Resource utilization and preparedness within the COVID-19 pandemic in Tunisian medical intensive care units: A nationwide retrospective multicentre observational study.

BACKGROUND: The worldwide SARS-CoV-2 pandemic represents the most recent global healthcare crisis. While all healthcare systems suffered facing the immense burden of critically-ill COVID-19 patients, the levels of preparedness and adaptability differed highly between countries. AIM: to describe resource mobilization throughout the COVID-19 waves in Tunisian University Medical Intensive Care Units (MICUs) and to identify discrepancies in preparedness between the provided and required resource. METHODS: This is a longitudinal retrospective multicentre observational study conducted between March 2020 and May 2022 analyzing data from eight University MICUs. Data were collected at baseline and at each bed expansion period in relation to the nation's four COVID-19 waves. Data collected included epidemiological, organizational and management trends and outcomes of COVID-19 and non-COVID-19 admissions. RESULTS: MICU-beds increased from 66 to a maximum of 117 beds. This was possible thanks to equipping pre-existing non-functional MICU beds (n = 20) and creating surge ICU-beds in medical wards (n = 24). MICU nurses increased from 53 to 200 of which 99 non-ICU nurses, by deployment from other departments and temporary recruitment. The nurse-to-MICU-bed ratio increased from 1:1 to around 1·8:1. Only 55% of beds were single rooms, 80% were equipped with ICU ventilators. These MICUs managed to admit a total of 3368 critically-ill patients (15% of hospital admissions). 33·2% of COVID-19-related intra-hospital deaths occurred within the MICUs. CONCLUSION: Despite a substantial increase in resource mobilization during the COVID-19 pandemic, the current study identified significant persisting discrepancies between supplied and required resource, at least partially explaining the poor overall prognosis of critically-ill COVID-19 patients.

Prognostic Value of Routine Blood Parameters in Intensive Care Unit COVID-19 Patients.

Introduction: Laboratory medicine has an important role in the management of COVID-19. The aim of this study was to analyze routinely available blood parameters in intensive care unit COVID-19 patients and to evaluate their prognostic value. Patients and methods: This is a retrospective, observational, single-center study including consecutive severe COVID-19 patients who were admitted into the intensive care unit of Ben Arous Regional Hospital in Tunisia from 28 September 2020 to 31 May 2021. The end point of the study was either hospital discharge or in-hospital death. We defined two groups based on the outcome: survivors (Group 1) and non-survivors (Group 2). Demographical, clinical, and laboratory data on admission were collected and compared between the two groups. Univariate and multivariate logistic regression analysis were performed to determine the predictive factors for COVID-19 disease mortality. Results: A total of 150 patients were enrolled. Eighty patients (53.3%) died and 70 (46.7%) survived during the study period. Based on statistical analysis, median age, Simplified Acute Physiology Score (SAPS II) with the serum levels of urea, creatinine, total lactate dehydrogenase (LDH), creatine kinase, procalcitonin and hs-troponin I were significantly higher in non-survivors compared to survivors. On multivariate analysis, LDH activity ≥ 484 U/L (OR=17.979; 95%CI [1.119-2.040]; p = 0.09) and hs-troponin I ≥ 6.55 ng/L (OR=12.492; 95%CI [1.691-92.268]; p = 0.013) independently predicted COVID-19 related mortality. Conclusion: Total LDH and hs-troponin I were independent predictors of death. However, further clinical investigations with even larger number of patients are needed for the evaluation of other laboratory biomarkers which could aid in assessing the prediction of mortality.

Toxin-induced cardiac arrest: frequency, causative agents, management and hospital outcome.

BACKGROUND: Cardiac arrest (CA) is a public health problem, with various etiologies and a fatal issue in 90-95% of cases. Toxin-induced cardiac arrests (TICA) are poorly described. Scarcity of national data prompted us to carry-out this study. AIM: To determine TICA frequency in a Tunisian reference center in toxicology and its hospital prognosis, and to describe its clinical and therapeutic aspects Methods : Data were collected retrospectively over an 8-years period. We included patients admitted for post-CA care with highly suspected or confirmed TICA. Clinical and toxicological data were recorded. RESULTS: We recorded 21 cases of TICA, which represented 48.8% of CA. A single toxic agent was incriminated in 90% of cases. Main causative agents identified in our series were pesticides and betablockers: chloralosed (n = 6), carbamate inhibitor of cholinesterase (n = 5), acebutolol (n = 4) and organophosphate (n = 2). One case of opiates and cocaine poisoning was reported. Median duration of "no flow" was 0 minutes. Mean duration of "low flow" was 13.74±9.15 minutes. An initial shockable rhythm was noted only in three patients. Mortality rate was 76% (16/21). Four of the five survivors had a Cerebral Performance Category Scale (CPC) 1, only one patient survived with a CPC 3. Factors associated with mortality were : the duration of "low flow" (p=0.02) and APACHE II score (p=0.014). APACHE II≥29 was the only independent factor (OR=2.0, 95%CI [1.07;3.71]). CONCLUSION: TICA were most frequently provoked by pesticides, mortality was high and was independently predicted by APACHE II score.

Compressive pleural effusion after ovarian hyperstimulation syndrome--a case report and review.

OBJECTIVE: To report a case of early onset ovarian hyperstimulation with massive pleural effusion and respiratory failure before IVF. DESIGN: Case report. SETTING: University teaching intensive care unit. PATIENT(S): A 26-year-old healthy woman with an unexplained infertility transferred to the intensive care unit on day 4 after hCG injection for early severe presentation of ovarian hyperstimulation syndrome with massive compressive pleural effusion before she underwent embryo transfer. INTERVENTION(S): Mechanical ventilation, thoracocentesis. MAIN OUTCOME MEASURE(S): Resolution of symptoms/stopping of embryos transfer. RESULT(S): Drainage of 5,300 mL of sterile exudative pleural fluid for a period of 48 hours, which permitted resolution of symptoms and allowed mechanical weaning. The IVF procedure was stopped. CONCLUSION(S): This case described is unusual in that the patient presented with early massive pleural effusion on day 4 after hCG injection and before embryo transfer. This is much earlier than in any case report elsewhere.

Epidemiology and risk factors for colonization and infection by Acinetobacter baumannii in an ICU in Tunisia, where this pathogen is endemic.

Because Acinetobacter baumannii has become an alarming endemic pathogen in our country we decided to conduct this prospective study, from January 2004 to December 2005, in order to determine risk factors and outcomes involved in clinical colonization or infection by A. baumannii in a 16-bed Tunisian intensive care unit (ICU). One hundred and two A. baumannii isolates were obtained from 63 patients, with an infection rate of 45%. The rate of multidrug-resistant (MDR) A. baumannii was 39% during the 2-year study, with an epidemic outbreak in October 2004. This outbreak was followed by closure of all the involved ICU rooms and the selective intestinal decontamination of patients, with polymyxin. During the 12-month post-intervention program (January-December 2005), the infection rate declined. The analysis of risk factors for the spread of A. baumannii showed that only the Simplified Acute Physiological Score (SAPS II) was involved. On the other hand, no risk factor was identified for multidrug resistance in patients either colonized or infected by A. baumannii. There was a statistically significant difference only in crude mortality (67.5% in MDR A. baumannii vs 46.7% in susceptible A. baumannii; P = 0.04).

Methanol poisoning in Tunisia: report of 16 cases.

Methanol poisoning continues to be a public health problem in Tunisia in spite of the different legislative measures. We report a series of 16 cases of methanol poisoning admitted to our Intensive Care Unit between December 2003 and April 2004. The patients' median age was 21.5 years (range 16 to 53 years) with a median SAPS II of 14 (range 12 to 84) and an APACHE II of 8 (range 6 to 36). The median latent period was 9.5 hours (range 4 to 24 hours) with a delay to medical consultation of 36 hours (range 6 to 48 hours), and a median serum methanol concentration of 1.4 g/L (range 0.19 to 3.62 g/L). Clinical signs included central nervous system symptoms (69%), gastrointestinal complaints (87%), visual disturbances (69%) and metabolic acidosis (94%). Three patients (19%) required mechanical ventilation because of deep coma or shock and died within 6 hours. Hemodialysis was performed in eleven patients (69%) because of visual disturbances and/or metabolic acidosis. One patient developed irreversible bilateral blindness and another unilateral blindness secondary to optic neuropathy. Statistical significant risk factors for the developing of visual disturbances were found to be the ingested quantity of methanol, the latent period, acidosis and serum methanol concentration on admission.

Prognostic value of human erythrocyte acetyl cholinesterase in acute organophosphate poisoning.

Acute organophosphate poisoning (OPP) such as dichlorvos may be monitored by the measurement of the erythrocyte acetyl cholinesterase (EAChE) and the serum cholinesterase (SChE) activities. The aim of this study was to look at correlation between the severity of the OPP judged by certain parameters such as coma, hemodynamic disturbances, respiratory failure, and the decrease of cholinesterases enzymes including EAChE and SChE at admission. Cholinesterase activity was determined upon admission and then on days 3 and 15 in the morning. Clinical effects, EAChE, and SChE activities data were investigated in 42 patients with OPP aged of 29.6 +/- 11.8 years with acute cholinergic crisis in all cases. They were comatose in 29% of cases, presenting both hypotension or shock and hypoxemia in 17% of cases. Fifteen of them (36%) required mechanical ventilation. The mean EAChE activity at admission was 24.3 +/- 11.6 micromol/mL per hour at 37 degrees C; it was 1260 +/- 2204 IU/L for SChE. There were no correlations between the EAChE and the SChE activities. The EAChE was decreased only in comatose patients and those presenting hypotension, hypoxemia, and bradycardia with a cutoff of 23.5 micromol/mL per hour at 37 degrees C. Death was observed in 2 patients with a deep decrease of the EAChE at 5 micromol/mL per hour at 37 degrees C in 1 case and 9 micromol/mL per hour at 37 degrees C in another. The kinetics of improvement of the EAChE activity below the cutoff showed the absence of statistical improvement of the EAChE activity on day 3 (16.6 +/- 9 vs 19.5 +/- 5.7 micromol/mL per hour at 37 degrees C); this improvement was remarkable on day 15 (16.6 +/- 9 vs 27.5 +/- 6.5micromol/mL per hour at 37 degrees C, P = .0004). In summary, the marked decrease of EAChE activity appears in this study as prognostic factor in acute OPP, and coma, respiratory failure, hemodynamic disturbances, and death are associated with a decrease of the EAChE of less than 23.5 micromol/mL per hour at 37 degrees C.

Impact of ceftazidime restriction on gram-negative bacterial resistance in an intensive care unit.

The present study included three periods: (1) a 12-month pre-restriction and control period in 2001; (2) a 12-month restriction period with reduced ceftazidime prescribing in favor of piperacillin-tazobactam (2002); (3) and a 24 month post-restriction period (2003-2004). Note that, for results, P represents the difference between 2002 and 2001; P', the difference between 2003 and 2001; and P'', the difference between 2004 and 2001. No changes in hygiene practices were observed during these three periods. The purpose of this study was to assess the effect of reducing ceftazidime use in an intensive care unit (ICU) upon Gram-negative bacterial resistance, particularly as regards Pseudomonas aeruginosa. During the three periods of the study, patients were similar concerning age, Simplified Acute Physiology Score (SAPSII), the site of nosocomial infection, and the requirements for mechanical ventilation (75% in 2001, 76% in 2002, 74% in 2003, and 85% in 2004). The most commonly isolated pathogens were P. aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae. The use of ceftazidime decreased significantly from 12.6% in 2001 to 9% in 2002, to 3% in 2003 (P' = 0.0009), and 2.6% in 2004 (P'' = 0.0001) in favor of piperacillin-tazobactam (0% 2001 to 3.7% in 2003; P' = 0.002; and 5% in 2004; P'' = 0.0001). Simultaneously, we observed a significant decrease in isolates of P. aeruginosa resistant to piperacillin-tazobactam (P = 0.03; P' = 0.004; P'' = 0.009), and those resistant to imipenem in 2003 (P' = 0.008). We also noted a significant decrease in A. baumannii isolates resistant to ceftazidime (P' = 0.01; P'' = 0.0004) and those resistant to imipenem in both 2002 and 2004 (P = 0.03; P'' = 0.04), and a considerable decrease in isolates of Klebsiella pneumoniae producing expanded spectrum betalactamase (ESBL) in 2003 and 2004 (P' = 0.04; P'' = 6.10(-5)). In contrast, we noted an increase in penicillinase-producing isolates of K. pneumoniae, from 6% in 2001 to 16% in 2002 (p = 0.01), 20% in 2003 (P' = 0.001), and 32% in 2004 (P'' = 10(-6)). We concluded that restriction of ceftazidime use was demonstrated to be efficient in reducing antimicrobial resistance, especially to K. pneumoniae ESBL.

Acute myocarditis and myocardial infarction induced by Paraphenylenediamine poisoning. Interest of angiocoronarography.

We present 2 cases of myocardial damage induced by Paraphenylenediamine (PPD) poisoning in young patients without any history of cardiovascular disease. ECG findings revealed the presence of localized ST segment elevation in precordial leads (V1-V4) in the first case and (V3-V6) in the second associated to an increase of the serum troponine T level at 23 ng/ml (case 1) and 29.7 ng/ml (case 2). The transthoracic echocardiography was in favour of diffuse myocarditis in the first case and of localized myocarditis or septo-apical myocardial infarction in the second. The angiocoronarography performed for the first time in the second case conclude on a septo-apical hypokinesia of the left ventricular resulting of a coronary spasm of the anterior interventricular artery.

Influence of activated charcoal on the pharmacokinetics and the clinical features of carbamazepine poisoning.

Carbamazepine (CBZ) poisoning has been associated with cases of severe toxicity and death. Multiple-dose activated charcoal was proposed to enhance the clearance of CBZ elimination, but there are no prospective controlled studies that demonstrated a change in clinical outcome after the use of multiple-dose activated charcoal. The aim of this study was to determine the CBZ elimination kinetics and the evolution of clinical features according to the dose of activated charcoal in acute poisoning patients. It is a prospective study for 6 months, from January to June 2004, including all pure acute CBZ-poisoned patients. Twelve patients were randomized to receive a multiple-dose activated charcoal (G1) or a simple dose of 1 g/kg (G2). Their mean age was 27.6+/-12.2 years; the Simplified Acute Physiology Score (SAPS II), 16.37+/-8.46; and the Acute Physiology and Chronic Health Evaluation (APACHE II), 8+/-3.96. They were 8 men and 4 women. The mean concentration of blood CBZ at hospital admission was of 29.42+/-6.68 mg/L. Each group includes 6 patients. The peak value of blood CBZ was comparable in the 2 groups: 33+/-3.46 mg/L (G1) vs 32.6+/-5.63 (G2) (P=.5); the requirement of mechanical ventilation was similar also (3 in each group). The duration of both coma and mechanical ventilation was significantly decreased in the first group compared with the second: 20.33+/-3.05 vs 29.33+/-4.11 hours for coma (P=.02) and 24.1+/-4.2 vs 36.4+/-3.6 hours for mechanical ventilation (P=.001). The length of stay was also significantly decreased in the first group: 30.3+/-3.4 vs 39.7+/-7.3 hours in the second group (P=.000006). Concurrently, we have noted a significant constant reduction of the half-life of CBZ from serum in the first group: 12.56+/-3.5 hours after multiple dose vs 27.88+/-7.36 hours after a simple dose (P=.0004). This decrease was correlated to the dose of charcoal. In summary, we can conclude that multiple-dose activated charcoal is more efficient than simple-dose; it permits a constant decrease of the half-life of blood CBZ without any rebound effect and could improve the prognosis by reducing the duration of coma and the length of stay.

Acute pancreatitis subsequent to voluntary methomyl and dichlorvos intoxication.

INTRODUCTION: Acute pancreatitis subsequent to methomyl (Lannate) had not been reported until 2005, when Markides published the first case. In our study, we report for the first time 2 cases of acute pancreatitis complicating voluntary methomyl intoxication and compare them with 5 cases of pancreatitis subsequent to dichlorvos poisoning admitted to our toxicological unit during the same period, between July 2001 and June 2003. CASE REPORTS: Patients included in this study were seriously poisoned because all developed muscarinic and nicotinic syndromes. Deep coma and respiratory failure requiring mechanical ventilation were noted in all methomyl-poisoned patients and in only 3 dichlorvos-poisoned patients. Acute pancreatitis occurred 24 to 72 hours after dosing and was characterized by painless abdominal paralytic ileus and vomiting. Clinical features and laboratory examinations were normalized by the fifth day under medical treatment. Complications such as intrapancreatic fluid collection occurred later between days 10 and 20 in 1 methomyl-poisoned patient who required secondary surgical drainage and in 1 dichlorvos-poisoned patient who was treated conservatively. Outcome was favorable in all cases. CONCLUSION: The developing of acute pancreatitis is a serious adverse effect following insecticide intoxication and is better known with dichlorvos than methomyl.