ABSTRACT
Introduction: Since 2015, the medical intensive care unit (ICU) with a focus on gastroenterology of the Department of Internal Medicine 1 at the University Hospital Regensburg, Germany, has a particular emphasis on interprofessional collaboration with staff nurses and hospital pharmacists. The hospital pharmacists have access to the hospital information system and the electronic charting program. Consultations take place on daily basis. Furthermore, weekly joint rounds within the antibiotic stewardship program are performed. Furthermore, there is a joint training and teaching of medical, nursing and pharmacy students within the intensive care training ward Regensburg (I'M A-STAR project). Aims & Methods: The study aims to investigate to what extent the newly introduced structural changes affect clinical and economic outcomes. We examined clinical performance data and consumption figures for antibiotics and other drugs over a 10-year period from 2011 to 2021. Data from the hospital pharmacy, hospital administration, electronic charting, and hospital information systems were included in the analyses. An electronic platform was developed specifically to improve documentation. The years 2020 and 2021 were considered separately due to the COVID-19 pandemic and the care of numerous COVID-19 patients in the ICU. Result(s): It could be shown that the pharmacist's recommendations regarding drug administration were mainly related to indication (43.6%), dosage (27.6%), interactions (9.4%), and side effects (4.1%). Antibiotic consumption was reduced by 12.2% from 2015 to 2019. Encouragingly, this included a 23.4% reduction in carbapenem use. Antibiotic spending was reduced by 24.9% overall. An analysis of the intensive care G-DRGs showed that the case-mix points increased significantly by 31.6% during the period under review. Similarly, patient severity of illness as measured by the SAPS II score increased by 21.4%. The proportion of mechanically ventilated patients exceeded 50%. In another analysis, antibiotic spending per case-mix point was calculated. While spending was EUR 60.22 per case-mix point in 2015, this could be reduced by 42.9% to EUR 34.37 per case-mix point by 2019. Conclusion(s): Through close interprofessional collaboration between physicians, staff nurses, and pharmacists, the consumption of antibiotics and other drugs (e.g., albumin) was significantly reduced, thus improving patient care. There was also a positive economic effect - with a simultaneous increase in case-mix points, expenditure on antibiotics was significantly reduced. Responsible use of resources and high-performance medicine are not contradictory. In our view, a close interprofessional collaboration between physicians, staff nurses, and pharmacists will be of outstanding importance in the future, particularly in intensive care medicine.
ABSTRACT
The aim was to describe the small bowel morphology with conventional B-mode and elastography and additionally to evaluate dynamic effects of COVID-19 associated small bowel microvascularization using CEUS with color coded perfusion parameters.Thirteen patients with severe COVID-19 acute respiratory distress syndrome (ARDS) were investigated. 13 patients required intensive care treatment with mechanical ventilation. Five patients required extracorporeal membrane oxygenation (ECMO). Contrast-enhanced ultrasound (CEUS) was performed by an experienced investigator as a bolus injection of up to 2.4âml sulfur hexafluoride microbubbles via a central venous catheter. In the parametric analysis of CEUS, the flare of microbubbles over time is visualized with colors. This is the first work using parametric analysis of CEUS to detect perfusion differences in the small bowel.Parametric analysis of CEUS in the intestinal phase was carried out, using DICOM loops for 20 seconds. In 5 patients, parametric analysis revealed intraindividual differences in contrast agent behavior in the small bowel region. Analogous to the computed tomography (CT) images parametric analysis showed regions of simultaneous hyper- and hypoperfusion of the small intestine in a subgroup of patients. In 5 patients, the parametric image of transmural global contrast enhancement was visualized.Our results using CEUS to investigate small bowel affection in COVID-19 suggest that in severe COVID-19 ARDS systemic inflammation and concomitant micro embolisms may lead to disruption of the epithelial barrier of the small intestine.This is the first study using parametric analysis of CEUS to evaluate the extent of small bowel involvement in severe COVID-19 disease and to detect microemboli. In summary, we show that in COVID-19 the small bowel may also be an important interaction site. This is in line with the fact that enterocytes have been shown to a plenitude of angiotensin converting enzyme (ACE)-2 receptors as entry sites of the virus.
ABSTRACT
Ten patients with confirmed COVID-19 disease were studied. Nine patients required intensive care treatment, among them four needed extracorporeal membrane oxygenation (ECMO). Contrast enhanced ultrasonography (CEUS) was performed by one experienced investigator as a bolus injection of up to 2.4âml of sulphur hexafluoride microbubbles via a central venous catheter. B-Mode evaluation and strain elastography showed mural edema of the small bowel with a thickness of up to 10âmm in all patients. We applied color coded Doppler sonography (CCDS) and power mode with flow-adapted parameters and early, dynamic capillary arterial contrast enhancement of bowel wall structures <10âs to assess perfusion of the small bowel. In all patients, reactive hyperemia was seen in the entire small bowel. In a subgroup of seven patients microbubbles translocated into the intestinal lumen. Thus, high-grade intestinal barrier disruption secondary to SARSCoV-2 infection can be postulated in these patients.This is the first description of perfusion changes and a disruption of the small bowel epithelial barrier in COVID-19 Patients using contrast ultrasonography and elastography.