Resource utilization and preparedness within the COVID-19 pandemic in Tunisian medical intensive care units: A nationwide retrospective multicentre observational study.

BACKGROUND: The worldwide SARS-CoV-2 pandemic represents the most recent global healthcare crisis. While all healthcare systems suffered facing the immense burden of critically-ill COVID-19 patients, the levels of preparedness and adaptability differed highly between countries. AIM: to describe resource mobilization throughout the COVID-19 waves in Tunisian University Medical Intensive Care Units (MICUs) and to identify discrepancies in preparedness between the provided and required resource. METHODS: This is a longitudinal retrospective multicentre observational study conducted between March 2020 and May 2022 analyzing data from eight University MICUs. Data were collected at baseline and at each bed expansion period in relation to the nation's four COVID-19 waves. Data collected included epidemiological, organizational and management trends and outcomes of COVID-19 and non-COVID-19 admissions. RESULTS: MICU-beds increased from 66 to a maximum of 117 beds. This was possible thanks to equipping pre-existing non-functional MICU beds (n = 20) and creating surge ICU-beds in medical wards (n = 24). MICU nurses increased from 53 to 200 of which 99 non-ICU nurses, by deployment from other departments and temporary recruitment. The nurse-to-MICU-bed ratio increased from 1:1 to around 1·8:1. Only 55% of beds were single rooms, 80% were equipped with ICU ventilators. These MICUs managed to admit a total of 3368 critically-ill patients (15% of hospital admissions). 33·2% of COVID-19-related intra-hospital deaths occurred within the MICUs. CONCLUSION: Despite a substantial increase in resource mobilization during the COVID-19 pandemic, the current study identified significant persisting discrepancies between supplied and required resource, at least partially explaining the poor overall prognosis of critically-ill COVID-19 patients.

Postobstructive pulmonary edema: A fatal complication in suicidal near-hanging.

Postobstructive pulmonary edema is a life-threatening complication that occurs after the removal of severe upper airway obstruction. Development of postobstructive pulmonary edema has been described after several cases of upper airway obstruction. However, postobstructive pulmonary edema developing after non-lethal hanging has not been reported widely in the literature. Herein, we describe a fatal case of postobstructive pulmonary edema in a 10-year-old girl, which was brought to the hospital with history of attempted suicide by hanging. At presentation, the girl was breathing laboriously. The oxygen saturation was of 82% and pulmonary auscultation revealed bilateral and diffuse crepitations. The chest computed tomographic scan showed bilateral diffuse infiltrates consistent with pulmonary edema. After 3 days of hospitalization, the respiratory state of the girl worsened leading to death despite intensive care. An autopsy was conducted and confirmed the diffuse pulmonary edema. Hence, this case confirms that delayed death in near hanging may occur. Pulmonary edema which develops subsequently in such patients is an uncommon mechanism of death that physicians should consider in emergency room.

Incidence and Impact of Pulmonary Embolism During Severe COPD Exacerbation.

BACKGROUND: Patients with COPD are at a high risk for pulmonary embolism (PE) because of systemic inflammation and co-existing comorbidities. We aimed to determine the incidence, risk factors, and impact of PE during COPD exacerbation requiring mechanical ventilation. METHODS: This prospective cohort study was conducted between March 2013 and May 2017. Subjects with severe COPD exacerbation requiring mechanical ventilation were included. A lower-limb ultrasonography or a multidetector helical computed tomography scan (MDCT) was performed according to Wells score. Subjects with ultrasonographic signs of phlebitis underwent MDCT to confirm PE. RESULTS: During the study period, 131 COPD subjects were admitted to the ICU for severe COPD exacerbation. The incidence of PE was 13.7%. Factors independently associated with PE were increased sputum volume (odds ratio [OR] = 0.106, 95% CI 0.029-0.385, P = .001), recent immobilization ≥ 7 d (OR = 5.024, 95% CI 1.470-17.170, P = .01), age ≥ 70 y (OR = 5.483, 95% CI 1.269-23.688, P = .02), and invasive mechanical ventilation at ICU admission (OR = 3.615, 95% CI 1.005-13.007, P = .049). ICU mortality was higher in the PE group (44% vs 11%). Predictive factors of mortality were PE (OR = 7.135, 95% CI 2.042-24.931, P = .002), SAPS II score at admission OR = 1.040, 95% CI 1.005-1.077, P = .02), and duration of mechanical ventilation (OR = 1.098, 95% CI 1.044-1.154, P < .001). CONCLUSION: PE was found to be a common etiology of severe exacerbation of COPD, leading to high mortality. Age, invasive mechanical ventilation, and immobilization were risk factors for PE.

Comparison Between Continuous and Intermittent Administration of Hydrocortisone During Septic Shock: A Randomized Controlled Clinical Trial.

OBJECTIVES: The best modality of administration of hydrocortisone during septic shock has been poorly evaluated and the guidelines remain unclear in this respect. This study aimed to compare bolus of hydrocortisone to a continuous infusion during septic shock. DESIGN: Randomized controlled, open-label trial. SETTING: Medical ICU of a university hospital. PATIENTS: Adult patients with septic shock requiring more than 2 mg/h (approximately 33.3 µg/mn) of norepinephrine after adequate fluid administration were eligible.Patients already receiving corticosteroids or who have a contraindication to corticosteroids, patients who died within 24 h and those with a decision of not to resuscitate were excluded. INTERVENTIONS: Patients were randomized either to receive hydrocortisone 200 mg/d by continuous infusion or by boluses of 50 mg every 6 h throughout the prescription of vasopressors with a maximum of 7 days. RESULTS: Twenty-nine patients were included in each group. Shock reversal was significantly higher in the HC bolus group (66% vs. 35%, P = 0.008). The median time to shock reversal was 5 days (95% CI, 4.31-5.69) in the HC bolus group compared to 6 days (95% CI, 4.80-7.19) in the HC continuous infusion group (log Rank = 0.048). The number of hours spent with blood glucose ≥ 180 mg/dL was higher in the HC continuous infusion group with a median of 64 h [IQR (2-100)] versus 48 h [IQR (14-107)] in the HC bolus group, (P = 0.60), and daily insulin requirements were similar between the two groups (P = 0.63). The occurrence of other side effects, mortality, and ICU LOS were similar between the study groups. CONCLUSION: Hydrocortisone administered by intermittent bolus was associated with higher shock reversal at day 7 compared with a continuous infusion.