ABSTRACT
Introduction: The COVID-19 virus has caused a massive strain on medical services worldwide. Throughout 2020 and 2021, hospitals and their Intensive Care Units (ICUs) have been inundated with patients suffering from critical illness due to COVID-19, many of whom developed multiorgan failure and required prolonged ICU stays.1 Malta is a Mediterranean island with a population of 500,000 people, with one main acute general hospital (Mater Dei Hospital) with a single 20-bed ICU. This meant that the COVID-19 pandemic surge had to be managed locally by increasing ICU capacity without access to a referral network of other hospital ICUs at different phases of the pandemic or the possibility of referral to ECMO services abroad. Objectives: Establish the demographics and outcomes of all patients admitted to ICU with COVID-19 in Malta. Methods: A single centre prospective cohort study conducted in the Intensive Care Units caring for COVID-19 patients at Mater Dei Hospital, Malta. Data was collected on admission and then daily until death or discharge from ICU. Results: The COVID-19 pandemic resulted in 252 patients being admitted to ICU from March 2020 to May 2021. The peak of admissions occurred in March 2021 with a maximum of 21 admissions in a week resulting in a peak of 33 COVID-19 ICU beds being utilized. This represents 165% of the normal 20 bed ICU capacity. There were 9 readmissions, these were excluded from data analysis. All patients admitted to ICU were treated with Dexamethasone and Remdesivir, and Tocizulimab from January 2021, unless contraindicated. Overall ICU mortality was 34% and increased to 46% in those requiring mechanical ventilation. Males were responsible for 75% of admissions but gender was not associated with ICU mortality. Older patients and those with ischemic heart disease (IHD) and diabetes had a significantly increased mortality as were those patients with a higher Sequential Organ Failure Assessment (SOFA) and lower PaO2/FiO2 (P/F) on admission (Table 1). The total number of patients requiring intubation during their admission was 173 (69%) with a median time to intubation of two days [IQR 1-4]. Proning was used for 124 (69%) of the mechanically ventilated patients for a median of 2 days per patient [IQR: 1 -3], similarly muscle relaxant infusion was also used in 124 of mechanically ventilated patients (69%) for a median of three days per patient [IQR: 2 -5]. The median duration of mechanical ventilation was 11 days [IQR: 6 -22.2] with a maximum of 63 days. Tracheostomies were performed in 59 (34%) of mechanically ventilated patients with a median duration of 14.5 days intubated prior to tracheostomy [IQR: 13 -17]. The median length of stay was 11.5 days [7-23]. Conclusion: This observational study represents all COVID-19 ICU admissions that occurred in Malta from March 2020 to May 2021 in the single institution caring for these patients in the country. We have demonstrated a predominantly male, elderly admission population with an increased mortality associated with age, ischemic heart disease and diabetes. Overall ICU mortality was 34% and 46% in ventilated patients, which is comparable to that found in other national databases.2.
ABSTRACT
Introduction: Following the publication of the ARDS Network (ARDSnet) trial over two decades ago lung protective ventilation with low tidal volumes has become a mainstay in the evidence based management of acute respiratory distress syndrome (ARDS). The ARDSnet trial protocol uses the Devine formula which is based on height and gender to calculate the predicted body weight (PBW) which is then used to calculate the tidal volume in ml/kg.1-2 The first step to calculating a safe tidal volume is measuring the patient's height. Visual estimates of patient's height are often inaccurate and measurements in some patient groups can be challenging. Various methods have been suggested to aid accuracy and ease of measurement. Once the height is known the second step is to use the Devine formula to calculate the PBW. This is often done using online calculators or using tables with height and the PBW. The third and final step is multiplying the PBW by the desired tidal volume in ml/kg typically starting at 6ml/kg. During the COVID-19 pandemic, the combination of various factors such as greatly increased doctor and nursing workload, use of personal protective equipment (PPE), concerns over the use of reusable equipment such as tape measures and difficult access to online calculators for PBW calculation when donned in PPE in some COVID-19 units made measuring height and calculating a safe tidal volume particularly challenging.3 Objectives: To develop a quick, safe way of calculating lung protective tidal volumes for ARDS patients including in COVID-19 Intensive care units. Methods: We used the Devine formula to calculate the PBW in males and females at every centimeter (cm) from 152cm to 200cm. Males PBW= 50 + (0.91 × [height in centimeters -152.4]) Female PBW= 45.5 + (0.91 × [height in centimeters -152.4]). We then multiplied the PBW by 6 to generate a 6ml/kg PBW tidal volume. Using image editing software, we then designed gender specific rulers with cm markings to measure height placed beside the corresponding calculated PBW and tidal volume 6ml/kg for that height. We also placed the ARDSnet PEEP/ Fio2 titration table. The resulting ruler when printed to scale can then be used as a disposable measuring tape that allows height, PBW and 6ml/kg tidal volume to be calculated easily with one measurement and without the need to resort to calculators, tables or reusable equipment. Results: Conclusions: These JPEG images can be downloaded and printed to scale. Once printed the ARDS 'rulers' allow easy and quick measurement of height, PBW and 6ml/kg tidal volume with one measurement without resorting to calculators or tables. As they are simply printed on standard paper, they are single use and therefore do not pose an infection control risk.
ABSTRACT
Introduction: The aim of the study was to determine the impact of COVID-19 pandemic on intensive care workload [1,2] at our only acute main general hospital on the island. During the pandemic surge in March 2021, our intensive care was running at 200% capacity. Mater Dei Hospital has a 20-bedded adult intensive care catering for a population of 500,000. Methods: This is a prospective cohort study conducted in the COVID- 19 Intensive Care Unit at Mater Dei Hospital, Malta. Data analysed is from March 2020 to May 2021. Data collected daily from admission until death or discharge from ICU. Results: A total of 261 patients with severe acute respiratory distress syndrome coronavirus 2 (SARS-Cov-2) required admission to our intensive care. ICU facilities required expansion into a total of 5 Intensive Care Units, therefore reaching a capacity of 44 intensive care beds during the peak month of March 2021. A maximum of 21 patients were admitted per week culminating to a total of 33 COVID-19 Intensive Care beds during the month of March 2021. A total of 179 patients (68.6%) required mechanical ventilation for a median duration of 11 days per patient. Proning was required in 124 mechanically ventilated patients (70.5%). 50 patients (20%) required CRRT with a maximum number of 7 patients per day requiring CRRT. Conclusions: COVID-19 pandemic transformed the way how we provide critical care with improved bed capacity, ICU triage and ICU devices. This study highlighted the need for more clinical guidelines and their availability for online use. This will positively impact the care of non-COVID patients. It also highlighted the need for more training of non-ICU staff to allow for surges in ICU capacity. The COVID-19 pandemic has seen Mater Dei hospital already investing in ICU personnel and equipment as this cannot be reactive to large scale events but must be a proactive planned strategy to enhance resilience of our ITU.