The importance of chest CT severity score and lung CT patterns in risk assessment in COVID-19-associated pneumonia: a comparative study.

Introduction: Chest computed tomography (CT) is suitable to assess morphological changes in the lungs. Chest CT scoring systems (CCTS) have been developed and use in order to quantify the severity of pulmonary involvement in COVID-19. CCTS has also been correlated with clinical outcomes. Here we wished to use a validated, relatively simple CTSS to assess chest CT patterns and to correlate CTSS with clinical outcomes in COVID-19. Patients and methods: Altogether 227 COVID-19 cases underwent chest CT scanning using a 128 multi-detector CT scanner (SOMATOM Go Top, Siemens Healthineers, Germany). Specific pathological features, such as ground-glass opacity (GGO), crazy-paving pattern, consolidation, fibrosis, subpleural lines, pleural effusion, lymphadenopathy and pulmonary embolism were evaluated. CTSS developed by Pan et al. (CTSS-Pan) was applied. CTSS and specific pathologies were correlated with demographic, clinical and laboratory data, A-DROP scores, as well as outcome measures. We compared CTSS-Pan to two other CT scoring systems. Results: The mean CTSS-Pan in the 227 COVID-19 patients was 14.6 ± 6.7. The need for ICU admission (p < 0.001) and death (p < 0.001) were significantly associated with higher CTSS. With respect to chest CT patterns, crazy-paving pattern was significantly associated with ICU admission. Subpleural lines exerted significant inverse associations with ICU admission and ventilation. Lymphadenopathy was associated with all three outcome parameters. Pulmonary embolism led to ICU admission. In the ROC analysis, CTSS>18.5 significantly predicted admission to ICU (p = 0.026) and CTSS>19.5 was the cutoff for increased mortality (p < 0.001). CTSS-Pan and the two other CTSS systems exerted similar performance. With respect to clinical outcomes, CTSS-Pan might have the best performance. Conclusion: CTSS may be suitable to assess severity and prognosis of COVID-19-associated pneumonia. CTSS and specific chest CT patterns may predict the need for ventilation, as well as mortality in COVID-19. This can help the physician to guide treatment strategies in COVID-19, as well as other pulmonary infections.

[Informativeness estimation for the main clinical and laboratory parameters in patients with severe COVID-19].

AIM: To conduct a retrospective assessment of the clinical and laboratory data of patients with severe forms of COVID-19 hospitalized in the intensive care and intensive care unit, in order to assess the contribution of various indicators to the likelihood of death. MATERIALS AND METHODS: A retrospective assessment of data on 224 patients with severe COVID-19 admitted to the intensive care unit was carried out. The analysis included the data of biochemical, clinical blood tests, coagulograms, indicators of the inflammatory response. When transferring to the intensive care units (ICU), the indicators of the formalized SOFA and APACHE scales were recorded. Anthropometric and demographic data were downloaded separately. RESULTS: Analysis of obtained data, showed that only one demographic feature (age) and a fairly large number of laboratory parameters can serve as possible markers of an unfavorable prognosis. We identified 12 laboratory features the best in terms of prediction: procalcitonin, lymphocytes (absolute value), sodium (ABS), creatinine, lactate (ABS), D-dimer, oxygenation index, direct bilirubin, urea, hemoglobin, C-reactive protein, age, LDH. The combination of these features allows to provide the quality of the forecast at the level of AUC=0.85, while the known scales provided less efficiency (APACHE: AUC=0.78, SOFA: AUC=0.74). CONCLUSION: Forecasting the outcome of the course of COVID-19 in patients in ICU is relevant not only from the position of adequate distribution of treatment measures, but also from the point of view of understanding the pathogenetic mechanisms of the development of the disease.

iSleepFirst: burnout, fatigue, and wearable-tracked sleep deprivation among residents staffing the medical intensive care unit.

PURPOSE: This study aimed to evaluate the relationship between sleep, burnout, and psychomotor vigilance in residents working in the medical intensive care unit (ICU). METHODS: A prospective cohort study of residents was implemented during a consecutive 4-week. Residents were recruited to wear a sleep tracker for 2 weeks before and 2 weeks during their medical ICU rotation. Data collected included wearable-tracked sleep minutes, Oldenburg burnout inventory (OBI) score, Epworth sleepiness scale (ESS), psychomotor vigilance testing, and American Academy of Sleep Medicine sleep diary. The primary outcome was sleep duration tracked by the wearable. The secondary outcomes were burnout, psychomotor vigilance (PVT), and perceived sleepiness. RESULTS: A total of 40 residents completed the study. The age range was 26-34 years with 19 males. Total sleep minutes measured by the wearable decreased from 402 min (95% CI: 377-427) before ICU to 389 (95% CI: 360-418) during ICU (p < 0.05). Residents overestimated sleep, logging 464 min (95% CI: 452-476) before and 442 (95% CI: 430-454) during ICU. ESS scores increased from 5.93 (95% CI: 4.89, 7.07) to 8.33 (95% CI: 7.09,9.58) during ICU (p < 0.001). OBI scores increased from 34.5 (95% CI: 32.9-36.2) to 42.8 (95% CI: 40.7-45.0) (p < 0.001). PVT scores worsened with increased reaction time while on ICU rotation (348.5 ms pre-ICU, 370.9 ms post-ICU, p < 0.001). CONCLUSIONS: Resident ICU rotations are associated with decreased objective sleep and self-reported sleep. Residents overestimate sleep duration. Burnout and sleepiness increase and associated PVT scores worsen while working in the ICU. Institutions should ensure resident sleep and wellness checks during ICU rotation.

Retrospective study of the effect of vaccination against SARS-CoV-2 in seriously ill patients admitted to an intensive care unit. / Estudio retrospectivo del efecto de la vacunación frente al SARS-CoV-2 en enfermos graves que ingresan en una unidad de cuidados intensivos.

BACKGROUND AND OBJECTIVE: Our study aims to compare the clinical and epidemiological characteristics, length of stay in the ICU, and mortality rates of COVID-19 patients admitted to the ICU who are fully vaccinated, partially vaccinated, or unvaccinated. PATIENTS AND METHODS: Retrospective cohort study (March 2020-March 2022). Patients were classified into unvaccinated, fully vaccinated, and partially vaccinated groups. We initially performed a descriptive analysis of the sample, a multivariable survival analysis adjusting for a Cox regression model, and a 90-day survival analysis using the Kaplan-Meier method for the death time variable. RESULTS: A total of 894 patients were analyzed: 179 with full vaccination, 32 with incomplete vaccination, and 683 were unvaccinated. Vaccinated patients had a lower incidence (10% vs. 21% and 18%) of severe ARDS. The survival curve did not show any differences in the probability of surviving for 90 days among the studied groups (p = 0.898). In the Cox regression analysis, only the need for mechanical ventilation during admission and the value of LDH (per unit of measurement) in the first 24 hours of admission were significantly associated with mortality at 90 days (HR: 5.78; 95% CI: 1.36-24.48); p = 0.01 and HR: 1.01; 95% CI: 1.00-1.02; p = 0.03, respectively. CONCLUSIONS: Patients with severe SARS-CoV-2 disease who are vaccinated against COVID-19 have a lower incidence of severe ARDS and mechanical ventilation than unvaccinated patients.

The long wave of COVID-19: a case report using Imagery Rehearsal Therapy for COVID-19-related nightmares after admission to intensive care unit.

Introduction: The COVID-19 pandemic caused several psychological consequences for the general population. In particular, long-term and persistent psychopathological detriments were observed in those who were infected by acute forms of the virus and need specialistic care in the Intensive Care Unit (ICU). Imagery rehearsal therapy (IRT) has shown promising results in managing nightmares of patients with different traumas, but it has never been used with patients admitted to ICUs for severe COVID-19 despite this experience being considered traumatic in the literature. Methods: The purpose of this case study is to describe the application of a four-session IRT for the treatment of COVID-related nightmares in a female patient after admission to the ICU. A 42-year-old Caucasian woman who recovered from a pulmonary rehabilitation program reported shortness of breath, dyspnea, and everyday life difficulties triggered by the long-COVID syndrome. She showed COVID-related nightmares and signs of post-traumatic symptoms (i.e., hyperarousal, nightmares, and avoidance of triggers associated with the traumatic situation). Psychological changes in the aftermath of a trauma, presence, and intensity of daytime sleepiness, dream activity, sleep disturbances, aspects of sleep and dreams, and symptoms of common mental health status are assessed as outcomes at the baseline (during the admission to pneumology rehabilitation) at 1-month (T1) and 3-month follow-up (T2). Follow-up data were collected through an online survey. Results: By using IRT principles and techniques, the patient reported a decrease in the intensity and frequency of bad nightmares, an increase in the quality of sleep, and post-traumatic growth, developing a positive post-discharge. Conclusion: Imagery rehearsal therapy may be effective for COVID-19-related nightmares and in increasing the quality of sleep among patients admitted to the ICU for the treatment of COVID-19. Furthermore, IRT could be useful for its brevity in hospital settings.

Incidence Rate and Factors Associated with Delirium and Subsyndromal Delirium in Patients with COVID-19 in an Intensive Care Unit.

BACKGROUND: Delirium subsyndrome (SSD) and delirium (DL) are known complications in the intensive care unit (ICU) and are associated with worse clinical outcomes. The aim of this study was to screen for SSD and DL in individuals with COVID-19 admitted to the ICU and to study the associated factors and clinical outcomes. METHOD: An observational, longitudinal study was conducted in the reference ICU for COVID-19. All admitted individuals with COVID-19 were screened for SSD and DL during their ICU stay using the Intensive Care Delirium Screening Checklist (ICDSC). Individuals with SSD and/or DL were compared to those without SSD and/or DL. RESULTS: Ninety-three patients were evaluated, of which 46.7% had SSD and/or DL. The incidence rate was 4.17 cases/100 person-days. Individuals with SSD and/or DL had higher severity of illness on admission to the ICU, as measured by the APACHE II score (median 16 versus 8 points, p < 0.001). SSD and/or DL were associated with longer ICU and hospital stays (median 19 versus 6 days, p < 0.001 and median 22 versus 7 days, p < 0.001, respectively). CONCLUSION: Individuals with SSD and/or DL had greater disease severity and longer ICU and hospital stays when compared to those without SSD and/or DL. This reinforces the importance of screening for consciousness disorders in the ICU.

Long-term outcomes in COVID-19 patients admitted to intensive care in Denmark: A nationwide observational study.

BACKGROUND: Among ICU patients with COVID-19, it is largely unknown how the overall outcome and resource use have changed with time, different genetic variants, and vaccination status. METHODS: For all Danish ICU patients with COVID-19 from March 10, 2020 to March 31, 2022, we manually retrieved data on demographics, comorbidities, vaccination status, use of life support, length of stay, and vital status from medical records. We compared patients based on the period of admittance and vaccination status and described changes in epidemiology related to the Omicron variant. RESULTS: Among all 2167 ICU patients with COVID-19, 327 were admitted during the first (March 10-19, 2020), 1053 during the second (May 20, 2020 to June 30, 2021) and 787 during the third wave (July 1, 2021 to March 31, 2022). We observed changes over the three waves in age (median 72 vs. 68 vs. 65 years), use of invasive mechanical ventilation (81% vs. 58% vs. 51%), renal replacement therapy (26% vs. 13% vs. 12%), extracorporeal membrane oxygenation (7% vs. 3% vs. 2%), duration of invasive mechanical ventilation (median 13 vs. 13 vs. 9 days) and ICU length of stay (median 13 vs. 10 vs. 7 days). Despite these changes, 90-day mortality remained constant (36% vs. 35% vs. 33%). Vaccination rates among ICU patients were 42% as compared to 80% in society. Unvaccinated versus vaccinated patients were younger (median 57 vs. 73 years), had less comorbidity (50% vs. 78%), and had lower 90-day mortality (29% vs. 51%). Patient characteristics changed significantly after the Omicron variant became dominant including a decrease in the use of COVID-specific pharmacological agents from 95% to 69%. CONCLUSIONS: In Danish ICUs, the use of life support declined, while mortality seemed unchanged throughout the three waves of COVID-19. Vaccination rates were lower among ICU patients than in society, but the selected group of vaccinated patients admitted to the ICU still had very severe disease courses. When the Omicron variant became dominant a lower fraction of SARS-CoV-2 positive patients received COVID treatment indicating other causes for ICU admission.

Clinical and cost effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for the prevention of hospital-acquired pressure injuries. A randomised controlled trial.

Pressure injuries affect 13.1% to 45.5% of patients in the intensive care unit and lead to pain and discomfort for patients, burden on healthcare providers, and unnecessary cost to the health system. Turning and positioning systems offer improvements on usual care devices, however the evidence of the effectiveness of such systems is still emerging. We conducted an investigator initiated, prospective, single centre, two group, non-blinded, randomised controlled trial to determine the effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for preventing PIs. The trial was prematurely discontinued after enrolment of 78 participants due to COVID-19 pandemic related challenges and lower than expected enrolment rate. The study groups were comparable on baseline characteristics and adherence to the interventions was high. Four participants developed a PI (in the sacral, ischial tuberosity or buttock region), n = 2 each in the intervention and control group. Each participant developed one PI. As the trial is underpowered, these findings do not provide an indication of the clinical effectiveness of the interventions. There was no participant drop-out or withdrawal and there were no adverse events, device deficiencies, or adverse device effects identified or reported. The results of our study (in particular those pertaining to enrolment, intervention adherence and safety) provide considerations for future trials that seek to investigate how to prevent PIs among ICU patients.

[Quality of life at 3 months of COVID-19 patients discharged from the intensive care unit during the COVID-19 pandemic in Guinea]. / Qualité de vie àtrois mois des patients sortis guéris du COVID-19 de l'unité de soins intensifs au cours de la pandémie de COVID-19 en Guinée.

Introduction: in sub-Saharan Africa, the impact of intensive care unit (ICU) hospitalization of COVID patients is not at all known in terms of quality of life because it is very poorly documented. The aim of this study was to describe the quality of life at three months of patients who had been in the ICU. Methods: we conducted a monocentric prospective cohort study over a 6-month period. Results: hundred and three (103) patients participated in the survey out of 123 patients discharged from the ICU during our study period, with a participation rate of 85%. The average length of stay in the ICU was 12 days with extremes of 2 and 36 days. The mean duration of oxygen therapy was 12±10 days. The assessment of quality of life with the SF-36 at 3 months after discharge from the intensive care unit showed impairment in eight domains, the most important of which were the emotional domain with a mean score of 57.6±44.6, the social functioning domain with a score of 60.77±24.07 and the vitality domain, which was 66.2±21.6. The global evaluation of the two main dimensions of the SF-36 showed a deficiency in the psychological dimension with a mean score of 64 with extremes of 12 and 90. This evaluation also showed an impairment of the physical dimension with a mean score of 70 with extremes of 20 and 97. Conclusion: our study showed a significant decrease in the quality of life of COVID-19 patients discharged from the intensive care unit.

Impact of the COVID-19 pandemic on the education and procedural volume of fellows in critical care medicine - a cross-sectional survey.

BACKGROUND: The COVID-19 pandemic has changed the way medical education is delivered. The purpose of this study was to assess the impact of the COVID-19 pandemic on the education and procedural volume of critical care and pulmonary critical care fellows. METHODS: We conducted a cross-sectional, internet-based, voluntary, anonymous, national survey of adult critical care fellows and academic attending physicians in critical care and pulmonary critical care fellowship programs in the United States between December 2020 and February 2021. Survey questions covered both didactic and non-didactic aspects of education and procedural volumes. Answers were ranked on a 5-point Likert scale. Survey responses were summarized by frequency with percentage. Differences between the responses of fellows and attendings were assessed with the Fisher's exact or Chi-Square test, using Stata 16 software (StataCorp LLC, College Station, TX). RESULTS: Seventy four individuals responded to the survey; the majority (70.3%) were male; less than one-third (28.4%) female. Respondents were evenly split among fellows (52.7%) and attendings (47.3%). 41.9% of survey respondents were from the authors' home institution, with a response rate of 32.6%. Almost two-thirds (62.2%) reported that fellows spend more time in the ICU since the onset of the pandemic. The majority noted that fellows insert more central venous catheters (52.7%) and arterial lines (58.1%), but perform fewer bronchoscopies (59.5%). The impact on endotracheal intubations was mixed: almost half of respondents (45.9%) reported fewer intubations, about one-third (35.1%) more intubations. Almost all respondents (93.0%) described fewer workshops; and one-third (36.1%) fewer didactic lectures. The majority (71.2%) noted less time available for research and quality improvement projects; half (50.7%) noted less bedside teaching by faculty and more than one-third (37.0%) less fellow interaction with faculty. Almost one-half of respondents (45.2%) reported an increase in fellows' weekly work hours. CONCLUSION: The pandemic has caused a decrease in scholarly and didactic activities of critical care and pulmonary critical care fellows. Fellows spend more time in ICU rotations, insert more central and arterial lines, but perform fewer intubations and bronchoscopies. This survey provides insights into changes that have occurred in the training of critical care and pulmonary critical care fellows since the onset of the COVID-19 pandemic.

Unchanged Characteristics and Survival among Critically Ill COVID-19 Patients during First, Second, and Third Waves: A Prospective Observational Cohort.

BACKGROUND: This study was carried out to compare characteristics and outcomes in patients with acute respiratory failure related to COVID-19 during first, second, and third waves. METHODS: We included consecutive adults admitted to the intensive care unit between March 2020 and July 2021. We compared three groups defined by the epidemic intake phase: waves 1 (W1), 2 (W2), and 3 (W3). RESULTS: We included 289 patients. Two hundred and eight (72%) patients were men with a median age of 63 years (IQR: 54-72), of whom 68 (23.6%) died in hospital. High-flow nasal oxygen (HFNO) was inversely associated with the need for invasive mechanical ventilation (MV) in multivariate analysis (p = 0.003) but not dexamethasone (p = 0.25). The day-90 mortality rate did not vary from W1 (27.4%) to W2 (23.9%) and W3 (22%), p = 0.67. By multivariate analysis, older age (odds ratio [OR]: 0.94/year, p < 0.001), immunodeficiency (OR: 0.33, p = 0.04), acute kidney injury (OR: 0.26, p < 0.001), and invasive MV (OR: 0.13, p < 0.001) were inversely associated with higher day-90 survival as opposed to the use of intermediate heparin thromboprophylaxis dose (OR: 3.21, p = 0.006). HFNO use and dexamethasone were not associated with higher day-90 survival (p = 0.24 and p = 0.56, respectively). CONCLUSIONS: In patients with acute respiratory failure due to COVID-19, survival did not change between first, second, and third waves while the use of invasive MV decreased. HFNO or intravenous steroids were not associated with better outcomes, whereas the use of intermediate dose of heparin for thromboprophylaxis was associated with higher day-90 survival. Larger multicentric studies are needed to confirm our findings.

Pulmonary Functional Outcomes at 3 Months in Critical COVID-19 Survivors Hospitalized during the First, Second, and Third Pandemic Waves.

INTRODUCTION: Despite improved management of patients with COVID-19, we still ignore whether pharmacologic treatments and improved respiratory support have modified outcomes for intensive care unit (ICU) surviving patients of the three first consecutive waves (w) of the pandemic. The aim of this study was to evaluate whether developments in the management of ICU COVID-19 patients have positively impacted respiratory functional outcomes, quality of life (QoL), and chest CT scan patterns in ICU COVID-19 surviving patients at 3 months, according to pandemic waves. METHODS: We prospectively included all patients admitted to the ICU of two university hospitals with acute respiratory distress syndrome (ARDS) related to COVID-19. Data related to hospitalization (disease severity, complications), demographics, and medical history were collected. Patients were assessed 3 months post-ICU discharge using a 6 min walking distance test (6MWT), a pulmonary function test (PFT), a respiratory muscle strength (RMS) test, a chest CT scan, and a Short Form 36 (SF-36) questionnaire. RESULTS: We included 84 ARDS COVID-19 surviving patients. Disease severity, complications, demographics, and comorbidities were similar between groups, but there were more women in wave 3 (w3). Length of stay at the hospital was shorter during w3 vs. during wave 1 (w1) (23.4 ± 14.2 days vs. 34.7 ± 20.8 days, p = 0.0304). Fewer patients required mechanical ventilation (MV) during the second wave (w2) vs. during w1 (33.3% vs. 63.9%, p = 0.0038). Assessment at 3 months after ICU discharge revealed that PFTs and 6MWTs scores were worse for w3 > w2 > w1. QoL (SF-36) deteriorated (vitality and mental health) more for patients in w1 vs. in w3 (64.7 ± 16.3 vs. 49.2 ± 23.2, p = 0.0169). Mechanical ventilation was associated with reduced forced expiratory volume (FEV1), total lung capacity (TLC), diffusing capacity for carbon monoxide (DLCO), and respiratory muscle strength (RMS) (w1,2,3, p < 0.0500) on linear/logistic regression analysis. The use of glucocorticoids, as well as tocilizumab, was associated with improvements in the number of affected segments in chest CT, FEV1, TLC, and DLCO (p < 0.01). CONCLUSIONS: With better understanding and management of COVID-19, there was an improvement in PFT, 6MWT, and RMS in ICU survivors 3 months after ICU discharge, regardless of the pandemic wave during which they were hospitalized. However, immunomodulation and improved best practices for the management of COVID-19 do not appear to be sufficient to prevent significant morbidity in critically ill patients.

Predictors of Pneumothorax in People With COVID-19 Pneumonia: A Multicenter Retrospective Investigation.

This multicenter retrospective investigation aimed to identify predictors of pneumothorax (PTX), pneumomediastinum (PM), and subcutaneous emphysema (SE) in patients with COVID-19 pneumonia admitted to the ICU. A total of 256 patients were included, with 128 in the case group and 128 in the control group. The study sample consisted of predominantly male patients with a mean age of around 53 years and a high prevalence of comorbidities. Significant predictors of PTX, PM, and SE included the presence of coronary artery disease, non-rebreather mask usage, high-flow oxygen therapy, mechanical ventilation, pressor usage, inpatient dialysis, steroid usage, sedative usage, narcotic usage, paralytic usage, elevated C-reactive protein levels, increased lung infiltration, the presence of PM and SE, mode of ventilation, duration of various respiratory support interventions, and severity of illness as indicated by APACHE and SOFA scores. These findings have important implications for the clinical management of patients with COVID-19 pneumonia, as they may help identify and closely monitor at-risk individuals, allowing for timely intervention and potentially improving clinical outcomes. Future research should focus on validating these predictors in larger cohorts and investigating the underlying mechanisms to develop targeted preventive and therapeutic strategies.

Prevalence of multidrug-resistant Gram-negative bacteria from blood cultures and rapid detection of beta-lactamase-encoding genes by multiplex PCR assay

Introduction This study aimed to determine the prevalence of multidrug-resistant Gram-negative bacteria (GNB) from blood cultures in a tertiary-care hospital and the multiplex PCR assay's ability to detect resistance genes. Methods A total of 388 GNB isolates obtained from hospitalized patients between November 2019 and November 2021 were included in the study. Antimicrobial susceptibility testing was done by VITEK 2 system and broth microdilution method. Beta-lactamase-encoding genes were detected by multiplex PCR assays, BioFire-Blood Culture Identification 2 (BCID2) panel (bioMerieux, France). Extended-spectrum beta-lactamases (ESBLs) were detected phenotypically with VITEK AST-GN71 card (bioMerieux, France). The isolates of GNB were classified into multidrug-resistant, extensively-drug-resistant, and pandrug-resistant categories, and their prevalence and distribution in different wards, including coronavirus diseases 2019 (COVID-19) intensive care units (ICU), were calculated. Results Results revealed that all isolates of Acinetobacter baumannii and Pseudomonas aeruginosa were multidrug-resistant as well as 91.6% of Enterobacter cloacae, 80.6% of Proteus mirabilis, and 76.1% of Klebsiella pneumoniae, respectively. In fermentative bacteria, blaOXA-48-like (58.1%), blaNDM (16.1%), blaKPC (9.7%) and blaVIM (6.5%) genes were detected. More than half of Enterobacter cloacae (58.3%) and Klebsiella pneumoniae (53.7%) produced ESBLs. Among non-fermenters, the blaNDM gene was carried by 55% of Pseudomonas aeruginosa and 19.5% of Acinetobacter baumannii. In the COVID-19 ICU, Acinetobacter baumannii was the most common isolate (86.1%). Conclusions This study revealed high proportions of multidrug-resistant blood isolates and various underlying resistance genes in Gram-negative strains. The BCID2 panel seems to be helpful for the detection of the most prevalent resistance genes of fermentative bacteria.Copyright © GERMS 2022.

Intensive Care Consultant: Superhero or normal human being but more capable!

Submission content Introduction: Intensive care medicine has become an admired, loved, hated, and definitely more interesting Specialty due to a special situation (COVID-19) that exposed the training process to numerous criticisms, positives, and negatives, and this is how I believe we could improve our beloved world. Proposal: 1. Ideal training program from medical school to Certificate of Completion of Training (CCT): * Medical school: In their last year they should do more than 1 week in the Intensive Care Unit (ICU) * Stage 1: there should be a core surgical training of at least 6 months * Stage 2: there should be a rotation on Psychiatry of at least 4 weeks with on calls in ICU and 2 weeks in Palliative Care * Stage 3: acting as a consultant for the last six months on ST7 with backup from a formal consultant, and * Surgical training should be included in the possible dual or triple CCT 2. How would we be assessed? I agree with the Faculty of Intensive Care Medicine (FICM) staging program assessment, with some modifications: * As ST7 the trainee should act as a consultant with back support at least 50% of the stage and need to be evaluated by a Multi-Source Feedback (MSF). * Clinical Fellows should have a consultant as a Certificate of Eligibility for Specialist Registration (CESR) guide who establishes the equivalent stage of training supporting them and assessing them under the same model. * Changing the way, the General Medical Council (GMC) conducts the CESR application and making it really equivalent to the ICM training with the FFICM curriculum. 3. What do we need to be taught? * Hot topics for ICU (academic), * Overseas talks to share experiences, * Ultrasound (FUSIC), * Wellbeing strategies, * Leadership training * Psychiatric and physiological effects post ICU for patients and staff, * The administrative and political model of the National Health Service (NHS), and * Communication skills to establish excellent relationships with the other specialties. 4. What would our working life look like? * Normal day: 8 am to 3 pm * Midday shift: 1 pm to 8:30 pm * Night shift: 8 pm to 8:30 am * A rolling rota of 12 weeks with 2 weekends during this time 5. How would you produce Intensive Care Medicine (ICM) Consultants of the future who both love their job and their life: * Starting with less intense shifts, * More cordial relationships between the teams, * Supporting ICM trainees and Fellows going through their CESR pathway, * Making the training more attractive to either male-female doctors getting them involved in as many different specialties as ICM can cover, Conclusion(s): Having full-time ICM Consultants should be welcome in all ICUs in the country, which is not at the moment. This will definitely attract a lot of excellent doctors who are 100% focused on ICM.

A case series of diabetic ketoacidosis associated with SGLT2 inhibitors

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are increasingly initiated as treatment for type 2 diabetes due to favourable cardiorenal characteristics. However, studies have identified an increased risk of diabetic ketoacidosis (DKA). We carried out a retrospective, case-based study at East and North Herts NHS Trust between February 2018 and December 2020. Fifteen cases of SGLT2i associated DKA were identified in people with presumed type 2 diabetes;33.3% were classed as euglycaemic DKA with a blood glucose of <11mmol/L. All cases were associated with a significant precipitating factor including diarrhoea, vomiting, reduced oral intake and sepsis. One case was related to COVID-19. Two people were subsequently found to have raised islet autoantibodies suggesting type 1 diabetes or latent autoimmune diabetes in adults. It is important that awareness of SGLT2i associated DKA is raised among users and health care practitioners, including the recognition of euglycaemic DKA. Sick day rules should be emphasised and reiterated at clinical encounters. Non-specialists in primary care, oncology and in perioperative settings should be empowered to advocate for temporary withdrawal and there should be readier access to blood ketone monitoring when required. When SGLT2i associated DKA occurs, due consideration should be given to evaluate the diabetes classification and investigate the circumstances of the event. Copyright © 2023 John Wiley & Sons.Copyright © 2023 John Wiley & Sons, Ltd.

Clinical Characteristics of Patients with Sars-Cov-2 Omicron Variant and COVID-19 Vaccination with Clinical Outcome Findings in Shanghai, China: A Single Center, Retrospective, Observational Study

Objectives: This study aimed to determine disease severity, clinical features, clinical outcome in hospitalized patients with the Omicron variant and evaluate the effectiveness of one-dose, two-dose, and three-dose inactivated vaccines in reducing viral loads, disease course, ICU admissions and severe diseases. Method(s): Retrospective cohort analysis was performed on 5,170 adult patients (>=18 years) identified as severe acute respiratory syndrome coronavirus 2 positive with Reverse Transcription Polymerase Chain Reaction admitted at Shanghai Medical Center for Gerontology between March 2022 and June 2022. COVID-19 vaccination effectiveness was assessed using logistic regression models evaluating the association between the risk of vaccination and clinical outcomes, adjusting for confounders. Result(s): Among 5,170 enrolled patients, the median age was 53 years, and 2,861 (55.3%) were male. 71.0% were mild COVID-19 cases, and cough (1,137 [22.0%]), fever (592 [11.5%]), sore throat (510 [9.9%]), and fatigue (334 [6.5%]) were the most common symptoms on the patient's first admission. Ct values increased generally over time and 27.1% patients experienced a high viral load (Ct value< 20) during their stay. 105(2.0%) of these patients were transferred to the intensive care unit after admission. 97.1% patients were cured or showed an improvement in symptoms and 0.9% died in hospital. The median length of hospital stay was 8.7+/-4.5 days. In multivariate logistic analysis, booster vaccination can significantly reduce ICU admissions and decrease the severity of COVID-19 outcome when compared with less doses of vaccine (OR=0.75, 95%CI, 0.62-0.91, P<=0.005;OR=0.99, 95%CI, 0.99-1.00, p<0.001). Conclusion(s): In summary, the most of patients who contracted SARSCoV-2 omicron variant had mild clinical features and patients with vaccination took less time to lower viral loads. As the COVID-19 pandemic progressed, an older and less vaccinated population was associated with higher risk for ICU admission and severe disease.Copyright © 2023

Creating a smart classroom on intensive care using assisted reality technology

Introduction: Medical students receive relatively little exposure to intensive care medicine throughout their undergraduate training in comparison to other specialties. The COVID-19 pandemic further hindered students' exposure with entrance to intensive care units (ICU) limited to conserve personal protective equipment (PPE) and reduce the risk of virus spread. To address this problem, this study explored the use of assisted reality technology to create a smart classroom whereby medical students can experience intensive care medicine with the COVID-19 risks mitigated. There is existing literature describing the use of live streaming ward rounds using wearable technology to teach medical students, however, we believe this is the first time assisted reality technology has been harnessed to develop a teaching curriculum on intensive care.1 Objectives: This study aimed to assess the feasibility of using a wearable headset with assisted reality technology to live stream intensive care teaching to remotely based medical students. Method(s): Three intensive care teaching sessions were live streamed to three groups of medical students using the AMA XpertEye wearable glasses. The teaching session focused on the intensive care bed space and equipment as well as the assessment of a critically unwell intensive care patient. Two educators were required to facilitate the optimum learning environment. One educator wore the assisted reality technology glasses on the ICU whilst the other educator remained with the students to facilitate group discussion. The educators had the means to communicate via inbuilt technology on the glasses. Feedback from students was collected using the evaluation of technology-enhanced learning materials (ETELM).2 Results: The response rate for the ETELM survey was 100%. Students strongly agreed that the session was well organised, relevant and that the navigation of technology-based components was logical and efficient. 'There was a strong instructor presence and personal touch to the session' returned the strongest positive response. 'This session will change my practice' received the most varied response from students, potentially due to their stage in undergraduate training and distance from actual clinical practice. Students strongly disagreed that their learning was affected by technology issues. Educators reported problems with securing a patient appropriate to be involved alongside the busy clinical demands of the ICU. Facilitation by trained educators was crucial to ensure the teaching sessions were high quality. Conclusion(s): The use of smart classrooms on intensive care using assisted reality technology was very well received by medical students and educators. The main limitations included the necessity to balance the delivery of teaching alongside the clinical demands of the unit, however this is arguably the case with most forms of clinical teaching. There is the potential to continue using smart classrooms in the post-pandemic period, as they provide an open and safe platform for students to explore intensive care medicine and to ask questions that they may feel less able to raise in the busy clinical environment.

Salt steps and sugar checks - Making arterial line use safer in our trust

Introduction: Arterial lines are used within our intensive care unit to allow invasive blood pressure monitoring and regular blood gas analysis. Inadvertent use of dextrose containing fluids in the flush have been associated with falsely high glucose readings. When these are acted on with insulin, it can cause devastating hypoglycaemic brain injury. There have been a number of deaths and other incidents relating to the wrong fluid being used in arterial line set up reported within the UK in recent years. In 2014 the AAGBI released a safety guideline on the use of arterial lines specifically to reduce to the risk of hypoglycaemic brain injury. Objective(s): Our objective was to ensure that 100% of arterial lines in use within Royal Victoria Hospital's intensive care unit were compliant with our trust policy on the management of arterial lines. Method(s): We audited our intensive care unit's compliance with our trust policy and found that we were 80% compliant. We formed a multi-disciplinary arterial line working group in order to tackle the problem. Our quality improvement project consisted of two main approaches: 1. To educate staff on how to manage arterial lines correctly. We divided the management of arterial lines into S.A.L.T steps (a 7 step bundle on "Setting up an Arterial Line Transducer") and SUGAR checks ( a series of red flag moments to prompt staff to review the patient prior to starting or increasing insulin administration).We developed educational posters for key areas in ICU and presented our findings at departmental meetings. 2. To change the system, in order to make it easier to do the right thing. We developed a Universal Adult Arterial Pack (UAAP) containing key components in the setup of an arterial line. This also included aide memoires for the S.A.L.T steps and SUGAR checks. In order to measure the effect of these changes, we: 1. Audited compliance on a regular basis. 2. Monitored serious bundle breaches ( for example no label, wrong fluid used) 3. Assessed usage of the UAAP. Result(s): 1. Bundle compliance improved during the first half of 2021, however then reduced in the second half with the number of serious bundle breaches increasing. This coincided with COVID surge 4 - associated with reduced nursing ratios and staff redeployment. 2. UAAP usage increased throughout the project, from an average of 6 to 9 per day. 86% of staff found the packs useful and 85% thought that they reduced the potential for error. Conclusion(s): The presence of a policy does not ensure that staff will know about it or adhere to it. Although we have not yet achieved our target of 100% compliance, we have seen evidence of how our project has the potential to do so in the near future. We aim to roll out our new e-learning module for staff education, manufacture our UAAP on a bigger scale, and disseminate the project to other departments within the trust.