scholarly journals Point-of-care echocardiography and thoracic ultrasound in the management of critically ill patients with COVID-19 infection: Experience in three regional UK intensive care units

2021 ◽  
pp. 175114372110453
Author(s):  
Helen Jordan ◽  
Hannah Preston ◽  
David P Hall ◽  
Hugh Gifford ◽  
Michael A Gillies
Keyword(s):  
Intensive Care ◽  
Right Ventricular ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Arterial Thrombosis ◽  
Point Of Care ◽  
Thoracic Ultrasound ◽  
Pulmonary Arterial ◽  
Right Ventricular Dilatation ◽  
B Lines

Introduction Point-of-care ultrasound (POCUS) has an established role in the management of the critically ill. Information and experience of its use in those with COVID-19 disease is still evolving. We undertook a review of cardiac and thoracic ultrasound examinations in patients with COVID-19 on the intensive care unit (ICU). Our aim was to report key findings and their impact on patient management. Methods A retrospective evaluation of critically ill patients with COVID-19 was undertaken in three adult ICUs, who received point-of-care cardiac and/or thoracic ultrasound during the 2019–2020 COVID-19 pandemic. We recorded baseline demographic data, principal findings, change in clinical management and outcome data. Results A total of 55 transthoracic echocardiographic examinations scans were performed on 35 patients. 35/55 (64%) echocardiograms identified an abnormality, most commonly a dilated or impaired right ventricle (RV) and 39/55 (70%) scans resulted in a change in management. Nine patients (26%) were found to have pulmonary arterial thrombosis on CTPA or post-mortem. More than 50% of these patients showed evidence of right ventricular dilatation or impairment. Of the patients who were known to have pulmonary arterial thrombosis and died, 83% had evidence of right ventricular dilatation or impairment. 32 thoracic ultrasound scans were performed on 23 patients. Lung sliding and pleural thickening were present bilaterally in all studies. Multiple B-lines were present in all studies, and sub-pleural consolidation was present bilaterally in 72%. Conclusion POCUS is able to provide useful and clinically relevant information in those critically ill with COVID-19 infection, resulting in change in management in a high proportion of patients. Common findings in this group are RV dysfunction, multiple B-lines and sub-pleural consolidation.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

2021 ◽  
pp. 088506662098828
Author(s):  
Madhumita Premkumar ◽  
Kamal Kajal ◽  
Anand V. Kulkarni ◽  
Ankur Gupta ◽  
Smita Divyaveer
Keyword(s):  
Intensive Care ◽  
Liver Failure ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Point Of Care ◽  
Kidney Injury ◽  
Regional Wall Motion ◽  
Chronic Liver ◽  
Chronic Liver Failure ◽  
Evidenced Based

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to “collateral damage” in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

scholarly journals Intensive care unit physician-delivered point of care renal tract ultrasound in acute kidney injury is feasible

2018 ◽  
Vol 19 (4) ◽  
pp. 313-318 ◽  
Author(s):  
Prashant Parulekar ◽  
Ed Neil-Gallacher ◽  
Alex Harrison
Keyword(s):  
Intensive Care Unit ◽  
Acute Kidney Injury ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Point Of Care ◽  
Kidney Injury ◽  
Diagnostic Quality ◽  
The Core ◽  
Low Incidence

Acute kidney injury is common in critically ill patients, with ultrasound recommended to exclude renal tract obstruction. Intensive care unit clinicians are skilled in acquiring and interpreting ultrasound examinations. Intensive Care Medicine Trainees wish to learn renal tract ultrasound. We sought to demonstrate that intensive care unit clinicians can competently perform renal tract ultrasound on critically ill patients. Thirty patients with acute kidney injury were scanned by two intensive care unit physicians using a standard intensive care unit ultrasound machine. The archived images were reviewed by a Radiologist for adequacy and diagnostic quality. In 28 of 30 patients both kidneys were identified. Adequate archived images of both kidneys each in two planes were possible in 23 of 30 patients. The commonest reason for failure was dressings and drains from abdominal surgery. Only one patient had hydronephrosis. Our results suggest that intensive care unit clinicians can provide focussed renal tract ultrasound. The low incidence of hydronephrosis has implications for delivering the Core Ultrasound in Intensive Care competencies.

scholarly journals Report of the first AKI Round Table meeting: an initiative of the ESICM AKI Section

2019 ◽  
Vol 7 (1) ◽  
Author(s):  
M. Ostermann ◽  
A. Schneider ◽  
T. Rimmele ◽  
I. Bobek ◽  
M. van Dam ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Critical Care ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Future Research ◽  
Knowledge Gaps ◽  
Blood Pressure Targets

Abstract Purpose Critical Care Nephrology is an emerging sub-specialty of Critical Care. Despite increasing awareness about the serious impact of acute kidney injury (AKI) and renal replacement therapy (RRT), important knowledge gaps persist. This report represents a summary of a 1-day meeting of the AKI section of the European Society of Intensive Care Medicine (ESICM) identifying priorities for future AKI research. Methods International Members of the AKI section of the ESICM were selected and allocated to one of three subgroups: “AKI diagnosis and evaluation”, “Medical management of AKI” and “Renal Replacement Therapy for AKI.” Using a modified Delphi methodology, each group identified knowledge gaps and developed potential proposals for future collaborative research. Results The following key research projects were developed: Systematic reviews: (a) epidemiology of AKI with stratification by patient cohorts and diagnostic criteria; (b) role of higher blood pressure targets in patients with hypertension admitted to the Intensive Care Unit, and (c) specific clearance characteristics of different modalities of continuous renal replacement therapy (CRRT). Observational studies: (a) epidemiology of critically ill patients according to AKI duration, and (b) current clinical practice of CRRT. Intervention studies:( a) Comparison of different blood pressure targets in critically ill patients with hypertension, and (b) comparison of clearance of solutes with various molecular weights between different CRRT modalities. Conclusion Consensus was reached on a future research agenda for the AKI section of the ESICM.

scholarly journals Cystatin C predicts long term mortality better than creatinine in a nationwide study of intensive care patients

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Johanna Helmersson-Karlqvist ◽  
Miklos Lipcsey ◽  
Johan Ärnlöv ◽  
Max Bell ◽  
Bo Ravn ◽  
...  
Keyword(s):  
Intensive Care ◽  
Critically Ill ◽  
Risk Prediction ◽  
Cystatin C ◽  
Mortality Risk ◽  
Critically Ill Patients ◽  
Cox Regression ◽  
Sample Tube ◽  
Long Term Mortality

AbstractDecreased glomerular filtration rate (GFR) is linked to poor survival. The predictive value of creatinine estimated GFR (eGFR) and cystatin C eGFR in critically ill patients may differ substantially, but has been less studied. This study compares long-term mortality risk prediction by eGFR using a creatinine equation (CKD-EPI), a cystatin C equation (CAPA) and a combined creatinine/cystatin C equation (CKD-EPI), in 22,488 patients treated in intensive care at three University Hospitals in Sweden, between 2004 and 2015. Patients were analysed for both creatinine and cystatin C on the same blood sample tube at admission, using accredited laboratory methods. During follow-up (median 5.1 years) 8401 (37%) patients died. Reduced eGFR was significantly associated with death by all eGFR-equations in Cox regression models. However, patients reclassified to a lower GFR-category by using the cystatin C-based equation, as compared to the creatinine-based equation, had significantly higher mortality risk compared to the referent patients not reclassified. The cystatin C equation increased C-statistics for death prediction (p < 0.001 vs. creatinine, p = 0.013 vs. combined equation). In conclusion, this data favours the sole cystatin C equation rather than the creatinine or combined equations when estimating GFR for risk prediction purposes in critically ill patients.

scholarly journals Impact of Renal Replacement Therapy on Mortality in Critically Ill Patients—The Nephrologist’s View within an Interdisciplinary Intensive Care Team

2021 ◽  
Vol 10 (15) ◽  
pp. 3379
Author(s):  
Matthias Klingele ◽  
Lea Baerens
Keyword(s):  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Positive Impact ◽  
Kidney Injury ◽  
Care Team ◽  
Critically Ill Patient ◽  
Late Start

Acute kidney injury (AKI) is a common complication in critically ill patients with an incidence of up to 50% in intensive care patients. The mortality of patients with AKI requiring dialysis in the intensive care unit is up to 50%, especially in the context of sepsis. Different approaches have been undertaken to reduce this high mortality by changing modalities and techniques of renal replacement therapy: an early versus a late start of dialysis, high versus low dialysate flows, intermittent versus continuous dialysis, anticoagulation with citrate or heparin, the use of adsorber or special filters in case of sepsis. Although in smaller studies some of these approaches seemed to have a positive impact on the reduction of mortality, in larger studies these effects could not been reproduced. This raises the question of whether there exists any impact of renal replacement therapy on mortality in critically ill patients—beyond an undeniable impact on uremia, hyperkalemia and/or hypervolemia. Indeed, this is one of the essential challenges of a nephrologist within an interdisciplinary intensive care team: according to the individual situation of a critically ill patient the main indication of dialysis has to be identified and all parameters of dialysis have to be individually chosen with respect to the patient’s situation and targeting the main dialysis indication. Such an interdisciplinary and individual approach would probably be able to reduce mortality in critically ill patients with dialysis requiring AKI.

scholarly journals Treatment of a Critically Ill COVID-19 Patient with the Seraph 100 Microbind Affinity Filter

TH Open ◽  
2021 ◽  
Vol 05 (02) ◽  
pp. e134-e138
Author(s):  
Anke Pape ◽  
Jan T. Kielstein ◽  
Tillman Krüger ◽  
Thomas Fühner ◽  
Reinhard Brunkhorst
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Randomized Trials ◽  
Clinical Course ◽  
Pharmacological Therapy ◽  
The European Union ◽  
Positive Effects ◽  
Special Patient

AbstractThe coronavirus disease 2019 (COVID-19) pandemic has a serious impact on health and economics worldwide. Even though the majority of patients present with moderate and mild symptoms, yet a considerable portion of patients need to be treated in the intensive care unit. Aside from dexamethasone, there is no established pharmacological therapy. Moreover, some of the currently tested drugs are contraindicated for special patient populations like remdesivir for patients with severely impaired renal function. On this background, several extracorporeal treatments are currently explored concerning their potential to improve the clinical course and outcome of critically ill patients with COVID-19. Here, we report the use of the Seraph 100 Microbind Affinity filter, which is licensed in the European Union for the removal of pathogens. Authorization for emergency use in patients with COVID-19 admitted to the intensive care unit with confirmed or imminent respiratory failure was granted by the U.S. Food and Drug Administration on April 17, 2020.A 53-year-old Caucasian male with a severe COVID-19 infection was treated with a Seraph Microbind Affinity filter hemoperfusion after clinical deterioration and commencement of mechanical ventilation. The 70-minute treatment at a blood flow of 200 mL/minute was well tolerated, and the patient was hemodynamically stable. The hemoperfusion reduced D-dimers dramatically.This case report suggests that the use of Seraph 100 Microbind Affinity filter hemoperfusion might have positive effects on the clinical course of critically ill patients with COVID-19. However, future prospective collection of data ideally in randomized trials will have to confirm whether the use of Seraph 100 Microbind Affinity filter hemoperfusion is an option of the treatment for COVID-19.

scholarly journals Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic

2021 ◽  
Author(s):  
Răzvan Bologheanu ◽  
Mathias Maleczek ◽  
Daniel Laxar ◽  
Oliver Kimberger
Keyword(s):  
Intensive Care ◽  
Length Of Stay ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Medical Specialty ◽  
Routine Care ◽  
Treatment Pathways ◽  
Icu Length Of Stay ◽  
Matched Study ◽  
The Impact

Summary Background Coronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed. Methods The objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching. Results A total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344. Conclusion In this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

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