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1.
Critical care (London, England) ; 26(1), 2022.
Article in English | EuropePMC | ID: covidwho-1609363

ABSTRACT

Introduction Survivors of acute respiratory failure (ARF) commonly experience long-lasting physical, cognitive, and/or mental health impairments. Unmet medication needs occurring immediately after hospital discharge may have an important effect on subsequent recovery. Methods and analysis In this multicenter prospective cohort study, we enrolled ARF survivors who were discharged directly home from their acute care hospitalization. The primary exposure was unmet medication needs. The primary outcome was hospital readmission or death within 3 months after discharge. We performed a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the exposure–outcome association, with an a priori sample size of 200 ARF survivors. Results We enrolled 200 ARF survivors, of whom 107 (53%) were female and 77 (39%) were people of color. Median (IQR) age was 55 (43–66) years, APACHE II score 20 (15–26) points, and hospital length of stay 14 (9–21) days. Of the 200 participants, 195 (98%) were in the analytic cohort. One hundred fourteen (57%) patients had at least one unmet medication need;the proportion of medication needs that were unmet was 6% (0–15%). Fifty-six (29%) patients were readmitted or died by 3 months;10 (5%) died within 3 months. Unmet needs were not associated (risk ratio 1.25;95% CI 0.75–2.1) with hospital readmission or death, although a higher proportion of unmet needs may have been associated with increased hospital readmission (risk ratio 1.7;95% CI 0.96–3.1) and decreased mortality (risk ratio 0.13;95% CI 0.02–0.99). Discussion Unmet medication needs are common among survivors of acute respiratory failure shortly after discharge home. The association of unmet medication needs with 3-month readmission and mortality is complex and requires additional investigation to inform clinical trials of interventions to reduce unmet medication needs. Study registration number: NCT03738774. The study was prospectively registered before enrollment of the first patient. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03848-3.

4.
Am J Crit Care ; 30(3): 238-241, 2021 05 01.
Article in English | MEDLINE | ID: covidwho-1134291

ABSTRACT

The sudden surge in cases of COVID-19 has presented unprecedented challenges in the care of critically ill patients with the disease. A disease-focused checklist was developed to supplement and streamline the existing structure of rounds during a time of significant resource constraint. A total of 51 critical care consultants across multiple specialties at a tertiary academic medical center were surveyed regarding their preference for a structured checklist. Among the respondents, 82% were in favor of a disease-focused checklist. Mechanical ventilation parameters, rescue ventilation strategies, sedation regimens, inflammatory markers specific to COVID-19, and family communication were the elements most commonly identified as being important for inclusion in such a checklist.


Subject(s)
COVID-19/therapy , Checklist , Critical Care , Pneumonia, Viral/therapy , Teaching Rounds , Boston , Female , Humans , Male , Needs Assessment , Pandemics , Pilot Projects , Pneumonia, Viral/virology , SARS-CoV-2 , Surveys and Questionnaires , Tertiary Care Centers
5.
J Intensive Care ; 8: 70, 2020.
Article in English | MEDLINE | ID: covidwho-757116

ABSTRACT

Corona virus 2 (SARS-CoV2/ Severe Acute Respiratory Syndrome Corona Virus 2) infection has emerged as a global health crisis. Incidence of thromboembolic disease is reported to be high in SARS-CoV2 disease and is seen in a multitude of organ systems ranging from cutaneous thrombosis to pulmonary embolism, stroke or coronary thrombosis sometimes with catastrophic outcomes. Evidence points towards a key role of thromboembolism, hypercoagulability and over production of proinflammatory cytokines mimicking a "cytokine storm" which leads to multiorgan failure. This brief narrative review highlights the pathophysiology and risk factors of thromboembolic disease and provides a framework for management of anticoagulation based on the current evidence.

6.
Anesthesiology ; 133(5): 985-996, 2020 11 01.
Article in English | MEDLINE | ID: covidwho-709139

ABSTRACT

Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.


Subject(s)
Betacoronavirus , Computer Simulation/standards , Coronavirus Infections/therapy , Healthcare Failure Mode and Effect Analysis/standards , Hospital Rapid Response Team/standards , Intensive Care Units/standards , Pneumonia, Viral/therapy , Boston/epidemiology , COVID-19 , Coronavirus Infections/epidemiology , Critical Care/methods , Critical Care/standards , Healthcare Failure Mode and Effect Analysis/methods , Humans , Pandemics , Pneumonia, Viral/epidemiology , Program Development/methods , Program Development/standards , Quality Improvement/standards , SARS-CoV-2
7.
J Cardiothorac Vasc Anesth ; 35(12): 3789-3796, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-705758

ABSTRACT

Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, is now a global pandemic affecting more than 12 million patients across 188 countries. A significant proportion of these patients require admission to intensive care units for acute hypoxic respiratory failure and are at an increased risk of developing cardiac arrhythmias. The presence of underlying comorbidities, pathophysiologic changes imposed by the disease, and concomitant polypharmacy, increase the likelihood of life-threatening arrhythmias in these patients. Supraventricular, as well as ventricular arrhythmias, are common and are associated with significant morbidity and mortality. It is important to understand the interplay of various causal factors while instituting strategies to mitigate the impact of modifiable risk factors. Furthermore, avoidance and early recognition of drug interactions, along with prompt treatment, might help improve outcomes in this vulnerable patient population.


Subject(s)
COVID-19 , Critical Illness , Arrhythmias, Cardiac/diagnosis , Arrhythmias, Cardiac/epidemiology , Humans , Pandemics , SARS-CoV-2
8.
Anesth Analg ; 131(2): 378-386, 2020 08.
Article in English | MEDLINE | ID: covidwho-423781

ABSTRACT

The morbidity, mortality, and blistering pace of transmission of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented worldwide health crisis. Coronavirus disease 2019 (COVID-19), the disease produced by SARS-CoV-2 infection, is remarkable for persistent, severe respiratory failure requiring mechanical ventilation that places considerable strain on critical care resources. Because recovery from COVID-19-associated respiratory failure can be prolonged, tracheostomy may facilitate patient management and optimize the use of mechanical ventilators. Several important considerations apply to plan tracheostomies for COVID-19-infected patients. After performing a literature review of tracheostomies during the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, we synthesized important learning points from these experiences and suggested an approach for perioperative teams involved in these procedures during the COVID-19 pandemic. Multidisciplinary teams should be involved in decisions regarding timing and appropriateness of the procedure. As the theoretical risk of disease transmission is increased during aerosol-generating procedures (AGPs), stringent infectious precautions are warranted. Personal protective equipment (PPE) should be available and worn by all personnel present during tracheostomy. The number of people in the room should be limited to those absolutely necessary. Using the most experienced available operators will minimize the total time that staff is exposed to an infectious aerosolized environment. An approach that secures the airway in the safest and quickest manner will minimize the time any part of the airway is open to the environment. Deep neuromuscular blockade (train-of-four ratio = 0) will facilitate surgical exposure and prevent aerosolization due to patient movement or coughing. For percutaneous tracheostomies, the bronchoscopist should be able to reintubate if needed. Closed-loop communication must occur at all times among members of the team. If possible, after tracheostomy is performed, waiting until the patient is virus-free before changing the cannula or downsizing may reduce the chances of health care worker infection. Tracheostomies in COVID-19 patients present themselves as extremely high risk for all members of the procedural team. To mitigate risk, systematic meticulous planning of each procedural step is warranted along with strict adherence to local/institutional protocols.


Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections/therapy , Infection Control , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Occupational Exposure/prevention & control , Perioperative Care , Pneumonia, Viral/therapy , Tracheostomy , Aerosols , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/transmission , Coronavirus Infections/virology , Humans , Occupational Exposure/adverse effects , Operative Time , Pandemics , Patient Care Team , Personal Protective Equipment , Pneumonia, Viral/diagnosis , Pneumonia, Viral/transmission , Pneumonia, Viral/virology , Risk Assessment , Risk Factors , SARS-CoV-2 , Time Factors , Tracheostomy/adverse effects , Treatment Outcome
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