Critical care delivery across health care systems in low-income and low-middle-income country settings: A systematic review.

Background: Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. Methods: A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. Results: A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions: This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. Registration: PROSPERO CRD42019146802.

The utility of bandemia in prognostication and prediction of mortality in sepsis.

Background: Bandemia, defined as a band count >10%, is indicative of underlying infection and is increasingly being used for early detection of sepsis. While an absolute band level has been linked to worse outcomes, its trend has not been extensively studied as a prognostic marker. In this study, we assessed patients admitted to the ICU with sepsis or septic shock and evaluated the correlation between bandemia trends and clinical trajectory among these patients. Methods: This study was a retrospective chart review. Band counts, serum lactate levels, and SOFA scores at 0 and 72 h after admission to the ICU were collected. Patients were risk stratified into groups depending on their SOFA trends, and corresponding band trends and serum lactate levels were compared. Results: 134 patients were included for analysis. There was a statistically significant decrease in bandemia trends for patients with a reduction in SOFA scores [median (IQR)-4.5 (-11, 0); p < 0.0001], and a statistically significant increase in bandemia trends for patients with worsening SOFA scores [median (IQR) 4 (0, 8); p = 0.0007]. Conclusion: Early trends of serum band levels in patients with sepsis or septic shock may help to predict a clinical trajectory and overall prognosis. More investigation is warranted as to whether incorporating bandemia trends, when used in conjunction with other known markers such as lactate levels, may help to guide bedside clinical decisions such as risk stratification, tailored therapies, and ultimately improve outcomes.

Critical care service delivery across healthcare systems in low-income and low-middle-income countries: protocol for a systematic review.

INTRODUCTION: Critical care in low-income and low-middle income countries (LLMICs) is an underdeveloped component of the healthcare system. Given the increasing growth in demand for critical care services in LLMICs, understanding the current capacity to provide critical care is imperative to inform policy on service expansion. Thus, our aim is to describe the provision of critical care in LLMICs with respect to patients, providers, location of care and services and interventions delivered. METHODS AND ANALYSIS: We will search PubMed/MEDLINE, Web of Science and EMBASE for full-text original research articles available in English describing critical care services that specify the location of service delivery and describe patients and interventions. We will restrict our review to populations from LLMICs (using 2016 World Bank classifications) and published from 1 January 2008 to 1 January 2020. Two-reviewer agreement will be required for both title/abstract and full text review stages, and rate of agreement will be calculated for each stage. We will extract data regarding the location of critical care service delivery, the training of the healthcare professionals providing services, and the illnesses treated according to classification by the WHO Universal Health Coverage Compendium. ETHICS AND DISSEMINATION: Reviewed and exempted by the Stanford University Office for Human Subjects Research and IRB on 20 May 2020. The results of this review will be disseminated through scholarly publication and presentation at regional and international conferences. This review is designed to inform broader WHO, International Federation for Emergency Medicine and partner efforts to strengthen critical care globally. PROSPERO REGISTRATION NUMBER: CRD42019146802.

The controversial role of corticosteroids in septic shock.

BACKGROUND: Several clinical trials and literature reviews have been conducted to evaluate the impact of corticosteroids on the physiological markers and clinical outcomes of patients in septic shock. While the findings have been somewhat contradictory, there is evidence of moderate benefit from the administration of low-dose corticosteroids to patients in septic shock. In this review, we discuss recent studies evaluating the impact of corticosteroids on morbidity and mortality in septic shock and explore future directions to fully elucidate when and how the administration of corticosteroid therapies can be beneficial. METHODS: A literature review was performed using the Mesh database of PubMed with the term "septic shock" and subheadings "therapeutic use", "drug therapy", "pharmacology", and "therapy" followed by the addition of "steroid". Filters were added to restrict the search to 18+ age, English and human studies, and articles published within the last 10 years. One hundred sixty-five articles were examined and twenty-five were deemed relevant to this review. RESULTS: The twenty-five articles reviewed here provide conflicting evidence as to the usefulness of corticosteroid treatments during septic shock. Several showed improved physiological outcomes, including rates of organ failure, need for life supporting interventions, adverse effects, inflammatory markers, and perfusion during the course of septic shock, as well as decreased mortality for a statistically significant number of patients. CONCLUSIONS: There remains a need for improved therapy for patients in septic shock. Corticosteroids have shown some potential in improving mortality rates and clinical markers. Additional studies are needed to determine the optimal role of corticosteroids in septic shock.

Current Approach to Undifferentiated Headache Management in the Emergency Department.

PURPOSE OF REVIEW: To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache. RECENT FINDINGS: Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.