Indirect Calorimetry Critical in Identifying Early Hypometabolism and Late-Stage Hypermetabolism in Post-surgical Patients

Background: Indirect calorimetry (IC) is the gold-standard procedure for measuring resting energy expenditure (REE) in hospitalized patients. Predictive energy equations commonly use static variables and rarely account for changes in REE throughout hospitalization. We hypothesize that predictive equations are typically inaccurate in surgical intensive care unit (ICU) patients. More specifically, we hypothesize that predictive equations often overpredict measured resting energy expenditure (mREE) in early-stage critical illness and underpredict needs later in surgical ICU stay, leading to over-/under-feeding and associated complications. Method(s): This prospective observational trial enrolled surgical ICU patients who underwent emergent or urgent operations for abdominal trauma, perforated viscus, or ischemic bowel within 72 hours of their surgical procedure. Metabolic assessments were performed using the COSMED Q-NRG + Metabolic Monitor ventilator, mask, and canopy at regular intervals during and post ICU admission until hospital discharge. Measurements were categorized by post-surgical intervention ICU admission days 0-3, 4-7, 8-14, 15-21, and 22-28. Patients with multiple measurements taken during the same time interval were averaged. mREE reported in calories (kcal) per kilogram (kg) of admission body weight per day were compared in obese (BMI > 30 kg/m2) and non-obese (BMI < 30 kg/m2) subgroups. Compared to IC, the Mifflin St Jeor (MSJ) equation determined predicted REE using ICU admission anthropometrics. Data are reported as mean+/-standard error of the mean (SEM) and median (interquartile range), and a two-sided p-value of <0.05 was determined significant. Result(s): In total, 18 surgical ICU patients who contributed 47 IC measurements were included in the analysis (Table 1). Most measures were obtained within the first 7 days of post-surgical ICU admission (72%). mREE peaked between days 8-14 in obese and non-obese subgroups (20.6 vs 28.5 kcal/kg;p = 0.02) and was lowest during 0-3 days of post-surgical ICU admission in both groups. Across all 5-time intervals, average kcal/ kg ranged from 14.7-20.6 among obese patients and from 20.1-28.5 in non-obese counterparts (Table 2). Non-obese patients had higher mREE per kg of body weight than obese patients at all time points (Figure 1). MSJ over-predicted mREE during the first 7 days post ICU admission in non-obese patients and within the first 3 days in obese patients and underpredicted mREE in both groups thereafter. Conclusion(s): Equations such as MSJ over- and under-predict mREE in post-operative surgical ICU patients depending on the days elapsed since post-surgical ICU admission. ASPEN's current guideline recommendation of 12-25 kcal/kg may also underfeed post-surgical populations while 25 kcal/kg may not support hypermetabolism among non-obese patients seen in week 2 following post-surgical ICU admission. Alternatively, MSJ multiplied by a 1.2 activity factor may account for hypermetabolism during this time. Notably, non-obese patients experienced greater hypermetabolism than obese patients during week 2 which is consistent with our previously published data in mechanically ventilated COVID- 19 patients. Additionally, the striking dichotomy between the mREE of obese and non-obese patients at all post-surgical time points should be considered in the clinical care of patients. Ultimately, IC remains the gold-standard means of measuring REE and is a critical tool to capture the dynamic nature of energy requirements in post-surgical populations as weight-based and predictive equations continually fall short. (Table Presented).

Retrospective study of risk factors for mortality in critically ill patients with COVID-19

Background: Mortality associated with COVID-19 varies in various reports, with minimal data on the factors associated with in-hospital mortality. Objective: To identify the risk factors for in-hospital death of patients with COVID-19 in an intensive care unit (ICU) in Qatar. Methods: A retrospective observational study of patients confirmed with COVID-19 and admitted to the medical-surgical ICU at The Cuban Hospital was carried out from April 12, 2020, to September 12, 2020. From patients' electronic medical records, demographic, clinical, laboratory, and radiology data was collected. Results: 275 patients with COVID-19 were admitted to the ICU, and 32 (11.6%) died. 56.1% were men, and the mean age was 52.2 years. According to the univariate analysis, patients with diabetes mellitus with end-organ damage (37.5%), cardiovascular disease (31.3%), dementia (9.4%), kidney disease (28.1%), chronic obstructive pulmonary disease (31.3%), and higher Charlson index had higher mortality. According to the multivariate analysis, an increase of mortality risk by 9% was observed for each additional year of age (Odds ratio [OR] 1.09;95% confidence interval [CI] 1.04-1.14), patients on mechanical ventilation (OR 27.33;95% CI 3.21-232.46), and those with adult respiratory distress (OR 15.85;95% CI 1.45-172.82) and elevated procalcitonin (OR 7.30;95% CI 1.25-42.58), and the PiO2/FiO2 ratio between 100 and 299 decreased the risk of death by 92% (OR 0.08;95% CI 0.02-0.39), in comparison to a PiO2/FiO2 ratio less than 100 or greater than 300. Conclusion: The study provides evidence about the risk of mortality among COVID-19 patients with a significant contribution of age, respiratory failure, and co-infections.

Fluid Management 100% Non-invasive for COVID Patient in ICU by Sterling Stroke Volume Guided Resuscitation ABS0007)

Aim and objective: Non-invasive fluid management in COVID shock patient in ICU. Materials and methods: Our hospital use sterling stroke volume-guided fluid management for COVID shock patients. In the University of Kansas health system evaluated 200 cases for stroke volume (sv) guided fluid resuscitation this study showed ICU length of stay reduced by 2.89 days, risk of mechanical ventilation reduced by 51%, initiation of acute dialysis therapy reduced by 13.2%, this system saves an estimated $14498 per treated patient this system use Bioreactance technology to measure sv in shock patient in two sensor place above the heart and two below the heart and continue measurement of sv done in 48 seconds. Validation studies over 500 patient published clinical studies result are same all major technologies (Swan Ganz, pulse contour, Doppler, fick) and over 100 peer-reviewed publications are there. This technique is 100% non-invasive accurate flexible-this sterling system use PLR or bolus test for sv management we are using in emergency for our Rapid Response Team in MICU OT for perioperative fluid management and all surgical ICU. Results: 1 ICU length of stay reduced by 2.89 days 2 risk of mechanical ventilation reduced by 51% 3 initiations of acute dialysis therapy reduced by 13.5% 4 save an estimated $14498 per treated patient. Conclusion: Sterling monitoring platforms use unique, patented Bioreactance technology to take measures continuously and precisely, and they require only four easy to place sensor pads. The sensors can be- anywhere on the chest two above the heart and two below the heart to create a box around the heart we advise sterling stroke volume guided fluid management in emergency medical ICU surgical ICU and perioperative and RRT for accurate fast and 100% non-invasive technique for COVID patient.

Administration of Inhaled Nitric Oxide for COVID and Non-COVID Acute Respiratory Distress Syndrome in the Intensive Care Unit: A Retrospective Cohort Analysis

Rationale: Inhaled nitric oxide (iNO) has been used for several years as an adjunctive therapy for improving oxygenation in adults with acute respiratory distress syndrome (ARDS). Recently, several authors have suggested iNO as a useful therapy in the setting of ARDS secondary to COVID-19. Nevertheless, there remains unclear evidence regarding the utility of iNO in adults with both COVIDand non-COVID-associated ARDS, and still less evidence regarding who might benefit from this costly treatment. We sought to investigate the effect of iNO on oxygenation in adults with ARDS secondary to both COVID and non-COVID etiologies, evaluate the difference in outcomes between patients with and without COVID receiving iNO, and explore the cost associated with the administration of iNO in an intensive care setting. Methods: We conducted a retrospective cohort study in the medical and surgical intensive care units at a tertiary-care academic medical center. All patients with ARDS who received iNO over a two-year period were considered for inclusion. Exclusion criteria included prior pulmonary hypertension already on a pulmonary vasodilator, initiation of iNO prior to arrival at our institution, or lack of an arterial blood gas immediately before and after the initiation of iNO. Outcomes measured included change in PaO2/FiO2, 30-day mortality, and the cost of iNO administration. Results: 177 consecutive patients were evaluated, of whom 108 met criteria for inclusion. Change in PaO2/FiO2 ratio following iNO administration was significantly smaller in patients with COVID than in patients with non-COVID ARDS (22.9% vs 60.4%, p = 0.002). Among COVID patients there was no significant improvement in PaO2/FiO2 following the administration of iNO (95% CI [-64%, 108%]). A response in PaO2/FiO2 (defined as >10% increase) was not associated with 30-day mortality (p = 0.29). The average cost of iNO administration among all patients was $66597.79, and there was a trend toward greater cost in patients deemed P/F responders ($76433 vs $53195, p = 0.07). There was no difference in these outcomes in patients receiving iNO for refractory hypoxia versus patients receiving iNO for RV dysfunction. Conclusions: In this study, iNO administration incurred an average cost of $66597.79 per patient and showed no association with improved PaO2/FiO2 ratio in patients with COVIDARDS. PaO2/FiO2 changes in COVID patients were significantly smaller than in non-COVID patients. An increase in PaO2/FiO2 > 10% was a poor predictor of 30-day mortality but did show a trend toward increased cost burden.

Neuromuscular electrical stimulation prevents the skeletal muscle weakness in patients with severe COVID-19 associated with sepsis and septic shock: a case series

Introduction: Neuromuscular electrical stimulation (NMES) results on muscle strength and functionality in patients with severe coronavirus disease 2019 (COVID-19) associated with sepsis and septic shock are unknown. Methods: Patients with severe COVID-19 associated with sepsis or septic shock were selected. The NMES intervention was performed on 7 consecutive days in a daily session of 40 min (frequency of 100 Hz and a pulse of 350 μs). Electrodes were positioned in the vastus medialis and vastus lateralis muscles, and inguinal region. The outcome measures were the femoris cross-sectional area (RF-CSA), thickness of the anterior compartment of the quadriceps muscle, rectus femoris echogenicity, International Classification of Functioning, Disability, and Health (ICF)-muscle strength, Physical Function ICU Test-scored (PFIT-s), Morton Mobility Index (DEMMI), and the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS). The patients were evaluated on days 1, 5, and 8. Results: The RF-CSA area decreased significantly (- 16.9%;p < 0.05) from days 1 to 8, but showed maintenance of the thickness of the anterior compartment of the quadriceps muscle (- 3.20%;p = 0.3) from days 1 to 8. These patients showed a reduction of 2.1% per day in the rectus femoris cross-sectional area and 0.3% per day in the thickness of the anterior compartment of the quadriceps muscle during 8 days. Patients showed maintenance of the echogenicity (1.3%;p = 0.8) from days 1 to 8 with an increase of 0.16% per day. All patients showed an increase in the MRC score and reduction of the ICF-muscle strength, meaning improved muscle strength from days 1 to 8 (p < 0.05). The PFIT-s increased from days 1 to 5 and improved until day 8 compared to day 5 (p < 0.05). DEMMI and SOMS scores increased on day 8 compared to days 1 and 5 (p < 0.05). Conclusions: NMES showed a protective effect on muscle strength and improve the functionality of patients with several COVID-19 associated with sepsis and septic shock.

Prediction of Bloodstream Infection Events and Infections of the Lower Respiratory Tract in ICU Patients: Expected and Unexpected Infections

Background. Bloodstream infection (BSI) - Central and Non-Central Line Associated - and infections of the lower respiratory tract (RESP) - pneumonia and non pneumonia lower respiratory infections - are some of the main causes of unexpected death in Intensive Care Units (ICUs). Although the leading causes of these infections are already known, risk prediction models can be used to identify unexpected cases. This study aims to investigate whether or not it is possible to build multivariate models to predict BSI and RESP events. Methods. Univariate and multivariate analysis using multiple logistic regression models were built to predict BSI and RESP events. ROC curve analysis was used to validate each model. Independent variables: 29 quantitative parameters and 131 categorical variables. BSI and RESP were identified using Brazilian Health Regulatory Agency protocols with data collected between January and November 2020 from a medical-surgical ICU in a Brazilian Hospital. Definitions: if an infection is 5% or less likely to occur according to the model used and it eventually occurs, it will be classified as "unexpected", or else, if an infection is 10% or less likely to occur, it will be classified as "probably unexpected". Otherwise, infections will be classified as "expected". Patients with a 30% or more risk for BSI or RESP will be classified as "high risk". Results. A total of 1,171 patients were accessed: 70 patients with BSI (95% confidence interval [CI], 3.1%-5%), 66 patients with RESP (95% CI, 2.9%-4.7%), 235 deaths (95% CI, 11.8%-14.9%). Of the 160 potential risk factors evaluated, logistic models for BSI and RESP identified respectively five and seven predictors (Tables 1 and 2, and Figure 1). Patients admitted to the ICU with Covid-19 had a three fold BSI risk and five times more RESP risk than patients without this diagnosis. Conclusion. The built models make possible the identification of the expected infections and the unexpected ones. Three main course of actions can be taken using these models and associated data: (1) Before the occurrence of BSI and RESP: to place high risk patients under more rigorous infection surveillance. (2) After the occurrence of BSI or RESP: to investigate "unexpected" infections. (3) At discharge: to identify high risk patients with no infections for further studies.

Phenobarbital versus benzodiazepines for alcohol withdrawal management: A retrospective comparison

INTRODUCTION: Benzodiazepine (BZD)-based regimens are first-line therapy for alcohol withdrawal syndrome (AWS). Phenobarbital (PHB) is an alternative treatment but with limited guidance for use. We evaluated the efficacy and safety of PHB compared to BZD for AWS. METHODS: This was a single-center retrospective cohort study. Adult patients were included if they received BZD symptom-triggered protocol or PHB monotherapy for management of AWS and excluded if they received both therapies, were COVID positive, or died within 48 hours of hospital admission. Data collection started on December 31, 2020 and data were collected in reverse chronological order until target sample size was attained. Primary endpoint evaluated was development of AWS-related complications. Secondary endpoints included need for adjunct therapy, duration of mechanical ventilation, hospital and ICU length of stay (LOS), and hospital mortality. Safety endpoints included incidence of hypotension, bradycardia, and significant respiratory depression. RESULTS: 100 patients out of 164 screened patients were included, with 50 patients in PHB and 50 patients in BZD cohorts. Baseline characteristics were similar, except more patients in PHB cohort had history of alcohol dependence (82% vs. 56%, p< 0.001). Majority of BZD patients were in medical ICU while PHB patients were in surgical ICU. Baseline median MINDS scores were similar [PHB, 10 (5-16) vs. BZD, 11 (5-15), p=0.99]. Median (IQR) phenobarbital loading dose given was 14.8 (12.8-15.9) mg/kg followed by maintenance dose 356 (259-389) mg with a duration of 5 (3-5) days. Total lorazepam-equivalent dose given was 19.3 (5.0-44.0) mg with a duration of 4 (3-5) days. There was no significant difference in the primary endpoint [4 (8%) vs. 4(8%), p=1.00]. MINDS score post therapy initiation was significantly higher in BZD cohort [5 (1-14) vs. 15 (8-19), p< 0.001]. Patients who received PHB therapy had significantly shorter ICU LOS in days [3 (1-7) vs. 5 (2-6), p< 0.001] but no difference in hospital LOS [PHB, 8 (5-13) vs. BZD, 7 (5-12), p=0.37]. There were no significant differences in other secondary and safety endpoints. CONCLUSION: In this study there was no difference in efficacy or safety of PHB in management of AWS compared to BZD. Larger studies to confirm PHB as first-line AWS therapy are warranted.

Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS

INTRODUCTION: With the COVID pandemic, and recently updated practice guidelines for neuromuscular infusion (NMBI) use during ARDS, the practices/perceptions of ICU physicians regarding NMBI use during ARDS may not be evidence-based. METHODS: We developed, tested, and electronicallyadministered a questionnaire (9 questions/70 subquestions) to medical and surgical ICU fellow and attending physicians at 3 geographically-diverse U.S. health systems (U Arizona, U Chicago, Mass General Brigham). The IRB-approved questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2 < 150) with critical hypoxemia where dyssynchrony causes were addressed and PEEP optimized. Weekly reminders were sent twice. RESULTS: Respondents [173/342(50.5%)] primarily worked as an attending 117(75%) in a medical ICU 94(60%) for 12±8 weeks/year. COVID+ ARDS patients were twice as likely to receive a NMBI (56±37 vs. 28±19%;p< 0.01). Respondents somewhat/strongly agreed a NMBI: should be reserved until after a trial of deep sedation 142 (82%) or proning 59 (34%), be dose-titrated based on trainof- four monitoring 107(62%);and effectively reduced dyssynchrony 149(86%), plateau pressure 106(62%) and barotrauma 102(60%). Few respondents [23(18%)] somewhat/strongly agreed a NMBI should be initiated at ARDS onset 20(12%) or administered at a fixed-dose 12(7%). Only 2/14 potential NMBI risks were frequently reported to be of high/very high concern: prolonged muscle weakness during steroids 135(79%) and paralysis awareness due to inadequate sedation 114(67%). Only absence of dyssynchrony 146(87%) was frequently reported to be a very/extremely important NMBI titration target. Train-of-four 78(46%) and BIS 39(23%) monitoring and plateau pressure 67(40%) or PaO2:FiO2 64(38%) evaluation were deemed less important. Absence of dysschrony 93(56%) and use ≥48 hours 87(53%) were preferred NMBI stopping criteria. For COVID+ patients, few felt reduced self-extubation and COVID aerosolization during reintubation 16(9%) or reduced ventilator adjustments 7(5%) were very/extremely important reasons for NMBI use. CONCLUSIONS: Most physicians agree NMBI infusions in ARDS should be reserved until after trials of deep sedation. Paralysis awareness and prolonged muscle weakness are the greatest NMBI use concerns. Unique considerations in COVID+ ARDS patients exist.

Evaluation of expanded pharmacist coverage in critical care areas during COVID-19

Background: During the first wave of the COVID-19 pandemic, an increased need for critical care pharmacist (CCP) coverage in the two medical/surgical intensive care units (ICUs) at the Queen Elizabeth II Health Sciences Centre (QEII HSC) in Halifax, Nova Scotia was identified. Description: CCP coverage was expanded in two medical/surgical ICUs from 8 hours per day, 5 days per week excluding holidays to 8 hours per day, 7 days per week including holidays. Action: Workflow within the pharmacy department was rearranged so that two CCPs, on a rotating schedule, provided dedicated clinical coverage to each ICU seven days a week. CCPs were not responsible for dispensary coverage during this time period. Evaluation: A 22 question survey was developed by the research team and distributed to all health care providers (HCP) who work in the medical/surgical ICUs. Survey questions solicited HCP perceptions and opinions on the impact of expanded CCP coverage;importance of 25 evidenceinformed CCP activities was assessed via 5-point Likert scale. Clinical pharmacist output, reported as the number of drug-therapy problems (DTPs) addressed over a 6-week period, was retrospectively evaluated. The majority of respondents agreed/strongly agreed with the following: CCP are integral members of the multidisciplinary healthcare team, CCP play an important role in improving patient outcomes, CCP presence in the unit and on patient care rounds allows HCP to concentrate on their own professional responsibilities, and that the expanded CCP coverage improved patient care. The majority of respondents categorized 23 of the 25 CCP activities as very important. During the 6-week time period, four CCPs addressed 798 DTPs for 140 discreet patients: an average of 5.7 DTPs per patient. Implications: HCPs felt that expanded CCP coverage improved patient care and that evidence-informed CCP activities were very important. Given the perceived impact of CCP in the ICU, novel staffing models are being explored to optimize CCP coverage.

Ethical Issues in Intensive Care Units during the COVID-19 Pandemic.

Coronavirus disease-2019 (COVID-19) outbreak began in December 2019 in China and has spread rapidly across the world. The healthcare system of each country has been affected from this situation. Undoubtedly, during this period several ethical issues have been raised. In this commentary, we aimed to make a discussion regarding the ethical issues that could be raised in the treatment of patients in the intensive care units during the COVID-19 pandemic. The objective of this article is to contribute to the wide current discussion regarding the appropriate measures that should be taken to protect the health and ensure the safety of the staff that comes in close contact with patients who are suspected or confirmed of having COVID-19. How to cite this article: Karampelias V, Spanidis Y, Roussakou E. Ethical Issues in Intensive Care Units during the COVID-19 Pandemic. Indian J Crit Care Med 2020;24(9):855-856.