Upcoming and urgent challenges in critical care research based on COVID-19 pandemic experience.

While the coronavirus disease 2019 (COVID-19) pandemic placed a heavy burden on healthcare systems worldwide, it also induced urgent mobilisation of research teams to develop treatments preventing or curing the disease and its consequences. It has, therefore, challenged critical care research to rapidly focus on specific fields while forcing critical care physicians to make difficult ethical decisions. This narrative review aims to summarise critical care research -from organisation to research fields- in this pandemic setting and to highlight opportunities to improve research efficiency in the future, based on what is learned from COVID-19. This pressure on research revealed, i.e., (i) the need to harmonise regulatory processes between countries, allowing simplified organisation of international research networks to improve their efficiency in answering large-scale questions; (ii) the importance of developing translational research from which therapeutic innovations can emerge; (iii) the need for improved triage and predictive scores to rationalise admission to the intensive care unit. In this context, key areas for future critical care research and better pandemic preparedness are artificial intelligence applied to healthcare, characterisation of long-term symptoms, and ethical considerations. Such collaborative research efforts should involve groups from both high and low-to-middle income countries to propose worldwide solutions. As a conclusion, stress tests on healthcare organisations should be viewed as opportunities to design new research frameworks and strategies. Worldwide availability of research networks ready to operate is essential to be prepared for next pandemics. Importantly, researchers and physicians should prioritise realistic and ethical goals for both clinical care and research.

Impact of ketamine as an adjunct sedative in acute respiratory distress syndrome due to COVID-19 Pneumonia.

PURPOSE: Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. MATERIALS AND METHODS: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. RESULTS: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. CONCLUSIONS: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Continuous Cloud-Based Early Warning Score Surveillance to Improve the Safety of Acutely Ill Hospitalized Patients.

INTRODUCTION: This study sought to evaluate the impact of changes made to the process of continually screening hospitalized patients for decompensation. METHODS: Patients admitted to hospital wards were screened using a cloud-based early warning score (modified National Early Warning Score [mNEWS]). Patient with mNEWS ≥7 triggered a structured response. Outcomes of this quality improvement study during the intervention period from February through August 2018 (1741 patients) were compared with a control population (1,610 patients) during the same months of 2017. RESULTS: The intervention group improved the time to the first lactate order within 24 hours of mNEWS ≥7 (p < .001), the primary outcome, compared with the control group. There was no significant improvement in time to intensive care unit (ICU) transfer, ICU length of stay (LOS), or hospital mortality. Among patients with a lactate ordered within 24 hours, there was a 47% reduction of in-hospital mortality (odds ratio 0.53, 95% confidence interval 0.3-0.89, p = .02) and a 4.7 day reduction in hospital LOS (p < .001) for intervention versus control cohorts. CONCLUSIONS: Cloud-based electronic surveillance can result in earlier detection of clinical decompensation. This intervention resulted in lower hospital LOS and mortality among patients with early detection of and intervention for clinical decompensation.

Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

PURPOSE: This study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates. METHODS: In this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team. RESULTS: Hospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED. CONCLUSION: Implementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.

Helmet CPAP revisited in COVID-19 pneumonia: A case series.

INTRODUCTION: Noninvasive positive pressure ventilation (NIPPV) plays an important role in the management of respiratory failure. However, since the emergence of the COVID-19 pandemic, utilization of traditional face mask NIPPV has been curtailed in part due to risk of aerosolization of respiratory particles and subsequent health care worker exposure. A randomized clinical trial in 2016 reported that an alternative interface, helmet NIPPV, may be more effective than traditional NIPPV at preventing intubation and improving mortality. The helmet NIPPV interface provides positive airway pressure, while also theoretically minimizing aerosolization, making it a feasible modality in management of respiratory failure in COVID-19 patients. CASE AND OUTCOMES: This report describes a single-center experience of a series of three COVID-19 patients with hypoxemic respiratory failure managed with helmet NIPPV. One patient was able to avoid intubation while a second patient was successfully extubated to NIPPV. Ultimately, the third patient was unable to avoid intubation with helmet NIPPV, although the application of the device was late in the progression of the disease. DISCUSSION: NIPPV is an important modality in the management of respiratory failure and has been shown to reduce the need for immediate endotracheal intubation in select populations. For patients unable to tolerate facemask NIPPV, the helmet provides an alternate interface. In COVID-19 patients, the helmet interface may reduce the risk of virus exposure to health care workers from aerosolization. Based on this experience, we recommend that helmet NIPPV can be considered as a feasible option for the management of patients with COVID-19, whether the goal is to prevent immediate intubation or avoid post-extubation respiratory failure. Randomized studies are needed to definitively validate the use of helmet NIPPV in this population. CONCLUSION: Helmet NIPPV is a feasible therapy to manage COVID-19 patients.

"Sacred Pause" in the ICU: Evaluation of a Ritual and Intervention to Lower Distress and Burnout.

BACKGROUND: Increased exposure to deaths in the intensive care unit (ICU) generate grief among ICU staff, which remains unresolved most of the time. Unresolved grief becomes cumulative and presents a risk factor for burnout. "sacred pause" is a ritual performed at patient's death to honor the lost life and recognize the efforts of the health-care team. OBJECTIVE: To study the impact of the ritual of sacred pause on the attitudes and behaviors of the ICU physicians and nurses. METHODS: Ten-question online anonymous survey was sent to ICU physicians and nurses in the medical ICU of a tertiary care hospital in July 2017. RESULTS: Thirty-four ICU team members completed the survey including 12 physicians and 22 nurses. Seventy sacred pause rituals were performed from July 2016 to June 2017. Seventy-nine percent respondents believed that the ritual brought closure and helped them overcome the feelings of disappointment, grief, distress, and failure after the death of their patient in ICU. Seventy-three percent agreed that the ritual has instilled and encouraged a sense of team effort. Eighty-two percent responded that the ritual makes their efforts feel appreciated. Many felt that the ritual should be a universal phenomenon in all ICUs. Only 55% respondents felt that the practice has a potential to decrease ICU burnout, many of them (42%) were undecided. CONCLUSION: Sacred pause brings closure, prevents cumulative grief and distress, builds resilience, promotes team effort, and improves professional satisfaction of ICU team. It may lower burnout syndrome in ICU, but further studies are warranted.

Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases.

AIM: To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU). METHODS: We performed a retrospective observational study of adult patients with the diagnosis of "HLH" admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society. RESULTS: Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer. CONCLUSION: HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.

Defining the practice of "no escalation of care" in the ICU.

OBJECTIVE: Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is "no escalation of care", often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved. DESIGN: We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included. SETTING: Sixteen bed medical ICU at a single large academic hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0-5 d). CONCLUSION: No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach.