The prevalence of acute kidney injury in patients with community-acquired pneumonia who required mechanical ventilation.

BACKGROUND: Community-acquired pneumonia (CAP) is a common reason for intensive care unit (ICU) admission and sepsis. Acute kidney injury (AKI) is a frequent complication of community-acquired pneumonia and is associated with increased short- and long-term morbidity and mortality and healthcare costs. OBJECTIVE: Describe the prevalence of AKI in patients with CAP requiring mechanical ventilation and evaluate its association with inhospital mortality. DESIGN: Retrospective cohort. SETTING: Intensive care unit. PATIENTS AND METHODS: We included patients with CAP on mechanical ventilation. Patients were categorized according to the development of AKI in the first 24 hours of ICU admission using the Kidney Disease Improving Global Outcomes (KDIGO) classification from no AKI, stage 1 AKI, stage 2 AKI, and stage 3 AKI. MAIN OUTCOME MEASURES: The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, hospital and ICU length of stay, ventilation duration, tracheostomy, and renal replacement therapy requirement. RESULTS: Of 1536 patients included in the study, 829 patients (54%) had no AKI while 707 (46%) developed AKI. In-hospital mortality was 288/829 (34.8%) for patients with no AKI, 43/111 (38.7%) for stage 1 AKI, 86/216 (40%) for stage 2 AKI, and 196/380 (51.7%) for stage 3 AKI (P<.0001). Multivariate analysis revealed that stages 1, 2, or 3 AKI compared to no AKI were not independently associated with in-hospital mortality. Older age, vasopressor use; decreased Glasgow coma scale, PaO2/Fio2 ratio and platelet count, increased bilirubin, lactic acid and INR were associated with increased mortality while female sex was associated with reduced mortality. CONCLUSION: Among mechanically ventilated patients with CAP, AKI was common and was associated with higher crude mortality. The higher mortality could not be attributed alone to AKI, but rather appeared to be related to multi-organ dysfunction. LIMITATIONS: Single-center retrospective study with no data on baseline serum creatinine and the use of estimated baseline creatinine distributions based on the MDRD (Modification of Diet in Renal Disease)equation which may lead to an overestimation of AKI. Second, we did not have data on the microbiology of pneumonia, appropriateness of antibiotic therapy or the administration of other medications that have been demonstrated to be associated with AKI.

Humidification during mechanical ventilation to prevent endotracheal tube occlusion in critically ill patients: A case control study.

BACKGROUND: Endotracheal tube (ETT) occlusion is a potentially life-threatening event. This study describes a quality improvement project to prevent ETT occlusion in critically ill patients. METHODS: After a cluster of clinically significant ETT occlusion incidents at a tertiary-care intensive care unit (ICU), the root cause analysis suggested that the universal use of heat moisture exchangers (HMEs) was a major cause. Then, we prospectively audited new ETT occlusion incidents after changing our practices to evidence-based active and passive humidification during mechanical ventilation (MV). We also compared the outcomes of affected patients with matched controls. RESULTS: During 100 weeks, 18 incidents of clinically significant ETT occlusion occurred on a median of 7 days after intubation (interquartile range, 4.8-9.5): 8 in the 10 weeks before and 10 in the 90 weeks after changing humidification practices (8.1 vs. 1.0 incidents per 1000 ventilator days, respectively). The incidents were not suspected in 94.4%, the peak airway pressure was >30 cm H2O in only 25%, and 55.6% were being treated for pneumonia when ETT occlusion occurred. Compared with 51 matched controls, ETT occlusion cases had significantly longer MV duration (median of 13.5 vs. 4.0 days; P = 0.002) and ICU stay (median of 26.5 vs. 11.0 days; P = 0.006) and more tracheostomy (55.6% vs. 9.8%; P < 0.001). The hospital mortality was similar in cases and controls. CONCLUSIONS: The rate of ETT occlusion decreased after changing humidification practices from universal HME use to evidence-based active and passive humidification. ETT occlusion was associated with more tracheostomy and a longer duration of MV and ICU stay.

Managing critical care during COVID-19 pandemic: The experience of an ICU of a tertiary care hospital.

BACKGROUND: The COVID-19 pandemic has strained ICUs worldwide. To learn from our experience, we described the critical care response to the outbreak. METHODS: This is a case study of the response of the Intensive Care Department (75-bed capacity) at a tertiary-care hospital to COVID-19 pandemic, which resulted in a high number of critically ill patients. RESULTS: Between March 1 and July 31, 2020, 822 patients were admitted to the adult non-cardiac ICUs with suspected (72%)/confirmed (38%) COVID-19. At the peak of the surge, 125 critically ill patients with COVID-19 were managed on single day. To accommodate these numbers, the bed capacity of 4 ICUs was increased internally from 58 to 71 beds (+40%) by cohorting 2 patients/room in selected rooms; forty additional ICUs beds were created in 2 general wards; one cardiac ICU was converted to managed non-COVID-19 general ICU patients and one ward was used as a stepdown for COVID-19 patients. To manage respiratory failure, 53 new ICU ventilators, 90 helmets for non-invasive ventilation and 47 high-flow nasal cannula machines were added to the existing capacity. Dedicated medical teams cared for the COVID-19 patients to prevent cross-contamination. The nurse-to-patient and RT-to-patient ratio remained mostly 1:1 and 1:6, respectively. One-hundred-ten ward nurses were up-skilled to care for COVID-19 and other ICU patients using tiered staffing model. Daily executive rounds were conducted to identify patients for transfer and at least 10 beds were made available for new COVID-19 admissions/day. The consumption of PPE increased multiple fold compared with the period preceding the pandemic. Regular family visits were not allowed and families were updated daily by videoconferencing and phone calls. CONCLUSIONS: Our ICU response to the COVID-19 pandemic required almost doubling ICU bed capacity and changing multiple aspects of ICU workflow to be able to care for high numbers of affected patients.