Increased time from physiological derangement to critical care admission associates with mortality.

BACKGROUND: Rapid response systems aim to achieve a timely response to the deteriorating patient; however, the existing literature varies on whether timing of escalation directly affects patient outcomes. Prior studies have been limited to using 'decision to admit' to critical care, or arrival in the emergency department as 'time zero', rather than the onset of physiological deterioration. The aim of this study is to establish if duration of abnormal physiology prior to critical care admission ['Score to Door' (STD) time] impacts on patient outcomes. METHODS: A retrospective cross-sectional analysis of data from pooled electronic medical records from a multi-site academic hospital was performed. All unplanned adult admissions to critical care from the ward with persistent physiological derangement [defined as sustained high National Early Warning Score (NEWS) > / = 7 that did not decrease below 5] were eligible for inclusion. The primary outcome was critical care mortality. Secondary outcomes were length of critical care admission and hospital mortality. The impact of STD time was adjusted for patient factors (demographics, sickness severity, frailty, and co-morbidity) and logistic factors (timing of high NEWS, and out of hours status) utilising logistic and linear regression models. RESULTS: Six hundred and thirty-two patients were included over the 4-year study period, 16.3% died in critical care. STD time demonstrated a small but significant association with critical care mortality [adjusted odds ratio of 1.02 (95% CI 1.0-1.04, p = 0.01)]. It was also associated with hospital mortality (adjusted OR 1.02, 95% CI 1.0-1.04, p = 0.026), and critical care length of stay. Each hour from onset of physiological derangement increased critical care length of stay by 1.2%. STD time was influenced by the initial NEWS, but not by logistic factors such as out-of-hours status, or pre-existing patient factors such as co-morbidity or frailty. CONCLUSION: In a strictly defined population of high NEWS patients, the time from onset of sustained physiological derangement to critical care admission was associated with increased critical care and hospital mortality. If corroborated in further studies, this cohort definition could be utilised alongside the 'Score to Door' concept as a clinical indicator within rapid response systems.

Use of Ultrasound to Determine Changes in Diaphragm Mechanics During A Spontaneous Breathing Trial.

OBJECTIVE: Assess change in ultrasound measures of diaphragm mechanics over the course of a 30-minute spontaneous breathing trial (SBT). DESIGN: Prospective observational study. SETTING: Single intensive care unit (Logan Hospital, Queensland, Australia), patients recruited from August 2016 to April 2018. PARTICIPANTS: Eligible patients were over the age of 18 years, ventilated for >24 hours, and planned to undergo an SBT. In total, 129 patients were screened. MAIN OUTCOME MEASURES: Ultrasound measures taken at 5 and 30 minutes during SBT: diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), and diaphragmatic contraction speed (DCS). Diaphragmatic rapid shallow breathing index (DRSBI) was calculated using DE/respiratory rate. The presence of diaphragmatic dysfunction (DD) was also determined using DTF < 30%, DE < 11 mm, or DRSBI > 1.6. RESULTS: Eighteen patients had ultrasound measures during an SBT. Four were unable to have DTF visualized. There was no significant change in DTF (n = 14, 32.41 ± 32.21 vs 23.19 ± 17.42, P = .33) or DE (n = 18, 1.72 ± 0.63 vs 1.66 ± 0.59, P = .63) over time. Diaphragmatic contraction speed increased over time (n = 18, 2.21 ± 1.25 vs 2.67 ± 1.61, P = .007). Diaphragmatic rapid shallow breathing index worsened over time (n = 18, 1.65 ± 1.02 vs 2.08 ± 1.51, P = .03). There was no significant change in the presence of DD. Diaphragmatic dysfunction by DTF 8/14 versus 10/14, by DE 4/18 versus 3/18, and by DRSBI 7/18 versus 9/18. No patients failed SBT and one patient failed extubation. CONCLUSIONS: Diaphragmatic mechanics may change over the course of an SBT. Further research is required to determine the clinical implications of these changes and the optimal timing of diaphragmatic ultrasound to predict weaning outcome. Diaphragmatic ultrasound may be less feasible than the published data suggest.

Open versus percutaneous tracheostomy in COVID-19: a multicentre comparison and recommendation for future resource utilisation.

PURPOSE: The COVID-19 pandemic placed an unprecedented demand on critical care services for the provision of mechanical ventilation. Tracheostomy formation facilitates liberation from mechanical ventilation with advantages for both the patient and wider critical care resource, and can be performed using both percutaneous dilatational and surgical techniques. We compared outcomes in those patients undergoing percutaneous dilatational tracheostomy to those undergoing surgical tracheostomy and make recommendations for provision of tracheostomy services in any future surge. METHODS: Multicentre multidisciplinary retrospective observational cohort study including 201 patients with COVID-19 pneumonitis admitted to an ICU in one of five NHS Trusts within the South London Adult Critical Care Network who required mechanical ventilation and subsequent tracheostomy. RESULTS: Percutaneous dilatational tracheostomy was performed in 124 (62%) of patients, and surgical tracheostomy in 77 (38%) of patients. There was no difference between percutaneous dilatational tracheostomy and surgical tracheostomy in either the rate of peri-operative complications (16.9 vs. 22.1%, p = 0.46), median [IQR(range)] time to decannulation [19.0 (15.0-30.2 (5.0-65.0)] vs. 21.0 [15.5-36.0 (5.0-70.0) days] or mortality (13.7% vs. 15.6%, p = 0.84). Of the 172 patients that were alive at follow-up, two remained ventilated and 163 were decannulated. CONCLUSION: In patients with COVID-19 pneumonitis that require tracheostomy to facilitate weaning from mechanical ventilation, there was no difference in outcomes between those patients that had percutaneous dilatational tracheostomy compared with those that had surgical tracheostomy. Planning for future surges in COVID-19-related critical care demands should utilise all available resource and expertise.

Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation.

COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU/hospital discharge.

A new tool for evaluating health equity in academic journals; the Diversity Factor.

Current methods to evaluate a journal's impact rely on the downstream citation mapping used to generate the Impact Factor. This approach is a fragile metric prone to being skewed by outlier values and does not speak to a researcher's contribution to furthering health outcomes for all populations. Therefore, we propose the implementation of a Diversity Factor to fulfill this need and supplement the current metrics. It is composed of four key elements: dataset properties, author country, author gender and departmental affiliation. Due to the significance of each individual element, they should be assessed independently of each other as opposed to being combined into a simplified score to be optimized. Herein, we discuss the necessity of such metrics, provide a framework to build upon, evaluate the current landscape through the lens of each key element and publish the findings on a freely available website that enables further evaluation. The OpenAlex database was used to extract the metadata of all papers published from 2000 until August 2022, and Natural language processing was used to identify individual elements. Features were then displayed individually on a static dashboard developed using TableauPublic, which is available at www.equitablescience.com. In total, 130,721 papers were identified from 7,462 journals where significant underrepresentation of LMIC and Female authors was demonstrated. These findings are pervasive and show no positive correlation with the Journal's Impact Factor. The systematic collection of the Diversity Factor concept would allow for more detailed analysis, highlight gaps in knowledge, and reflect confidence in the translation of related research. Conversion of this metric to an active pipeline would account for the fact that how we define those most at risk will change over time and quantify responses to particular initiatives. Therefore, continuous measurement of outcomes across groups and those investigating those outcomes will never lose importance. Moving forward, we encourage further revision and improvement by diverse author groups in order to better refine this concept.

Survival benefit of extracorporeal membrane oxygenation in severe COVID-19: a multi-centre-matched cohort study.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) has become an established therapy for severe respiratory failure in coronavirus disease 2019 (COVID-19). The added benefit of receiving ECMO in COVID-19 remains uncertain. The aim of this study is to analyse the impact of receiving ECMO at specialist centres on hospital mortality. METHODS: A multi-centre retrospective study was conducted in COVID-19 patients from 111 hospitals, referred to two specialist ECMO centres in the United Kingdom (UK) (March 2020 to February 2021). Detailed covariate data were contemporaneously curated from electronic referral systems. We analysed added benefit of ECMO treatment in specialist centres using propensity score matching techniques. RESULTS: 1363 patients, 243 receiving ECMO, were analysed. The best matching technique generated 209 matches, with a marginal odds ratio (OR) for mortality of 0.44 (95% CI 0.29-0.68, p < 0.001) and absolute mortality reduction of 18.2% (44% vs 25.8%, p < 0.001) for treatment with ECMO in a specialist centre. CONCLUSION: We found ECMO provided at specialist centres conferred significant survival benefit. Where resources and specialism allow, ECMO should be widely offered.

Physiological Basis of Extracorporeal Membrane Oxygenation and Extracorporeal Carbon Dioxide Removal in Respiratory Failure.

Extracorporeal life support (ECLS) for severe respiratory failure has seen an exponential growth in recent years. Extracorporeal membrane oxygenation (ECMO) and extracorporeal CO2 removal (ECCO2R) represent two modalities that can provide full or partial support of the native lung function, when mechanical ventilation is either unable to achieve sufficient gas exchange to meet metabolic demands, or when its intensity is considered injurious. While the use of ECMO has defined indications in clinical practice, ECCO2R remains a promising technique, whose safety and efficacy are still being investigated. Understanding the physiological principles of gas exchange during respiratory ECLS and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. In this review, we will present the physiological basis of gas exchange in ECMO and ECCO2R, and the implications of their interaction with native lung function. We will also discuss the rationale for their use in clinical practice, their current advances, and future directions.