies analyzing the recovery potentials post-ICU among adults, who spent at least 48 hours at the ICU. Methodological quality of the studies was assessed via PEDro Scale.
Results: Nine randomized controlled trials were included. These took place mainly at specialized rehabilitation gyms as well as patients home environments. Studies analyses showed that treatment group showed improvement in functional ability in relation to control group. Nevertheless, differences between two groups were not statistically significant (P<0.05). The majority of studies assessed cardiorespiratory endurance and muscular strength.
Conclusions: The included rehabilitation programs were determined to be effective. Although they didn’t prove any statistically significant difference between groups, quality of life enhancements and stress reduction were reported. Hence, new randomized controlled trials are required in order to provide more accurate data on the potential benefits of rehabilitation strategies among post-ICU patients.

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Multiple Organ Dysfunction Secondary to Herpes Simplex Virus -1 Reactivation After Treatment With Dexamethasone and Sarilumab for Covid-19 Disease

Thomas Roe*, Sam Waddy, Nikitas Nikitas

University Hospitals Plymouth NHS Trust, Plymouth, Devon, United Kingdom

DOI: 10.2478/jccm-2023-0010

Introduction: The immunological response to the SARS-CoV-2 virus and the treatment of COVID-19 disease present a potential susceptibility to viral reactivation, particularly Herpes simplex virus-1 (HSV-1).
Case Presentation: A 49-year-old female presented to hospital with severe COVID-19 pneumonitis and was given sarilumab and dexamethasone. She was intubated and ventilated in the intensive care unit (ICU) and initially demonstrated biochemical and clinical evidence of improvement. This was followed by a severe acute deterioration in respiratory, renal, and cardiovascular function, accompanied by a vesicular rash on the face. Polymerase chain reaction confirmed HSV-1 reactivation and treatment with acyclovir was commenced. After 49 days in ICU the patient was successfully weaned from all organ support, and she made a satisfactory recovery.
Conclusions: HSV-1 reactivation is common in COVID-19 and likely contributes to poorer clinical outcomes. The mechanism causing susceptibility to viral reactivation is not clearly defined, however, the development of critical illness induced immunosuppression via dysfunction of interferon and interleukin pathways is a likely mechanism. This effect could be perpetuated with immunosuppressant medications, although further research is needed to characterise this phenomenon.

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Lung Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy

Celeste Dias1,4, Alexandre de Castro1, Rita Gaio2,3, Ricardo Silva2, Eduarda Pereira4, Elisabete Monteiro1,4

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

DOI: 10.2478/jccm-2023-0009

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.

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Early Lactate Clearance as a Determinant of Survival in Patients with Sepsis: Findings from a Low-resource Country

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

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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Accuracy of Critical Care Ultrasonography Plus Arterial Blood Gas Analysis Based Algorithm in Diagnosing Aetiology of Acute Respiratory Failure

Rajesh Panda, Saurabh Saigal, Rajnish Joshi, Abhijit Pakhare, Ankur Joshi, Jai Prakash Sharma, Sahil Tandon

All India Institute of Medical Science – Bhopal, Madhya Pradesh, India

DOI: 10.2478/jccm-2023-0006

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.

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Rebranding Nutritional Care for Critically Ill Patients

Liliana Elena Mirea, Cristian Cobilinschi, Ioana Marina Grințescu

Anaesthesia and Intensive Care Clinic, Clinical Emergency Hospital of Bucharest
“Carol Davila” University of General Medicine, Bucharest

DOI: 10.2478/jccm-2023-0008

Since the organic and molecular roles and function of nutrients in supporting homeostasis for hospitalized patients have been already stated, remarkable advances have been achieved in the field of clinical nutrition [1]. Replacing the old terminology of “nutritional support” with the new concept of “nutritional therapy” both European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Enteral and Parenteral Nutrition (ASPEN) emphasized that adequate nutrients administration reduces oxidative stress, metabolic response and sustains the immune response [1, 2]. The persistently increased prevalence of hospital malnutrition, inappropriate nutritional support during hospitalisation contributes undeniably to an increased mortality, especially in intensive care units [3].
In order to promote the importance of nutritional care and increase awareness among authorities and clinicians, “The International Declaration on the Human Right to Nutritional Care” was adopted during ESPEN Congress 2022 in Vienna. This Declaration highlights that nutritional therapy is a human right in the same manner as the right to food and health [4]. Moreover, all the undersigned societies, including Romanian Society of Enteral and Parenteral Nutrition (ROSPEN), raise awareness of the high prevalence of disease-related malnutrition along with the lack of access to appropriate nutritional support during and after hospitalisation. [More]

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