Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis.

INTRODUCTION: We recently reported a high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 admitted to the intensive care units (ICUs) of three Dutch hospitals. In answering questions raised regarding our study, we updated our database and repeated all analyses. METHODS: We re-evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction and/or systemic arterial embolism in all COVID-19 patients admitted to the ICUs of 2 Dutch university hospitals and 1 Dutch teaching hospital from ICU admission to death, ICU discharge or April 22nd 2020, whichever came first. RESULTS: We studied the same 184 ICU patients as reported on previously, of whom a total of 41 died (22%) and 78 were discharged alive (43%). The median follow-up duration increased from 7 to 14 days. All patients received pharmacological thromboprophylaxis. The cumulative incidence of the composite outcome, adjusted for competing risk of death, was 49% (95% confidence interval [CI] 41-57%). The majority of thrombotic events were PE (65/75; 87%). In the competing risk model, chronic anticoagulation therapy at admission was associated with a lower risk of the composite outcome (Hazard Ratio [HR] 0.29, 95%CI 0.091-0.92). Patients diagnosed with thrombotic complications were at higher risk of all-cause death (HR 5.4; 95%CI 2.4-12). Use of therapeutic anticoagulation was not associated with all-cause death (HR 0.79, 95%CI 0.35-1.8). CONCLUSION: In this updated analysis, we confirm the very high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 pneumonia.

Incidence of thrombotic complications in critically ill ICU patients with COVID-19.

INTRODUCTION: COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. METHODS: We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. RESULTS: We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. CONCLUSION: The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.

A randomized trial comparing two intraosseous access devices in intrahospital healthcare providers with a focus on retention of knowledge, skill, and self-efficacy.

INTRODUCTION: Intraosseous access is recommended in vitally compromised patients if an intravenous access cannot be easily obtained. Intraosseous infusion can be initiated by various healthcare providers. Currently, there are two mechanical intraosseous devices approved by the U.S. Food and Drug Administration (FDA) for use in adults and children. A comparison is made in this study of the theoretical and practical performance by anesthesiologists and registered nurses of anesthesia (RNAs) in the use of the battery-powered device (device A) versus the spring-loaded needle device (device B). This study entailed a 12-month follow-up of knowledge, skill retention, and self-efficacy measured by standardized testing. METHODS: A prospective randomized trial was performed, initially comparing 15 anesthesiologists and 15 RNAs, both on using the two types of intraosseous devices. A structured lecture and skill station was given with the educational aids provided by the respective manufacturers. Individual knowledge and practical skills were tested at 0, 3, and 12 months after the initial course. RESULTS: There was no statistical significant difference in the retention of theoretical knowledge between RNAs and anesthesiologists on all testing occasions. However, the self-efficacy of the anesthesiologists is significantly higher (p < 0.01) than the self-efficacy of the RNAs for both devices, on any testing occasion. Insufficient skills were local disinfection (both groups, both devices) and attachment of the needle to the intravenous line (RNAs with both devices). In 33 % of all device B handlings, unsafe practice occurred. CONCLUSION: The use of device A is safer in handling in comparison to device B at 12 months follow-up. The hypothesis that doctors are more qualified in obtaining intraosseous access has been disproven, as anesthesiologists were as successful as RNAs. However, the low self-efficacy of RNAs in the use of intraosseous devices could diminish the chance of them actually using one.

Effect of the colloids gelatin and HES 130/0.4 on blood coagulation in cardiac surgery patients: a randomized controlled trial.

OBJECTIVE: The choice of the prime solution for cardiopulmonary bypass can play an important role in limiting the effect on blood coagulation, but it is still unclear what the effect of colloids on blood coagulation is. The aim of this study was to investigate the effect of synthetic colloids on blood loss and blood coagulation in patients after on-pump coronary artery bypass graft (CABG) procedures. METHODS: Sixty elective, on-pump CABG patients were randomly assigned to receive the prime solutions lactated Ringer's solution combined with hydroxyethyl starch 130/0.4 (HES, 6% Volulyte, Fresenius Kabi Nederland BV, Zeist, the Netherlands) (HES group) or gelatin (Gelofusin(®), B Braun Melsung AG, Melsungen, Germany) (Gelo group). Blood loss was assessed using post-operative chest tube output; secondary endpoints were number of blood component transfusions, routine coagulation test values and rotation thromboelastometry values (Rotem(®) delta, Pentapharm GmbH, Munich, Germany). RESULTS: Total post-operative chest tube output was 500 ± 420 ml in the HES group versus 465 ± 390 ml in the Gelo group (p = 0.48). No significant differences were observed in any of the routine coagulation tests values, thromboelastometry parameters or number of blood component transfusions between the groups. CONCLUSIONS: In this randomized, controlled trial of adults after on-pump CABG procedures, there was no significant difference in blood loss or blood coagulation between the HES group and the Gelo group.

Clinical evaluation of a new tracheal impedance cardiography method.

Non-invasive cardiac output measurement by means of impedance cardiography has been evaluated before, and agreement with other methods has been variable. We decided to study a newly developed tracheal impedance device, that is claimed to be more accurate and reliable. This incorporates new software and mathematical formulae, that are designed to reduce signal noise from diathermy, leading to improved accuracy. In 25 cardiothoracic surgery patients, simultaneous measurements were performed using both pulmonary artery thermodilution and the tracheal impedance device, at five peri-operative time points: before skin incision; after weaning from cardiopulmonary bypass; after sternal closure; and 30 min and 2 h after arrival in the intensive care unit. Mean cardiac output, bias and 95% limits of agreement were 5.3, 0.03 and -2.8 to 2.8 l.min(-1) , respectively. Tracheal impedance showed good correlation with measurement trends using thermodilution in 88% of measurements, with a mean (95% limit of agreement) angular bias of -9.0° (-83.3 to 65.3°). However, the wide limits of agreement and high percentage error of 53% that were apparent in this study mean that, in its present guise, tracheal impedance is not an acceptable alternative to thermodilution in cardiac surgical patients.

Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

[Percutaneous dilatating tracheostomy in intensive-care patients: technique, indications and complications]. / Percutane dilaterende tracheostomie bij intensive-carepatiënten: techniek, indicaties en complicaties.

Since tracheal cannulas are increasingly used to wean intensive-care patients from respiratory machines, more doctors and nurses will find themselves having to take care of patients with tracheostomas. Indications for tracheal cannula use include the likelihood of prolonged mechanical ventilation and/or difficult weaning. Percutaneous dilatational tracheotomy is a relatively simple procedure for inserting a tracheal cannula. It is performed using a modified Seldinger technique, carried out under general anaesthesia; use of a bronchoscope during the operation makes the procedure simpler and safer. When it is difficult to pinpoint the source of problems arising in patients fitted with a tracheal cannula, it must always be considered that the cannula might be the cause. Although rare, complications may arise several weeks or months after decanulation, such as stenosis of the trachea, changes in voice and fistula formation between the trachea and skin. A strict surveillance protocol is needed to recognize and treat late complication.

Noninvasive measurement of cardiac output: two methods compared in patients with mitral regurgitation.

In search for the origin of the less reliable cardiac output (CO) estimations by means of electrical impedance cardiography (EIC), the authors hypothesized that cardiac valve pathology might be one of the reasons. Twenty-six patients were examined by means of echo Doppler (ED) and EIC. The cardiac valve status was obtained by means of echocardiography and color Doppler flow, while CO was obtained by means of both methods. Seventeen patients had no valve pathology (nVP) while nine patients had mild to moderate mitral regurgitation (MVR). The overall correlation between the calculation of CO by means of the two methods was good (r = 0.85, p < 0.001, mean difference and standard deviation: 0.20+/-0.74 L/min), while there was no significant difference between the paired values. After division into an nVP and an MVR population, the results showed an even closer agreement between the CO values in the nVP population (r = 0.88, p < 0.001, mean difference and standard deviation: 0.15+/-0.68 L/min). Furthermore, significant differences were found in the first derivative of the impedance (dZ/dt) signals of these groups. Although the agreement between ED and EIC was slightly lower in the MVR population, EIC reliably estimated CO, even in case of MVR. The impedance signal itself gave an indication for the existence of MVR.

Does impedance cardiography reliably estimate left ventricular ejection fraction?

OBJECTIVE: The objective of our study was to evaluate impedance cardiography (IMP) as a noninvasive method to determine the left ventricular ejection fraction (LVEF). METHODS. A total of 24 patients, 8 men and 16 women, aged 45.0 +/- 12.9 years, participated in the study. They used cardiotoxic chemotherapeutic drugs or suffered from cardiac failure. LVEF was measured by means of IMP (LVEFimp) and radionuclide ventriculography (LVEFnuc). LVEFimp was calculated in three ways. Capan and colleagues [13] proposed a formula in which LVEF (LVEFCap) can be calculated from the systolic time intervals, namely, left ventricular ejection time and preejection time. Judy and colleagues [14] described a systolic (S) and a diastolic (D) part in the first derivative curve of the impedance signal. The ratio S/D might equal the LVEF (LVEFJud). A new LVEF calculation was introduced (LVEFimp) in this study based on the first derivative of the impedance signal, the thoracic impedance, and heart rate. RESULTS: Mean LVEFCap was 59.9 +/- 8.4%, which did not differ from LVEFnuc (59.9 +/- 7.1%). However the correlation between both methods was not significant (r = 0.29). Mean LVEFJud was 63.9 +/- 17.4%, which was not significantly different from LVEFnuc, with a fair correlation (r = 0.55). Mean LVEFimp was 59.2 +/- 9.4%, with a better correlation with radionuclide ventriculography (r = 0.75). CONCLUSIONS: The results of this study indicate that the equations that have been used until now can be improved. The new equation provides reliable LVEF values in this group of patients.

Non-invasive monitoring of blood volume during hemodialysis: its relation with post-dialytic dry weight.

Hemodialysis has a profound effect on fluid balance. Since fluid is initially withdrawn from the intravascular compartment, blood volume will decrease rapidly. A fluid shift (refill) from the overhydrated interstitium towards the intravascular compartment counteracts hypovolemia. Underestimation of postdialytic dry weight will cause interstitial dehydration and consequently a low refill capacity. This can cause hypovolemia-induced hypotension, a serious problem in the daily practice of hemodialysis: during one out of three sessions a hypotensive episode occurs. Clinical criteria to estimate post-dialytic dry weight are insensitive. We have developed non-invasive methods to estimate dry weight and changes in blood volume (BV) more accurately. The aim of this study was to investigate the relation between hydration state of the patient and changes in BV during treatment. Therefore, 37 hemodialysis patients were divided into three groups according to their post-dialytic extracellular fluid volume (EFV), which was measured by means of the non-invasive conductivity method: de- (N = 11), normo- (N = 18), and overhydrated (N = 8). Using an on-line optical reflection method, changes in BV were measured continuously during hemodialysis. BV decrease, corrected for ultrafiltration, was stronger in the dehydrated (4.4 +/- 1.5%/liter) than in the normohydrated (3.3 +/- 1.5%/liter) and overhydrated (2.7 +/- 1.9%/liter) groups. In the dehydrated group, the frequency of hypotensive episodes (48.5 +/- 20.2%) was significantly greater compared to the normohydrated (20.5 +/- 23.5%) or overhydrated (6.5 +/- 6.5%) group, P < 0.005.(ABSTRACT TRUNCATED AT 250 WORDS)