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Introduction: Aberdeen Royal Infirmary is a low volume centre carrying out approximately 13 oesophagectomies per annum. Due to minimal exposure to post-operative oesophagectomy patients, staff had low perceived confidence in their management within the Intensive Care Unit (ICU). After an initial pause due to the COVID-19 pandemic, oesophagectomy service provision restarted in June 2020. Prior to this project, no standardised care pathway existed for post-operative oesophagectomy patients. A protocol driven management pathway was implemented within the ICU setting in October 2020. Objective(s): 1. Standardise the first 5 days of post-operative care for oesophagectamies 2. Improve 30 day mortality rate 3. Reduce opiate use on step down to High Dependency Unit (HDU) 4. Improve ICU Medical and Nursing staff perceived confidence in the management of oesophagectomy patients. Method(s): A multi-disciplinary approach was taken, with input from ICU, Surgical, Anaesthetic, Physiotherapy, Nursing, Pain and HDU teams. Standards of care for post-operative oesophagectomy patients were identified and a protocol was subsequently produced for use within ICU with reference to current Enhanced Recovery After Surgery (ERAS) guidelines.1 The protocol covered the first 5 days of post-operative care. It identified tasks to be completed each day and highlighted which staff group was responsible for performing each task. Additionally, an information sheet was distributed to Medical and Nursing ICU staff to educate them on oesophagectomy patients and recognition of potential complications that arise when caring for this patient group. Data on 30 day mortality and opiate use at step down to HDU was collected from electronic notes. This was collected retrospectively prior to implementation of the protocol from January 2019 - July 2020 and prospectively following its implementation, from October 2020 - December 2021. ICU staff perceived confidence in managing post-operative oesophagectomy patients was measured using a combined quiz and survey. It was completed by staff prior to introduction of the protocol. Following implementation of the protocol and distribution of the information sheet, the quiz and survey was repeated to evaluate improvement in staff confidence. Result(s): A total of 38 oesophagectomy cases were identified. 21 cases were reviewed prior to implementation of the protocol, with 1 mortality at 30 days. 17 cases were reviewed following implementation of the protocol, with 0 mortalities at 30 days. Qualitative scoring showed a 20% increase in staff confidence to manage this patient group. Review of drug prescription charts revealed a reduction in dose of modified release opiates at step down to HDU. Conclusion(s): Oesophagectomy is major surgery and causes significant staff anxiety in low volume centres. This protocol has successfully standardised care for this patient group and allowed continuation of this essential service provision during the COVID-19 pandemic. This protocol improved 30 day mortality, reduced opiate use at step down to HDU and improved ICU staff perceived confidence in caring for post-operative oseophagectomy patients.
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Introduction: Critical care patients commonly have disrupted sleep patterns, with reduction of REM sleep, duration of sleep, increased fragmentation and loss of circadian rhythm.1 Causes include the patients' pathophysiology, medications administered and the busy critical care environment. Data collection showed that our patients were sleeping, on average, for a single block of sleep of 3.5 hours. Delirium rates and its known deleterious effects are highly associated with poor sleep, as well as an impairment of psychomotor performance and neurocognitive dysfunction. Sleep deprivation in the healthy population impairs lymphocyte action, cytokine production and pro-inflammatory balance, as well as a reduction in respiratory function and prolongation of respiratory support.2 Objectives: To firstly measure the sleep quality and explore the reasons behind poor sleep from the patients themselves and to gauge the MDT knowledge and interest in sleep, as a fundamental component of patient management. Then using the results we aimed to improve the duration and quality of the patients sleep on high dependency unit. Method(s): The Adapted Richard Campbell Sleep Questionnaire was given to all patients in the HDU over a 4 week period. Results were analysed, then stored for post intervention comparison. The duration of sleep was documented for all patients and a staff questionnaire was done to assess knowledge and concern of staff. Interventions included a staff sleep awareness week with education and prompts attached to the charting tables promoting sleep. Face masks and ear plugs were freely available to be distributed at the evening ward round. The critical care pharmacist identified medications that could alter the patients ability to achieve REM sleep - e.g. evening administered PPIs, and melatonin was commenced early when sleep was troublesome. Estates fixed soft close doors and soft closed bins supplied for clinical areas. After interventions, there was a further 4 week study period where the above factors were repeated. The need for natural light was highlighted and thus this was optimized in the ward environment and those physiologically able were offered trips outdoors to facilitate normal day night wake cycle. With the COVID pandemic ongoing we also endeavored to limit movement overnight of venerable patients. Result(s): The original data collection was of 45 patients with multiple data points, and the second of 27 patients with multiple data points. Results from the Adapted Richard Campbell Sleep Questionnaire were compared using a one tailed students t test. There were significant increases in the subjective quality of sleep (p=0.046) and quantity of sleep (p=0.00018). Reasons given as to improvement of sleep were reduction in discomfort from monitoring and the bed (p=0.026), reduced ambient light (p=0.031) and reduced impact from the presence of other patients (p=0.002). Conclusion(s): There was marked improvement in the awareness of the importance of sleep within the critical care team after education promoting a change in attitude and culture towards sleep. We are planning a second iteration targeting sedation, noise from monitors and staff and overnight interventions. Although this has been done with level 2 patients, extension to level 3 areas would be beneficial.
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Background: This QIP was initially conducted during COVID-19 because there were concerns that many patients on the intensive care unit did not have a DNAR form. The pandemic has been a time where establishing appropriate ceilings of care is particularly important. Many of the patients on intensive care had been admitted due to haematological complications arising from COVID-19 including pulmonary embolism, thrombocytopenia and disseminated intravascular coagulation. Lack of DNAR forms has serious implications including the inappropriate use of cardiopulmonary resuscitation and uncertainty for the medical team regarding ceilings of care for critically unwell patients. These were the main drivers for change. Method(s): Data were collected over a 12-month period on ICU from the critical care electronic and written records. This included the presence of a DNAR form, time from ICU admission to DNAR form completion, as well as accuracy and detail on the form. Result(s): Only 50% of patients had a DNAR form completed and of these, cardiopulmonary resuscitation was only recommended in 27% cases. Time taken for completion of the form ranged from 0 to 20 days. Following discussion of these concerning findings in the ITU departmental meeting, several changes were made including mandatory discussions and adding DNAR status for each patient onto handover sheets, as well as electronic reminders for DNAR status. The second cycle of the QIP showed a 35% improvement with 85% of patients having a completed DNAR form. Conclusion(s): This QIP highlights the importance of DNAR form completion for all patients, given that only 27% of the 50% patients who had completed DNAR forms were deemed suitable for CPR. It also shows that introducing measures that make DNAR discussions mandatory leads to an improvement in DNAR form completion. Given the success in intensive care, this QIP has now been expanded to the high dependency unit and haematology wards to improve DNAR form completion for all haematology patients.
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Introduction: Bronchiolitis is the most common cause for paediatric respiratory hospital admissions in young children in the UK.1 Following the relaxation of international SARS-Cov-2 lockdown measures a potential national surge in cases was predicted, highlighting a need for more collaborative working across core specialities.2 This prompted the use of the principles of Inter-Professional Education (IPE) to prepare and deliver an intervention to improve outcomes for these patients.3 Objectives: * To plan, deliver and evaluate an educational intervention focussed on improving the knowledge, skills and attitudes needed to care for a sick child with bronchiolitis * To utilise the principles of IPE to improve competence and confidence across core specialities involved in the care of a sick child with bronchiolitis Methods: A team from the Adult Intensive Care Unit (AICU) and the Paediatric High Dependency Unit (PHDU) from the Royal Berkshire Hospital in Reading delivered an inter-professional teaching session focussed on caring for the sick child with bronchiolitis. The patient journey was utilised as a framework to teach the core knowledge, skills and attitudes needed to clinically manage a child from the Emergency Department (ED) to the Intensive Care Unit (ICU). Each session included a lecture about bronchiolitis - describing pathophysiology and how to recognise the deteriorating child;a skills and drills tutorial - highlighting the need for weight-based calculations for high flow nasal oxygen, intravenous fluids and drugs;and a practical simulation scenario - focussing on the stabilisation and management of a sick child awaiting retrieval to the Paediatric Intensive Care Unit (PICU). Result(s): 135 healthcare professionals from a range of adult and paediatric disciplines involved in the care of children across the patient journey attended one of fourteen teaching sessions delivered between September to December 2021. Attendees completed a feedback questionnaire. One hundred and twenty-two (90%) reported an extremely high degree of satisfaction overall, with many saying they would recommend the teaching sessions to others. Areas of personal and professional development were highlighted across the following main themes: gaining theoretical knowledge;understanding key equipment;performing drug calculations;preparing for intubation and ventilation;assessing the need for chest physiotherapy techniques;and more collaborative team-working. Free text comments demonstrated that the attendees felt the teaching sessions: built confidence through the sharing of new or improved knowledge and skills;facilitated a safe space to practice using simulation;and provided the opportunity to learn about and from each other. Many of the attendees also commented on areas they wanted to reinforce and further develop in daily clinical practice as a direct result of the sessions. Conclusion(s): On-going evaluation is taking place as the teaching sessions continue throughout the year, facilitating the inclusion of additional inter-professional groups from across core specialities. These sessions have been used as a template for the development of further planned IPE with a more varied range of paediatric clinical cases and presentations. These will continue to build on the transferable knowledge and skills that increase competence and confidence in caring for the sick child whilst developing a more collaborative practice-ready workforce.
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Introduction: Critically-ill obstetric patients admitted to general intensive care units (ICU) are a rare and unique population for whom excellent care is essential to prevent devastating physical and psychological morbidity. Admissions are often unanticipated and can present challenges to obstetric and intensive care MDTs. 2018 Enhanced Maternal Care (EMC) Guidelines provide standards for caring for these women, and the 2022 Ockenden review exposed the association of peripartum ICU admission with undertreated psychological trauma and a desire for individualised debriefing [1,2]. We audited the care of obstetric admissions to general ICUs in our quaternary centre. We sought evidence of psychological morbidity to improve follow-up pathways in line with 2022 Ockenden actions. Method(s): Retrospective online case note review of maternity admissions to general ICUs between 1/1/2021-1/1/2022 compared to EMC audit standards. Exclusion criteria: <22/40 gestation, >6/52 postpartum and admissions to our level 2 labour ward high dependency unit. Result(s): 25 patients were admitted to general ICUs over 12 months. Median age was 35-39 years, mean parity was 1. The commonest indication was obstetric haemorrhage (n = 10). 15 of 25 patients required level 3 care, median length of stay was 1.5 days. Documentation of daily obstetric MDT ward round was variable, as was mother-baby contact. 0 of 25 women were seen in obstetric anaesthesia clinic after discharge, only 1 received outpatient ICU follow-up. 50% of postnatal admissions (n = 14) had documentation of significant psychological distress. In response a local checklist was developed with key colleagues to support collaborative working and standardise quality care. It includes automatic referral into obstetric anaesthesia clinic and access to a novel perinatal mental health service. Discussion(s): A peripartum admission to ICU is highly likely to be experienced as traumatic [2]. The incidence of obstetric ICU admissions may increase in the context of greater clinical complexity of the UK pregnant population and COVID-19, whilst the non-anaesthetic ICU workforce may have little obstetric training. Obstetric anaesthetists are therefore uniquely skilled to facilitate quality resuscitation and referral to ICU, but gold-standard holistic care extends beyond admission. We believe regular audit and dedicated local care pathways which incorporate proactive debriefing and psychological health can improve the care of this important group of women.Copyright © 2023 Elsevier Ltd
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Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Objective(s): To provide a service that supports and empowers patients with their recovery from critical illness. Improving quality of life, speed of recovery and reducing longer term health care needs. Method(s): Referral criteria for the clinic included COVID-19 patients who received advanced respiratory support within intensive care and the high dependence unit. 8 weeks post discharge patients had a telephone appointment where ongoing symptoms could be identified. Advice around recovery, signposting to resources and onward referrals to appropriate specialities were provided. At 10 weeks post discharge patients had lung function tests and a chest X-ray which were reviewed by respiratory consultants. Based on the combination of these assessments, patients would be discharged or referred into the multidisciplinary team (MDT) follow-up clinic. The face to face clinic consisted of appointments with an intensivist, clinical psychologist, physiotherapist, and occupational therapist. Where needed patients would also be seen by a speech and language therapist or dietitian. Patients were seen only once in follow up clinic but again would be referred onto appropriate services within trust or the community, including but not exclusively community therapy services, secondary care services, SALT, dietetic or psychology clinics. Result(s): One of the key outcomes was the need for 147 onward referrals (an average of 1.13 referrals per patient). This included, 31 referrals to musculoskeletal physiotherapy outpatients for problems originating or made worse by their admission. 20 referrals to secondary care, including cardiology and ENT. 16 referrals to community occupational therapy, for provision of equipment, home adaptations and support in accessing the community. Subjectively, patient feedback was excellent. When asked what they felt was the most valuable thing they had taken from the clinic they reported: "Reassurance";"To know I'm not alone, others feel like this";"They listened to me and gave advice";"The ability to ask anything I wanted and the obvious kindness and support from all the clinicians I saw". Conclusion(s): Onward referral rates made by the follow-up clinic highlight the many issues faced by patients following discharge from ICU and hospital. With timely recognition and management, we can prevent a majority of these symptoms manifesting into chronic problems. This has the potential to lower the long-term burden on health care and improve quality of life for patients in both the short and long term. Without the follow-up clinic, these issues may have been missed or delayed. This reinforces the importance of the follow-up clinic and the need for ongoing investment.
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The proceedings contain 117 papers. The topics discussed include: informing local policy through an audit of the assessment, management and outcomes of intermediate and high-risk patients with pulmonary embolism;an initial exploration into the use of a novel virtual reality system to aid rehabilitation in intensive care;surprising chest radiograph- air in mediastinum;exploring tissue donation as part of end-of-life wishes- a duty of care following death on ICU?;the impact of deprivation on respiratory support unit outcomes in COVID-19 patients, and highlights from wave 2 data in Portsmouth;survey of attitudes towards end of life care as a tool in identifying areas for improvement;a quality improvement project regarding family communication within critical care;sleep promotion in a busy inner city high dependency unit;findings from a regional survey of critical care nursing staff focusing on retention and factors that influence wellbeing;and tracking functional recovery post critical illness.
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Introduction: Catestatin (CST) is a peptid with imunomodulatory, antiinflammatory, and antimicrobial activities. Acute coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus can cause a systemic disease range unpredictably from mild flu-like disease to multiple organ failure. Despite many studies and scientific interest for COVID 19, there is lack of information regarding correlation between serum CST levels and clinical course od COVID 19. There are only few studies investigated CST plasma levels at COVID 19 patients, but mostly at ICU-patients, and those studies revealed that COVID 19 patients release significant amounts of CST in the plasma and CST predicts a poor COVID-19 outcome. In our work the aim was to demonstrate plasma CST levels and correlation with clinical outcome in a group of severe COVID 19 patients admitted in non-ICU department. Method(s): The subjects were patients admitted during second surge of COVID 19 in April and May 2020 in non-ICU unit for COVID 19 patients (high dependency unit) in Infectology department of University Hospital Split, Croatia. The reason of admission was pulmonary infiltrates and COVID 19 positivity confirmed with nucleic acid test. In study were included 32 subjects (25 females, 7 males) (Table 1). An enzyme-linked immunosorbent assay was used for serum CST levels assessment. Result(s): We found significant positive correlation between serum CST levels and: C-reactive protein (r = 0.423, p = 0.008), D-dimers (r = 0.395, p = 0.013), hsTNT (high sensitivity troponin T) (r = 0.603, p < 0.001), proBNP (N-terminal-pro brain natriuretic peptide) (r = 0.569, p < 0.001), and hospitalisation days (r = 0.388, p = 0.014). There was significant difference between groups of participants with SOFA < 3 (n = 18) and SOFA > 3 (n = 14) in catestatin serum levels (7.25 +/- 3.66 vs. 11.05 +/- 9.52 ng/ml;p = 0.065). Conclusion(s): This study confirmed that serum CST levels could have important role as clinical prognostic parameter among non-ICU COVID 19 patients.
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Case report Background: With the continued rise of COVID-19 hospitalizations due to variants, breakthrough infections and vaccine hesitancy, current treatment regimens must be evaluated. Corticosteroids (CS) have been shown to decrease mortality in patients who require oxygen, especially those on invasive mechanical ventilation [Pinzo et al. 2021]. Steroids also lower intubation rates and transfer to intensive care units [Ahmad et al. 2021]. Methylprednisolone (MP) and dexamethasone (DEX) have been used for the treatment of COVID-19 patients with varied data on outcomes. Having obtained the patient's consent, the case below aims to highlight the use of both MP and DEX in the management of COVID-19 ARDS. Case: A 61-year- old male with a history of prostate cancer in remission presented with fever for 2 weeks and cough and dyspnoea for 2 days. He denied any gastrointestinal or neurological symptoms. He was unvaccinated to COVID-19 and reported recent exposure. On examination his oxygen saturation was 89% on room air and on auscultation, decreased air entry and crepitations were noted bilaterally. COVID-19 infection was confirmed by a positive nasopharyngeal swab. Lab investigations revealed an elevated C-Reactive Protein (CRP) of 26 mg/L, with a normal leukocyte count and renal function. Chest radiograph showed scattered consolidations bilaterally. A diagnosis of ARDS was made and non-invasive ventilation via dual oxygen therapy was initiated. He was later admitted to the High Dependency Unit (HDU) for continuous positive airway pressure ventilation. A tapering dose of MP was administered starting with a loading dose of 1g intravenously (IV) followed by 250 mg IV daily for 3 days and then 1 mg/kg twice daily until discharged from the HDU. MP was then switched to DEX 8mg IV daily and continued until supplemental oxygen was no longer needed. Serial blood draws noted a gradual decline in the CRP value. He was subsequently discharged and followed up in an outpatient setting. Conclusion(s): Current guidelines recommend fixed dosing regimens of CS in COVID-19 ARDS. This case demonstrates the effectiveness of using tapered MP followed by DEX in the management of COVID-19 ARDS. As such CS should not be a fixed dose regimen but rather tailored to the patient's requirements with dose adjustments guided by supplemental oxygen demand and CRP values. Further research is required on CS potency and dosing in COVID-19 associated pulmonary disease.
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Introduction: There is sparse literature on child and adolescent consultation liaison psychiatry during the COVID pandemic in India. Aims and objectives: To study the patterns of Child and Adolescent Consultation Liaison Psychiatry Services at a Covid-19 Designated Tertiary Medical College and Hospital Material(s) and Method(s): This was a retrospective chart-based study. Institutional Ethics Committee clearance was obtained. It was conducted from April 2020-21. The inclusion criteria comprised records of children and adolescents who were referred for consultation liaison services while they were admitted in COVID-19 designated tertiary hospital. Incomplete records were excluded. Data was tabulated and analysed with descriptive analysis. Result(s): We found 50 referrals out of which 42 records were complete and 8 incomplete were excluded. There were 47.62% boys and 52.38% girls with the mean age (10.8 years) All the 42 patients had been tested for COVID-19 at the time of intake admission as per hospital protocol. We found that 11.9% were confirmed cases of COVID-19 disease and 88.1% had tested negative for COVID-19 disease .The referrals were received mostly from Paediatric Intensive Care Unit (57.14%) followed by Paediatric ward (26.19%) and Special Paediatrics COVID High Dependency Unit (16.67%). The most common psychiatric disorder in COVID negative patients was adjustment disorder with deliberate self-harm (35.14%) and in COVID positive patients was delirium (60%) .The most commonly used medication were Escitalopram, Risperidone and Clonazepam. Conclusion(s): We conclude that psychiatric disorders were prevalent in child and adolescent patients admitted during COVID 19 pandemic and had a distinct profile.
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Background & Purpose: Pregnant women are at higher risk of developing severe COVID-19 compared with non-pregnant women, particularly in the third trimester1. Despite ongoing campaigns, the proportion of pregnant women vaccinated against SARS-CoV-2 is lower than in the general population2. The medium-term effects of COVID-19 during pregnancy are not well characterized. We report a cohort of pregnant women admitted to hospital with moderate-to-severe COVID-19. Method(s): Data from clinical records were retrospectively collected from all pregnant women admitted through the maternity assessment unit at St. Thomas' Hospital, between January 2021 and January 2022, due to COVID-19 requiring oxygen to maintain saturations >94%. Result(s): Fourteen women were identified (age=33.4+/-5.2 years;42.8% Caucasian;28.6% Black), requiring admission at 31+/-4.7 weeks gestation. Only two were double vaccinated (14.2%). Body mass index (BMI) was 27.2+/-6.4 kg/m2. Two women had concomitant co-morbidities (asthma and type 1 diabetes). They were managed in the obstetric high- dependency unit (level 1), barring one that required invasive ventilation for one day. The Delta variant was most commonly implicated (43%). All women requiring oxygen received steroids. Four women received Tocilizumab and three casirivimab/imdevimab;two received both. Four women were delivered by emergency Caesarean section due to maternal or fetal concerns, while the others continued their pregnancies. There was one late intrauterine death at 35 weeks. Women were followed-up for an average of six weeks. At follow-up in the obstetric medicine COVID-19 clinic, all women had complete resolution of COVID-19 on clinical examination, pulse oximetry and chest radiograph. Conclusion(s): In 14 pregnant women requiring admission to hospital for hypoxia secondary to moderate-to-severe COVID-19, concomitant co-morbidities and high BMI were not prevalent. Most were not vaccinated against SARS-CoV-2. Despite experiencing moderate-to-severe COVID-19, they had complete clinical and radiological resolution at six weeks follow-up.
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The COVID-19 Pneumonia with diabetic ketoacidosis is a dreadful health condition. Diabetic ketoacidosis is one of the severe metabolic complications and it can be precipitated by infection. We presented a case of 48 years female with no known comorbidities who presented with COVID-19 symptoms and with Diabetic Ketoacidosis. The case presented with elevated inflammatory markers, high anion gap metabolic acidosis with type I respiratory failure. During admission, the oxygen saturation had marked drop, later her improvement was steady followed by gradual tapering of the oxygenation. Marked improvement was noticed in the subsequent follow-up. COVID-19 infection can be precipitated by preexisting diabetes or newly diagnosed diabetes and the severity of COVID-19 infection is more pronounced in patients with diabetes mellitus, thus should be managed timely and accordingly. The scarce studies among the COVID-19 cases with diabetic ketoacidosis reflect the need for further studies for the availability of a wider range of information. Copyright © 2021, Kathmandu University. All rights reserved.
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BACKGROUND AND AIM: Bronchiolitis is the most common cause for paediatric respiratory hospital admissions in young children in the UK. Following the relaxation of international SARS-Cov-2 lockdown measures a potential national surge in cases was predicted. This highlighted the need to deliver an educational intervention to improve outcomes for these patients. Inter-Professional Education (IPE) was utilised in our hospital. METHOD(S): A team from the Adult Intensive Care Unit (AICU) and the Paediatric High Dependency Unit (PHDU) delivered an inter-professional teaching session focused on caring for the sick child with bronchiolitis. The patient journey was used as a framework to teach the core knowledge, skills and attitudes needed to clinically manage a child from the Emergency Department (ED) to the Intensive Care Unit (ICU). The session included a lecture about bronchiolitis, a paediatric skills tutorial and a simulation scenario. RESULT(S): 135 healthcare professionals from a range of disciplines involved in the care of children across the patient journey attended the teaching session which was delivered twelve times over a 3-month period. They completed a feedback questionnaire. One hundred and twenty-two (90%) reported an extremely high degree of satisfaction. Areas of development highlighted the following themes: gaining theoretical knowledge, understanding equipment, performing drug calculations, preparing for intubation, assessing the need for chest physiotherapy and understanding teamworking. CONCLUSION(S): The teaching sessions have been used as a template for the development of further planned IPE teaching across a range of paediatric clinical cases and presentations, developing a more collaborative practice-ready workforce for the care of the sick child.
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BACKGROUND AND AIM: PIMS-TS is a multisystem inflammatory condition which has high morbidity requiring intensive care, most commonly due to the need for cardiovascular support. AIM: Review of patients managed on high dependency unit with PIMS-TS - who required inotropic support and their echocardiographic findings. METHOD(S): This is a retrospective analysis of the echocardiogram and inotropic support for all children admitted to HDU with a diagnosis of PIMS-TS, from October 2020-December 2021. RESULT(S): Thirty (10%) patients were admitted to HDU from the 300 patients diagnosed over the 15month period. Echocardiograms were performed on days 1, 3 and 7 to assess the coronaries and myocardial dysfunction. Echocardiogram was often performed when patients were already on inotropic support. Fifteen (50%) patients did not require any respiratory support. All patients required fluid resuscitation, between 20mls/kg to 70mls/kg. Ten (33%) out of thirty patients showed reduced fraction shortening on echocardiogram reflecting myocardial dysfunction. Patients with reduced myocardial function on echocardiogram required a median of 40mls/kg of resuscitation fluid, no difference when compared to other patients. Of those with myocardial dysfunction 50% patients required double inotropic agents rather than single agents. Two patients have coronary arteries ectasia - both patients only needed single agents. CONCLUSION(S): Patients with coronary ectasia or myocardial dysfunction did not require more support than patients with normal coronaries. Echocardiography findings provided reassurance when managing children requiring vasoactive therapy on HDU but ultimately clinician decision-making was a driver on management rather than echocardiographic findings.
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BACKGROUND AND AIM: Alder Hey is a tertiary children's hospital in North-West England. The High Dependency Unit (HDU) is part of a large Critical Care unit consisting of 21 Paediatric Intensive Care beds and 15 HDU beds. All 120 HDU staff including medical, nursing and allied health professionals, were invited to become Wellbeing Champions and eleven members volunteered. Wellbeing Champions, supported by the two Clinical Psychologists, were introduced on HDU in February 2021 with the aim of promoting staff wellbeing, signposting to appropriate support services and developing innovative approaches to engage staff in conversations around their mental wellbeing. AIM: This evaluation aimed to determine utilisation of Wellbeing Champions and explore the perception of support offered. METHOD(S): A short-anonymised survey was circulated by email to all HDU staff and their responses collated. RESULT(S): 26 responses were returned. 92% of respondents were aware of the HDU Wellbeing Champions. 70% of respondents had taken part in psychology-led support session. 50% of respondents had received support from a HDU Wellbeing Champion. 88% of respondents felt supported at work during Covid-19 pandemic. 76% of respondents felt valued at work. Support and ease of accessibility were the top two descriptors for the Wellbeing Champions. CONCLUSION(S): The results show a positive response to the new role of the HDU Wellbeing Champions. HDU Wellbeing Champions have been a useful resource to support staff wellbeing and we aim to continue the staff support in the form staff support meetings every two weeks.
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BACKGROUND AND AIM: Alder Hey is a tertiary children's hospital in North-West England. Patients who require respiratory support in the form of non-invasive ventilation (NIV) are managed in the High Dependency Unit (HDU) jointly by the lead subspecialist teams and critical care service. Escalation and weaning strategies varied significantly between consultants. To provide consistent practice, a protocol was implemented with agreement from all the stakeholders and used from March 2020. AIMS: To evaluate the impact of using an agreed protocol on (1) ventilation days and (2) length of stay (LOS) in HDU. METHOD(S): A year's baseline data (March 2019-February 2020) was compared with the implementation year (March 2020-February 2021). Patients who deteriorated requiring invasive ventilation and those who progressed to long term ventilation were excluded. RESULT(S): In the pre-intervention year, 115 patients received 963 ventilation days over 1203 HDU days, with a mean of 8.4 ventilation days [IQR 5-9] and LOS of 10.5 days per patient. In the post-intervention year, 63 patients received 261 ventilation days over 667 HDU days, with a mean of 4.1 ventilation days [IQR 3-6] and LOS of 10.6 days per patient. CONCLUSION(S): COVID-19 lockdown restrictions almost halved the number of patients requiring NIV (63 vs 115), with reduced admissions across all specialties. Despite this, we demonstrated that unifying the management of NIV halved the ventilation days (4.1 vs 8.4) however, this reduction was not translated to a reduced length of stay on HDU.
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The proceedings contain 536 papers. The topics discussed include: burden and predictors of mortality of acute tropical infections in pediatric intensive care unit in a tertiary care teaching hospital in northern India;application of metagenomic next-generation sequencing (MNGS) in diagnosing pneumonia of children;serum vimentin predicts mortality in pediatric severe sepsis: a prospective observational study;impact of age and airway resistance on the reliability of peak inspiratory pressure to estimate plateau pressure in children;incidence of air leak syndrome in pediatric patients with SARS-CoV-2 pneumonia and respiratory failure;regional compliance guidance positive end-expiratory pressure render Pendelluft in pediatric acute respiratory syndrome;implementation of guidelines reduces non-invasive ventilation days for patients managed on high dependency unit;adequacy of energy and protein administration during nutritional support in Latin American critically ill children: a preliminary report of the NUTRIPIC study;and relationship between early enteral nutrition and clinical outcomes in critically ill pediatric populations: a systematic review.
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BACKGROUND: A significant proportion of children with SARs-CoV-2-related illnesses have been admitted to the Pediatric intensive care unit (ICU), although often for closer monitoring or concerns related to comorbidities or young age. This may have resulted in inappropriate ICU admissions, waste of resources, ICU overcrowding, and stress for young patients and caregivers. The Pediatric Intermediate Care Unit (IMCU) may represent an appropriate setting for the care of children whose monitoring and treatment needs are beyond the resources of a general pediatric ward, but who do not qualify for critical care. However, research on pediatric IMCUs and data on their performance is very limited. METHODS: We conducted a single-center retrospective study including all patients aged 0-18 with acute COVID-19 or multisystem inflammatory syndrome in children (MIS-C), admitted to a newly established stand-alone 12-bed pediatric IMCU at Gaslini Hospital, Genoa, Italy, between 1 March 2020 and 31 January 2022. Each IMCU room has a multiparameter monitor connected to a control station and can be equipped as an ICU room in case of need for escalation of care, up to ECMO support. IMCU and ICU are adjacent and located on the same floor, allowing a timely escalation from intermediate to critical care in the IMCU, with staff changes without the need for patient transfer. RESULTS: Among 550 patients hospitalized for acute COVID-19 or MIS-C, 106 (19.2%, 80 with acute COVID-19, and 26 MIS-C) were admitted to IMCU. Three of them (2.8%) required escalation to critical care due to the worsening of their conditions. Forty-seven patients (44%) were discharged home from the IMCU, while the remaining 57 (55%) were transferred to low-intensity care units after clinical improvement. CONCLUSIONS: In our study, the need for pediatric ICU admission was low for both acute COVID-19 patients (0.8%) and MIS-C patients (3.1%) compared to the literature data. The IMCU represented an adequate setting for children with COVID-19-related illness who need a higher level of care, but lack strict indications for ICU admission, thus preventing ICU overcrowding and wasting of economic and logistical resources. Further studies are needed to better assess the impact of an IMCU on hospital costs, ICU activity, and long-term psychological sequelae on children and their families.
Subject(s)
COVID-19 , Pandemics , Humans , Child , Retrospective Studies , COVID-19/epidemiology , COVID-19/therapy , SARS-CoV-2 , Critical Care/methods , Intensive Care Units , Intensive Care Units, PediatricABSTRACT
Introduction: The primary objective of this study was to assess whether proton pump inhibitor (PPI) use at pre-admission affected clinical outcomes among covid 19 hospitalised patients. Aims & Methods: Prospectively captured data was analysed to include patients (>18 year) at the hospital with covid 19 infection . PPI data was derived from hospital and primary care records and the study period is over between February 2020 and February 2021.Clinical outcomes of covid 19 patients who were on proton pump inhibitors preadmission were compared with that of covid 19 patients who were not on proton pump inhibitors at the same time. The primary endpoint of the study was 60-day mortality, intensive care unit admission, high dependency unit admission as well as the development of covid-19 complications. Additional endpoints included length of critical care admission. Result(s): A total of 305 patients were included in the study,158 were on proton pump inhibitors and 147 not on proton pump inhibitor at index admission. There were 101 males and 57 females with a mean age of 61.65 in the PPI group, and in the no-PPI group there were 92 males and 55 females with a mean age of 57.28. The mean length of stay was9.98 in the PPI group and 11.83 in the non-PPI group. There was a slightly increased mortality rate of 29.93% in the non-PPI group compared with 28.48 % in the PPI group. Intensive Care Unit (ITU) and High Dependency Unit (HDU) admissions were higher in the non-PPI group (64.62%,30.6% respectively) than in the PPI group (58.22%,27.21%). Complications were more common in the non-PPI group;84.3% had pulmonary complications,7.3% had thromboembolic complications. In the PPI group 72.15% had pulmonary complications which was over 10 % less than in the non-PPI group, 4.4% had thromboembolic complications which was 1.66 times less than the non-PPI group. Conclusion(s): In Our study PPI usage at index admission failed to show any worsening of outcomes in Covid 19 hospitalised patients, as opposed to recent published papers. This proposed causation needs further evaluation via well conducted prospective studies.
ABSTRACT
Introduction: SARS-CoV-2 infection can cause manifestations in multiple systems in the body.1 Haematological system is one such system which can be affected by both SARS-CoV-2 infection and critical illness. There are some studies that have shown that thrombocytopaenia can be associated in patients with SARS-CoV-2 infection.2 There is minimal data on its prevalence and outcome on critically ill patients. One study has shown that low platelet is associated with worsening of respiratory parameters and long term adverse outcome in critically ill.3 Identifying the presence of thrombocytopaenia and its consequences is important to manage critically ill COVID-19 patients. Objectives: To identify the prevalence and consequences of thrombocytopaenia and the presence of other causes of thrombocytopaenia in critically ill COVID-19 patients. Methods: A retrospective observational study was done in COVID designated Intensive care unit and High dependency unit in Base Hospital-Teldeniya, Sri Lanka. All patients with positive SARS-CoV-2 testing who later develops pneumonia with oxygen dependency and requiring ICU or HDU care were included in the study. Data was collected from patient records for the duration from 1st of January 2021 to 30th of June 2021. Their demographic data, data related to platelet counts and other causes leading to thrombocytopaenia were collected. Thrombocytopaenia was categorised as mild (platelet count 100-150× 109/L), Moderate (50-100×109/L) and severe (less than 50×109/L) Results: Total of 189 patients were admitted to either ICU or HDU requiring oxygen therapy due to COVID pneumonia during the study period. The mean age was 60.59 years with SD of 14.9. Age range was 16 to 94 years. 63 patients (33.33%) had thrombocytopenia with 8 (12.69%), 19 (30.15%) and 36 (57.14%) had severe, moderate, and mild thrombocytopenia respectively. 28 (44.4%) of the patients had low platelets at the time of admission. 28.5% of the patients had another cause for thrombocytopenia. Figure 1 shows other causes contributed to thrombocytopenia. Out of the patents who had thrombocytopenia 17 (26.9%) patients died. This was equal to 48.7% of all critical care deaths. The proportion of death among patients with thrombocytopenia was fund to be significant compared to that of patients with a normal platelet count. (p=0.045) Conclusions: Thrombocytopenia may arise due to multiple aetiologies in critically ill patients. Our study shows that at least 1/3 of the critically ill patients with COVID-19 infection develop thrombocytopenia at some point of their course of illness. It is important to have an insight on the progression of the illness and the outcome in order to plan discharge and follow up for these patients.