Reducing broad-spectrum antibiotic use in intensive care unit between first and second waves of COVID-19 did not adversely affect mortality.

BACKGROUND: The COVID-19 pandemic increased the use of broad-spectrum antibiotics due to diagnostic uncertainty, particularly in critical care. Multi-professional communication became more difficult, weakening stewardship activities. AIM: To determine changes in bacterial co-/secondary infections and antibiotics used in COVID-19 patients in critical care, and mortality rates, between the first and second waves. METHODS: Prospective audit comparing bacterial co-/secondary infections and their treatment during the first two waves of the pandemic in a single-centre teaching hospital intensive care unit. Data on demographics, daily antibiotic use, clinical outcomes, and culture results in patients diagnosed with COVID-19 infection were collected over 11 months. FINDINGS: From March 9th, 2020 to September 2nd, 2020 (Wave 1), there were 156 patients and between September 3rd, 2020 and February 1st, 2021 (Wave 2) there were 235 patients with COVID-19 infection admitted to intensive care. No significant difference was seen in mortality or positive blood culture rates between the two waves. The proportion of patients receiving antimicrobial therapy (93.0% vs 81.7%; P < 0.01) and the duration of meropenem use (median (interquartile range): 5 (2-7) vs 3 (2-5) days; P = 0.01) was lower in Wave 2. However, the number of patients with respiratory isolates of Pseudomonas aeruginosa (4/156 vs 21/235; P < 0.01) and bacteraemia from a respiratory source (3/156 vs 20/235; P < 0.01) increased in Wave 2, associated with an outbreak of infection. There was no significant difference between waves with respect to isolation of other pathogens. CONCLUSION: Reduced broad-spectrum antimicrobial use in the second wave of COVID-19 compared with the first wave was not associated with significant change in mortality.

Influence of respiratory and inflammatory parameters preceding intubation on survival of patients with COVID-19 ARDS- A single centre retrospective analysis.

It remains unclear if intubation and ventilation earlier in the disease course confers a survival advantage in acute respiratory distress syndrome. Our objective was to determine whether patients with COVID-19 who died following mechanical ventilation were more advanced in their disease compared to survivors. Forty-seven patients admitted directly to our centre received ventilation, of who 26 (57%) patients died. The rate of fall in SpO2:FiO2 ratio (p = 0.478) and increasing respiratory rate (p = 0.948) prior to IMV were similar between survivors and non-survivors. Our data support a trial of continuous positive airway pressure prior to IMV in patients with moderate-to-severe COVID-19 ARDS.

Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis.

Videolaryngoscopy (VL) may improve the success of orotracheal intubation compared with direct laryngoscopy (DL). We performed a systematic search of PubMed, Embase, and CENTRAL databases for studies comparing VL and DL for emergency orotracheal intubations outside the operating room. The primary outcome was rate of first-pass intubation, with subgroup analyses by location, device used, clinician experience, and clinical scenario. The secondary outcome was complication rates. Data are presented as [odds ratio (95% confidence intervals); P-values]. We identified 32 studies with 15 064 emergency intubations. There was no difference in first-pass intubation with VL compared with DL [OR=1.28, (0.99-1.65); P=0.06]. First-pass intubations were increased with VL compared with DL in the intensive care unit (ICU) [2.02 (1.43-2.85); P<0.001], and similar in the emergency department or pre-hospital setting. First-pass intubations were similar with GlideScope®, but improved with the CMAC® [1.32 (1.08-1.62); P=0.007] compared with DL. There was greater first-pass intubation with VL compared with DL amongst novice/trainee clinicians [OR=1.95 (1.45-2.64); P<0.001], but not amongst experienced clinicians or paramedics/nurses. There was no difference in first-pass intubation with VL compared with DL during cardiopulmonary resuscitation or trauma. VL compared with DL was associated with fewer oesophageal intubations [OR=0.32 (0.14-0.70); P=0.003], but more arterial hypotension [OR=1.49 (1.00-2.23); P=0.05]. In summary, VL compared with DL is associated with greater first-pass emergency intubation in the ICU and amongst less experienced clinicians, and reduces oesophageal intubations. However, VL is associated with greater incidence of arterial hypotension. Further trials investigating the utility of VL over DL in specific situations are required.

Association between day and time of admission to critical care and acute hospital outcome for unplanned admissions to adult general critical care units: cohort study exploring the 'weekend effect'.

BACKGROUND: We aimed to identify any association between day and time of admission to critical care and acute hospital outcome. METHODS: We conducted a cohort study using prospectively collected data from the national clinical audit of adult critical care. We included 195 428 unplanned admissions from 212 adult general critical care units in England, Wales and Northern Ireland, between April 1, 2013 and March 31, 2015 in the analysis. RESULTS: Hourly admission rates for unplanned admissions varied more than three-fold during the 24 h cycle. Overall acute hospital mortality was 26.8%. Before adjustment, acute hospital mortality was similar between weekends and weekdays but was significantly lower for admissions at night compared with the daytime (-3.4%, -3.8 to -3.0%; P<0.001). After adjustment for casemix, there remained no difference between weekends and weekdays (-0.0%, -0.4 to +0.3%; P=0.87) or between nighttime and daytime (-0.2%, -0.5 to +0.1%; P=0.21). Delays in admission were reported for 4.3% of admissions and were slightly more common during weekdays than weekends and in the daytime than at night. Delayed admission was associated with a small increase in acute hospital mortality, but adjusting for this did not affect the estimates of the effect of day and time of admission. CONCLUSIONS: The day of week and time of admission have no influence on patient mortality for unplanned admissions to adult general critical care units within the UK. Ways to improve critical care and hospital systems to minimize delays in admission and potentially improve outcomes need to be ascertained in future research.

Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis.

Patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery. Augmentation of oxygen delivery index (DO2I) with i.v. fluids and inotropes (goal-directed therapy, GDT) has been shown to reduce postoperative mortality and morbidity in high-risk patients. Concerns regarding cardiac complications associated with fluid challenges and inotropes may prevent clinicians from performing GDT in patients who need it most. We hypothesized that GDT is not associated with an increased risk of cardiac complications in high-risk, non-cardiac surgical patients. We performed a systematic search of Medline, Embase, and CENTRAL databases for randomized controlled trials (RCTs) of GDT in high-risk surgical patients. Studies including cardiac surgery, trauma, and paediatric surgery were excluded. We reviewed the rates of all cardiac complications, arrhythmias, myocardial ischaemia, and acute pulmonary oedema. Meta-analyses were performed using RevMan software. Data are presented as odds ratios (ORs), [95% confidence intervals (CIs)], and P-values. Twenty-two RCTs including 2129 patients reported cardiac complications. GDT was associated with a reduction in total cardiovascular (CVS) complications [OR=0.54, (0.38-0.76), P=0.0005] and arrhythmias [OR=0.54, (0.35-0.85), P=0.007]. GDT was not associated with an increase in acute pulmonary oedema [OR=0.69, (0.43-1.10), P=0.12] or myocardial ischaemia [OR=0.70, (0.38-1.28), P=0.25]. Subgroup analysis revealed the benefit is most pronounced in patients receiving fluid and inotrope therapy to achieve a supranormal DO2I, with the use of minimally invasive cardiac output monitors. Treatment of high-risk surgical patients GDT is not associated with an increased risk of cardiac complications; GDT with fluids and inotropes to optimize DO2I during early GDT reduces postoperative CVS complications.

Update on hemodynamic monitoring and management in septic patients.

Severe sepsis and septic shock are associated with significant mortality. Effective management of this clinical syndrome includes early resuscitation with fluids and vasoactive drugs to maintain vital organ perfusion and oxygen delivery. Understanding the different approach to the management of sepsis during the resuscitation and ongoing management phases is essential to initiate context- and time-specific interventions. Manipulation of hemodynamic variables to achieve a balance between oxygen delivery and consumption forms the cornerstone of hemodynamic optimisation. Minimally invasive and completely non-invasive cardiac output monitors have been developed, but require validation in this specific cohort of patients. The trend in hemodynamic parameters is particularly important when any intervention to augment cardiac output is carried out (functional hemodynamic monitoring). Cardiac output monitors and surrogates of tissue oxygenation are only able to guide management, as patient outcome is determined by acquisition and interpretation of accurate data, and suitable management decisions.

Puerperal sepsis.

Infections during pregnancy are relatively prevalent, and the majority of cases are managed well in the community. Occasionally, however, infections may be life-threatening. Sepsis may be associated with multiple organ dysfunction and a high mortality. The treatment of sepsis is time critical and requires early fluid resuscitation and antibiotics. Early involvement of other specialties and allied health-care professionals to provide a multidisciplinary approach to patient care is important. Continuous monitoring of maternal vital signs and provision of supportive care for multiple organ dysfunction are best done within the intensive care unit. Despite advances in patient care, the mortality rate associated with maternal sepsis remains high. Health-care services in low-income countries face particular problems that account for an increased incidence of puerperal sepsis and maternal mortality. These include lack of access to health care, septic abortions and a greater incidence of human immunodeficiency virus. The key to management of sepsis is early recognition, aggressive resuscitation, antibiotic administration and source control.

Severe pre-eclampsia and hypertensive crises.

Hypertensive disorders of pregnancy are one of the leading causes of peripartum morbidity and mortality globally. Hypertensive disease in pregnancy is associated with a spectrum of severity, ranging from mild pregnancy-induced hypertension to eclampsia. Although most cases of pre-eclampsia may be managed successfully, severe pre-eclampsia is a life-threatening multisystem disease associated with eclampsia, HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome, acute kidney injury, pulmonary oedema, placental abruption and intrauterine foetal death. Management of severe pre-eclampsia includes identification of high-risk patients, optimisation of antenatal care, early intervention and the identification and early management of complications. In the first instance, oral anti-hypertensive agents, including labetalol, nifedipine and methyldopa, should be tried. If oral anti-hypertensive agents have failed to adequately control blood pressure, intravenous anti-hypertensives should be considered. Commonly used intravenous anti-hypertensives include labetalol, hydralazine and glyceryl trinitrate. In addition to anti-hypertensive agents, close attention should be given to regular clinical examination, assessment of fluid balance, neurologic status and monitoring of other vital signs. Magnesium sulphate should be considered early to prevent seizures. Delivery of the baby is the definitive management of severe pre-eclampsia.

Provision of critical care services for the obstetric population.

Management of the peripartum patient is a challenging aspect of critical care that requires consideration of both the physiological changes associated with pregnancy as well as the well-being of the foetus. In the UK, for every maternal death, approximately 118 near-miss events or severe acute maternal morbidities (SAMMs) occur. While a dedicated anaesthetic cover is usually provided on larger labour wards in the UK and US, a close communication with intensive care and other medical specialties must still be maintained. Medical outreach teams and early warning scores may help facilitate the early identification of clinical deterioration and prompt treatment. Ultimately level of care is allocated according to the clinical need, not the location, which may be a designated room, a normal labour room or a recovery area. Specialist obstetric units that provide high-dependency care facilities show lower rates of maternal transfer to critical care units and improved continuity of care before and after labour. The benefits of obstetric high-dependency units (HDUs) are likely to be determined by a number of logistic aspects of the hospital organisation, including hospital size and available resources. There remains a striking contrast in the burden of maternal mortality and morbidity and intensive care unit (ICU) resources between high- and low-income countries. The countries with the highest maternal mortality rates have the lowest number of ICU beds per capita. In under-resourced countries, patients admitted to ICUs tend to have higher illness severity scores, suggesting delayed admission to the ICU. The appropriate training of midwives is essential for successful HDUs located within labour wards.

Patients with end-stage renal disease admitted to the intensive care unit: systematic review.

The number of patients with end-stage renal disease (ESRD) is increasing worldwide, with a growing demand on healthcare services. A systematic review of the literature was performed to determine the requirement for intensive care unit (ICU) services, reasons for admission, predictors of mortality, and short- and long-term outcomes of ESRD patients admitted to ICU. Sixteen studies were identified, comprising 6591 ICU admissions. Cardiovascular disease and sepsis accounted for the majority of admissions. Acute illness severity scores tend to overestimate mortality among ESRD patients. Critical illness associated with acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with significantly higher hospital mortality compared with ESRD patients admitted to the ICU [odds ratio (OR) 3.9; 3.5-4.4; P<0.0001]. However, hospital mortality of ESRD patients is less favourable compared with matched patients with mild AKI (OR 1.5; 1.4-1.6; P<0.0001). Although the mortality rate remains high shortly after hospital discharge, the duration of increased mortality risk is unclear. Patients with ESRD frequently benefit from ICU admission, despite chronic co-morbidity. Further studies are required to modify and validate existing illness severity scores for ESRD patients admitted to the ICU, and to establish the duration of increased mortality risk after discharge from ICU.

Management of the dialysis patient in general intensive care.

The incidence of end-stage renal disease (ESRD) is rising and represents an important group of patients admitted to intensive care units (ICU). ESRD patients have significant co-morbidities and specific medical requirements. Renal replacement therapy (RRT), cardiovascular disease, disorders of electrolytes, drug metabolism, and sepsis are discussed. This review provides a practical approach to problems specific to the ESRD patient and common problems on ICU that require special consideration in ESRD patients. ESRD patients are at risk of hyperkalaemia. I.V. insulin and nebulized salbutamol lower serum potassium until definitive treatment with RRT is instituted. ESRD patients are prone to hypocalcaemia, which requires i.v. replacement if associated with complications. Midazolam has delayed metabolism and elimination in renal impairment and should be avoided. Morphine and its derivatives accumulate in renal failure and shorter-acting opiates are preferable. The use of diuretics is limited to patients with residual urine output. When required, therapeutic systemic anticoagulation should be achieved with unfractionated heparin as it is reversible and its metabolism and clearance are independent of renal function. The risk of sepsis is higher among ESRD patients when compared with patients with normal renal function. Empiric treatment should include both Gram-positive and Gram-negative cover, and methicillin-resistant Staphylococcus aureus cover if the patient has a dialysis catheter. Cardiovascular events account for the majority of deaths among ESRD patients. Troponin-I and CK-MB in combination should be used as markers of acute myocardial damage in the appropriate context, whereas B-type natriuretic peptide and troponin-T values are of less value.

Use of ice-cold crystalloid for inducing mild therapeutic hypothermia following out-of-hospital cardiac arrest.

OBJECTIVE: Out of hospital cardiac arrest (OHCA) results in a significant mortality and neurological disability in survivors. The application of mild therapeutic hypothermia (MTH) to patients who have suffered an OHCA with a ventricular rhythm results in a significant reduction in mortality and neurological disability in survivors. The optimal timing of this intervention has not been clearly established; however there is emerging evidence to suggest that maximal benefit is gained from initiation at the earliest time point. Despite this, recent surveys have shown a considerable delay in initiating MTH, with variable uptake in emergency departments (EDs), where a number of impediments to delivery have been identified. METHOD: We have reviewed the literature to determine what are the barriers to the initiation of MTH in the ED. We also reviewed the literature on the use of ice-cold crystalloids as a practical, simple, effective, and safe method to induce MTH. RESULTS: Among the several reasons, the perception of a lack of a practical method and logistical constraints are cited as common barriers. However, the available literature on the use of ice-cold crystalloids suggests that this is a safe and effective method of inducing MTH. CONCLUSION: ED staff need to be aware that the use of ice-cold fluids is an inexpensive, readily available and easy to perform method of inducing MTH in patients who suffer an out-of hospital cardiac arrest with a ventricular rhythm. We therefore suggest that ice-cold crystalloid is routinely stocked in emergency departments and, unless contraindicated, is used to induce MTH. Optimal post-resuscitation care also includes timely treatment of the cause of the OHCA and maintenance of MTH. Staff education and care bundles may help to facilitate optimal inter-departmental management of the patient.