Lung Protective Ventilation Adherence and Outcomes for Patients With COVID-19 Acute Respiratory Distress Syndrome Treated in an Intermediate Care Unit Repurposed to ICU Level of Care.

OBJECTIVE: During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs). DESIGN: Retrospective observational study using electronic medical record data. SETTING: Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system. PATIENTS: Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39]). CONCLUSIONS: In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.

The Role of Intermediate Care in Supporting Critically Ill Patients and Critical Care Infrastructure.

Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.

Case Report: Pentosan Polysulfate Sodium Maculopathy Originally Diagnosed as Pattern Macular Dystrophy.

SIGNIFICANCE: Pentosan polysulfate sodium (PPS) maculopathy is a clinical entity characterized by a pigmentary maculopathy in the setting of chronic exposure to PPS. Pentosan polysulfate sodium is indicated for discomfort related to interstitial cystitis/painful bladder syndrome. Given a reported interstitial cystitis/painful bladder syndrome prevalence up to 2%, recognition is critical to mitigate visual sequelae. PURPOSE: We present an observational case report demonstrating typical findings of PPS maculopathy in a patient originally diagnosed with a pattern macular dystrophy. We demonstrate the importance of medical history, medication profile review, and multimodal imaging in the diagnosis and management. The patient provided written informed consent for medical information and images to be published. CASE REPORT: A 55-year-old White woman presented with a painless, bilateral loss of vision and bilateral pigmentary maculopathy that was initially diagnosed as pattern macular dystrophy. Detailed review of medical history, medication profile, and subsequent studies, including optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence, fluorescein angiography, and genetic studies, ultimately led to the diagnosis of PPS maculopathy. Pentosan polysulfate sodium was discontinued, and ongoing surveillance with multimodal imaging was encouraged. CONCLUSIONS: Because toxic maculopathies are an uncommon diagnosis, screening and recognition of PPS maculopathy are critical in the primary eye care setting. Discontinuation of the insulting agent may be necessary to prevent potentially severe and irreversible vision loss in the at-risk population.

Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones.

INTRODUCTION: Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number. METHODS: This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results. RESULTS: 125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2-85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82-98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65-86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63-100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria. CONCLUSION: In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.