Deciding not to re-admit a patient to the intensive care unit (ICU) poses an ethical dilemma for ICU physicians. We aimed to describe and understand the attitudes and perceptions of ICU physicians ...regarding non-readmission of patients to the ICU.
Multicenter, qualitative study using semi-directed interviews between January and May 2019. All medical staff working full-time in the ICU of five participating centres (two academic and three general, non-academic hospitals) were invited to participate. Participants were asked to describe how they experienced non-readmission decisions in the ICU, and to expand on the manner in which the decision was made, but also on the traceability and timing of the decision. Interviews were recorded, transcribed and analyzed using textual content analysis.
In total, 22 physicians participated. Interviews lasted on average 26±7 minutes. There were 14 men and 8 women, average age was 35±9 years, and average length of ICU experience was 7±5 years. The majority of respondents said that they regretted that the question of non-readmission was not addressed before the initial ICU admission. They acknowledged that the ICU stay did lead to more thorough contemplation of the overall goals of care. Multidisciplinary team meetings could help to anticipate the question of readmission within the patient's care pathway. Participants reported that there is a culture of collegial decision-making in the ICU, although the involvement of patients, families and other healthcare professionals in this process is not systematic. The timing and traceability of non-readmission decisions are heterogeneous.
Non-readmission decisions are a major issue that raises ethical questions surrounding the fact that there is no discussion of the patient's goals of care in advance. Better anticipation, and better communication with the patients, families and other healthcare providers are suggested as areas that could be targeted for improvement.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Obesity is commonly reported in COVID-19 patients and is associated with poorer outcomes. It is suggested that leptin could be the missing link between obesity and severe COVID-19. Our study aimed to ...unravel the link between adipokines, COVID-19 status, immune response, and outcomes in severe pneumonia.
In this prospective observational single-center study, 63 immunocompetent patients with severe pneumonia (36 non-COVID-19 and 27 COVID-19) were enrolled, most required intensive care. Clinical and biological characteristics (glucose metabolism, plasma adipokines, and cytokine concentrations) and outcomes were compared.
At similar baseline severity, COVID-19 patients required mechanical ventilation for significantly longer than non-COVID-19 patients (p = 0.0049). Plasma concentrations of leptin and adiponectin were respectively positively and negatively correlated with BMI and glucose metabolism (glycemia and insulinemia), but not significantly different between the two groups. Leptin levels were negatively correlated with IL-1β and IL-6, but the adipokines were not correlated with most other inflammatory mediators, baseline severity (SOFA score), or the duration of mechanical ventilation.
Adipokine levels were correlated with BMI but not with most inflammatory mediators, severity, or outcomes in severe pneumonia, regardless of the origin. The link between obesity, dysregulated immune response, and life-threatening COVID-19 requires further investigation.
ClinicalTrials.gov: NCT03505281.
Background While outcome improvement with extracorporeal CO.sub.2 removal (ECCO.sub.2R) is not demonstrated, a strong pathophysiological rational supports its use in the setting of acute respiratory ...distress syndrome (ARDS) and COPD exacerbation. We aimed to describe our single-center experience of ECCO.sub.2R indications and outcome. Methods Patients treated with ECCO.sub.2R in our medial ICU, from March 2014 to November 2017, were retrospectively enrolled. Primary end point was evolution of ventilator settings during the two first days following ECCO.sub.2R start. Results Thirty-three patients received ECCO.sub.2R. Seventeen were managed with HemolungR, 10 with PrismalungR, 4 with ILAR, and 2 with CardiohelpR. Indications for ECCO.sub.2R were mild or moderate ARDS (n = 16), COPD exacerbation (n = 11), or uncontrolled hypercapnia due to other causes (n = 6). Four patients were not intubated at the time of ECCO.sub.2R start. Median duration of ECCO.sub.2R treatment was 7 days 5-10. In ARDS patients, between baseline and day 2, median tidal volume and driving pressure decreased from 5.3 4.4-5.9 mL/kg and 10 8-15 to 3.8 3.3-4.1 mL/kg and 9 8-11, respectively. Prone positioning was performed in 10 of the 16 patients, without serious adverse event. In COPD patients, between baseline and day 2, median ventilation minute and PaCO2 decreased significantly from respectively 7.6 6.6-8.7 L/min and 9.4 8.4-10.1 kPa to 5.8 4.9-6.2 L/min and 6 5.3-6.8 kPa. Four out of 11 COPD patients were extubated while on ECCO.sub.2R. Device thrombosis occurred in 5 patients (15%). Hemolysis was documented in 16 patients (48%). One patient died of intracranial hemorrhage, while on ECCO.sub.2R. Twenty-four patients were discharged from ICU alive. Twenty-eight day mortality was 31% in ARDS, 9% in COPD patients, and 50% in other causes of refractory hypercapnic respiratory failure. Conclusion ECCO.sub.2R was useful to apply ultra-protective ventilation among ARDS patients and improved PaCO.sub.2, pH, and minute ventilation in COPD patients. Keywords: Extracorporeal CO2 removal, Acute respiratory distress syndrome, Chronic obstructive pulmonary disease exacerbation
Background
We conducted a systematic review of studies investigating lock solutions for use in non‐tunneled hemodialysis catheters.
Methods
We searched PubMed and Cochrane databases from inception to ...June 11, 2021. Study inclusion criteria were: randomized trial or observational study, adults (>18 years), with acute kidney injury (AKI); and temporary non‐tunneled catheters. We recorded bleeding events, catheter dysfunction and complications.
Results
Of 649 studies identified, 6 were included (4 randomized, 1 non‐randomized trial, 1 retrospective cohort study; sample sizes 78–1496 patients). Citrate was compared to heparin in 4 studies, to saline in 1, and ethanol versus saline in 1. Event‐free survival of non‐tunneled catheters did not differ between groups. Catheter‐related infections and adverse events were less frequent with citrate locks, but reached statistical significance in only two studies.
Conclusion
Existing data are too heterogeneous to enable recommending one type of catheter lock over any other for non‐tunneled hemodialysis catheters.
Biofilm (BF) growth is believed to play a major role in the development of ventilator-associated pneumonia (VAP) in the intensive care unit. Despite concerted efforts to understand the potential ...implication of endotracheal tube (ETT)-BF dispersal, clinically relevant data are lacking to better characterize the impact of its mesostructure and microbiological singularity on the occurrence of VAP. We conducted a multicenter, retrospective observational study during the third wave of the COVID-19 pandemic, between March and May 2021. In total, 64 ETTs collected from 61 patients were included in the present BIOPAVIR study. Confocal microscopy acquisitions revealed two main morphological aspects of ETT-deposited BF: (1) a thin, continuous ribbon-shaped aspect, less likely monobacterial and predominantly associated with Enterobacter spp., Streptococcus pneumoniae or Viridans streptococci, and (2) a thicker, discontinuous, mushroom-shaped appearance, more likely characterized by the association of bacterial and fungal species in respiratory samples. The microbiological characterization of ETT-deposited BF found higher acquired resistance in more than 80% of analyzed BF phenotypes, compared to other colonization sites from the patient's environment. These findings reveal BF as a singular microbiological compartment, and are of added clinical value, with a view to future ETT-deposited BF-based antimicrobial stewardship in critically ill patients. Trial registration NCT04926493. Retrospectively registered 15 June 2021.
Background
In comatose patients receiving oro-tracheal intubation for mechanical ventilation (MV), the risk of aspiration is increased. Aspiration can lead to chemical pneumonitis (inflammatory ...reaction to the gastric contents), or aspiration pneumonia (infection caused by inhalation of microorganisms). Distinguishing between the two types is challenging. We tested the interest of using a decisional algorithm based on procalcitonin (PCT) values to guide initiation and discontinuation of antibiotic therapies in intubated patients.
Methods
The PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial is a multicenter, prospective, randomized, controlled, single-blind, superiority study comparing two strategies: (1) an intervention group where threshold PCT values were used to guide initiation and discontinuation of antibiotics (PCT group); and (2) a control group, where antibiotic therapy was managed at the physician’s discretion. Patients aged 18 years or over, intubated for coma (Glasgow score ≤ 8), with MV initiated within 48 h after admission, were eligible. The primary endpoint was the duration of antibiotic treatment during the first 15 days after admission to the ICU.
Results
From 24/2/2015 to 28/8/2019, 1712 patients were intubated for coma in the 5 participating centers, of whom 166 were included in the study. Data from 159 were available for intention-to-treat analysis: 81 in the PCT group, and 78 in the control group. Overall, 67 patients (43%) received antibiotics in the intensive care unit (ICU); there was no significant difference between groups (37 (46%) vs 30 (40%) for PCT vs control,
p
= 0.432). The mean duration of antibiotic treatment during the first 15 days in the ICU was 2.7 ± 3.8 days; there was no significant difference between groups (3.0 ± 4.1 days vs 2.3 ± 3.4 days for PCT vs control,
p
= 0.311). The mean number of days under MV was significantly higher in the PCT group (3.7 ± 3.6 days) than in controls (2.7 ± 2.5 days,
p
= 0.033). The duration of ICU stay was also significantly longer in the PCT group: 6.4 ± 6.5 days vs 4.6 ± 3.5 days in the control group (
p
= 0.043). After adjustment for SAPS II score, the difference in length of stay and duration of mechanical ventilation between groups was no longer significant.
Conclusion
The use of PCT values to guide therapy, in comparison to the use of clinical, biological (apart from PCT) and radiological criteria, does not modify exposure to antibiotics in patients intubated for coma.
Trial registration
Clinicaltrials.gov Identifier NCT02862314.
We investigated experiences of families who provide consent for research on behalf of a loved-one hospitalized in intensive care (ICU).
Multicentre, qualitative, descriptive study using ...semi-directive interviews in 3 ICUs. Eligible relatives were aged >18 years, and had provided informed consent for a clinical trial on behalf of a patient hospitalized in ICU. Interviews were conducted from 06/2018 to 06/2019 by a qualified sociologist, recorded and transcribed.
Fifteen relatives were interviewed; average age 50.3 ± 15 years. All emphasized their interest in clinical research, seeing it as a duty. Involving their loved-one in research allowed them to find meaning in the events. Participants underlined that trust in caregivers and communication are determinant. The strict regulation of research was perceived as a guarantee of safety. Participants felt they lacked the intellectual capacity and knowledge to question explanations. The greatest fear was not that they might incur a risk for the patient, but rather, that they might deprive the patient of a chance at a cure.
Acceptance of research opportunities by relatives on behalf of decisionally-incapacitated patients is underpinned by trust in the physicians and the legislative framework. Communication and the quality of information provided by the caregivers are key.
•In a qualitative study, we interviewed 15 relatives who consented to research on behalf of a loved-one hospitalized in the ICU.•Participants underlined that trust in caregivers is determinant, and communication is key.•The strict regulation of research in France was perceived as a guarantee of safety.•The greatest fear was not of incurring a risk, but rather, of depriving the patient of a chance at a cure.
We investigated the criteria that hospitalized patients in intensive care units (ICUs) deem important when designating relatives who are best qualified to interact with the caregiving staff.
We ...conducted an exploratory, observational, prospective, multicenter study between March 1, 2018, and October 31, 2018, within two ICUs. A 12-item questionnaire was distributed to patients in the ICUs by the investigating physicians. Patients were considered eligible if they had a good understanding of the French language and if they had not officially designated surrogates before ICU admission.
Seventy-one patients whose average age was 63.9± 17.3 years, of whom 21 (29.5%) were females, completed the questionnaire. The average Charlson comorbidity score was 2.5 ± 2.4, and the average Simplified Acute Physiology Score (SAPS II) was 39.8 ± 16.5. The main etiology was respiratory infection (40.8%), followed by sepsis (23.9%). The most important criteria identified by patients when selecting reference persons were a good knowledge of the patient's wishes and values, an emotional attachment to the patient, and being a family member.
Our findings reveal that ICU patients considered the following criteria to be critical when designating reference persons: knowledge of their wishes and the existence of emotional and family attachments.
Is IL-6 the Right Target in COVID-19 Severe Pneumonia? Blot, Mathieu; Bourredjem, Abderrahmane; Binquet, Christine ...
American journal of respiratory and critical care medicine,
01/2021, Letnik:
203, Številka:
1
Journal Article
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