Up to 31 January 2020, there have been 9811 officially reported confirmed cases of 2019-novel coronavirus (nCoV) infection in China since the epidemic began in December 2019 (updated data available at https ://gisan ddata .maps.arcgi s.com/apps/opsda shboa rd/index .html#/ bda75 94740 fd402 99423 467b4 8e9ec f6). With the rapid transmission, the epidemic has spread throughout the country, and 177 cases have been reported in Sichuan Province. As nCoV infection is a highly contagious disease with high mortality (3–15%) [1–3] and West China Hospital (WCH) is the largest hospital in the southwest of China and the referral medical center in Sichuan Province, it is our responsibility to prepare for admission of additional critically ill patients as a matter of emergency. We have held several expert meetings and have reviewed the related literature to develop a plan to respond to the epidemic [4, 5]. The purpose of the plan is to enable us to provide the maximum level of care to critically ill patients while ensuring the protection of medical staff.
Abstract Background The effect of different spontaneous breathing trial (SBT) methods on lung volume and ventilation distribution has not been well clarified in post-cardiac surgery patients. Methods In this prospective observational study, patients underwent 30 min of pressure-support ventilation (PSV)-SBT [PS 8 cmH2O, zero positive end-expiratory pressure (ZEEP)], followed by a 30-min T-piece trial if tolerated. Electrical impedance tomography (EIT) was used to continuously monitor regional lung ventilation and end-expiratory lung volume (EELV) at baseline, PSV-SBT 3 min, PSV-SBT 30 min, T-piece SBT 3 min and T-piece SBT 30 min. EELVloss = [VTbaseline/tidal impedance variation (TIV)baseline] × ΔEELI. EELVloss PSV was defined as volume loss at 30 min of PSV-SBT and EELVloss T-piece was defined as volume loss during T-piece SBT. Results In 60 patients who complied with both SBT steps, 43 succeeded (71.7%) and 17 failed (28.3%) the T-piece SBT. Compared to the success group, the failure group exhibited a higher incidence of pendelluft (52.9% vs. 23.3%, p = 0.045) and significantly greater EELVloss at T-piece SBT 30 min (623[459,746] ml vs. 511[376,702]ml, p = 0.003). However, the success group showed greater EELVloss PSV than the failure group (322[247,459] ml vs. 199[166, 269] ml, p < 0.001), which was an abnormal pattern. Notably, the failure group had lower TIV (2102[1769,2562] vs. 2742[2153,3872], p = 0.005) and a higher respiratory rate (RR) than baseline at PSV-SBT 30 min (20[17,24] vs. 16[12,18], p < 0.001). Furthermore, we classified all patients into two groups based on the predominant reduction of volume loss: P-volume loss group (N = 37, EELVloss PSV > EELVloss T-piece) and T-volume loss group (N = 23, EELVloss T-piece > EELVloss PSV). In addition, the T-volume loss group had a higher weaning failure rate than the P-volume loss group (52.2% [12/23] vs. 13.5% [5/37], p < 0.001) and was associated with reduced baseline dorsal ventilation (39%[37%,43%] vs. 44%[41%,50%], p = 0.023). ROC analysis suggested that a dorsal ventilation threshold of 40.5% was associated with T-volume loss. Conclusions The successful weaning patients had a higher reduction of EELVloss PSV and a lower reduction of EELVloss T-piece. In the weaning failure patients, the paradox of lower EELVloss PSV that was accompanied by a high RR and low VT might be associated with air trapping. Attention should be paid to using EELVloss PSV to identify weaning failure.
Medical emergencies. Critical care. Intensive care. First aid
Johanne Rauwenhoff, Gøril Storvig, Bert Lenaert
et al.
A substantial number of people experience persistent post-concussion symptoms (PPCS) following a concussion. Traditional retrospective assessments, such as the Rivermead Post Concussion Symptoms Questionnaire (RPQ), are prone to memory biases and do not capture the day-to-day variability of PPCS. In this study, we explored the association between daily registrations of PPCS and the RPQ. We also examined the variability of PPCS trajectories over time. Nineteen participants registered PPCS symptoms for 28 days using an mHealth app and then completed the RPQ. From the final 7 days, average, highest, and last-day symptom scores were calculated and correlated with corresponding RPQ items. Scores from the full 28-day period were used to compute the within-person standard deviation and mean squared successive difference (MSSD) for each symptom that participants rated as the most bothersome. Correlations between the RPQ and daily registrations were weak-to-medium (range: 0.343, 0.590). The retrospective RPQ explained up to 35% of the variance in average daily registrations of PPCS. The MSSD ranged from 0 to 16.29, and the within-person SD from 0 to 3.25. Visual analyses showed that participants with identical RPQ item scores often exhibited different PPCS variability. This was also true for different symptoms within the same participant. This study highlights the potential additional value of daily registrations for capturing the dynamic and fluctuating nature of PPCS, which may be missed by retrospective questionnaires administered at one time point. PPCS vary both within and between individuals over time and reducing this complexity to a single total score oversimplifies a nuanced reality. Larger studies are needed to confirm these findings, and future work should investigate the clinical relevance of capturing daily variations in PPCS.
Medical emergencies. Critical care. Intensive care. First aid
Background. Workplace-based assessment (WPBA) is a new technology for evaluating medical residents that is believed to be more effective than traditional multiple-choice tests or exam-based assessment methods. The aim of the study was to investigate the WPBA efficacy in final-year medical residents: multi-source feedback (360°) assessment, direct procedure assessment (Anaesthesia-Clinical Evaluation Exercise (A-CEX)) and clinical case-based assessment, and to identify difficult competencies, which graduate residents acquire the least successfully. Materials and methods. From April 1 to June 15, 2023, 36 residents were evaluated at the workplace: the multi-source feedback 360°-evaluation form was filled out by three representatives of the medical team where the resident worked during the on-site part of the residency (1 anesthesiologist, 1 nurse and 1 other specialist); the form of direct procedure assessment was filled out by the teacher on face-to-face bases directly during the resident’s performance of the general anesthesia in low-risk patients (American Society of Anesthesiologists (ASA) I or II), preoperative examination of low-risk patients (ASA I or II) and neuraxial anesthesia in low-risk patients (ASA I or II) with the following feedback; assessment based on a clinical case was carried out by teachers during the conference of residents, where each of them presented a clinical case of anesthetic management or treatment of a critically ill patient. Results. According to the results of the multi-source feedback (360°) evaluation, most of the residents have received 7 or more points out of 10 possible. Communication with the medical team (odds ratio (OR) 1.9 [1.05–3.5], p = 0.048) and management in a critical situation (OR 2 [1.14–3.83], p = 0.024) were most difficult competencies during the multi-source feedback (360°) assessment. During direct procedure of general anesthesia, the most difficult competencies were: 1) management in a critical situation — knowledge/recognition of risks and how to avoid and treat them (OR 5.29 [1.9–14.4], p = 0.001 compared to documentation); 2) solving problems, making decisions (OR 12.6 [1.5–10,4], p = 0.007 compared to documentation); 3) interaction in the team (OR 2.7 [1.1–6.5], p = 0.049). No problematic competencies were identified during the assessment of neuraxial anesthesia competencies and preoperative examination. Conclusions. WPBA techniques such as multi-source feedback (360°) assessment, direct procedure evaluation (A-CEX) and clinical case-based assessment are effective in final year residents, improving their communication skills, readiness to work independently, help identify skill deficiencies. Communication with the medical team and management in a critical situation were difficult competencies during the multi-source feedback (360°) evaluation. Difficult competences during the direct evaluation of general anesthesia turned out to be the management in a critical situation; solving problems, making decisions; interaction in the team. No problematic competencies were identified during the assessment of neuraxial anesthesia competencies and preoperative examination.
Medical emergencies. Critical care. Intensive care. First aid
Onyenekwe C. Chinedum , Ezugwu U. Modestus , Onyenekwe N. Ogochukwu , Osakue O. Nosakhare , Obu. Ifeoma , Ehiaghe F. Alfred , Osakue N. Eric , Akaahan Achiaku , Edet S. Eno and Ehiaghe I. Joy .
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Medical emergencies. Critical care. Intensive care. First aid
Behiye Deniz Kosovalı, Gül Meral Kocabeyoğlu, Nevzat Mehmet Mutlu
et al.
Objective: The patients admitted to coronavirus disease-2019 (COVID-19) intensive care units (ICUs) with the suspicion of COVID-19 in the first four months of the pandemic were evaluated both in diagnostics and according to periods of the pandemic.
Materials and Methods: The data of 1,430 patients admitted to the COVID-19 ICUs were recorded with the same algorithm in a single-center retrospectively. Patients were classified as COVID-19 and non-COVID-19 patients according to polymerase chain reaction results, radiological and clinical findings. Also, COVID-19 patients were compared as dying and surviving. Additionally, the data of patients admitted to COVID-19 ICUs during the onset of the pandemic and during the normalization period were also compared.
Results: Of 1,430 patients, 630 were included in the COVID-19 group and 800 in the non-COVID-19 group. While there was a significant difference in the mean age of the groups, there was no difference between the genders (p=0.001, p=0.262 respectively). The age in the COVID-19 and deceased group was higher than that in the survivors (p<0.001). The most common presenting symptom was dyspnea (51.2%), while hypertension’s most common comorbidity (51.2%). During the normalization period, the rate of patients admitted to the ICU with the diagnosis of COVID-19 and the mortality rates in the ICU was higher.
Conclusion: The initial period of the pandemic was spent understanding COVID-19, which entered our lives as a mystery at the same time. It was a guiding period for us to treat patients more effectively while protecting the community and healthcare professionals.
Elena Segura-Grau, Pedro Antunes, Juliana Magalhães
et al.
In recent years, ultrasonography has gained unmatched importance in medical practice. After the initial use for central vascular access placement and regional anaesthesia, its application has expanded to airway, ocular, abdominal, lung and cardiac ultrasound, with the concept of point of care ultrasound (POCUS) gaining acceptability and applicability in the most diverse situations. In fact, it has recently been acclaimed as the fifth pillar to bedside evaluation [1].
Performing a POCUS-guided evaluation has proved to be of value in emergency medicine, with studies demonstrating improved diagnosis and better outcomes [2]. Similarly, in critical care, systematic ultrasound evaluation has been shown to decrease the use of conventional diagnostic imaging tools and time on mechanical ventilation and improve the management of fluid therapy [3]. Recognition of the benefit of ultrasound evaluation in the perioperative period has been increasing. In fact, the need to master clinical ultrasound evaluation has led the Canadian anaesthesiology academic centres to issue recommendations regarding the scope of practice and required training for perioperative POCUS [4].
Anesthesiology, Medical emergencies. Critical care. Intensive care. First aid
Emanuelle Olympia Silva Ribeiro, Rik Gosselink, Lizandra Eveline da Silva Moura
et al.
Background Respiratory muscle strength in patients with an artificial airway is commonly assessed as the maximal inspiratory pressure (MIP) and is measured using analogue or digital manometers. Recently, new electronic loading devices have been proposed to measure respiratory muscle strength. This study evaluates the agreement between the MIPs measured by a digital manometer and those according to an electronic loading device in patients being weaned from mechanical ventilation. Methods In this prospective study, the standard MIP was obtained using a protocol adapted from Marini, in which repetitive inspiratory efforts were performed against an occluded airway with a one-way valve and were recorded with a digital manometer for 40 seconds (MIPDM). The MIP measured using the electronic loading device (MIPELD) was obtained from repetitively tapered flow resistive inspirations sustained for at least 2 seconds during a 40-second test. The agreement between the results was verified by a Bland-Altman analysis. Results A total of 39 subjects (17 men, 55.4±17.7 years) was enrolled. Although a strong correlation between MIPDM and MIPELD (R=0.73, P<0.001) was observed, the Bland-Altman analysis showed a high bias of –47.4 (standard deviation, 22.3 cm H2O; 95% confidence interval, –54.7 to –40.2 cm H2O). Conclusions The protocol of repetitively tapering flow resistive inspirations to measure the MIP with the electronic loading device is not in agreement with the standard protocol using one-way valve inspiratory occlusion when applied in poorly cooperative patients being weaned from mechanical ventilation.
Medical emergencies. Critical care. Intensive care. First aid
Critical emergency medicine is the medical field concerned with management of critically ill patients in the emergency department (ED). Increased ED stay due to intensive care unit (ICU) overcrowding has a negative impact on patient care and outcome. It has been proposed that implementation of critical care services in the ED can negate this effect. Two main Critical Emergency Medicine models have been proposed, the “resource intensivist” and “ED-ICU” models. The resource intensivist model is based on constant presence of an intensivist in the traditional ED setting, while the ED-ICU model encompasses the notion of a separate ED-based unit, with monitoring and therapeutic capabilities similar to those of an ICU. Critical emergency medicine has the potential to improve patient care and outcome; however, establishment of evidence-based protocols and a multidisciplinary approach in patient management are of major importance.
Background Unavailability or saturation of the intensive care unit may be associated with the fatality of COVID-19. Prioritizing the patients for hospitalization and intensive care may be critical for reducing the fatality of COVID-19. This study aimed to develop and validate a new integer-based scoring system for predicting patients with COVID-19 requiring intensive care, using only the predictors available upon triage. Methods This is a retrospective study using cohort data from the Korean Centers for Disease Control and Prevention that included all admitted patients with COVID-19 between January 19 and June 3, 2020, in South Korea. The primary outcome was patients requiring intensive care defined as actual admission to the intensive care unit; at any time use of an extracorporeal life support device, mechanical ventilation, or vasopressors; and death. Patients admitted until March 20 were included for the training dataset to develop the prediction models and externally validated for the patients admitted afterward. Two logistic regression models were developed with different predictors and the predictive performance was compared: one with patient-provided variables and the other with added radiologic and laboratory variables. An integer-based scoring system was developed based on the developed logistic regression model. Results A total of 5193 patients were considered, with 4663 patients included after excluding patients with age under 18 or insufficient data. For the training dataset, 3238 patients were included. Of the included patients, 444 (9.5%) patients required intensive care. The model developed with only the clinical variables showed an area under the curve of 0.884 for the validation set. The performance did not differ when radiologic and laboratory variables were added. Seven variables were selected for developing an integer-based scoring system: age, sex, initial body temperature, dyspnea, hemoptysis, history of chronic kidney disease, and activities of daily living. The area under the curve of the scoring system was 0.880. Conclusions An integer-based scoring system was developed for predicting patients with COVID-19 requiring intensive care, with high performance. This system may aid decision support for prioritizing the patient for hospitalization and intensive care, particularly in a situation with limited medical resources.
Behrang Rezvani Kakhki, Mohsen Miri, Morteza Talebi Doluee
et al.
Orotracheal intubation is one of the sure ways to manage airways in critical patients (1, 2). Failed intubation (Failure to properly place the endotracheal tube (ETT) in trachea) is a rather common event (3). There have been many techniques to confirm proper intubation, but none of them are applicable in all conditions. Methods such as capnography, tracheal sonography and chest-X-ray, were introduced for verification of proper tracheal intubation but they have their own limitations (4, 5). Given the significance of proper airway management, the authors focused on a secondary method of verifying proper intubation using tracheal tactile method and compared it to existing methods.
Medical emergencies. Critical care. Intensive care. First aid
Purpose Some publications suggest high rates of healthcare-associated infections (HAIs) and of nosocomial pneumonia portending a poor prognosis in ICU cancer patients. A better understanding of the epidemiology of HAIs in these patients is needed. Methods A retrospective analysis of all the patients hospitalized for ≥ 48 h during a 12-year period in the 12-bed ICU of the Gustave Roussy hospital, monitored prospectively for ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) and for use of medical devices. Results During 3388 first stays in the ICU, 198 cases of VAP and 103 primary, 213 secondary, and 77 catheter-related BSIs were recorded. The VAP rate was 24.5/1000 ventilator days (95% confidence interval [CI] 21.2–28.0); the catheter-related BSI rate was 2.3/1000 catheter days (95% CI 1.8–2.8). The cumulative incidence during the first 25 days of exposure was 58.8% (95% CI 49.1–66.6%) for VAP, 8.9% (95% CI, 6.2–11.5%) for primary, 15.1% (95% CI 11.6–18.5%) for secondary and 5.0% (95% CI 3.2–6.8%) for catheter-related BSIs. VAP or BSIs were not associated with a higher risk of ICU mortality. Conclusions This is the first study to report HAI rates in a large cohort of critically ill cancer patients. Although both the incidence of VAP and the rate of BSI are higher than in general ICU populations, this does not impact patient outcomes. The occurrence of device-associated infections is essentially due to severe medical conditions in patients and to the characteristics of malignancy.