Characterization of the Inflammatory Response to Severe COVID-19 Illness.

Rationale: Coronavirus disease (COVID-19) is a global threat to health. Its inflammatory characteristics are incompletely understood.Objectives: To define the cytokine profile of COVID-19 and to identify evidence of immunometabolic alterations in those with severe illness.Methods: Levels of IL-1ß, IL-6, IL-8, IL-10, and sTNFR1 (soluble tumor necrosis factor receptor 1) were assessed in plasma from healthy volunteers, hospitalized but stable patients with COVID-19 (COVIDstable patients), patients with COVID-19 requiring ICU admission (COVIDICU patients), and patients with severe community-acquired pneumonia requiring ICU support (CAPICU patients). Immunometabolic markers were measured in circulating neutrophils from patients with severe COVID-19. The acute phase response of AAT (alpha-1 antitrypsin) to COVID-19 was also evaluated.Measurements and Main Results: IL-1ß, IL-6, IL-8, and sTNFR1 were all increased in patients with COVID-19. COVIDICU patients could be clearly differentiated from COVIDstable patients, and demonstrated higher levels of IL-1ß, IL-6, and sTNFR1 but lower IL-10 than CAPICU patients. COVID-19 neutrophils displayed altered immunometabolism, with increased cytosolic PKM2 (pyruvate kinase M2), phosphorylated PKM2, HIF-1α (hypoxia-inducible factor-1α), and lactate. The production and sialylation of AAT increased in COVID-19, but this antiinflammatory response was overwhelmed in severe illness, with the IL-6:AAT ratio markedly higher in patients requiring ICU admission (P < 0.0001). In critically unwell patients with COVID-19, increases in IL-6:AAT predicted prolonged ICU stay and mortality, whereas improvement in IL-6:AAT was associated with clinical resolution (P < 0.0001).Conclusions: The COVID-19 cytokinemia is distinct from that of other types of pneumonia, leading to organ failure and ICU need. Neutrophils undergo immunometabolic reprogramming in severe COVID-19 illness. Cytokine ratios may predict outcomes in this population.

Transfer of critically ill adults-assessing the need for training.

BACKGROUND: Transfer of critically ill patients within the hospital is commonly associated with adverse incidents, but, despite this, no standardised training exists on how to carry out this task. Very little information is published in the literature on the learning needs of staff undertaking these transfers, and this limits our ability to provide a focused and appropriate educational intervention. AIMS: This study aimed to explore the organisational, environmental and individual issues that increase risk to patients during intrahospital transport (IHT) and to explore the potential educational solutions to these issues as articulated by these practitioners. METHODS: This qualitative descriptive study was conducted in an Irish tertiary hospital critical care unit. Semi-structured interviews were conducted on critical care practitioners until data saturation was achieved. After manual transcription of the data, they were then analysed to identify themes. RESULTS: Two themes emerged: challenges related to intrahospital transport and plans to improve intrahospital transport. CONCLUSIONS: Organisational, communication and individual issues need to be considered when addressing problems associated with IHT. A multifaceted approach is needed, with a focus on organisational solutions in the form of checklists as well as educational interventions such as interprofessional education initiatives. Further studies on implementation of educational initiatives will add to the findings we report here.

Effects of fentanyl added to a mixture of intrathecal bupivacaine and morphine for spinal anaesthesia in elective caesearean section.

BACKGROUND: The use of either fentanyl or morphine intrathecally as adjuncts to bupivacaine for spinal anaesthesia in caesarean deliveries is commonplace. However, the use of fentanyl in combination with morphine and bupivacaine in elective caesarean section is debatable. We hypothesized that while the addition of intrathecal fentanyl to morphine and bupivacaine increases side effects, it does not improve the clinical quality of anaesthesia or analgesia in elective caesarean deliveries. METHODS: In this case-controlled, double-blinded study, women undergoing elective caesarean deliveries received intrathecal fentanyl plus morphine with bupivacaine (Group 1) or intrathecal morphine with bupivacaine alone (Group 2). Patients were assessed at 4 hours for pain at rest and on movement using the visual analog scale (VAS), time taken for sensory block to T6 and side effects. RESULTS: Fifty patients were randomized into Group 1 (n = 25) and Group 2 (n = 25). There was no difference in the mean VAS scores at rest or on movement between the two groups. At 4 hours, the mean (SD) VAS scores at rest were 13.2 (13.7) mm and 12.0 (11.5) mm in Group 1 and 2, respectively (P = 0.739). The mean (SD) VAS scores on movement in Group 1 were 38.0 (18.2) mm, and in Group 2 were 28.4 (12.4) mm (P = 0.349). Group 1 took 7.34 hours to the first request for postoperative opioid analgesia while Group 2 took 7.08 hours (P = 0.749). Correspondingly, patient satisfaction ratings were comparable for both groups, the mean (SD) rating in Group 1 at 84.4 (11.11) compared to Group 2 at 87.6 (9.02), (P = 0.269). Patients in both groups had similar onset of T6 block. The incidence of side effects was higher in Group 1 than Group 2. CONCLUSION: Our study found that the addition of intrathecal fentanyl to morphine and bupivacaine did not have an advantage for short-term postoperative analgesia, but increased the incidence of opioid-related side effects and thus cost of care in a maternal population attending for elective caesarean section.