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2.
Medicine (Baltimore) ; 100(19): e25771, 2021 May 14.
Article in English | MEDLINE | ID: covidwho-2190997

ABSTRACT

INTRODUCTION: Corona virus disease-2019 (COVID-19) presents primarily with respiratory symptoms. However, extra respiratory manifestations are being frequently recognized including gastrointestinal involvement. The most common gastrointestinal symptoms are nausea, vomiting, diarrhoea and abdominal pain. Gastrointestinal perforation in association with COVID-19 is rarely reported in the literature. PATIENT CONCERNS AND DIAGNOSIS: In this series, we are reporting 3 cases with different presentations of gastrointestinal perforation in the setting of COVID-19. Two patients were admitted with critical COVID-19 pneumonia, both required intensive care, intubation and mechanical ventilation. The first one was an elderly gentleman who had difficult weaning from mechanical ventilation and required tracheostomy. During his stay in intensive care unit, he developed Candidemia without clear source. After transfer to the ward, he developed lower gastrointestinal bleeding and found by imaging to have sealed perforated cecal mass with radiological signs of peritonitis. The second one was an obese young gentleman who was found incidentally to have air under diaphragm. Computed tomography showed severe pneumoperitoneum with cecal and gastric wall perforation. The third case was an elderly gentleman who presented with severe COVID-19 pneumonia along with symptoms and signs of acute abdomen who was confirmed by imaging to have sigmoid diverticulitis with perforation and abscess collection. INTERVENTIONS: The first 2 cases were treated conservatively. The third one was treated surgically. OUTCOME: Our cases had a variable hospital course but fortunately all were discharged in a good clinical condition. CONCLUSION: Our aim from this series is to highlight this fatal complication to clinicians in order to enrich our understanding of this pandemic and as a result improve patients' outcome.


Subject(s)
COVID-19/complications , Gastrointestinal Tract/injuries , Rupture, Spontaneous/etiology , Adult , Aged , Critical Care/organization & administration , Humans , Male , Pandemics , Rectum/injuries , SARS-CoV-2 , Stomach/injuries
3.
Infect Control Hosp Epidemiol ; 43(7): 834-839, 2022 Jul.
Article in English | MEDLINE | ID: covidwho-2185189

ABSTRACT

OBJECTIVES: An accurate estimate of the average number of hand hygiene opportunities per patient hour (HHO rate) is required to implement group electronic hand hygiene monitoring systems (GEHHMSs). We sought to identify predictors of HHOs to validate and implement a GEHHMS across a network of critical care units. DESIGN: Multicenter, observational study (10 hospitals) followed by quality improvement intervention involving 24 critical care units across 12 hospitals in Ontario, Canada. METHODS: Critical care patient beds were randomized to receive 1 hour of continuous direct observation to determine the HHO rate. A Poisson regression model determined unit-level predictors of HHOs. Estimates of average HHO rates across different types of critical care units were derived and used to implement and evaluate use of GEHHMS. RESULTS: During 2,812 hours of observation, we identified 25,417 HHOs. There was significant variability in HHO rate across critical care units. Time of day, day of the week, unit acuity, patient acuity, patient population and use of transmission-based precautions were significantly associated with HHO rate. Using unit-specific estimates of average HHO rate, aggregate HH adherence was 30.0% (1,084,329 of 3,614,908) at baseline with GEHHMS and improved to 38.5% (740,660 of 1,921,656) within 2 months of continuous feedback to units (P < .0001). CONCLUSIONS: Unit-specific estimates based on known predictors of HHO rate enabled broad implementation of GEHHMS. Further longitudinal quality improvement efforts using this system are required to assess the impact of GEHHMS on both HH adherence and clinical outcomes within critically ill patient populations.


Subject(s)
Cross Infection , Hand Hygiene , Critical Care , Cross Infection/prevention & control , Electronics , Guideline Adherence , Humans , Infection Control , Ontario
4.
6.
Chest ; 162(1): 256-264, 2022 07.
Article in English | MEDLINE | ID: covidwho-2158581

ABSTRACT

BACKGROUND: In 2019, the United States experienced a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). More than one-half of these patients required admission to an ICU. RESEARCH QUESTION: What are the recent literature and expert opinions which inform the diagnosis and management of patients with critical illness with EVALI? STUDY DESIGN AND METHODS: To synthesize information critical to pulmonary/critical care specialists in the care of patients with EVALI, this study examined data available from patients hospitalized with EVALI between August 2019 and January 2020; reviewed the clinical course and critical care experience with those patients admitted to the ICU; and compiled opinion of national experts. RESULTS: Of the 2,708 patients with confirmed or probable EVALI requiring hospitalization as of January 21, 2020, a total of 1,604 (59.2%) had data available on ICU admission; of these, 705 (44.0%) were admitted to the ICU and are included in this analysis. The majority of ICU patients required respiratory support (88.5%) and in severe cases required intubation (36.1%) or extracorporeal membrane oxygenation (6.7%). The majority (93.0%) of these ICU patients survived to discharge. Review of the clinical course and expert opinion provided insight into: imaging; considerations for bronchoscopy; medical treatment, including use of empiric antibiotics, antiviral agents, and corticosteroids; respiratory support, including considerations for intubation, positioning maneuvers, and extracorporeal membrane oxygenation; and patient outcomes. INTERPRETATION: Review of the clinical course of patients with EVALI requiring ICU admission and compilation of expert opinion provided critical insight into pulmonary/critical care-specific considerations for this patient population. Because a large proportion of patients hospitalized with EVALI required ICU admission, it is important to remain prepared to care for patients with EVALI.


Subject(s)
Electronic Nicotine Delivery Systems , Lung Injury , Vaping , Critical Care , Humans , Lung , Lung Injury/chemically induced , Lung Injury/epidemiology , United States/epidemiology , Vaping/adverse effects
7.
Adv Exp Med Biol ; 1353: 81-89, 2021.
Article in English | MEDLINE | ID: covidwho-2157936

ABSTRACT

INTRODUCTION: A novel coronavirus was identified in the last days of 2019, which caused a cluster of pneumonia cases in Wuhan, China. Since Coronavirus Disease 2019 (COVID-19) was identified and caused a pandemic, morbidity and mortality caused by acute respiratory distress syndrome (ARDS) and other disease-related complications are being struggled against in intensive care units (ICUs). METHODS: In this chapter, clinical features, epidemiological properties, and management of critically ill COVID-19 patients aree discussed with the support of recent literature. RESULTS: Since there isn't a definitively proven treatment for the disease, the management of critical illness is adequate supportive medical care based upon the basic principles of critically ill patient management. Supportive oxygen therapy modalities and mechanical ventilation strategies are most challenging issues during the course of the disease in ICUs. Additionally, using combinations of investigational drugs is beneficial for the management of the disease. Because the disease is highly contagious, infection control measures to stop the disease's nosocomial spread are crucial. CONCLUSION: The basis of management in critically ill COVID-19 patients is providing adequate ICU care. Additionally, a combination of promising treatment strategies specific to the disease may be beneficial and should be monitored carefully.


Subject(s)
COVID-19 , Critical Care , Critical Illness , Humans , Intensive Care Units , Pandemics , Respiration, Artificial , SARS-CoV-2
9.
Curr Opin Crit Care ; 28(6): 660-666, 2022 Dec 01.
Article in English | MEDLINE | ID: covidwho-2152245

ABSTRACT

PURPOSE OF REVIEW: To review the clinical problem and noninvasive treatments of hypoxemia in critically-ill patients with coronavirus disease 2019 pneumonia and describe recent advances in evidence supporting bedside decision making. RECENT FINDINGS: High-flow nasal oxygen and noninvasive ventilation, along with awake prone positioning are potentially helpful therapies for acute hypoxemic respiratory failure. High-flow nasal oxygen therapy has been widely implemented as a form of oxygen support supported by prepandemic randomized controlled trials showing possible benefit over noninvasive ventilation. Given the sheer volume of patients, noninvasive ventilation was often required, and based on a well conducted randomized controlled trial there was a developing role for helmet-interface noninvasive. Coupled with noninvasive supports, the use of awake prone positioning demonstrated physiological benefits, but randomized controlled trial data did not demonstrate clear outcome superiority. SUMMARY: The use of noninvasive oxygen strategies and our understanding of the proposed mechanisms are evolving. Variability in patient severity and physiology may dictate a personalized approach to care. High-flow nasal oxygen may be paired with awake and spontaneously breathing prone-positioning to optimize oxygen and lung mechanics but requires further insight before widely applying to clinical practice.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , Humans , COVID-19/therapy , Respiratory Insufficiency/therapy , Oxygen Inhalation Therapy , Hypoxia/therapy , Oxygen , Critical Care , Lung , Randomized Controlled Trials as Topic
11.
Rev Assoc Med Bras (1992) ; 68(10): 1458-1463, 2022.
Article in English | MEDLINE | ID: covidwho-2140983

ABSTRACT

OBJECTIVE: This study aimed to describe sepsis progression in critical COVID-19 patients using the SOFA score and investigate its relationship with mortality. METHODS: Three researchers collected and analyzed retrospective clinical and laboratory data found in electronic health records from all patients admitted to a severe COVID-19 exclusive intensive care unit from March 2020 to October 2020. Mixed-effect logistic regression was used to evaluate SOFA (Sepsis-3) score variables as mortality prediction markers, while Kaplan-Meier survival curves were used to compare mortality between groups of patients. Cox proportional hazard models were used to further stratify mortality association between variants. RESULTS: A total of 73 patients were included. Temporal COVID-19-related sepsis progression analysis indicates difference in degrees and timing between different organ dysfunction over time. Sepsis-3 Cardiovascular Dysfunction characterized by severe hypotension added to the use of any vasopressor drugs was the only parameter associated with in-hospital death during the first 5 days of hospital admission (OR 2.19; 95%CI 1.14-4.20; p=0.01). CONCLUSION: Increased Sepsis-3 Cardiovascular Dysfunction score, characterized as hypotension associated with the use of vasopressor drugs in the first days of intensive care unit stay, is related to higher mortality in COVID-19 patients and may be a useful prognostic prediction tool.


Subject(s)
COVID-19 , Hypotension , Sepsis , Humans , COVID-19/complications , Retrospective Studies , Hospital Mortality , Critical Care
12.
Ann Am Thorac Soc ; 19(11): 1900-1906, 2022 Nov.
Article in English | MEDLINE | ID: covidwho-2140773

ABSTRACT

Rationale: There are limited data on the impact of the coronavirus disease (COVID-19) pandemic on intensive care unit (ICU) recovery clinic care delivery practices. Objectives: We sought to better understand the patient-level factors affecting ICU recovery clinic care and changing clinical thinking during the COVID-19 pandemic. We also sought to understand how the COVID-19 pandemic sparked innovation within ICU recovery clinics. Methods: A multicenter qualitative study was conducted with ICU recovery clinic interprofessional clinicians involved with the Critical and Acute Illness Recovery Organization (CAIRO) between February and March 2021. Data were collected using semistructured interviews and were analyzed using thematic analysis. Key themes were organized in a working analytical framework. Results: Twenty-nine participants from 15 international sites participated in the study. Participants identified three patient-level key themes that influenced care delivery in ICU recovery programs: 1) social isolation, 2) decreased emotional reserve in patients and families, and 3) substantial social care needs. Changes in ICU recovery clinic care delivery occurred at both the clinician level (e.g., growing awareness of healthcare disparities and inequities, recognition of financial effects of illness, refinement of communication skills, increased focus on reconstructing the illness narrative) and the practice level (e.g., expansion of care delivery modes, efforts to integrate social care) in response to each of the patient-level themes. Identified gaps in ICU recovery clinic care delivery during the COVID-19 pandemic included a need for multidisciplinary team members, access to care issues (e.g., digital poverty, health insurance coverage, language barriers), and altered family engagement. Conclusions: This study demonstrates that addressing patient-level factors such as efforts to integrate social care, address financial needs, refine provider communication skills (e.g., empathic listening), and enhance focus on reconstructing the illness narrative became important priorities during the ICU recovery clinic visit during the COVID-19 pandemic. We also identified several ongoing gaps in ICU recovery clinic care delivery that highlight the need for interventions focused on the integration of social and clinic services for critical care survivors.


Subject(s)
COVID-19 , Pandemics , Humans , Critical Illness , Intensive Care Units , Qualitative Research , Critical Care/psychology
15.
BMJ Open ; 12(11): e060422, 2022 11 22.
Article in English | MEDLINE | ID: covidwho-2137703

ABSTRACT

OBJECTIVES: Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania. DESIGN: This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: Medline, Embase and Global Health databases were searched covering the period 2010 to 17 November 2020. ELIGIBILITY CRITERIA: We included studies that reported on forms of critical care offered, critical care services offered and/or costs and resources used in the provision of care in Tanzania published from 2010. DATA EXTRACTION AND SYNTHESIS: Quality assessment of the articles and data extraction was done by two independent researchers. The Reference Case for Estimating the Costs of Global Health Services and Interventions was used to assess quality of included studies. A narrative synthesis of extracted data was conducted. Costs were adjusted and reported in 2019 US$ and TZS using the World Bank GDP deflators. RESULTS: A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: intensive care unit (ICU) delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. Paediatric critical care equipment was more scarce than equipment for adults. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (eg, oxygen, personal protective equipment), services and human resources were identified as inputs to specific critical care services in Tanzania. CONCLUSION: There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilisation and costs across specialties and hospitals of different level in low/middle-income countries like Tanzania to inform planning, priority setting and budgeting for critical care services. PROSPERO REGISTRATION NUMBER: CRD42020221923.


Subject(s)
Critical Care , Intensive Care Units , Adult , Humans , Child , Tanzania , Critical Illness/therapy , Global Health
16.
Intensive Care Med ; 48(12): 1775-1777, 2022 Dec.
Article in English | MEDLINE | ID: covidwho-2128545

Subject(s)
Critical Care , Humans , Aged
17.
Int J Infect Dis ; 111: 108-116, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-2113607

ABSTRACT

OBJECTIVES: To validate and recalibrate the CURB-65 and pneumonia severity index (PSI) in predicting 30-day mortality and critical care intervention (CCI) in a multiethnic population with COVID-19, along with evaluating both models in predicting CCI. METHODS: Retrospective data was collected for 1181 patients admitted to the largest hospital in Qatar with COVID-19 pneumonia. The area under the curve (AUC), calibration curves, and other metrics were bootstrapped to examine the performance of the models. Variables constituting the CURB-65 and PSI scores underwent further analysis using the Least Absolute Shrinkage and Selection Operator (LASSO) along with logistic regression to develop a model predicting CCI. Complex machine learning models were built for comparative analysis. RESULTS: The PSI performed better than CURB-65 in predicting 30-day mortality (AUC 0.83, 0.78 respectively), while CURB-65 outperformed PSI in predicting CCI (AUC 0.78, 0.70 respectively). The modified PSI/CURB-65 model (respiratory rate, oxygen saturation, hematocrit, age, sodium, and glucose) predicting CCI had excellent accuracy (AUC 0.823) and good calibration. CONCLUSIONS: Our study recalibrated, externally validated the PSI and CURB-65 for predicting 30-day mortality and CCI, and developed a model for predicting CCI. Our tool can potentially guide clinicians in Qatar to stratify patients with COVID-19 pneumonia.


Subject(s)
COVID-19 , Community-Acquired Infections , Pneumonia , Critical Care , Hospital Mortality , Humans , Pneumonia/diagnosis , Pneumonia/therapy , Prognosis , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index
18.
BMJ Case Rep ; 15(11)2022 Nov 15.
Article in English | MEDLINE | ID: covidwho-2119323

ABSTRACT

During the COVID-19 pandemic, it was recognised that SARS-CoV-2 can cause multisystem illness. Non-respiratory complications observed early in the pandemic were haematological in nature. A rare but serious haematological complication of COVID-19 infection is pancytopaenia. We describe a case of an older adult without pre-existing haematological disease or risk factors for cell dyscrasia with severe pancytopaenia induced by COVID-19, who developed critical illness requiring respiratory support in intensive care and died. Our case report highlights that de novo pancytopaenia may only present with mild dermatological manifestations and may indicate severe COVID-19 infection. Management is primarily supportive and early involvement of haematology should be sought.


Subject(s)
COVID-19 , Pancytopenia , Humans , Aged , COVID-19/complications , Pandemics , SARS-CoV-2 , Critical Care
19.
Int J Environ Res Public Health ; 19(22)2022 Nov 16.
Article in English | MEDLINE | ID: covidwho-2116196

ABSTRACT

BACKGROUND: The COVID-19 pandemic has imposed great pressure on healthcare facilities, exposing healthcare professionals to various challenges that may result in the onset of moral distress, a condition of psychological distress caused by the inability to act as it would be most morally appropriate. The purpose of this research was to investigate the experience lived by nurses who worked in an intensive care unit during the COVID-19 pandemic. METHODS: This is a phenomenological study using interpretative phenomenological analysis. Sixteen nurses who worked in the COVID-19 Intensive Care Unit of Northern Italian Hospitals from January to April 2022 were selected through purposive sampling. Data on experiences, thoughts, and symptoms were collected through semi-structured interviews with in-person and remote modalities. RESULTS: Five themes and fourteen subthemes emerged from the study. The themes are: (1) pride, isolation, and fear; (2) teamwork and organisation; (3) moral/ethical aspect; (4) true heroes; and (5) dignity. CONCLUSIONS: This study highlights the impact of the COVID-19 pandemic on intensive care unit nurses. It has emerged that the risk of moral distress is high among healthcare workers in the front line of the fight against the virus. This condition should be avoided and managed through early psychological interventions, sharing of experiences, and a good organization that supports decision-making and professional well-being.


Subject(s)
COVID-19 , Humans , COVID-19/epidemiology , Pandemics , Stress, Psychological/psychology , Morals , Critical Care
20.
Turk J Med Sci ; 52(5): 1689-1696, 2022 Oct.
Article in English | MEDLINE | ID: covidwho-2113781

ABSTRACT

BACKGROUND: While chloride (Cl) is the most abundant anion in the serum, it is unfortunately one of the most commonly disregarded laboratory test results routinely drawn upon admission into the medical intensive care unit (MICU). We aimed to investigate the relation between in-hospital mortality, different pathologies requiring admission to the MICU, serum Cl levels, and other biochemical tests in a tertiary center. METHODS: The prospective study included data from 373 patients admitted to the ICU of a tertiary care center between 2017 and 2019. Data of patients under 18, pregnant patients or patients who were in the MICU for under 48 h were excluded. Comorbidity status, complete blood count, biochemistry tests, and blood gas analysis results of all patients included in the study were collected and recorded. Univariate and multivariate analyses were performed with the obtained data. RESULTS: : Of the patients included in the study, 158 (42.4%) were discharged, and 215 (57.6%) died. In the receiver operator characteristics curve analysis performed to determine the discriminating power of Cl levels with a cut-off value of >98 mEq/L in relation to mortality, its sensitivity was found to be 84% and specificity 60%. According to Kaplan-Meier analysis results, mortality rate was higher (60% vs 46%) and survival time was lower (19.0 ± 1.46 vs. 23.0 ± 4.36 days; p = 0.035) in the patient group with high Cl levels compared to the patient group with normal or low Cl levels. In the Cox regression analysis, it was found that the survival time of the patients hospitalized in the MICU was associated with the variables of Cl, presence of cancer diagnosis and pCO2 (hazard ratio: 1.030 (1.008-1.049), 2.260(1.451-3.500), and 1.020 (1.003-1.029); p < 0.05, respectively). DISCUSSION: Mortality in MICU patients were found to increase in association with higher Cl levels at admission, presence of cancer disease, and higher pCO2 levels. In addition, it should not be ignored that there may be an important relationship between renal failure and hyperchloremia in MICU patients.


Subject(s)
Critical Care , Water-Electrolyte Imbalance , Humans , Prospective Studies , Prognosis , Intensive Care Units
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