Frailty in Critically Ill Patients with COVID-19: The Lessons Learned.

The coronavirus disease 2019 (COVID-19) pandemic has unquestionably transformed the field of intensive care medicine. Never have we witnessed millions of patients develop acute respiratory failure in such a short span of time. This led to extensive resource constraints and difficulty in treating patients. However, this also gave rise to several innovations that have spurred the development and progress of intensive care medicine as a specialty. In this chapter, we explore an overview of frailty, the impact of frailty in patients with severe COVID-19 respiratory failure, and the available supports, by summarising the current literature. This chapter also discusses the lessons learnt from each of the sections that can be applied to daily clinical practice. The chapter also proposes insights into future research.

Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review.

Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower quality communication from clinicians, and report worse quality of dying than other patients. There are many contributory factors, including system (eg, lack of intensive outpatient symptom management resources), clinician (eg, low-quality serious illness communication), and patient (eg, cultural norms) factors. System and clinician factors contribute to disparities and ought to be remedied, while patient factors simply reflect differences in care and may not be appropriate targets for intervention.

The 2022-2023 Pediatric Respiratory Illness Surge: Survey of Acute and Critical Care Resource Use.

OBJECTIVE: A surge of pediatric respiratory illnesses beset the United States in late 2022 and early 2023. This study evaluated within-surge hospital acute and critical care resource availability and utilization. The study aimed to determine pediatric hospital acute and critical care resource use during a respiratory illness surge. METHODS: Between January and February 2023, an online survey was sent to the sections of hospital medicine and critical care of the American Academy of Pediatrics, community discussion forums of the Children's Hospital Association, and PedSCCM-a pediatric critical care website. Data were summarized with median values and interquartile range. RESULTS: Across 35 hospitals with pediatric intensive care units (PICU), increase in critical care resource use was significant. In the month preceding the survey, 26 (74%) hospitals diverted patients away from their emergency department (ED) to other hospitals, with 46% diverting 1-5 patients, 23% diverting 6-10 patients, and 31% diverting more than 10 patients. One in 5 hospitals reported moving patients on mechanical ventilation from the PICU to other settings, including the ED (n = 2), intermediate care unit (n = 2), cardiac ICU (n = 1), ward converted to an ICU (n = 1), and a ward (n = 1). Utilization of human critical care resources was high, with PICU faculty, nurses, and respiratory therapists working at 100% capacity. CONCLUSIONS: The respiratory illness surge triggered significant hospital resource use and diversion of patients away from hospitals. Pediatric public health emergency-preparedness should innovate around resource capacity.

Mobile Critical Care in Resource-Limited Settings: An Unmet Need.

Care of the critically ill in resource-limited areas, inside or outside the intensive care unit (ICU), is indispensable. Murthy and Adhikari noted that about 70% of patients in low-middle income (LMIC) areas could benefit from good critical care. Many patients in resource-limited settings still die before getting to the hospital. Investing in capacity building by strengthening and expanding ICU capability and training intensivists, critical care nurses, respiratory therapists, and other ICU staff is essential, but this process will take years. Also, having advanced healthcare facilities that are still far from remote areas will not do much to alleviate distance and mode of transportation as barriers to achieving good critical care. This paper discusses the importance of mobile critical care units (MCCUs) in supporting and enhancing existing emergency medical systems. MCCUs will be crucial in addressing critical delays in transportation and time to receive appropriate lifesaving critical care in remote areas. They are incredibly versatile and could be used to transfer severely ill patients to a higher level of care from the field, safely transfer critically ill patients between hospitals, and, sometimes, almost more importantly, provide standalone short-term critical care in regions where ICUs might be absent or immediately inaccessible. MCCUs should not be used as a substitute for primary care or to bypass readily available services at local healthcare centers. It is essential to rethink the traditional paradigm of 'prehospital care' and 'hospital care' and focus on improving the care of critically ill patients from the field to the hospital.

Limitations of life-sustaining treatments in intensive care units in Croatia: a multicenter retrospective study.

AIM: In order to gain insight into the current prevailing practices regarding the limitation of life-sustaining treatment in intensive care units (ICUs) in Croatia, we assessed the frequency of limitation and provision of certain treatment modalities, as well as the associated patient and ICU-related factors. METHODS: A multicenter retrospective cross-sectional study was conducted in 17 ICUs in Croatia. We reviewed the medical records of patients deceased in 2017 and extracted data on demographic, clinical, and health care variables. A logistic regression analysis was conducted to determine the associations between these variables and treatment modalities. RESULTS: The study enrolled 1095 patients (55% male; mean age 69.9±13.7). Analgesia and sedation were discontinued before the patient's death in 23% and 34% of the cases, respectively. Patients older than 71 years were less often mechanically ventilated (P<0.001), and less frequently received inotropes and vasoactive therapy (P=0.002) than younger patients. Patients hospitalized in the ICU for less than 7 days less frequently had discontinuation of mechanical ventilation and inotropes and vasoactive therapy than patients hospitalized for 8 days and longer (P<0.001). Logistic regression analysis showed that ICU type was a crucial determinant, with multidisciplinary and surgical ICUs being associated with higher odds of intubation, mechanical ventilation, vasoactive and inotropic therapy, analgesia, and sedation. CONCLUSION: Older patients and those diagnosed with stroke and intracranial hemorrhage received fewer therapeutic modalities. All the observed treatment modalities were more frequently discontinued in patients who were hospitalized in the ICU for a prolonged time.

Outcomes After Interhospital Critical Care Transfer.

OBJECTIVE: Patients who undergo interhospital transfer, particularly for intensive care unit (ICU) care, experience greater length of stay and mortality. There is evidence that patients transferred for surgical ICU care experience higher mortality rates; however, differences in length of stay or mortality across other ICU types remain unclear. The goals of this work were to assess how length of stay and mortality differ by ICU subspecialties. METHODS: We conducted a retrospective analysis of an existing critical care transfer data repository. We used multiple and logistic regression to identify significant factors that contribute to differences in length of stay and mortality for surgical ICU patients. RESULTS: There were no differences in length of stay or mortality based on ICU subspecialty. For every 1-year increase in age, mortality odds increased by 8.6% (P = .002). Patients transferred from an ICU had a longer length of stay by 6.3 days (P < .001). Non-Caucasian patients had a shorter length of stay by 3.4 days (P = .012). CONCLUSION: Length of stay and mortality are not influenced by ICU subspecialty. Further research is needed to determine the mechanism by which sending unit type and race influence length of stay and identify other factors that predict mortality for SICU patients.

Flexible Fiber-Optic Scope Use in Retrieval Medicine: A Case Series.

OBJECTIVE: The use of flexible fiber-optic scopes is increasing across critical care specialities, but there is limited literature on their use in retrieval medicine. This study aims to describe a case series in which flexible fiber-optic scopes were used by New South Wales Ambulance Aeromedical Operations critical care teams. METHODS: A retrospective case series was performed in our service from January 1, 2019, to December 31, 2021. We searched our electronic medical retrieval database for the terms "aScope," "Awake Fibreoptic Intubation (AFOI)," "Fibreoptic Intubation (FOI)," and "Nasal Endotracheal Tube (ETT)" to identify when a flexible fiber-optic scope was used. RESULTS: There were 16 uses of flexible fiber-optic scopes during the study period. The most common procedure was awake nasal fiber-optic intubation, which was performed during 9 cases, 7 of which were successful. Other procedures performed included 4 cases of intubation through a supraglottic airway, 1 case of an asleep fiber-optic intubation, 1 case of flexible nasoendoscopy for upper airway assessment, and 1 case of fiber-optic bronchoscopy via tracheostomy. These procedures were performed by anesthetic, emergency and intensive care doctors. This case series describes 4 of these cases in more detail. CONCLUSION: This case series demonstrates a variety of procedural and diagnostic uses for flexible fiber-optic scopes in retrieval medicine. These procedures can have an important bearing on decision making and patient management. The training and clinical governance provided by our service in this skill appears to be safe and robust with high success rates of awake fiber-optic intubations.

Peri-Intubation Push-Dose Vasopressors in Critical Care Transport.

OBJECTIVE: Push-dose vasopressors are commonly administered to attenuate peri-intubation hypotension. The aim of this study was to describe the current use of push-dose vasopressors in critical care transport. METHODS: This was a retrospective chart review of adult patients (≥ 18 years) intubated between January 2017 and May 2023 who received push-dose vasopressors. The outcomes were incidence of push-dose vasopressor administration and the frequency of initiation or an increase in continuous vasopressor infusion. RESULTS: Of the 334 patients intubated during this period, 49 (14.7%) received push-dose vasopressors in the peri-intubation period. The mean preintubation shock index was 1.1 ± 0.5. Of those who received push-dose vasopressors, 34 (69.4%) received multiple push doses; the mean number of administrations was 2.5 ± 1.9. Most patients had persistent or recurrent hypotension (n = 39, 79.6%). Fifteen (30.6%) were started on a continuous vasopressor infusion, and 3 (11.1%) had an increase in an existing infusion postintubation. CONCLUSION: Although push-dose vasopressors are convenient and appropriate in many settings, they inadequately address hypotension in critically ill patients with underlying shock. Further investigation is required to better elucidate the role of peri-intubation push-dose and continuous vasopressors in the critical care transport setting.

The Impact of Location and Asset Type on the Success of Advanced Airway Management in a Critical Care Transport Environment.

OBJECTIVE: Advanced airway management (AAM) is a critical component of prehospital critical care. Airway management in flight can be more challenging because of spatial, ergonomic, and environmental factors. This study examines the frequency of in-flight intubation (IFI), first-pass success (FPS) rates, and definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) across different locations of airway management. METHODS: We conducted a retrospective database analysis of all patients transported between January 2016 and July 2021 who received AAM from a single air medical service. Patient records were reviewed for location of intubation, patient characteristics, and FPS and DASH-1A rates. The primary outcome was the frequency of IFI. The secondary outcomes included FPS and DASH-1A rates by location and type of transport asset. RESULTS: During the study period, 473 patients required AAM. Three percent (15/473) of patients were intubated in an in-flight setting, 28% (130/473) were intubated on scene, and 70% (328/473) were intubated in a health care facility. The primary reason for IFI was unanticipated cardiac arrest or clinical deterioration. The overall FPS rate was 69% (328/473), and the DASH-1A rate was 49% (194/399). Based on the location of AAM, the FPS and DASH-1A rates were the lowest for on-scene intubations (56% [74/130] and 27% [20/74], respectively). Most of the on-scene AAM took place with rotor wing flight crews. CONCLUSION: Airway management occurs infrequently in an in-flight setting and is necessary because of patient deterioration or cardiac arrest. Based on our results, we identified opportunities for targeted AAM quality improvement and clinical governance.

Simulation-Based Learning to Assess and Improve Critical Care Transport Team Members' Knowledge of Pediatric Intubation: A Quality Improvement Project.

OBJECTIVE: The care of critically ill neonatal and pediatric patients requiring transport is optimized by using specialty transport teams. Research demonstrates that training is best accomplished through routine simulation. At the project site, no simulation-based learning is provided to critical care transport team members. This project aimed to implement a simulation-based learning program to improve the knowledge and self-competency of neonatal and pediatric critical care transport team members. METHODS: Team members participated in two 9-week paired pediatric simulations that incorporated intubation and mechanical ventilation. Testing was conducted through a knowledge test and self-competency survey completed before and after both simulations and a performance checklist for each simulation. RESULTS: There was a statistically significant increase in knowledge test scores from the baseline knowledge test to each subsequent test (P ≤ .001, P = .002, and P ≤ .001). For self-competency, there was a statistically significant increase from the first survey to the second (P ≤ 0.001) and fourth (P ≤ .001). From the first to the second simulation, there was a statistically significant increase in performance (P ≤ .001). CONCLUSION: Paired simulation-based learning allows for the assessment and improvement of team members' knowledge. Future research should focus on how this improved knowledge translates to patient care.

Post COVID-19 mucormycosis in critical care settings: A prospective cohort study in a tertiary care center in Egypt.

BACKGROUND: The emergence of mucormycosis as a life-threatening fungal infection after the coronavirus disease of 2019 (COVID-19) is a major concern and challenge, but there is limited information on the risk factors for mortality in patients. METHODS: We conducted a prospective cohort study from May 2021 to April 2022 to determine the in-hospital outcomes of post-COVID-19 mucormycosis during the intensive care unit (ICU) stay. The sample of the study was collected as consecutive sampling using all accessible patients in the study period. The Statistical Package for Social Sciences (SPSS), version 25 (IBM, Chicago, Illinois, USA) was used for statistical analysis. RESULTS: Among 150 patients with post-COVID-19 mucormycosis, the majority had a primary sinus infection (86.0 %), while 11.3 % had both sinus and ocular infections, and 2.7 % had sinus and cutaneous infections. Around 21 % (n = 31) of patients deceased after staying in the ICU for a median (range) of 45.0 (10.0-145.0) days. The majority of the patients who deceased had pneumonia patches on computed tomography (CT) (90.3 %) while none of the patients who were discharged had pneumonia patches (p < 0.001). The deceased group had higher rates of pulmonary embolism (93.5 %) compared to the surviving groups (21.8 %). In a multivariate Cox regression analysis, the risk of death was higher in older patients above 60 years old (hazard ratio (95 %CI): 6.7 (1.73-15.81)), increase among patient with history of steroid administration (hazard ratio (95 %CI): 5.70 (1.23-10.91)), who had facial cutaneous infection with mucormycosis (hazard ratio (95 %CI): 8.76 (1.78-25.18)), patients with uncontrolled diabetes (hazard ratio (95 %CI): 10.76 (1.78, 65.18)), and total leukocytic count (TLC>10 ×103 mcL) (hazard ratio (95 %CI): 10.03 (3.29-30.61)). CONCLUSIONS: Identifying high-risk patients especially old diabetic patients with corticosteroid administration and detecting their deterioration quickly is crucial in reducing post-COVID-19 mucormycosis mortality rates, and these factors must be considered when developing treatment and quarantine strategies.

Adiposity and mortality among intensive care patients with COVID-19 and non-COVID-19 respiratory conditions: a cross-context comparison study in the UK.

BACKGROUND: Adiposity shows opposing associations with mortality within COVID-19 versus non-COVID-19 respiratory conditions. We assessed the likely causality of adiposity for mortality among intensive care patients with COVID-19 versus non-COVID-19 by examining the consistency of associations across temporal and geographical contexts where biases vary. METHODS: We used data from 297 intensive care units (ICUs) in England, Wales, and Northern Ireland (Intensive Care National Audit and Research Centre Case Mix Programme). We examined associations of body mass index (BMI) with 30-day mortality, overall and by date and region of ICU admission, among patients admitted with COVID-19 (N = 34,701; February 2020-August 2021) and non-COVID-19 respiratory conditions (N = 25,205; February 2018-August 2019). RESULTS: Compared with non-COVID-19 patients, COVID-19 patients were younger, less often of a white ethnic group, and more often with extreme obesity. COVID-19 patients had fewer comorbidities but higher mortality. Socio-demographic and comorbidity factors and their associations with BMI and mortality varied more by date than region of ICU admission. Among COVID-19 patients, higher BMI was associated with excess mortality (hazard ratio (HR) per standard deviation (SD) = 1.05; 95% CI = 1.03-1.07). This was evident only for extreme obesity and only during February-April 2020 (HR = 1.52, 95% CI = 1.30-1.77 vs. recommended weight); this weakened thereafter. Among non-COVID-19 patients, higher BMI was associated with lower mortality (HR per SD = 0.83; 95% CI = 0.81-0.86), seen across all overweight/obesity groups and across dates and regions, albeit with a magnitude that varied over time. CONCLUSIONS: Obesity is associated with higher mortality among COVID-19 patients, but lower mortality among non-COVID-19 respiratory patients. These associations appear vulnerable to confounding/selection bias in both patient groups, questioning the existence or stability of causal effects.

Intensive Care Management of Severe Hyponatraemia-An Observational Study.

Background and Subject: Hyponatraemia is a common electrolyte disorder. For patients with severe hyponatraemia, intensive care unit (ICU) admission may be required. This will enable close monitoring and allow safe management of sodium levels effectively. While severe hyponatraemia may be associated with significant symptoms, rapid overcorrection of hyponatraemia can lead to complications. We aimed to describe the management and outcomes of severe hyponatraemia in our ICU and identify risk factors for overcorrection. Materials and Methods: This was a retrospective single-centre cohort that included consecutive adults admitted to the ICU with serum sodium < 120 mmol/L between 1 January 2017 and 8 March 2023. Anonymised data were collected from electronic records. We included 181 patients (median age 67 years, 51% male). Results: Median admission serum sodium was 113 mmol/L (IQR: 108-117), with an average rate of improvement over the first 48 h of 10 mmol/L/day (IQR: 5-15 mmol/L). A total of 62 patients (34%) met the criteria for overcorrection at 48 h, and they were younger, presented with severe symptoms (seizures/arrythmias), and had lower admission sodium concentration. They were more likely to be treated with hypertonic saline infusions. Lower admission sodium was an independent risk factor for overcorrection within 48 h, whereas the presence of liver cirrhosis and fluid restriction was associated with normal correction. No difference was identified between the normal and overcorrected cohorts for ICU/hospital length of stay or mortality. Conclusions: In some patients with severe hyponatraemia, overcorrection is inevitable to avoid symptoms such as seizures and arrhythmias, and consequently, we highlight the key factors associated with overcorrection. Overall, we identified that overcorrection was common and concordant with the current literature.

Using a Military-Civilian Partnership to Enhance Clinical Readiness and Sustainment for Air Force Critical Care Nurses.

BACKGROUND: Decreases in size, capability, clinical volumes, case mixes, and complex care opportunities in military treatment facilities contribute to the atrophy of clinical skills among medical professionals in these facilities. LOCAL PROBLEM: The COVID-19 pandemic resulted in a 39% decline in admissions to a military critical care unit. The decrease in patient census contributed to skill sustainment challenges. METHODS: To identify methods to combat skill atrophy, the CINAHL and PubMed databases were searched using the terms peacetime effect, military-civilian partnership, and skill sustainment. Active-duty critical care nurses stationed at a military treatment facility implemented a military-civilian partnership with a civilian medical facility for clinical skill sustainment. RESULTS: One year after implementation, 39 critical care nurses had completed 511 shifts, gaining clinical experiences seldom achieved at the military facility. A survey of these nurses demonstrated that 8 of 17 (47%) gained experience treating patients requiring intra-aortic balloon pumps or continuous renal replacement therapy, 6 of 17 (36%) gained experience with patients requiring a ventricular assist device, 12 of 17 (71%) acquired hands-on experience with intracranial pressure monitoring, and 14 of 17 (82%) reported vasoactive intravenous infusion manipulation. CONCLUSIONS: This article highlights the importance of evaluating clinical practice within the military health system, developing military-civilian partnerships, and removing military-civilian partnership barriers for nurses and other health care professionals. Failure to implement military-civilian partnerships may adversely affect the clinical competency of the military nurse force.

Social Disparities and Critical Illness during the Coronavirus Disease 2019 Pandemic: A Narrative Review.

The coronavirus disease 2019 (COVID-19) pandemic raised new considerations for social disparities in critical illness including hospital capacity and access to personal protective equipment, access to evolving therapies, vaccinations, virtual care, and restrictions on family visitation. This narrative review aims to explore evidence about racial/ethnic and socioeconomic differences in critical illness during the COVID-19 pandemic, factors driving those differences and promising solutions for mitigating inequities in the future. We apply a patient journey framework to identify social disparities at various stages before, during, and after patient interactions with critical care services and discuss recommendations for policy and practice.