Burden of nosocomial infections in intensive care units: Cost of antibiotics, the extra length of stay and mortality rate.

Background: Healthcare-associated infections (HAIs) in intensive care unit (ICU) patients significantly complicate the normal hospitalization process and affect patients' condition, length of hospitalization, mortality, and treatment cost. In this study, we aimed to determine the prevalence and economic burden of HAIs. Methods: The study involved all patients with a confirmed HAIs (based on CDC/NHSN case-definitions); in the general ICU of a tertiary university hospital in Tehran, from April 2020 to March 2021. The patients' information, including length of hospitalization, outcome, type and cost of prescribed antibiotics, were recorded. Results: During the study period, 119 HAIs were found in 1395 (43% F / 57% M) patients. The prevalence of nosocomial infections was 8.53%. The mean duration of hospitalization in all ICU patients was 4.7 ± 3.1 days, and 31.85 ± 18.96 days in patients with HAIs. The most common organisms involved in HAIs are Acinetobacter baumannii (54.6%), Klebsiella pneumoniae (30.3%), E. coli (15.1%), and Enterococcus spp. (12%). Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 36.08, 17.57, and 8.86, respectively. The total cost of antibiotics for HAIs was € 105,407. Among these, the highest consumption costs were for carbapenems, followed by colistin and caspofungin. Conclusion: This study showed the high burden of nosocomial infections in ICUs. Strategies for more strict infection prevention and control are necessary to reduce this burden.

Immediate effects of kinesiology tape on quadriceps muscle peak torque and knee joint repositioning error in healthy males: Effects of different tensions and directions.

BACKGROUND: Knee joint injuries may result from compromised quadriceps muscle strength or diminished knee joint proprioception. The application of Kinesio tape (KT) on the quadriceps muscle from origin to insertion (OTI-KT) or insertion to origin (ITO-KT) could impact knee joint proprioception and quadriceps muscle strength. This study aims to assess the effects of different tensions and directions of KT application on active and passive knee joint repositioning errors (AJRE and PJRE) and peak concentric and eccentric peak torque (CPT and EPT) of the quadriceps muscles in healthy males. METHOD: Twenty-one healthy males participated in this repeated-measures study design. CPT, EPT, AJRE, and PJRE of the dominant limb were measured by a Biodex dynamometer before and after applying OTI-KT with 0%, 15%, and 40% extra tensions and ITO-KT with 0% tension. RESULTS: ITO-KT demonstrated a significant reduction in AJRE (p < 0.05). Meanwhile, for OTI-KT, a statistically significant difference was observed in both AJRE and PJRE concerning time (F1,126 = 19.74, p < 0.05 for AJRE; F1,126 = 9.96, p < 0.05 for PJRE) and tension (F2,126 = 22.14, p < 0.05 for AJRE; F2,126 = 20.67, p < 0.05 for PJRE). CONCLUSION: Applying KT, especially OTI KT with 40% and 15% extra tension, shows potential in enhancing knee proprioception without immediate impacts on quadriceps muscle torque. This suggests applications in sports performance and knee injury rehabilitation.

Postoperative cognitive dysfunction: a concept analysis.

BACKGROUND: Post-operative cognitive dysfunction (POCD) is a concern for clinicians that often presents post-surgery where generalized anesthesia has been used. Its prevalence ranges from 36.6% in young adults to 42.4% in older individuals. Conceptual clarity for POCD is lacking in the currently body literature. Our two-fold purpose of this concept analysis was to (1) critically appraise the various definitions, while also providing the best definition, of POCD and (2) narratively synthesize the attributes, surrogate or related terms, antecedents (risk factors), and consequences of the concept. METHOD: The reporting of our review was guided by the PRISMA statement and the 6-step evolutionary approach to concept analysis developed by Rodgers. Three databases, including Medline, CINAHL, and Web of Science, were searched to retrieve relevant literature on the concept of POCD. Two independent reviewers conducted abstract and full-text screening, data extraction, and appraisal. The review process yielded a final set of 86 eligible articles. RESULT: POCD was defined with varying severities ranging from subtle-to-extensive cognitive changes (1) affecting single or multiple cognitive domains that manifest following major surgery (2), is transient and reversible, and (3) may last for several weeks to years. The consequences of POCD may include impaired quality of life, resulting from withdrawal from the labor force, increased patients' dependencies, cognitive decline, an elevated risk of dementia, rising healthcare costs, and eventual mortality. CONCLUSION: This review resulted in a refined definition and comprehensive analysis of POCD that can be useful to both researchers and clinicians. Future research is needed to refine the operational definitions of POCD so that they better represent the defining attributes of the concept.

Evaluation of acute, subacute, and subchronic toxicity of a hepatoprotective herbal formulation.

Background: The possible toxicity of natural products must be tested before being used in the market. The present work aimed to evaluate acute, subacute, and subchronic toxicity of an herbal formulation containing Anethum graveolens, Cynara scolymus, Citrus aurantium, Portulaca oleracea, and Silybum marianum. Material and methods: Acute toxicity (2000 mg/kg, single dose) and sub-acute toxicity (600 and 1200 mg/kg/day, 4 weeks) tests were performed on female and male rats according to OECD 423 and OECD 407 guidelines, respectively. In the subchronic study (12 weeks), the animals were divided into three groups (6 females and 6 males per group): control, low-dose group (food supplemented with 300 mg/kg of the herbal product), and high-dose group (600 mg/kg). Results: The herbal product at a single dose of 2000 mg/kg did not induce mortality for 14 days. In the sub-acute study, administration of the product for 28 days at 1200 mg/kg/day had no effect on survival, appetite (water and food consumption), body weight, serum biochemical parameters (BUN, creatinine, AST, ALT, ALP, bilirubin, albumin), histology of vital organs (liver, kidney, heart, brain), and hematological markers related to erythrocyte, platelet, and leukocyte. Similarly, in the subchronic study, the product did not induce mortality, change in histology of the vital organs, or alteration in hematological or biochemical parameters (except for an increase in ALP in female rats received 600 mg/kg). Conclusion: The formulated product shows no signs of toxicity in rats up to 2000 mg/kg, 1200 mg/kg, and 600 mg/kg in acute, subacute, and subchronic phases, respectively. It is suggested to monitor ALP levels in females in case of long-term use of the product.

Simulation-based design optimization of a wrist exoskeleton.

Exoskeletons are widely used in the field of rehabilitation robotics. Upper limb exoskeletons (ULEs) can be very useful for patients with diminished ability to control their limbs in aiding activities of daily living (ADLs). The design of ULEs must account for a human's limitations and ability to work with an exoskeleton. It can typically be achieved by the involvement of vulnerable end-users in each design cycle. On the other hand, simulation-based design methods on a model with human-in-the-loop can limit the design cycles, thereby reducing research time and dependency on end users. This study makes it evident by using a case where the design of an exoskeleton wrist can be optimized with the usage of a torsional spring at the joint, that compensates for the required motor torque. Considering the human-in-the-loop system, the multibody modeling results show that the usage of a torsional spring in the joint can be useful in designing a lightweight and compact exoskeleton joint by downsizing the motor.Clinical Relevance- The proposed methodology of designing an upper-limb exoskeleton has a utility in limiting design cycles and making it both convenient and useful to assist users with severe impairment in ADLs.

Assessing Mode-Switching Strategies for Assistive Robotic Manipulators Using a Preliminary Version of the Novel Non-invasive Tongue-Computer Interface.

The inductive tongue-computer interface allows individuals with tetraplegia to control assistive devices. However, controlling assistive robotic arms often requires more than 14 different commands, which cannot always fit into a single control layout. Previous studies have separated the commands into modes, but few have investigated strategies to switch between them. In this feasibility study, we compare the efficiency of switching modes using buttons, swipe gestures and double taps using a preliminary version of a new non-invasive mouthpiece unit (nMPU), which includes an integrated activation unit and a single sensor board. Three participants controlled a JACO assistive robot to pick up a bottle using different mode-switching strategies. Compared with switching modes with buttons, switching modes with swipes and double taps increased the task completion time by 21% and 58% respectively. Therefore, we recommend that configurations with multiple modes for the non-invasive tongue-computer interface include buttons for mode-switching.Clinical relevance- Cumbersome mode-switching strategies can lower a control interface's responsiveness and contribute to end-user abandonment of assistive technologies. This study showed that using buttons to switch modes is more reliable. Moreover, this study will inform the development of future control layouts with improved usability.

Using workspace restrictiveness for adaptive velocity adjustment of assistive robots and upper limb exoskeletons.

Individuals with severe disabilities can benefit from assistive robotic systems (ARS) for performing activities of daily living. However, limited control interfaces are available for individuals who cannot use their hands for the control, and most of these interfaces require high effort to perform simple tasks. Therefore, autonomous and intelligent control strategies were proposed for assisting with the control in complex tasks. In this paper, we presented an autonomous and adaptive method for adjusting an assistive robot's velocity in different regions of its workspace and reducing the robot velocity where fine control is required. Two participants controlled a JACO assistive robot to grasp and lift a bottle with and without the velocity adjustment method. The task was performed 9.1% faster with velocity adjustment. Furthermore, analyzing the robot trajectory showed that the method recognized highly restrictive regions and reduced the robot end-effector velocity accordingly.Clinical relevance- The autonomous velocity adjustment method can ease the control of ARSs and improve their usability, leading to a higher quality of life for individuals with severe disabilities who can benefit from ARSs.

Knee joint repositioning error in different trunk positions among females with chronic nonspecific low back pain: A cross-sectional study.

PURPOSE: Proprioception is a self-perceived sense of position and movement of one's body and its deficits can lead to motor control problems such as delayed muscle reflexes. Previous studies have confirmed lumbar proprioception impairments among individuals with Low Back Pain (LBP), which can afflict the normal central sensory-motor control and hence increases the risk of abnormal loading on the lumbar spine. Although the local investigation of proprioception is important, its influence on other joints in a kinetic chain particularly between extremities and spine should not be ignored. Therefore, the aim of this study was to compare the proprioception of knee joint in different trunk positions among females with chronic nonspecific low back pain (CNSLBP) and healthy females. DESIGN: The study included 24 healthy subjects and 25 patients with CNSLBP participated in this study. Repositioning error of knee joint in four different lumbar positions including flexion, neutral position, 50% ROM of left rotation and 50% ROM right rotation was evaluated using an inclinometer. Absolute error and constant error were obtained and analyzed. RESULTS: Absolute error in flexion and neutral positions in the individuals with CNSLBP were significantly higher than in healthy individuals; whereas, there was no significant difference in absolute and constant error between the two groups in 50% rotation to either side. CONCLUSION: This study showed that knee joint repositioning accuracy was reduced in patients with CNSLBP compared to healthy ones.

Adherence to recommendations for the evaluation and management of fungal infections in a referral teaching hospital in Iran: A retrospective cross-sectional study.

INTRODUCTION: Early diagnosis and appropriate management of fungal infections are critical for reducing complications and mortality in hospitalized patients. Due to the lack of appropriate local management protocols as well as the unavailability and cost of advanced tests for diagnosis of fungal infections, the irrational use of antifungals is a concern in developing countries. OBJECTIVES: This study was designed to evaluate diagnosis and management of fungal infections in hospitalized patients. METHODS: In a retrospective cross-sectional study, the use of parenteral antifungal medications among hospitalized patients was evaluated according to the prepared protocols adapted from the international guidelines. RESULTS: Among 151 patients, diagnostic approaches were appropriate and inappropriate in 90 and 61 patients respectively. Indications for antifungal drug administration were empiric therapy (80.1%) followed by targeted therapy (19.2%) and prophylaxis (0.7%). The indications were appropriate and inappropriate in 123 and 28 patients respectively. Selection of antifungals was appropriate in 117 patients, inappropriate in 16 patients, and was not assessable in other cases. The doses of antifungal medications were appropriate and inappropriate in 111 and 14 patients respectively. Among 151 patients, the duration of treatment was appropriate just in 33 cases. The techniques for antifungal administration were appropriate in 133 patients and inappropriate in 18 cases. CONCLUSIONS: Due to limited access to diagnostic tests, most parenteral antifungal medications were administered as empiric therapy. The diagnostic workups, treatment monitoring, and follow-up were inadequate in most patients. Development of local diagnostic and management protocols for invasive fungal infections and considering a stewardship program for antifungal medications are essential for each medical center.

Predictors of Non-invasive Ventilation Failure and Associated Factors Among the COVID-19 Patients Admitted to Intensive Care Unit.

Background: Non-invasive ventilation (NIV) is a method of oxygenation supply that eliminates the need for an endotracheal airway. Non-invasive ventilation failure is defined as the necessity for endotracheal intubation or death during the NIV trial. Objectives: This study aimed to identify the predictors and associated factors of NIV failure in coronavirus disease 2019 (COVID-19) patients admitted to an intensive care unit (ICU). Methods: This retrospective, longitudinal cohort study utilized electronic medical records of COVID-19 patients admitted to the ICU. A total of 150 patients were included in the study. Patient demographics, medical history, laboratory tests, partial pressure of carbon dioxide (PCO2), oxygen saturation (SpO2), heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR score), and the ratio of oxygen saturation (ROX) index (the SpO2/fraction of inspired oxygen [FIO2] to respiratory rate [SF] ratio) were recorded. Non-invasive ventilation failure was determined based on the need for endotracheal intubation or cardiac-respiratory arrest while on NIV. Results: Of 150 patients, 55.3% were male (mean age: 55.9 years), with an NIV failure rate of 67.3%, a mortality rate of 66.7%, and 3.3% of patients requiring tracheostomy after NIV failure. The ROX index consistently decreased over time, and an increase in the HACOR score and PCO2 after 6 hours of commencing NIV were the predictors of NIV failure. Additionally, higher levels of lactate dehydrogenase, lower SF ratios, and higher APACHE scores upon ICU admission were significantly associated with NIV failure. Notably, the erythrocyte sedimentation rate (ESR) as an inflammatory index, SF ratio upon ICU admission, HACOR score, ROX index, and PCO2 after 12 hours were significant predictors of in-hospital mortality in patients receiving NIV. Conclusions: The ROX index, HACOR scale, and PCO2 are significant predictors of both NIV failure and in-hospital mortality.

Soluble ACE2 as a Risk or Prognostic Factor in COVID-19 Patients: A Cross-sectional Study.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel severe acute respiratory syndrome coronavirus. The first known receptor for this virus in the human body is angiotensin-converting enzyme 2 (ACE2), the same receptor for the SARS virus. Methods: A total of 38 hospitalized adult (18 years) patients with laboratory or clinically confirmed coronavirus disease 2019 (COVID-19) were identified in the infectious disease ward of Tehran Imam Khomeini hospital complex in this single-center cross-sectional study. A blood sample was taken at the time of hospitalization and a second one was taken 48 hours later. Blood samples are kept frozen at -80 degrees Celsius. After the complete collection of samples, the ACE2 level of the samples was measured using a serum sACE2 detection ELISA kit. The data were analyzed using SPSS v26. P value of 0.05 was considered statistically significant. An analysis of covariance was performed to examine the mean differences in day 7 serum ACE2 concentration among the 2 groups after adjusting for the baseline serum ACE2 concentration. The 1-way multivariate analysis of variance was used to determine whether there were any differences between independent groups (mechanical ventilation yes/no) on serum ACE2 levels at 3 different times. Results: The mean age of patients was 64.13 ± 16.49 years, 21 patients (55.3%) were men, 16 patients (42%) were polymerase chain reaction test positive, and 15 patients (39.5%) died. A total of 35 individuals (92.1%) had chest computed tomography images that indicated lung involvement. A comparison of the 2 groups of patients who died and were discharged revealed that serum ACE2 at the first (p=0.033) and third (7th day) measurements were statistically different (p=0.026). Patients had a mean of serum ACE2. The results indicated that the day 7 serum ACE2 concentration did significantly differ between the 2 groups after controlling for the baseline serum ACE2 concentration (p=0.023). The model explained about 73.61% of the variance in the 7-day serum ACE2 concentration. Specifically, after adjusting for the baseline concentration, survived patients had the lowest level of serum ACE2 concentration (1 ± 0.65) on the 7th day compared with the deceased patient group (2.83 ± 1.12). Conclusion: Soluble ACE2 in the serum of COVID-19 patients who died, later on, was significantly higher than the discharged patients when the samples were taken seven days after admission. It is suggested that serum soluble ACE2 level could be used as a prognostic factor for COVID-19 patients' outcomes and also their need for mechanical ventilation.

Effects of Exercise on COVID-19 Patients: A Narrative Review.

Background: Challenges concerning patient management exist worldwide, particularly in the critical care. In this review, we have summarized some studies regarding respiratory physiotherapy and exercise in COVID-19 patients. Methods: For searching related articles, PubMed, Google Scholar, Embase, and the Web of Science databases were used. Keywords such as "respiratory physiotherapy" and "COVID-19," "exercise," "effect of exercise in COVID-19," and "respiratory physiotherapy for COVID-19 in ICU" were used to identify related papers until December 2021. The abstracts and entire texts were evaluated by 3 separate reviewers. Results: During the symptomatic phase, individuals may benefit from brief durations of bed rest. Exercise appears to provide both emotional and physical benefits for individuals in the early stages of infection. As a result, it may lower viral load, minimize cytokine storm, shorten the acute phase, and expedite recovery. Mild exercise may also increase the autophagy pathway, which improves the immune system function in response to COVID-19 infection. Keeping this in mind, intense activity, especially without the guidance of an expert physical therapist, is not advantageous during the inflammatory period and may even be regarded a second hit phenomenon. Mild exercises during bed rest (e.g., acute phase) may reduce the risk of pulmonary capillary coagulation and deep vein thrombosis. Conclusion: Although respiratory physiotherapy and prone positioning in hospitalized patients, particularly in critical care, can be challenging for medical staff, they are cost-effective and noninvasive approaches for COVID-19 patients. Early physiotherapy and muscle training exercise for patients in the intensive care unit (ICU) seems to be beneficial for patients and may reduce bed rest-induced weakness, improve oxygenation, and reduce length of stay. Finally, breathing exercises can improve some symptoms of COVID-19, like dyspnea and weakness.

Development of inductive sensors for a robotic interface based on noninvasive tongue control.

Tongue based robotic interfaces have shown the potential to control assistive robotic devices developed for individuals with severe disabilities due to spinal cord injury. However, current tongue-robotic interfaces require invasive methods such as piercing to attach an activation unit (AU) to the tongue. A noninvasive tongue interface concept, which used a frame integrated AU instead of a tongue attached AU, was previously proposed. However, there is a need for the development of compact one-piece sensor printed circuit boards (PCBs) to enable activation of all inductive sensors. In this study, we developed and tested four designs of compact one-piece sensor PCBs incorporating inductive sensors for the design of a noninvasive tongue-robotic interface. We measured electrical parameters of the developed sensors to detect activation and compared them with a sensor of the current version of the inductive tongue-computer interface (ITCI) by moving AUs with different contact surfaces at the surface of the sensors. Results showed that, the newly developed inductive sensors had higher and wider activation than the sensor of ITCI and the AU with a flat contact surface had 3.5 - 4 times higher activation than the AU with a spherical contact surface. A higher sensor activation can result in a higher signal to noise ratio and thus a higher AU tracking resolution.

The impact of interdisciplinarity and user involvement on the design and usability of an assistive upper limb exoskeleton - a case study on the EXOTIC.

This study describes an interdisciplinary approach to develop a 5 degrees of freedom assistive upper limb exoskeleton (ULE) for users with severe to complete functional tetraplegia. Four different application levels were identified for the ULE ranging from basic technical application to interaction with users, interaction with caregivers and interaction with the society, each level posing requirements for the design and functionality of the ULE. These requirements were addressed through an interdisciplinary collaboration involving users, clinicians and researchers within social sciences and humanities, mechanical engineering, control engineering media technology and biomedical engineering. The results showed that the developed ULE, the EXOTIC, had a high level of usability, safety and adoptability. Further, the results showed that several topics are important to explicitly address in relation to the facilitation of interdisciplinary collaboration including, defining a common language, a joint visualization of the end goal and a physical frame for the collaboration, such as a shared laboratory. The study underlined the importance of interdisciplinarity and we believe that future collaboration amongst interdisciplinary researchers and centres, also at an international level, can strongly facilitate the usefulness and adoption of assistive exoskeletons and similar technologies.

User Based Development and Test of the EXOTIC Exoskeleton: Empowering Individuals with Tetraplegia Using a Compact, Versatile, 5-DoF Upper Limb Exoskeleton Controlled through Intelligent Semi-Automated Shared Tongue Control.

This paper presents the EXOTIC- a novel assistive upper limb exoskeleton for individuals with complete functional tetraplegia that provides an unprecedented level of versatility and control. The current literature on exoskeletons mainly focuses on the basic technical aspects of exoskeleton design and control while the context in which these exoskeletons should function is less or not prioritized even though it poses important technical requirements. We considered all sources of design requirements, from the basic technical functions to the real-world practical application. The EXOTIC features: (1) a compact, safe, wheelchair-mountable, easy to don and doff exoskeleton capable of facilitating multiple highly desired activities of daily living for individuals with tetraplegia; (2) a semi-automated computer vision guidance system that can be enabled by the user when relevant; (3) a tongue control interface allowing for full, volitional, and continuous control over all possible motions of the exoskeleton. The EXOTIC was tested on ten able-bodied individuals and three users with tetraplegia caused by spinal cord injury. During the tests the EXOTIC succeeded in fully assisting tasks such as drinking and picking up snacks, even for users with complete functional tetraplegia and the need for a ventilator. The users confirmed the usability of the EXOTIC.

Cochlear implantation outcomes in children with global developmental delay.

OBJECTIVE: As the number of hearing loss cochlear implant candidates who suffer from global developmental delay has dramatically increased, we aimed to study the prognosis of implantation in this group. MATERIALS AND METHODS: In this cross-sectional case-control study, we utilized the Ages and Stages Questionnaire third edition (ASQ-3) to investigate the prognosis of cochlear implantation and its rehabilitation in 26 congenitally deaf children who suffered from global developmental delay compared with those in 25 non-delayed cases with the same conditions in two time periods, namely the first diagnosis of hearing loss and 18 months after the surgery and rehabilitation program. The data were analyzed using Statistical Package for Social Sciences, version 21 (SPSS-21). RESULTS: By the time of hearing loss diagnosis (six months old), the performance of all the global developmentally delayed hearing loss children in five subtests of the ASQ-3 scale was significantly lower than that of their non-delayed peers. Meanwhile, they improved significantly in two gross motor and social development subtests 18 months after the surgery and rehabilitation. CONCLUSION: Along with the general improvement of delay developed children with sensorineural hearing loss after cochlear implantation, global developmental assessment in the process of candidacy and after implantation is an essential factor that needs to be considered.

Evaluation of the Relationship between Nutritional Status of COVID-19 Patients Admitted to the ICU and Patients' Prognosis: A Cohort Study.

Background: Malnutrition in COVID-19 critically ill patients can lead to poor prognosis. This study aimed to evaluate the association between nutritional status (or risk) and the prognosis of critically ill COVID-19 patients. In this study, prognosis is the primary outcome of "hospital mortality" patients. The second outcome is defined as "need for mechanical ventilation." Methods and Materials: In this single-center prospective cohort study, 110 patients admitted to the Intensive Care Unit of Imam Khomeini Hospital Complex (Tehran, Iran) between April and September 2021 were enrolled. Participants formed a consecutive sample. MNA-SF, NRS-2002, mNUTRIC, and PNI scores were used to evaluate nutritional assessment. Patients' lab results and pulse oximetric saturation SpO2/FiO2 (SF) ratio at the time of intensive care unit (ICU) admission were collected. Patients were screened for nutritional status and categorized into two groups, patients at nutritional risk and nonrisk. Results: Sixty-five (59.1%) of all patients were men. The overall range of age was 52 ± 15. Thirty-six (32.7%) of patients were obese (BMI ≥ 30). The hospital mortality rate was 59.1% (n = 65). According to the different criteria, malnutrition rate was 67.3% (n = 74) (NRS), 28.2% (n = 31) (MNA), 34.5% (n = 38) (mNUTRIC), and 58.2% (n = 64) (PNI). There was a statistically significant association between chronic kidney disease (CKD) and mNUTRIC risk (OR = 13.5, 95% CI (1.89-16.05), P=0.002), diabetes mellitus (DM) and MNA risk (OR = 2.82, 95% CI (1.01-7.83), P=0.041), hypertension (HTN) and MNA risk (OR = 5.63, 95% CI (2.26-14.05), P < 0.001), and malignancy and mNUTRIC risk (P=0.048). The nutritional risk (all tools) significantly increased the odds of in-hospital death and need for mechanical ventilation. The length of stay was not significantly different in malnourished patients. Conclusion: In the critical care setting of COVID-19 patients, malnutrition is prevalent. Malnutrition (nutritional risk) is associated with an increased risk of need for mechanical ventilation and in-hospital mortality. Patients with a history of HTN, CKD, DM, and cancer are more likely to be at nutritional risk at the time of ICU admission.

Various Aspects of Non-Invasive Ventilation in COVID-19 Patients: A Narrative Review.

Non-invasive ventilation (NIV) is primarily used to treat acute respiratory failure. However, it has broad applications to manage a range of other diseases successfully. The main advantage of NIV lies in its capability to provide the same physiological effects as invasive ventilation while avoiding the placement of an artificial airway and its associated life-threatening complications. The war on the COVID-19 pandemic is far from over. The present narrative review aimed at identifying various aspects of NIV usage, in COVID-19 and other patients, such as the onset time, mode, setting, positioning, sedation, and types of interface. A search for articles published from May 2020 to April 2021 was conducted using MEDLINE, PMC central, Scopus, Web of Science, Cochrane Library, and Embase databases. Of the initially identified 5,450 articles, 73 studies and 24 guidelines on the use of NIV were included. The search was limited to studies involving human cases and English language articles. Despite several reported benefits of NIV, the evidence on the use of NIV in COVID-19 patients does not yet fully support its routine use.

Deciding When to Intubate a COVID-19 Patient.

Background: The SARS-CoV-2 pandemic is one of the most significant challenges for healthcare providers, particularly in the critical care setting. The timing of intubation in COVID-19 patients seems to be challenging. Therefore, we aimed to investigate how it may have a survival benefit, and we determined which clinical characteristics were associated with outcomes. Methods: This cross-sectional study was conducted in the Imam Khomeini Hospital Complex. We randomly selected patients admitted to intensive care units and, based on intubation status, categorized them into three subgroups (early, late, and not intubated). Early intubation is defined as intubation within 48 hours of ICU admission, and late intubation is defined as intubation after 48 hours of ICU admission. Results: Early-intubated patients were more likely to have dyspnea than late-intubated patients, and late-intubated patients had a higher mean heart rate than early-intubated patients. The neutrophil/lymphocyte ratio was significantly (P < 0.05) lower in not-intubated patients than in other patients. There was no difference in NLR between early- and late-intubated patients. Mean serum creatine phosphokinase and troponin I levels were higher in late-intubated patients than in early- and not-intubated patients. Early-intubated patients had a lower ROX index than late-intubated patients. Patients with higher scores of APACHE 2, respiratory rates, and neutrophil to lymphocyte ratio were more likely to be intubated. Increasing APACHE and SOFA scores were associated with decreased odds of survival. Conclusions: There were no statistically significant differences in total mortality between early- and late-intubated patients. APACHE 2 scores, NLR, RR, and history of ischemic heart disease are some of the appropriate predictors of intubation. Higher respiratory rates (tachypnea) can be an indicator of early intubation. The ROX index is one of the most sensitive and capable tools for predicting intubation. Intubation status is a potent predictor of in-hospital mortality.

Invasive Airway "Intubation" in COVID-19 Patients; Statistics, Causes, and Recommendations: A Review Article.

CONTEXT: Severe coronavirus disease 2019 (COVID-19) can induce acute respiratory distress, which is characterized by tachypnea, hypoxia, and dyspnea. Intubation and mechanical ventilation are strategic treatments for COVID-19 distress or hypoxia. METHODS: We searched PubMed, Embase, and Scopus databases to identify relevant randomized control trials, observational studies, and case series published from April 1, 2021. RESULTS: 24 studies were included in this review. Studies had been conducted in the USA, China, Spain, South Korea, Italy, Iran, and Brazil. Most patients had been intubated in the intensive care unit. Rapid sequence induction had been mostly used for intubation. ROX index can be utilized as the predictor of the necessity of intubation in COVID-19 patients. According to the studies, the rate of intubation was 5 to 88%. It was revealed that 1.4 - 44.5% of patients might be extubated. Yet obesity and age (elderly) are the only risk factors of delayed or difficult extubation. CONCLUSIONS: Acute respiratory distress in COVID-19 patients could require endotracheal intubation and mechanical ventilation. Severe respiratory distress, loss of consciousness, and hypoxia had been the most important reasons for intubation. Also, increased levels of C-reactive protein (CRP), ferritin, d-dimer, and lipase in combination with hypoxia are correlated with intubation. Old age, diabetes mellitus, respiratory rate, increased level of CRP, bicarbonate level, and oxygen saturation are the most valuable predictors of the need for mechanical ventilation. ICU admission mortality following intubation was found to be 15 to 36%. Awake-prone positioning in comparison with high-flow nasal oxygen therapy did not reduce the risk of intubation and mechanical ventilation. There was no association between intubation timing and mortality of the infected patients. Noninvasive ventilation may have survival benefits.