A Metabolomics approach for the diagnosis Of SecondAry InfeCtions in COVID-19 (MOSAIC): a study protocol.

BACKGROUND: Critically ill patients with COVID-19 are at an increased risk of developing secondary bacterial infections. These are both difficult to diagnose and are associated with an increased mortality. Metabolomics may aid clinicians in diagnosing secondary bacterial infections in COVID-19 through identification and quantification of disease specific biomarkers, with the aim of identifying underlying causative microorganisms and directing antimicrobial therapy. METHODS: This is a multi-centre prospective diagnostic observational study. Patients with COVID-19 will be recruited from critical care units in three Scottish hospitals. Three serial blood samples will be taken from patients, and an additional sample taken if a patient shows clinical or microbiological evidence of secondary infection. Samples will be analysed using LC-MS and subjected to bioinformatic processing and statistical analysis to explore the metabolite changes associated with bacterial infections in COVID-19 patients. Comparisons of the data sets will be made with standard microbiological and biochemical methods of diagnosing infection. DISCUSSION: Metabolomics analyses may provide additional strategies for identifying secondary infections, which might permit faster initiation of specific tailored antimicrobial therapy to critically ill patients with COVID-19.

Propofol Target-Controlled Infusion in Emergency Department Sedation (ProTEDS): a multicentre, single-arm feasibility study.

BACKGROUND: Procedural sedation is a core skill of the emergency physician. Bolus administration of propofol is widely used in UK EDs. Titrated to an end point of sedation, it has a rapid effect but has been associated with adverse incidents. The use of a target-controlled infusion (TCI) of propofol is not routine but may reduce the incidence of adverse incidents.The primary aims of this single-arm feasibility study were patient satisfaction and to establish recruitment rates for a randomised controlled trial comparing propofol TCI to bolus administration. METHODS: Four EDs in Scotland, UK, participated. Patients aged 18-65 years, with anterior shoulder dislocation, weight ≥ 50kg, fasted ≥ 90 min were screened. Patients underwent reduction of their dislocated shoulder using TCI propofol. The primary end point was patient satisfaction recorded on a Visual Analogue Scale. RESULTS: Between 3 April 2017 and 31 December 2018, 25 patients were recruited with a recruitment rate of 20% for the 16-month recruitment window, with a temporary pause to allow amendment of drug dosage.Two patients were excluded. Twenty achieved adequate sedation, defined as a Modified Observer's Assessment of Alertness/Sedation Scale (OAA/S) 3. Successful reduction was achieved in all adequately sedated. Patient satisfaction was documented in 14 patients, mean±SD of 97±9 and time to sedation was 25±8 min. No adverse events were recorded using the Society of Intravenous Anaesthesia adverse event reporting tool. CONCLUSION: Propofol TCI was acceptable as a method of procedural sedation for patients. The lower than expected recruitment rates highlight the need for dedicated research support. TRIAL REGISTRATION NUMBER: NCT03442803.

Effect of target-controlled propofol infusion to reduce the incidence of adverse events for procedural sedation in the emergency department: a systematic review.

The administration of propofol target-controlled infusion (TCI) for procedural sedation is standard in a range of hospital settings except for the Emergency Department (ED). Propofol TCI could be an alternative, safer way to provide procedural sedation in the ED compared with other methods of propofol administration. We compare the incidence of adverse events using propofol TCI compared with other methods of propofol administration. We conducted a systematic review of the literature from 1946 to January 2019 identifying studies that compared propofol TCI with other propofol regimens for procedural sedation in the adult population. Studies were assessed for risk of bias using the Cochrane Collaboration risk of bias tool. Seven articles were included. There was significant methodological heterogeneity in all aspects of study designs and definitions of adverse events which precluded a meta-analysis. A systematic review of the studies demonstrated fewer respiratory and cardiovascular adverse outcomes in three of the seven studies. It was not possible to determine if propofol TCI reduces the incidence of adverse events when compared with other sedating regimens using propofol using a descriptive systematic review of the relevant literature. Further research is required to compare the incidence of adverse events using propofol TCI for procedural sedation with other methods of administration in the ED. Future systematic reviews and meta-analysis comparisons would be aided by the use of standard adverse event reporting tools such as that of the Society of Intravenous Anaesthesia.