ABSTRACT
Introduction The COVID-19 pandemic created new challenges due to the high numbers and the high symptom burden of end-of-life patients on respiratory support. Methods We conducted an audit of end-of-life patients on the respiratory HDU wards at Whipps Cross Hospital between 17/09/2020-30/01/2021. Results 84 patients receiving respiratory support (in the form of CPAP and HFNT) died during that time at a mean age of 77 (95% CI 67-87) and median of 79 years. All but one death, which followed a cardiac arrest, were expected. The most common clinical indicator for a patient approaching end-of-life was hypoxia on respiratory support, which was documented in 36 (43%) patients, followed by terminal agitation in 27 (32%) patients. Objections to the medical assessment of terminal illness were raised by 3 families and in 1 case the patient had conflicting wishes. The average time between recognition of a terminal deterioration and death was 1.4 days with a median of 2 days. 29 (35%) patients did not have a specialist palliative care review primarily due to the rapid patient deterioration. 25 (30%) patients were not visited by a relative due to the infection risk. 72 (86%) patients were weaned off respiratory support and those who continued did so due to a medical or patient decision. Despite most patients (82%) receiving continuous subcutaneous infusions with an opiate and benzodiazepine most patients had persistent terminal symptoms: 51 (74%) on infusions had agitation and 38 (55%) were persistently breathlessness. Discussion This data highlights some of the major difficulties faced in caring for patients with COVID on respiratory support and approaching end of life. With the inevitably persisting nature of this pandemic and the possibility of future pandemics still present, it is vital to be able to offer guidance and multidisciplinary input to ensure comfort and dignity for these patients.
ABSTRACT
Background: Water retention leading to worsening congestion is a common reason for heart failure (HF) hospitalisation. Increases in aldosterone, due to increased secretion (driven by angiotensin and hyperkalaemia) and reduced degradation (due to hepatic dysfunction), contribute to congestion. Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in advanced HF. However, use of MRA is often limited by hyperkalaemia, renal dysfunction and hypotension. Hyperkalaemia can be corrected by potassium binding agents. Methods: An open-label, randomised, multi-centre (up to 100 UK sites) trial investigating the use of a potassium binding agent, patiromer, to facilitate higher doses of MRA for HF with worsening congestion requiring treatment with ≥80mg/day of furosemide (or equivalent). Patients are first entered on an unconsented screening-log (approved by the UK Health Research Authority) and then asked to consent to a registry (no exclusion criteria). If they agree, and are eligible (systolic blood pressure ≥90mmHg, eGFR ≥30mL/min/1.73 m2, no other terminal disease, no active infection or myocardial ischaemia), they are invited to participate in a randomised trial. Patients who consent for the trial enter a run-in phase of ≤35 days, when they receive ≤100mg/day of spironolactone. If serum potassium rises to >5.0mmol/L, the patient is randomised either to receive an MRA at guideline recommended doses or to have spironolactone increased ≤200mg/day, using patiromer to manage hyperkalaemia, providing eGFR remains ≥30mL/min and the patient does not become hypotensive. The primary outcome of the first phase of the trial (n = 400) is severity of congestion at 60-days but patients will be followed The RELIEHF Registry & Randomised Trial long-term for morbidity and mortality. An adaptive trial design allows recruitment to be increased up to 2.000 patients. Results: The conduct of the trial has been disrupted by COVID. As of January 2022, from 10 sites, >300 patients (40% women;median age 76 (65-83) years have been screened, >100 (37% women;median age 72 (62-80) years) have consented for the registry and >25 for the randomised trial. Of patients screened, about 50% were asked for registry-consent, of whom one third refused. The main reason for not asking was that the care-team considered it inappropriate due to patient frailty and/or cognitive dysfunction. Most patients who consented for the registry agreed, in principle, to participate in a randomised trial. Most patients have tolerated 100mg of spironolactone during the run-in period. Conclusions: For a high proportion of patients admitted to hospital with worsening HF, research staff do not deem it appropriate to approach them to ask for research consent. Most patients with HF who were asked to participate in research were willing to do so and to participate in a randomised trial, although a substantial proportion were not eligible for this trial. Of those who were, the majority tolerated spironolactone at a dose of 100mg/day.
ABSTRACT
Introduction: Evidence demonstrates that 25-33% of hospitalized patients with COVID-19 develop delirium [1,2], with rates up to 65% in critically ill patients [3]. Several potential reasons, including the use of deep sedation and invasive mechanical ventilation (IMV), as well as the restrictions to limit infection transmission, such as prohibition of family visits and minimal contact with health staff were identified [4]. Although factors and outcomes associated with delirium are well documented, limited data are available regarding severe COVID-19 patients. Aims: This study aims to estimate the rates of delirium in critically ill COVID-19 patients and to analyze factors that may be associated with its development, as well as to examine long-term outcomes. Methods: From March to May 2020 (in COVID-19 first wave), all adult patients (≥18y.o.) admitted due to COVID-19, in the Intensive Care Medicine Department (ICMD) of a University Hospital (CHUSJ), in Porto, Portugal, were assessed, unless they had a ICMD length of stay (LoS) ≤24h, terminal illness or major sensory loss or inability to communicate at the time of follow-up. Participants were evaluated during a scheduled telephone follow-up appointment with a comprehensive protocol, including: Six-item Cognitive Impairment Test (6CIT) (cognitive impairment);Patient Health Questionnaire (PHQ-9) (symptoms of depression);General Anxiety Disorder (GAD-7) (symptoms of anxiety);and EuroQol five-dimension five-level questionnaire (EQ-5D-5L) (health-related quality of life-HRQoL), which includes EQ-Visual Analogue Scale (EQ-VAS) (global health status patient perception). Data on acute illness severity, sedative/analgesic drugs use, respiratory support and major complications (including delirium, nosocomial infections and difficulty weaning from mechanical ventilation) during ICMD stay, were obtained from hospital electronic records review. Patients with and without delirium were compared, using Mann-Whitney test for continuous variables, and Chi-square or Fisher tests for paired categorical variables (significance level of 0.05). This study is part of an ongoing larger multidisciplinary research project (MAPA-Mental Health in Critically ill patients with COVID-19). Results: The sample included 59 patients (median age=65 years;66.1% male). Delirium was registered in almost half of the sample (49.2%). Patients with delirium were significantly older (median=72 vs. 62;p=0.010) and presented more nosocomial infections (82.8% vs 53.3%;p=0.032) particularly ventilator-associated pneumonia (75.9% vs. 33.3%;p=0.003). Also, they were significantly more likely to be deeply sedated (89.7% vs 60%;p=0.021), more often required IMV (89.7% vs 60%;p=0.021). Moreover, those with delirium stayed longer in the hospital (median=67 vs 37 days;p=0.014). Concerning HRQoL, assessed at follow-up appointment, patients who have developed delirium reported more problems in self-care (48.3% vs 10%;p=0.003) and in everyday activities (79.3% vs 53.3%;p=0.035) after hospital discharge. Nevertheless, no statistically significant differences were found for cognitive impairment, symptoms of anxiety and depression. Conclusions: Delirium was common in this critically ill COVID-19 sample, namely in older patients, who have been deeply sedated, invasively ventilated or had major ICU complications. It was associated with longer hospital stay and worse HRQoL. Recognizing potential associated factors will allow the identification of high-risk patients that should be targeted for early screening with preventive interventions to minimize the adverse outcomes associated to delirium in critical COVID-19 patients. No conflict of interest