ABSTRACT
INTRODUCTION: ARDS net trial recommends keeping low tidal volumes (6-8 cc/IBW) and plateau pressures less than 30 cm H20. However, it is not well studied if sporadic elevation or continuous elevation of plateau pressures results in poor outcomes. We hypothesize that persistent elevation of p plat for >24 hrs. or > 6 times (measured 4 hrs. apart) continuously is associated with increased mortality. METHOD(S): Retrospective chart review of patients admitted with COVID-19 during the surge of August to September 2021 at Houston Methodist Baytown hospital. Inclusion Criteria- COVID-19 patients with respiratory failure, ards and intubated. Plateau pressures are recorded every 4 hrs. Data obtained from EPIC ICU flowsheet. Persistent elevation was defined as all the plateau pressures measured for > 24 hrs. and are continuously elevated. Exclusion criteria - patients admitted to ICU with cardiac arrest, patients who are covid negative and covid positive, but no ARDS are excluded. Tidal volume recorded is when the first highest p plateau pressure was documented. Descriptive statistics and t-tests were used to interpret the results. RESULT(S): Out of a total of 48 patients, only 12 patients survived, and 36 patients died. Mortality rate- 75%. Survivors vs. non survivors average Age(y) 42 vs.55 (p< 0.05), Tidal volume 5.98 ml/PBW vs.6.03 ml/PBW (p=0.105), Normal elastance 4.06 vs. 4.07(p=0.44), Delta P 22 vs.23(p=0.27) and ventilatory ratio 84 vs. 98(p< 0.05) were calculated during maximum plateau pressures. In patients with continuous p plat >30, 29 (85%) patients died and 5 (15%) survived. OR- 5.8 (P< 0.05). Out of the 5 patients that survived 2 went on ECMO. Intermittent p plat elevation was noted in 11 out of 14 patients who did not have continuous p plat elevation. CONCLUSION(S): Ventilatory ratio, a simple index of impaired ventilation and physiological dead space was higher in nonsurvivors compared with survivors. Continuous p plat elevation for more than 24 hrs. that is resistant to intervention might be an indirect indicator of worsening lung ventilation and increasing mortality. Rather than a single-time daily measurement of variables like delta P or p plateau pressure multiple measurements and trends might be helpful to prognosticate patients that might have poor outcomes and indicate worsening lung function.
ABSTRACT
INTRODUCTION: Spontaneous breathing trials are a part of the ABCDEF bundle to improve outcomes like decreasing mechanical ventilator days, hospitalization, and ICU LOS. Protocol-guided SBT has been shown to help in this process successfully. There is not much data comparing pre-Covid-19 to during Covid -19 years in terms of ability to meet the protocol-driven SBT trial and outcomes after meeting the criteria. We sought to compare the above through our study. METHOD(S): We reviewed the ventilator-related data at Houston Methodist Baytown hospital from 2018 to 2021. 2018-2019 Pre Covid-19 compared to 2020-2021 Covid -19 years. SBT protocol that the Houston Methodist system has approved has been used for evaluating patients. Descriptive statistics and t-test were used to compare the groups. RESULT(S): Comparing pre-covid-19 to covid-19 years data, the number of ventilator days doubled during the COVID period 5664 vs.10705 (p < 0.05). There were fewer patients meeting protocol-guided SBT criteria and less percentage of daily SBTs being performed (31 % vs. 18%,p< 0.05). % of SBTs passed (44% vs. 32%, p< 0.05) pre COVID-19 compared to COVID years. Once SBTs passed, the number of patients receiving liberation orders was the same (78% vs. 79 %, p=0.37). CONCLUSION(S): There were more ventilator days during the covid years of 2020-2021. Following the protocol, there were a lesser number of SBTs performed and passed during the COVID-19 years. This is most likely due to COVID -19 related lung injury, prolonged use of medications like a neuromuscular blockade, higher sedation that might have caused diaphragmatic weakness, prolonged ventilator days, and inability to meet the SBT criteria. Other factors like healthcare workers shortage or increased patient-to-nursing, Respiratory therapist shortage, and physician ratios might have also contributed. Patients might be harder to wean with COVID -19, and early tracheostomies and disposition might be considered in COVID-19 patients.
ABSTRACT
INTRODUCTION: ICU-acquired delirium results in increased LOS, duration of mechanical ventilation, and mortality. Patients with COVID are at increased risk. Current literature suggests that delirium without coma occurs in at least about 30 % of COVID patients admitted to ICU. In our ICU we use an EPIC EMR-based daily ICU checklist with ABCDEF bundle during our rounds and utilized virtual ICU during the daytime in addition to the nights with peak surges. With our study, we wanted to evaluate the incidence of Delirium during our COVID year of 2021 and its relation to Mortality rate and ICU Length of stay (LOS). METHOD(S): A retrospective evaluation of patients admitted to Houston Methodist Baytown ICU from January to December 2021. Patients with covid positive were included. Data were obtained from the EPIC and ICU dashboard. Compliance with the ABCDEF ICU checklist was reviewed by auditing 20 patient charts per month. Delirium screening compliance was evaluated on AM and PM shifts for all ICU patients. Hospital ICU acquired delirium % was defined as all patients discharged from the ICU unit in that month that didn't have a positive CAM-ICU in the first 48 hrs. and then had a positive CAM-ICU after 48 hrs. in the ICU. ICU Mortality rate is defined as the percentage of patients with ICU stays who expired during ICU stay. Descriptive statistics and linear regression were used to compare and correlate. RESULT(S): In 2021, we had 377 ICU patients with COVID positive, an Average CMI of 4.986, and a LOS index of 1.24. Compliance with the daily ABCDEF ICU Checklist was 98%. Compliance to am screening was 89.41% vs. pm screening 90.56%. Mean Incidence of ICU acquired Delirium in COVID patients was only 7.14 % (2.77- 15.22) with peaks occurring during COVID surges. Linear regression analysis predicted a strong direct relationship between Delirium % and ICU Mortality rate (P< 0.05), and ICU Length of Stay(P< 0.05). CONCLUSION(S): Our data from 2021 shows Delirium % that is significantly less than the incidence. The lower % might have been from continuing to adhere to the ABCDEF bundle, utilization of the ICU checklist, and effective use of virtual ICU. Hospital ICU acquired delirium % correlated with ICU mortality and ICU length of stay. Hence, it is important to continue to focus on ways to decrease ICU delirium.