scholarly journals Critical illness neuro-myopathy (CINM) and focal amyotrophy in intensive care unit (ICU) patients with SARS-CoV-2: a case series

2020 ◽  
Author(s):  
Nicola Alessandro Nasuelli ◽  
Roberto Pettinaroli ◽  
Laura Godi ◽  
Claudio Savoini ◽  
Fabiola De Marchi ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Case Series ◽  
Icu Patients

scholarly journals Iatrogenic blood loss due to daily laboratory testing and the risk of subsequent anaemia in intensive care unit patients: case series

2021 ◽  
Author(s):  
Kamil Witosz ◽  
Olga Wojnarowicz ◽  
Łukasz J. Krzych
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Blood Loss ◽  
Laboratory Testing ◽  
Case Series ◽  
Study Group ◽  
Icu Patients ◽  
Wide Range ◽  
Median Volume

Introduction: Anaemia is associated with a wide range of negative outcomes. Diagnostic blood loss (DBL) may contribute to its occurrence. We aimed to evaluate DBL and its impact on haemoglobin (HGB) concentration and developing anaemia in the intensive care unit (ICU) patients. Methods: A study group comprised of 36 adult ICU patients. DBL during 7 consecutive, post-admission days was calculated. Anaemia occurrence was assessed using the WHO thresholds. Data on HGB and haematocrit (HCT) was subjected to analysis. Results: Upon admission, 24 (67%) patients were diagnosed with anaemia, on the eighth day 29 (80%) subjects (with 6 new cases). The median volume of blood collected was 143.15 mL (IQR 121.4–161.65) per week. No differences in DBL were found between the subjects with newly developed anaemia and their counterparts (p=0.4). The median drop of HGB (HbΔ) was 18 gL–1 (IQR 5–28) and the median drop of haematocrit (HtΔ) was 4.55% (IQR 1.1–7.95). There was no correlation between neither HbΔ and DBL (p=0.8) nor HtΔ and DBL (p=0.7). There were also no differences in HbΔ/HtΔ when age, gender or the primary critical illness were taken into account for the analysis (p>0.05 for all). The 7-day fluid balance was associated with haemoglobin drop (R=0.45; p=0.006). Conclusions: Anaemia is frequent in ICU patients. Diagnostic blood loss in our institution is acceptable and seems to protect patients against significant iatrogenic blood loss and subsequent anaemia. Dilutional anaemia may interfere with the results so before-after interventional research is needed to explore this interesting topic.

scholarly journals Long-Term Cognitive Impairment After Critical Illness

2018 ◽  
pp. 86-90
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Cognitive Impairment ◽  
Critical Illness ◽  
Cognitive Outcomes ◽  
Adult Patients ◽  
Illness Experience ◽  
Icu Patients ◽  
Global Cognition

This case focuses on long-term cognitive impairment after critical illness by asking the question: What is the prevalence of long-term cognitive impairment after critical illness, and does the duration of delirium and use of sedative or analgesic medications affect cognitive outcomes? This study demonstrated that 74% of adult patients with critical illness experience delirium during their hospital course. Furthermore, patients in the intensive care unit (ICU) setting commonly experience global cognition and executive function deficits at 3 and 12 months following hospitalization. These findings highlight the importance of careful delirium surveillance in ICU patients.

scholarly journals Neurogenic vs. Myogenic Origin of Acquired Muscle Paralysis in Intensive Care Unit (ICU) Patients: Evaluation of Different Diagnostic Methods

Diagnostics ◽  
2020 ◽  
Vol 10 (11) ◽  
pp. 966
Author(s):  
Humberto D.J. Gonzalez Marrero ◽  
Erik V. Stålberg ◽  
Gerald Cooray ◽  
Rebeca Corpeno Kalamgi ◽  
Yvette Hedström ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Critical Illness ◽  
Diagnostic Methods ◽  
Muscle Stimulation ◽  
Muscle Paralysis ◽  
Icu Patients ◽  
Muscle Biopsies ◽  
Electrophysiological Methods

Introduction. The acquired muscle paralysis associated with modern critical care can be of neurogenic or myogenic origin, yet the distinction between these origins is hampered by the precision of current diagnostic methods. This has resulted in the pooling of all acquired muscle paralyses, independent of their origin, into the term Intensive Care Unit Acquired Muscle Weakness (ICUAW). This is unfortunate since the acquired neuropathy (critical illness polyneuropathy, CIP) has a slower recovery than the myopathy (critical illness myopathy, CIM); therapies need to target underlying mechanisms and every patient deserves as accurate a diagnosis as possible. This study aims at evaluating different diagnostic methods in the diagnosis of CIP and CIM in critically ill, immobilized and mechanically ventilated intensive care unit (ICU) patients. Methods. ICU patients with acquired quadriplegia in response to critical care were included in the study. A total of 142 patients were examined with routine electrophysiological methods, together with biochemical analyses of myosin:actin (M:A) ratios of muscle biopsies. In addition, comparisons of evoked electromyographic (EMG) responses in direct vs. indirect muscle stimulation and histopathological analyses of muscle biopsies were performed in a subset of the patients. Results. ICU patients with quadriplegia were stratified into five groups based on the hallmark of CIM, i.e., preferential myosin loss (myosin:actin ratio, M:A) and classified as severe (M:A < 0.5; n = 12), moderate (0.5 ≤ M:A < 1; n = 40), mildly moderate (1 ≤ M:A < 1.5; n = 49), mild (1.5 ≤ M:A < 1.7; n = 24) and normal (1.7 ≤ M:A; n = 19). Identical M:A ratios were obtained in the small (4–15 mg) muscle samples, using a disposable semiautomatic microbiopsy needle instrument, and the larger (>80 mg) samples, obtained with a conchotome instrument. Compound muscle action potential (CMAP) duration was increased and amplitude decreased in patients with preferential myosin loss, but deviations from this relationship were observed in numerous patients, resulting in only weak correlations between CMAP properties and M:A. Advanced electrophysiological methods measuring refractoriness and comparing CMAP amplitude after indirect nerve vs. direct muscle stimulation are time consuming and did not increase precision compared with conventional electrophysiological measurements in the diagnosis of CIM. Low CMAP amplitude upon indirect vs. direct stimulation strongly suggest a neurogenic lesion, i.e., CIP, but this was rarely observed among the patients in this study. Histopathological diagnosis of CIM/CIP based on enzyme histochemical mATPase stainings were hampered by poor quantitative precision of myosin loss and the impact of pathological findings unrelated to acute quadriplegia. Conclusion. Conventional electrophysiological methods are valuable in identifying the peripheral origin of quadriplegia in ICU patients, but do not reliably separate between neurogenic vs. myogenic origins of paralysis. The hallmark of CIM, preferential myosin loss, can be reliably evaluated in the small samples obtained with the microbiopsy instrument. The major advantage of this method is that it is less invasive than conventional muscle biopsies, reducing the risk of bleeding in ICU patients, who are frequently receiving anticoagulant treatment, and it can be repeated multiple times during follow up for monitoring purposes.

Microbiome in Critical illness: An Unconventional and Unknown Ally

2021 ◽  
Vol 28 ◽  
Author(s):  
Christian Zanza ◽  
Tatsiana Romenskaya ◽  
Duraiyah Thangathurai ◽  
Veronica Ojetti ◽  
Angela Saviano ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Pathogenic Bacteria ◽  
Fecal Microbiota Transplantation ◽  
Bacterial Flora ◽  
The Body ◽  
Cochrane Library ◽  
Icu Patients ◽  
Infection Spread

Background: The digestive tract represents an interface between the external environment and the body where the interaction of a complex polymicrobial ecology has an important influence on health and disease. The physiological mechanisms that are altered during the hospitalization and in the intensive care unit (ICU) contribute to the pathobiota’s growth. Intestinal dysbiosis occurs within hours of being admitted to ICU. This may be due to different factors, such as alterations of normal intestinal transit, administration of variuos medications or alterations in the intestinal wall which causes a cascade of events that will lead to the increase of nitrates and decrease of oxygen concentration, liberation of free radicals. Objective: This work aims to report the latest updates on the microbiota’s contribution to developing sepsis in patients in the ICU department. In this short review were reviewed the latest scientific findings on the mechanisms of intestinal immune defenses performed both locally and systemically. In addition, we considered it necessary to review the literature to report the current best treatment strategies to prevent the infection spread which can bring systemic infections in patients admitted to ICU. Material and Methods: This review has been written to answer at three main questions: what are the main intestinal flora’s defense mechanisms that help us to prevent the risk of developing systemic diseases on a day-to-day basis? What are the main dysbiosis’ systemic abnormalities? What are the modern strategies that are used in the ICU patients to prevent the infection spread? Using the combination of following keywords: microbiota and ICU, ICU and gut, microbiota and critical illness, microbiota and critical care, microbiota and sepsis, microbiota and infection, gastrointestinal immunity,in the Cochrane Controlled Trials Register, the Cochrane Library, medline and pubmed, google scholar, ovid/wiley. Finally, we reviewed and selected 72 articles. We also consulted the site ClinicalTrials.com to find out studies that are recently conducted or ongoing. Results: The critical illness can alter intestinal bacterial flora leading to homeostasis disequilibrium. Despite numerous mechanisms, such as epithelial cells with calciform cells that together build a mechanical barrier for pathogenic bacteria, the presence of mucous associated lymphoid tissue (MALT) which stimulates an immune response through the production of interferon-gamma (IFN-y) and THN-a or by stimulating lymphocytes T helper-2 produces anti-inflammatory cytokines. But these defenses can be altered following a hospitalization in ICU and lead to serious complications such as acute respiratory distress syndrome (ARDS), health care associated pneumonia (HAP) and ventilator associated pneumonia (VAP), Systemic infection and multiple organ failure (MOF), but also in the development of coronary artery disease (CAD). In addition, the microbiota has a significant impact on the development of intestinal complications and the severity of the SARS-COVID-19 patients. Conclusion: The microbiota is recognized as one of the important factors that can worsen the clinical conditions of patients who are already very frailty in intensive care unit. At the same time, the microbiota also plays a crucial role in the prevention of ICU associated complications. By using the resources, we have available, such as probiotics, symbiotics or fecal microbiota transplantation (FMT), we can preserve the integrity of the microbiota and the GUT, which will later help maintain homeostasis in ICU patients.

scholarly journals 375. COVID 19 infection in a Massachusetts community hospital

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S257-S258
Author(s):  
Raul Davaro ◽  
alwyn rapose
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Essential Hypertension ◽  
Severe Acute Respiratory Syndrome ◽  
High Mortality ◽  
Case Series ◽  
World Health ◽  
Minimal Risk ◽  
The Impact

Abstract Background The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections has led to 105690 cases and 7647 deaths in Massachusetts as of June 16. Methods The study was conducted at Saint Vincent Hospital, an academic health medical center in Worcester, Massachusetts. The institutional review board approved this case series as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent. All consecutive patients who were sufficiently medically ill to require hospital admission with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample were included. Results A total of 109 consecutive patients with COVID 19 were admitted between March 15 and May 31. Sixty one percent were men, the mean age of the cohort was 67. Forty one patients (37%) were transferred from nursing homes. Twenty seven patients died (24%) and the majority of the dead patients were men (62%). Fifty one patients (46%) required admission to the medical intensive care unit and 34 necessitated mechanical ventilation, twenty two patients on mechanical ventilation died (63%). The most common co-morbidities were essential hypertension (65%), obesity (60%), diabetes (33%), chronic kidney disease (22%), morbid obesity (11%), congestive heart failure (16%) and COPD (14%). Five patients required hemodialysis. Fifty five patients received hydroxychloroquine, 24 received tocilizumab, 20 received convalescent plasma and 16 received remdesivir. COVID 19 appeared in China in late 2019 and was declared a pandemic by the World Health Organization on March 11, 2020. Our study showed a high mortality in patients requiring mechanical ventilation (43%) as opposed to those who did not (5.7%). Hypertension, diabetes and obesity were highly prevalent in this aging population. Our cohort was too small to explore the impact of treatment with remdesivir, tocilizumab or convalescent plasma. Conclusion In this cohort obesity, diabetes and essential hypertension are risk factors associated with high mortality. Patients admitted to the intensive care unit who need mechanical ventilation have a mortality approaching 50 %. Disclosures All Authors: No reported disclosures

scholarly journals Lung ultrasound predicts clinical course but not outcome in COVID-19 ICU patients: a retrospective single-center analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Stephanie-Susanne Stecher ◽  
Sofia Anton ◽  
Alessia Fraccaroli ◽  
Jeremias Götschke ◽  
Hans Joachim Stemmler ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Lung Ultrasound ◽  
Clinical Course ◽  
Point Of Care ◽  
Clinical Deterioration ◽  
Normal Lung ◽  
Icu Patients ◽  
Standardized Protocol ◽  
Ultrasound Score

Abstract Background Point-of-care lung ultrasound (LU) is an established tool in the first assessment of patients with coronavirus disease (COVID-19). Purpose of this study was to evaluate the value of lung ultrasound in COVID-19 intensive care unit (ICU) patients in predicting clinical course and outcome. Methods We analyzed lung ultrasound score (LUS) of all COVID-19 patients admitted from March 2020 to December 2020 to the Internal Intensive Care Unit, Ludwig-Maximilians-University (LMU) of Munich. LU was performed according to a standardized protocol at ICU admission and in case of clinical deterioration with the need for intubation. A normal lung scores 0 points, the worst LUS has 24 points. Patients were stratified in a low (0–12 points) and a high (13–24 points) lung ultrasound score group. Results The study included 42 patients, 69% of them male. The most common comorbidities were hypertension (81%) and obesity (57%). The values of pH (7.42 ± 0.09 vs 7.35 ± 0.1; p = 0.047) and paO2 (107 [80–130] vs 80 [66–93] mmHg; p = 0.034) were significantly reduced in patients of the high LUS group. Furthermore, the duration of ventilation (12.5 [8.3–25] vs 36.5 [9.8–70] days; p = 0.029) was significantly prolonged in this group. Patchy subpleural thickening (n = 38; 90.5%) and subpleural consolidations (n = 23; 54.8%) were present in most patients. Pleural effusion was rare (n = 4; 9.5%). The median total LUS was 11.9 ± 3.9 points. In case of clinical deterioration with the need for intubation, LUS worsened significantly compared to baseline LU. Twelve patients died during the ICU stay (29%). There was no difference in survival in both LUS groups (75% vs 66.7%, p = 0.559). Conclusions LU can be a useful monitoring tool to predict clinical course but not outcome of COVID-19 ICU patients and can early recognize possible deteriorations.

scholarly journals Should the CIWA-Ar be the standard monitoring strategy for alcohol withdrawal syndrome in the intensive care unit?

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Tessa L. Steel ◽  
Shewit P. Giovanni ◽  
Sarah C. Katsandres ◽  
Shawn M. Cohen ◽  
Kevin B. Stephenson ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Alcohol Withdrawal ◽  
Withdrawal Syndrome ◽  
Alcohol Withdrawal Syndrome ◽  
Patient Characteristics ◽  
Response To Treatment ◽  
Alternative Measure ◽  
Icu Patients ◽  
Verbal Responses

Abstract Background The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is commonly used in hospitals to titrate medications for alcohol withdrawal syndrome (AWS), but may be difficult to apply to intensive care unit (ICU) patients who are too sick or otherwise unable to communicate. Objectives To evaluate the frequency of CIWA-Ar monitoring among ICU patients with AWS and variation in CIWA-Ar monitoring across patient demographic and clinical characteristics. Methods The study included all adults admitted to an ICU in 2017 after treatment for AWS in the Emergency Department of an academic hospital that standardly uses the CIWA-Ar to assess AWS severity and response to treatment. Demographic and clinical data, including Richmond Agitation-Sedation Scale (RASS) assessments (an alternative measure of agitation/sedation), were obtained via chart review. Associations between patient characteristics and CIWA-Ar monitoring were tested using logistic regression. Results After treatment for AWS, only 56% (n = 54/97) of ICU patients were evaluated using the CIWA-Ar; 94% of patients had a documented RASS assessment (n = 91/97). Patients were significantly less likely to receive CIWA-Ar monitoring if they were intubated or identified as Black. Conclusions CIWA-Ar monitoring was used inconsistently in ICU patients with AWS and completed less often in those who were intubated or identified as Black. These hypothesis-generating findings raise questions about the utility of the CIWA-Ar in ICU settings. Future studies should assess alternative measures for titrating AWS medications in the ICU that do not require verbal responses from patients and further explore the association of race with AWS monitoring.

scholarly journals Beta-Lactams Toxicity in the Intensive Care Unit: An Underestimated Collateral Damage?

2021 ◽  
Vol 9 (7) ◽  
pp. 1505
Author(s):  
Claire Roger ◽  
Benjamin Louart
Keyword(s):  
Risk Factors ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Clinical Manifestations ◽  
Acute Interstitial Nephritis ◽  
Convulsive Status Epilepticus ◽  
Beta Lactam ◽  
Beta Lactams ◽  
Drug Induced ◽  
Icu Patients

Beta-lactams are the most commonly prescribed antimicrobials in intensive care unit (ICU) settings and remain one of the safest antimicrobials prescribed. However, the misdiagnosis of beta-lactam-related adverse events may alter ICU patient management and impact clinical outcomes. To describe the clinical manifestations, risk factors and beta-lactam-induced neurological and renal adverse effects in the ICU setting, we performed a comprehensive literature review via an electronic search on PubMed up to April 2021 to provide updated clinical data. Beta-lactam neurotoxicity occurs in 10–15% of ICU patients and may be responsible for a large panel of clinical manifestations, ranging from confusion, encephalopathy and hallucinations to myoclonus, convulsions and non-convulsive status epilepticus. Renal impairment, underlying brain abnormalities and advanced age have been recognized as the main risk factors for neurotoxicity. In ICU patients, trough concentrations above 22 mg/L for cefepime, 64 mg/L for meropenem, 125 mg/L for flucloxacillin and 360 mg/L for piperacillin (used without tazobactam) are associated with neurotoxicity in 50% of patients. Even though renal complications (especially severe complications, such as acute interstitial nephritis, renal damage associated with drug induced hemolytic anemia and renal obstruction by crystallization) remain rare, there is compelling evidence of increased nephrotoxicity using well-known nephrotoxic drugs such as vancomycin combined with beta-lactams. Treatment mainly relies on the discontinuation of the offending drug but in the near future, antimicrobial optimal dosing regimens should be defined, not only based on pharmacokinetics/pharmacodynamic (PK/PD) targets associated with clinical and microbiological efficacy, but also on PK/toxicodynamic targets. The use of dosing software may help to achieve these goals.

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