Outcomes of patients with COVID-19 acute respiratory distress syndrome requiring invasive mechanical ventilation admitted to an intensive care unit in South Africa.

BACKGROUND: Up to 32% of patients with COVID-19 pneumonia may require intensive care unit (ICU) admission or mechanical ventilation. Data from low- and middle-income countries on COVID-19 acute respiratory distress syndrome (ARDS) are limited. Groote Schuur Hospital in Cape Town, South Africa, expanded its intensive care service to support patients with COVID-19 ARDS requiring invasive mechanical ventilation (IMV). OBJECTIVES: To report on patients' characteristics and outcomes from the first two pandemic waves. METHODS: All patients with COVID-19 ARDS admitted to the ICU for IMV were included in this prospective cohort study. Data were collected from 5 April 2020 to 5 April 2021. RESULTS: Over the 12-month study period, 461 patients were admitted to the designated COVID-19 ICU. Of these, 380 met the study criteria and 377 had confirmed hospital discharge outcomes. The median (range) age of patients was 51 (17 - 71) years, 50.5% were female, and the median (interquartile range (IQR)) body mass index was 32 (28 - 38) kg/m2. The median (IQR) arterial oxygen partial pressure to fractional inspired oxygen (P/F) ratio was 97 (71 - 128) after IMV was initiated. Comorbidities included diabetes (47.6%), hypertension (46.3%) and HIV infection (10.5%). Of the patients admitted, 30.8% survived to hospital discharge with a median (IQR) ICU length of stay of 19.5 (9 - 36) days. Predictors of mortality after adjusting for confounders were male sex (odds ratio (OR) 1.74), increasing age (OR 1.04) and higher Sequential Organ Failure Assessment (SOFA) score (OR 1.29). CONCLUSIONS: In a resource-limited environment, the provision of IMV support in the ICU achieved 30.8% hospital survival in patients with COVID-19 ARDS. The ability to predict survival remains difficult given this complex disease.

Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma).

BACKGROUND: The role of fluids in trauma resuscitation is controversial. We compared resuscitation with 0.9% saline vs hydroxyethyl starch, HES 130/0.4, in severe trauma with respect to resuscitation, fluid volume, gastrointestinal recovery, renal function, and blood product requirements. METHODS: Randomized, controlled, double-blind study of severely injured patients requiring >3 litres of fluid resuscitation. Blunt and penetrating trauma were randomized separately. Patients were followed up for 30 days. RESULTS: A total of 115 patients were randomized; of which, 109 were studied. For patients with penetrating trauma (n=67), the mean (sd) fluid requirements were 5.1 (2.7) litres in the HES group and 7.4 (4.3) litres in the saline group (P<0.001). In blunt trauma (n=42), there was no difference in study fluid requirements, but the HES group required significantly more blood products [packed red blood cell volumes 2943 (1628) vs 1473 (1071) ml, P=0.005] and was more severely injured than the saline group (median injury severity score 29.5 vs 18; P=0.01). Haemodynamic data were similar, but, in the penetrating group, plasma lactate concentrations were lower over the first 4 h (P=0.029) and on day 1 with HES than with saline [2.1 (1.4) vs 3.2 (2.2) mmol litre⁻¹; P=0.017]. There was no difference between any groups in time to recovery of bowel function or mortality. In penetrating trauma, renal injury occurred more frequently in the saline group than the HES group (16% vs 0%; P=0.018). In penetrating trauma, maximum sequential organ function scores were lower with HES than with saline (median 2.4 vs 4.5, P=0.012). No differences were seen in safety measures in the blunt trauma patients. CONCLUSIONS: In penetrating trauma, HES provided significantly better lactate clearance and less renal injury than saline. No firm conclusions could be drawn for blunt trauma. STUDY REGISTRATION: ISRCTN 42061860.

The organisational response of a hospital critical care service to the COVID-19 pandemic: The Groote Schuur Hospital experience.

Background: There are limited data about the coronavirus disease-19 (COVID-19)-related organisational responses and the challenges of expanding a critical care service in a resource-limited setting. Objectives: To describe the ICU organisational response to the pandemic and the main outcomes of the intensive care service of a large state teaching hospital in South Africa. Methods: Data were extracted from administrative records and a prospective patient database with ethical approval. An ICU expansion plan was developed, and resource constraints identified. A triage tool was distributed to referring wards and hospitals. Intensive care was reserved for patients who required invasive mechanical ventilation (IMV). The total number of ICU beds was increased from 25 to 54 at peak periods, with additional non-COVID ICU capacity required during the second wave. The availability of nursing staff was the main factor limiting expansion. A ward-based high flow nasal oxygen (HFNO) service reduced the need for ICU admission of patients who failed conventional oxygen therapy. A team was established to intubate and transfer patients requiring ICU admission but was only available for the first wave. Results: We admitted 461 COVID-19 patients to the ICU over a 13-month period from 5 April 2020 to 5 May 2021 spanning two waves of admissions. The median age was 50 years and duration of ICU stay was 9 days. More than a third of the patients (35%; n=161) survived to hospital discharge. Conclusion: Pre-planning, leadership, teamwork, flexibility and good communication were essential elements for an effective response. A shortage of nurses was the main constraint on ICU expansion. HFNO may have reduced the requirement for ICU admission, but patients intubated after failing HFNO had a poor prognosis. Contributions of the study: We describe the organisational requirements to successfully expand critical care facilities and strategies to reduce the need for invasive mechanical ventilation in COVID-19 pneumonia. We also present the intensive care outcomes of these patients in a resource-constrained environment.

Limitation of life support: frequency and practice in a London and a Cape Town intensive care unit.

OBJECTIVES: To examine the frequency of limiting (withdrawing and withholding) therapy in the intensive care unit (ICU), the grounds for limiting therapy, the people involved in the decisions, the way the decisions are implemented and the patient outcome. DESIGN: Prospective survey. Ethical approval was obtained. SETTING: ICUs in tertiary centres in London and Cape Town. PATIENTS: All patients who died or had life support limited. INTERVENTIONS: Data collection only. RESULTS: There were 65 deaths out of 945 ICU discharges in London and 45 deaths out of 354 ICU discharges in Cape Town. Therapy was limited in 81.5% and 86.7% respectively (p = 0.6) of patients who died. The mean ages of patients whose therapy was limited were 60.2 years and 51.9 years (p = 0.014) and mean APACHE II scores 18.5 and 22.6 (p = 0.19) respectively. The most common reason for limiting therapy in both centres was multiple organ failure. Both medical and nursing staff were involved in most decisions, which were only implemented once wide consensus had been reached and the families had accepted the situation. Inotropes, ventilation, blood products, and antibiotics were most commonly withdrawn. The mean time from admission to the decision to limit therapy was 11.2 days in London and 9.6 days in Cape Town. The times to outcome (death in all patients) were 13.2 h and 8.1 h respectively. CONCLUSIONS: Withdrawal of therapy occurred commonly, most often because of multiple organ failure. Wide consensus was reached before a decision was made, and the time to death was generally short.

Mechanical tracheal obstruction due to an intramural esophageal hematoma following endoscopic variceal sclerotherapy.

Endoscopic injection sclerotherapy is widely used as treatment for bleeding esophageal varices. Esophageal intramural hematoma is a rare complication following endoscopic injection sclerotherapy. Patients present with pain and dysphagia due to esophageal obstruction. We present the first reported case of respiratory failure resulting from an intramural hematoma causing posterior tracheobronchial compression. Although patients with alcoholic cirrhosis and bleeding varices requiring respiratory support generally have a poor prognosis this may be an occasion when ventilatory support may be expected to be easily withdrawn after hematoma resolution.

Chylous ascites following abdominal aortic surgery.

Chylous ascites is an extremely rare complication of abdominal aortic surgery. A case with a successful outcome is presented, followed by a review of the 17 published cases. Chylous ascites can result in nutritional imbalance, immunological deficit and respiratory dysfunction. Paracentesis confirms the diagnosis and provides symptomatic relief. Conservative management, beginning with a low-fat diet and medium-chain triglyceride (MCT) supplementation, is recommended, changing to total parenteral nutrition if unsuccessful. Failure of non-operative treatment may necessitate the need for laparotomy and ligation of leaking lymphatics or peritoneovenous shunting.

Severe ovarian hyperstimulation after follicular aspiration.

In order to maximise the chances of pregnancy, most successful in vitro fertilisation programmes use a combination of ovulation induction agents. This treatment can lead to the hyperstimulation syndrome. Aspiration of the follicles is believed to avoid this syndrome. Despite this approach, hyperstimulation syndrome may still develop. The clinical picture and treatment of a patient with severe hyperstimulation is discussed.

Hyperlipidemia, pregnancy and pancreatitis.

Hypertriglyceridemia is a recognized complication of pregnancy. In patients with familial hypertriglyceridemia, the biochemical changes are greatly enhanced during pregnancy and may be associated with acute pancreatitis, a potentially fatal triad. Three patients were studied, in one of whom previously undiagnosed hyperlipidemia resulted in a fatal attack of fulminant acute pancreatitis. In the other two patients, this complication was avoided by close monitoring and restriction of dietary facts. A history of episodic abdominal cramps, often beginning in early childhood, or the presence of lipemic fasting plasma should alert the clinician to the presence of severe familial hypertriglyceridemia. Early diagnosis allows for the institution of relatively simple management strategies, which diminish the risk of pancreatitis.

Postoperative pain control with a continuous infusion of epidural sufentanil in the intensive care unit: a comparison with epidural morphine.

A prospective, randomized, double-blind trial was conducted to compare the analgesic actions and side effects of sufentanil continuously infused (5 micrograms/h) into the lumbar epidural space (L2-3) with those of an infusion of lumbar epidural morphine (0.5 mg/h). Forty patients admitted to an intensive care unit after elective major abdominal surgery participated over a varying period of 24-40 h. Post-operative pain was treated with an epidural bolus of either sufentanil (50 micrograms) or morphine (5 mg), followed by a continuous infusion of the same opiate. The quality of pain relief was similar in each group. The sufentanil group had a more rapid onset of analgesia. The incidence of nausea and vomiting, pruritus, and drowsiness was similar in the two groups. In spontaneously breathing patients there were no respiratory complications requiring treatment. Forced vital capacities were statistically significantly better during the first 1-4 h with sufentanil.

The effect of fuel source on amino acid metabolism in critically ill patients.

The ideal energy substrate for critically ill patients receiving total parenteral nutrition (TPN) remains controversial. While glucose has been proved to have nitrogen sparing properties in postoperative patients, critically ill patients tolerate glucose loads poorly and fat appears to be an obligatory fuel in sepsis. Furthermore, it is not yet certain whether the changes in whole body protein metabolism induced by critical illness are influenced by the nature of the TPN provided. This study was conducted on patients admitted to a surgical intensive care unit (SICU) who fulfilled the criteria of requiring TPN and mechanical ventilation for at least four days. Patients were randomized to receive either glucose (G) or equicaloric proportions of glucose and lipid (GF) as an intravenous energy source. TPN was commenced early, within 24-48 hr of trauma or surgery and admission to the ICU. Nonprotein calorie intake was 125% of calculated basal energy expenditure. Nitrogen balance was calculated from 24-hr urinary urea excretion. Protein synthesis, turnover, and catabolism were measured on Day 4 of the study using an established radiolabeled C14-leucine technique. Degree of sepsis and illness were calculated using published scores. Fifty patients entered the trial but 32 were excluded by Day 4. Of the 18 patients completing an initial four day study, eight went on to complete a second study on the alternative regimen--a total of 26 studies (14 G, 12 GF). Net protein synthesis was achieved in 18 studies (12 G, 6 FG) and positive nitrogen balance by Day 4 in 22 studies. Four patients on the G regimen were withdrawn due to glucose intolerance while none of the patients on GF developed glucose intolerance or hyperlipidaemia. Both whole body protein synthesis and catabolism correlated significantly with degree of sepsis. The type of TPN fuel used, G and GF, did not appear to influence whole body protein dynamics, both regimens achieving greatly improved whole body protein kinetics.

Reticuloendothelial function and plasma fibronectin in a murine model of intra-abdominal sepsis.

The lung is the target organ most frequently involved in the early phase of multiple organ failure. Microembolisation of the pulmonary vasculature by bacterial and non-bacterial particles and debris with failure of the clearance mechanism of the reticuloendothelial system (RES) and depletion of plasma fibronectin have been implicated in the pathogenesis. The present study examined the concurrent changes in plasma fibronectin, RES phagocytic function, organ localisation of bacterial and non-bacterial particles and the levels of circulating endotoxin and fibrin degradation products in a clinically relevant murine model of severe intra-abdominal infection. Progressive sepsis was associated with deteriorating RES phagocytic function to 45% of control values within 48 h of sepsis induction. There was decreased hepatosplenic uptake and increased pulmonary localisation of bacterial and lipid emulsion particles. Plasma fibronectin increased in septic animals within 48 h suggesting increased fibronectin production. These changes would support the hypothesis that altered RES function may facilitate pulmonary microembolisation in the pathogenesis of septic multiple organ failure.

A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital. Part II. Management of patients.

During the outbreak of Crimean-Congo haemorrhagic fever (CCHF) at Tygerberg Hospital 8 patients were diagnosed positive. CCHF was diagnosed in another patient several months later. The treatment of these 9 cases is outlined. When it became evident that CCHF could present with a spectrum of severity, treatment was adjusted according to each patient's requirements. The essential components consisted of correction of haematological abnormalities combined with hyperimmune serum; the latter is particularly important for the severely ill patient with no antibodies to CCHF. The antiviral agents ribavirin and interferon were used but evidence to substantiate their application in future cases was inconclusive. Interferon was discontinued because of severe side-effects, many of which simulated the clinical features of CCHF. Objective improvement after corticosteroid treatment was noted in only 1 patient, but some of her symptoms could have been due to a transfusion reaction. Antibiotics were not routinely used. The 2 patients who died were diagnosed late, did not receive hyperimmune serum, and eventually developed multi-organ failure. The course of CCHF can probably be modified if the diagnosis is made early, if antiserum is given, and if the haematological abnormalities are promptly corrected.