Tag Archives: intensive care

Outcomes of Patients Transferred to Tertiary Center by Life-Saving System in Saudi Arabia. A Propensity Score Matching Observational Study

DOI: 10.2478/jccm-2024-0038

Background: Inter-hospital transfer is intended to provide access to centralized special care for critically ill patients, when resources in their hospitals are not available. However, an empirical gap exists in available evidence, as outcomes of transferred patients to higher centers are inconsistent.
Method: Single center propensity score matching retrospective observational study. Life-Saving transfers during 2023 were matched to direct admissions to the ICU. Hospital mortality, ICU length of stay, and costs of both groups were compared.
Results: During the study period, 328 Life-Saving transfers were matched to 656 direct admissions. Propensity score matching eliminated all imbalances between groups. Hospital mortality was not different between groups, there were 114 (34.8%) hospital mortalities of Life-Saving transfers, while there were 216 (32.9%) hospital mortalities of direct admissions, with a percent difference of 1.9% (95% CI: -4.5%, 8.4%); p value = 0.6, this result persisted in the sensitivity analysis. There were no differences in mortality risks for all the studied subgroups except pediatric patients. ICU length of stay of direct admissions and Life-Saving transfers were 10 ± 13.1 and 11.6 ± 12.4 days respectively, mean difference was statistically significant (-1.6 [95% CI: -3.2, 0.1]; p = 0.005). Life-Saving transfers entailed significantly higher costs per admission by 28,200 thousand SAR (95% CI: 26,400 – 30,000; p < 0.001).
Conclusion: Our study shows no difference in hospital mortality between Life-Saving transfers and direct admissions to ICU, however, Life-Saving transfers had a longer ICU length of stay, and higher costs per admission.

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Uncommon Malposition of an Ultrasound-Guided Central Venous Catheter in the Renal Vein through the Superficial Femoral Vein: A Case Report

DOI: 10.2478/jccm-2024-0026

Introduction: Malposition is a relatively rare complication associated with peripherally inserted central catheters (PICCs), particularly in cases of superficial femoral vein (SFV) catheterization. To the best of our knowledge, we are the first to report this rare case of SFV PICC malposition in the contralateral renal vein.
Case presentation: An 82-year-old woman underwent bedside cannulation of the SFV for PICC under ultrasound guidance. Subsequent radiographic examination revealed an unexpected misplacement, with the catheter tip positioned toward the contralateral renal vein. After pulling out the catheter on the basis of the X-ray result, it was observed that the catheter retained its function.
Conclusion: Although rare, tip misplacement should be considered in SFV PICC placement. Prompt correction of the tip position is crucial to prevent catheter malfunction and further catastrophic consequences. For critical patients receiving bedside SFV PICC insertion, postoperational X-ray is crucial for enhancing safety.

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Clinical Profile and Course of Patients with Acute Respiratory Distress Syndrome due to Covid-19 in a Middle-Income Region in Mexico

DOI: 10.2478/jccm-2024-0022

Introduction: COVID-19 leads to severe clinical complications that culminate in respiratory failure and acute respiratory distress syndrome (ARDS). Despite reports of some comorbidities that contribute to the development of COVID-19-mediated ARDS, there is great variation in mortality rates among critical COVID-19 patients in the world. To date, no studies have described the incidence and comorbidities associated with ARDS due to COVID-19 in the northeastern region of Mexico.
Aim of the study: To describe patients diagnosed with ARDS due to COVID-19 in the northeastern region of Mexico, as well as its variations in comparison with other regions of the country.
Material and Methods: We conducted a prospective and observational study in a tertiary care center in Northeastern Mexico. All patients diagnosed with SARS-CoV-2 infection and requiring management in the intensive care unit were included. We developed a database that was updated daily with the patients´ demographic information, pre-existing diseases, disease severity, and clinical variables.
Results: The incidence of ARDS secondary to COVID-19 in HRAEV was high in comparison with other reports. Diabetes mellitus was the risk factor most associated with COVID-19-mediated ARDS.
Conclusion: Based on our findings and those previously reported in the literature, there are differences that we discuss between northeastern and central Mexico, and analyze other areas evaluated around the world.

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The Human Microbiome in Intensive Care – A Journey Forward?

DOI: 10.2478/jccm-2023-0032

The human microbiome, defined as a personal, genomic signature of our latent or manifest infectious profile (bacterial, viral, fungal), located predominantly in the digestive tract, opens the door to personalized medicine studies on a scale larger than the human genome in terms of data that can be analyzed and interpreted. Compared to the human genome, which has approximately 23,000 genes, the European Metagenomics of the Human Intestinal Tract and the Human Microbiome Project have reported 3.3 million non-redundant microbial genes [1]. [More]

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Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

DOI: 10.2478/jccm-2023-0026

Background: Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism’s health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness.
Objective: The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density.
Material and methods: This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients.
Results: Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity.
Conclusion: The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.

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

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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Intensive Care Based Interventions to Reduce Family Member Stress Disorders: A Systematic Review of the Literature

DOI: 10.2478/jccm-2022-0014

Background: Increasing awareness of the emotional impact of an Intensive Care Unit (ICU) hospitalization on patients and their families has led to a rise in studies seeking to mitigate Post Intensive Care Syndrome (PICS) for both groups. In efforts to decrease symptoms of anxiety and depression, ICUs have implemented a variety of programs to reduce family distress.
Methods: We conducted a systematic review of experimental studies which aimed to reduce stress related disorders in family members after the experience of having a patient admitted to the ICU. Multiple databases were searched for randomized controlled trials or nonrandomized comparative trials which targeted family members or surrogate decision makers. A total of 17 studies were identified for inclusion in the review representing 3471 participants.
Results: We describe those interventions which we qualitatively assigned as “not passive,” or those which actively engaged the family to express themselves, as more likely to be successful in both the available pediatric and adult literature than interventions which we identified as “passive.” Studies which described active engagement of family members demonstrated comparative improvements in symptoms of depression, anxiety, and PTSD, as well as reduced hospital costs in the case of two studies.
Discussion: This review may serve to aid in the development of future interventions targeted at reducing family stress and PICS following an ICU hospitalization.

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Should We Go “Regional” in Intensive Care?

DOI: 10.2478/jccm-2021-0042

Pain is one of the major concerns in Intensive Care Units (ICU). The majority of the patients admitted in ICU experience a certain degree of pain during their stay. Opioid analgesia constitutes the main analgesic option for ICU patients [1].
Opioids are known to have serious side effects, some of them such as ileus, respiratory depression, which leads to prolonged mechanical ventilation, can interfere with the patient’s outcome can lengthen the stay in ICU and leads to iatrogenic withdrawal syndrome (IWS) [1, 2]. In the last few years, a new concept of pain management in ICU patients was introduced: opioid free analgesia (OFA). This concept implies achieving good quality analgesia without using any type of opioids, in any manner [3]. [More]

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The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured patients

DOI: 10.2478/jccm-2021-0014

Background: Traumatic brain injury is a leading cause of morbidity and mortality worldwide. The relationship between hyperoxia and outcomes in patients with TBI remains controversial. We assessed the effect of persistent hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI.
Method: This was a retrospective cohort study of all adults with moderate-severe TBI admitted to the ICU between 1st January 2016 and 31st December 2019 and who required invasive mechanical ventilation. Arterial blood gas data was recorded within the first 3 hours of intubation and then after 6-12 hours and 24-48 hours. The patients were divided into two categories: Group I had a PaO2 < 120mmHg on at least two ABGs undertaken in the first twelve hours post intubation and Group II had a PaO2 ≥ 120mmHg on at least two ABGs in the same period. Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score ≥ 4).
Results: The study included 309 patients: 54.7% (n=169) in Group I and 45.3% (n=140) in Group II. Hyperoxia was not associated with increased mortality in the ICU (20.1% vs. 17.9%, p=0.62) or hospital (20.7% vs. 17.9%, p=0.53), moreover, the hospital discharge mean (SD) Glasgow Coma Scale (11.0(5.1) vs. 11.2(4.9), p=0.70) and mean (SD) Glasgow Outcome Score (3.1(1.3) vs. 3.1(1.2), p=0.47) were similar. In multivariable logistic regression analysis, persistent hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.71, 95% CI 0.34-1.35, p=0.29). PaO2 within the first 3 hours was also not associated with mortality: 121-200mmHg: aOR 0.58, 95% CI 0.23-1.49, p=0.26; 201-300mmHg: aOR 0.66, 95% CI 0.27-1.59, p=0.35; 301-400mmHg: aOR 0.85, 95% CI 0.31-2.35, p=0.75 and >400mmHg: aOR 0.51, 95% CI 0.18-1.44, p=0.20; reference: PaO2 60-120mmHg within 3 hours. However, hyperoxia >400mmHg was associated with being less likely to have good neurological (GOS ≥4) outcome on hospital discharge (aOR 0.36, 95% CI 0.13-0.98, p=0.046; reference: PaO2 60-120mmHg within 3 hours.
Conclusion: In intubated patients with moderate-severe TBI, hyperoxia in the first 48 hours was not independently associated with hospital mortality. However, PaO2 >400mmHg may be associated with a worse neurological outcome on hospital discharge.

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Precision Medicine and its Role in the Treatment of Sepsis: A Personalised View

DOI: 10.2478/jccm-2019-0017

In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient.
PM is about using multiple data sets to create a digital human mapping. A person’s biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual’s unique genetic make-up.
Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU.
The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.

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