Antibiotics misuse and overuse are concerning issues worldwide, especially in low middle-income countries. These practices contribute to the increasing rates of antimicrobial resistance. One ...efficient strategy to avoid them is antimicrobial stewardship programs. In this review, we focus on the possible approaches to spare the prescription of polymyxins and carbapenems for the treatment of
, carbapenem-resistant
, and
infections. Additionally, we highlight how to implement cumulative antibiograms and biomarkers to a sooner de-escalation of antibiotics.
Implementation of Tele-ICU during the COVID-19 pandemic Macedo, Bruno Rocha de; Garcia, Marcos Vinicius Fernandes; Garcia, Michelle Louvaes ...
Jornal brasileiro de pneumologia,
01/2021, Letnik:
47, Številka:
2
Journal Article
Recenzirano
Odprti dostop
To describe the implementation of a Tele-ICU program during the COVID-19 pandemic, as well as to describe and analyze the results of the first four months of operation of the program.
This was a ...descriptive observational study of the implementation of a Tele-ICU program, followed by a retrospective analysis of clinical data of patients with COVID-19 admitted to ICUs between April and July of 2020.
The Tele-ICU program was implemented over a four-week period and proved to be feasible during the pandemic. Participants were trained remotely, and the program had an evidence-based design, the objective being to standardize care for patients with COVID-19. More than 100,000 views were recorded on the free online platforms and the mobile application. During the study period, the cases of 326 patients with COVID-19 were evaluated through the program. The median age was 60 years (IQR, 49-68 years). There was a predominance of males (56%). There was also a high prevalence of hypertension (49.1%) and diabetes mellitus (38.4%). At ICU admission, 83.7% of patients were on invasive mechanical ventilation, with a median PaO2/FiO2 ratio < 150. It was possible to use lung-protective ventilation in 75% of the patients. Overall, in-hospital mortality was 68%, and ICU mortality was 65%.
Our Tele-ICU program provided multidisciplinary training to health care professionals and clinical follow-up for hundreds of critically ill patients. This public health care network initiative was unprecedented and proved to be feasible during the COVID-19 pandemic, encouraging the creation of similar projects that combine evidence-based practices, training, and Tele-ICU.
To develop and apply a competency-based test to assess learning among internal medicine residents during a respiratory ICU rotation at a university hospital.
We developed a test comprising 19 ...multiple-choice questions regarding knowledge of mechanical ventilation (MV) and 4 self-assessment questions regarding the degree of confidence in the management of MV. The test was applied on the first and last day of a 30-day respiratory ICU rotation (pre-rotation and post-rotation, respectively). During the rotation, the residents had lectures, underwent simulator training, and shadowed physicians on daily bedside rounds focused on teaching MV management.
Fifty residents completed the test at both time points. The mean score increased from 6.9 ± 1.2 (pre-rotation) to 8.6 ± 0.8 (post-rotation; p < 0.001). On questions regarding the approach to hypoxemia, the recognition of patient-ventilator asynchrony, and the recognition of risk factors for extubation failure, the post-rotation scores were significantly higher than the pre-rotation scores. Confidence in airway management increased from 6% before the rotation to 22% after the rotation (p = 0.02), whereas confidence in making the initial MV settings increased from 31% to 96% (p < 0.001) and confidence in adjusting the ventilator modes increased from 23% to 77% (p < 0.001).
We developed a competency-based test to assess knowledge of MV among residents before and after an rotation in a respiratory ICU. Resident performance increased significantly after the rotation, as did their confidence in caring for patients on MV.
Patients with unilateral diaphragmatic paralysis (UDP) may present with dyspnoea without specific cause and limited ability to exercise. We aimed to investigate the diaphragm contraction mechanisms ...and nondiaphragmatic inspiratory muscle activation during exercise in patients with UDP, compared with healthy individuals.
Pulmonary function, as well as volitional and nonvolitional inspiratory muscle strength were evaluated in 35 patients and in 20 healthy subjects. Respiratory pressures and electromyography of scalene and sternocleidomastoid muscles were continuously recorded during incremental maximal cardiopulmonary exercise testing until symptom limitation. Dyspnoea was assessed at rest, every 2 min during exercise and at the end of exercise with a modified Borg scale.
Inspiratory muscle strength measurements were significantly lower for patients in comparison to controls (all p<0.05). Patients achieved lower peak of exercise (lower oxygen consumption) compared to controls, with both gastric (-9.8±4.6 cmH
O
8.9±6.0 cmH
O) and transdiaphragmatic (6.5±5.5 cmH
O
26.9±10.9 cmH
O) pressures significantly lower, along with larger activation of both scalene (40±22% EMGmax
18±14% EMGmax) and sternocleidomastoid (34±22% EMGmax
14±8% EMGmax). In addition, the paralysis group presented significant differences in breathing pattern during exercise (lower tidal volume and higher respiratory rate) with more dyspnoea symptoms compared to the control group.
The paralysis group presented with exercise limitation accompanied by impairment in transdiaphragmatic pressure generation and larger accessory inspiratory muscles activation compared to controls, thereby contributing to a neuromechanical dissociation and increased dyspnoea perception.
It is unknown if patients with cancer and acute respiratory failure due to COVID-19 have different clinical or cancer-related characteristics, decisions to forgo life-sustaining therapies (LST), and ...mortality compared to patients with cancer and acute respiratory failure due to other causes. In a cohort study, we tested the hypothesis that COVID-19 was associated with increased in-hospital mortality and decreased decisions to forgo LST in patients with cancer and acute respiratory failure. We employed two multivariate logistic regression models. Propensity score matching was employed as sensitivity analysis. We compared 382 patients without COVID-19 with 65 with COVID-19. Patients with COVID-19 had better performance status, less metastatic tumors, and progressive cancer. In-hospital mortality of patients with COVID-19 was lower compared with patients without COVID-19 (46.2 vs. 74.6%;
< 0.01). However, the cause of acute respiratory failure (COVID-19 or other causes) was not associated with increased in-hospital mortality adjusted odds ratio (OR) 1.27 (0.55-2.93; 95% confidence interval, CI) in the adjusted model. The percentage of patients with a decision to forgo LST was lower in patients with COVID-19 (15.4 vs. 36.1%;
= 0.01). However, COVID-19 was not associated with decisions to forgo LST adjusted OR 1.21 (0.44-3.28; 95% CI) in the adjusted model. The sensitivity analysis confirmed the primary analysis. In conclusion, COVID-19 was not associated with increased in-hospital mortality or decreased decisions to forgo LST in patients with cancer and acute respiratory failure. These patients had better performance status, less progressive cancer, less metastatic tumors, and less organ dysfunctions upon intensive care unit (ICU) admission than patients with acute respiratory failure due to other causes.
In patients with post-extubation respiratory distress, delayed reintubation may worsen clinical outcomes. Objective measures of extubation failure at the bedside are lacking, therefore clinical ...parameters are currently used to guide the need of reintubation. Electrical activity of the diaphragm (EAdi) provides clinicians with valuable, objective information about respiratory drive and could be used to monitor respiratory effort.
We describe the case of a patient with Chronic Obstructive Pulmonary Disease (COPD), from whom we recorded EAdi during four different ventilatory conditions: 1) invasive mechanical ventilation, 2) spontaneous breathing trial (SBT), 3) unassisted spontaneous breathing, and 4) Noninvasive Positive Pressure Ventilation (NPPV). The patient had been intubated due to an exacerbation of COPD, and after four days of mechanical ventilation, she passed the SBT and was extubated. Clinical signs of respiratory distress were present immediately after extubation, and EAdi increased compared to values obtained during mechanical ventilation. As we started NPPV, EAdi decreased substantially, indicating muscle unloading promoted by NPPV, and we used the EAdi signal to monitor respiratory effort during NPPV. Over the next three days, she was on NPPV for most of the time, with short periods of spontaneous breathing. EAdi remained considerably lower during NPPV than during spontaneous breathing, until the third day, when the difference was no longer clinically significant. She was then weaned from NPPV and discharged from the ICU a few days later.
EAdi monitoring during NPPV provides an objective parameter of respiratory drive and respiratory muscle unloading and may be a useful tool to guide post-extubation ventilatory support. Clinical studies with continuous EAdi monitoring are necessary to clarify the meaning of its absolute values and changes over time.
Abstract Purpose Automated weaning modes are available in some mechanical ventilators, but no studies compared them hitherto. We compared the performance of 3 automated modes under standard and ...challenging situations. Methods We used a lung simulator to compare 3 automated modes, adaptive support ventilation (ASV), mandatory rate ventilation (MRV), and Smartcare, in 6 situations, weaning success, weaning failure, weaning success with extreme anxiety, weaning success with Cheyne-Stokes, weaning success with irregular breathing, and weaning failure with ineffective efforts. Results The 3 modes correctly recognized the situations of weaning success and failure, even when anxiety or irregular breathing were present but incorrectly recognized weaning success with Cheyne-Stokes. MRV incorrectly recognized weaning failure with ineffective efforts. Time to pressure support (PS) stabilization was shorter for ASV (1-2 minutes for all situations) and MRV (1-7 minutes) than for Smartcare (8-78 minutes). ASV had higher rates of PS oscillations per 5 minutes (4-15), compared with Smartcare (0-1) and MRV (0-12), except when extreme anxiety was present. Conclusions Smartcare, ASV, and MRV were equally able to recognize weaning success and failure, despite the presence of anxiety or irregular breathing but performed incorrectly in the presence of Cheyne-Stokes. PS behavior over the time differs among modes, with ASV showing larger and more frequent PS oscillations over the time. Clinical studies are needed to confirm our results.
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