Epidemiology of critically ill patients in intensive care units in Nepal: a retrospective observational study

Background: Epidemiological data on critically ill patients is crucial for understanding resource utilisation, gaps in quality of care and for supporting surveillance of endemic or emerging diseases. We report the epidemiology of critically ill patients from 17 intensive care units (ICUs) in Nepal using an established and standardised ICU registry. Methods: The ICU registry data is collected prospectively and includes data on case mix, severity, organ support and outcomes. We conducted a retrospective observational study with all adult (≥18 years) critically ill patients admitted to 17 ICUs in Nepal between September 2019 and September 2022. We report on case mix, treatment received, severity of illness, standardised mortality rates (SMR), discharge outcomes and ICU service activity. Descriptive statistics were used to report the findings. Results: Of the 18603 unique admissions, 14% were operative, with 35% emergency surgeries. Patients' median age was 57 (IQR 40-71) and 59% were male. Hypertension and diabetes were common comorbidities and pneumonia accounted for 26% of all admissions. During the ICU stay, 39% of patients received mechanical ventilation, 29% received vasoactive medication and 10% received renal replacement therapy. The median predicted risk of death was 0.1 (IQR 0.1-0.3) using APACHE II and 0.2 (IQR 0.1-0.4) using eTropICS. The median SMR was 0.7 (IQR 0.5-0.8) and 0.8 (IQR 0.6-1.4) using eTropICS and APACHE II, respectively. Median length of stay was 4 days (IQR 2-7). Eighteen percent died in the ICU;of those alive at discharge, 12% went home, 84% went to another department and 3% went to another hospital. COVID-19 was the most common notifiable disease reported (12% of all admissions). Median ICU turnover was 9% (IQR 6-14) with bed capacity ranging from 43-278. Conclusions: These findings should guide forecasting and service planning to ensure ICUs can optimally care for critically ill patients in Nepal.

Characteristics and Outcome of Patients with COVID-19 Undergoing Invasive Mechanical Ventilation for Respiratory Failure in a Tertiary Level Hospital in Nepal.

BACKGROUND: Corona virus disease 2019 has become a global health issue. The goal of this study was to investigate the characteristics and outcomes of patients with corona virus disease 2019 undergoing invasive mechanical ventilation and identify factors associated with mortality. METHODS: Ninety four consecutive critically ill patients with confirmed corona virus disease 2019 undergoing invasive mechanical ventilation were included in this retrospective, single-center, observational study. The outcome variable was mortality of patients undergoing invasive mechanical ventilation and factors associated with it during intensive care unit stay. RESULTS: Seventy nine (84%) out of 94 patients with confirmed corona virus disease 2019 who underwent invasive mechanical ventilation didn't survive. Ninety four percent of patients who had Type 2 Diabetes Mellitus did not survive in comparison to 72 percent of patients who didn't have Type 2 Diabetes Mellitus. Similarly, 48 (94.1%) out of 51 patients with a positive C-reactive protein value didn't survive in comparison to 31 (72%) out of 43 patients with a negative C-reactive protein. CONCLUSIONS: The presence of Type 2 Diabetes Mellitus and a positive C-reactive protein value were strongly associated with mortality. Patients with a Sequential organ failure assessment score of more than eight at intensive care unit admission and peak D-dimer level of more than or equal to two during intensive care unit stay didn't show significant association with mortality. These findings need further exploration through larger prospective studies.

Combination of convalescent plasma therapy and repurposed drugs to treat severe COVID-19 patient with multimorbidity.

Combination of convalescent plasma therapy and repurposed drugs such as dexamethasone and remdesivir could be beneficial for severe COVID-19 patients with obesity and chronic diseases such as diabetes and hypertension.

Operationalisation of the Randomized Embedded Multifactorial Adaptive Platform for COVID-19 trials in a low and lower-middle income critical care learning health system.

The Randomized Embedded Multifactorial Adaptive Platform (REMAP-CAP) adapted for COVID-19) trial is a global adaptive platform trial of hospitalised patients with COVID-19. We describe implementation in three countries under the umbrella of the Wellcome supported Low and Middle Income Country (LMIC) critical  care network: Collaboration for Research, Implementation and Training in Asia (CCA). The collaboration sought to overcome known barriers to multi centre-clinical trials in resource-limited settings. Methods described focused on six aspects of implementation: i, Strengthening an existing community of practice; ii, Remote study site recruitment, training and support; iii, Harmonising the REMAP CAP- COVID trial with existing care processes; iv, Embedding REMAP CAP- COVID case report form into the existing CCA registry platform, v, Context specific adaptation and data management; vi, Alignment with existing pandemic and critical care research in the CCA. Methods described here may enable other LMIC sites to participate as equal partners in international critical care trials of urgent public health importance, both during this pandemic and beyond.