Understanding the Course of Critical Illness Through a Lifeworld Approach

An increasing number of individuals receive and survive intensive care treatment; however, several individuals experience problems afterward, which may threaten recovery. Grounded in a lifeworld approach, the aim of this study was to explore and describe what intensive care patients experience as limiting and strengthening throughout their illness trajectories. Ten former intensive care patients were interviewed three to eight months after hospital discharge. Using Giorgi’s phenomenological analysis, a general structure of gaining strength through a caring interaction with others was revealed. The structure consisted of three constituents: feeling safe through a caring presence, being seen and met as a unique person, and being supported to restore capacity. Being met with a humanistic approach and individualized care appeared to be important, and the findings are discussed within the framework of lifeworld-led care. To facilitate improved aftercare of the critically ill, more tailored support throughout the illness trajectory is needed.

Characterising the dynamics of cerebral metabolic dysfunction following traumatic brain injury: A microdialysis study in 619 patients

Traumatic brain injury (TBI) is a major cause of death and disability, particularly amongst young people. Current intensive care management of TBI patients is targeted at maintaining normal brain physiology and preventing secondary injury. Microdialysis is an invasive monitor that permits real-time assessment of derangements in cerebral metabolism and responses to treatment. We examined the prognostic value of microdialysis parameters, and the inter-relationships with other neuromonitoring modalities to identify interventions that improve metabolism. This was an analysis of prospective data in 619 adult TBI patients requiring intensive care treatment and invasive neuromonitoring at a tertiary UK neurosciences unit. Patients had continuous measurement of intracranial pressure (ICP), arterial blood pressure (ABP), brain tissue oxygenation (PbtO2), and cerebral metabolism and were managed according to a standardized therapeutic protocol. Microdialysate was assayed hourly for metabolites including glucose, pyruvate, and lactate. Cerebral perfusion pressure (CPP) and cerebral autoregulation (PRx) were derived from the ICP and ABP. Outcome was assessed with the Glasgow Outcome Score (GOS) at 6 months. Relationships between monitoring variables was examined with generalized additive mixed models (GAMM). Lactate/Pyruvate Ratio (LPR) over the first 3 to 7 days following injury was elevated amongst patients with poor outcome and was an independent predictor of ordinal GOS (p<0.05). Significant non-linear associations were observed between LPR and cerebral glucose, CPP, and PRx (p<0.001 to p<0.05). GAMM models suggested improved cerebral metabolism (i.e. reduced LPR with CPP >70mmHg, PRx <0.1, PbtO2 >18mmHg, and brain glucose >1mM. Deranged cerebral metabolism is an important determinant of patient outcome following TBI. Variations in cerebral perfusion, oxygenation and glucose supply are associated with changes in cerebral LPR and suggest therapeutic interventions to improve cerebral metabolism. Future prospective studies are required to determine the efficacy of these strategies.

Immunofluorescence studies on the expression of the SARS-CoV-2 receptors in human term placenta

Until September 2021, the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2; COVID-19) pandemic caused over 217 million infections and over 4.5 million deaths. In pregnant women the risk factors for the need of intensive care treatment are generally the same as in the overall population. Of note, COVID-19+ women deliver earlier than COVID-19- women, and the risk for severe neonatal and perinatal morbidity and mortality is significantly higher. The probability and pathways of vertical transmission of the virus from the pregnant woman to the fetus are highly controversial. Recent data have shown that 54 (13%) of 416 neonates born to COVID-19-positive women were infected. Here, we investigated term placentas collected before the SARS-CoV-2 pandemic and studied the main COVID-19 receptors ACE2, TMPRSS2, as well as NRP1. We performed qPCR and immunofluorescence on cryosections in combination with markers for syncytiotrophoblast, endothelial cells, macrophages and stromal cells. The qPCR studies showed expression of both the truncated delta form of ACE2, which does not bind the COVID-19 spike protein, and the long form. The ACE2 antibody used does not distinguish between the two forms. We did not observe expression of the canonical SARS-CoV-2 entry machinery on syncytio- and cytotrophoblast. ACE2 and TMPRSS2 are co-expressed in a subpopulation of stromal cells, which in part are CD68-positive macrophages. NRP1 is localized to endothelial cells. In sum, the term placenta is not an organ that directly favors vertical transmission of COVID-19, however, microtraumas and placentitis may weaken its barrier function.

The Characteristics of Post-Intensive Care Syndrome to Inform Occupational Therapy Practice During the Post-Intensive Care Period: A Systematic Scoping Review.

Background: As the demand for intensive care treatment increases, so too does the number of people surviving critical illness. Since 2010, the term “post-intensive care syndrome” has been used to describe the constellation of new or worsening physical, cognitive, and psychological impairments that persist after intensive care discharge. This review aimed determine the characteristics of PICS present during the first year following discharge from the ICU to inform occupational therapists working with this population during the post-intensive care period. Methods: A systematic scoping review has been conducted according to the PRISMA-ScR Checklist. Seven key databases were searched from inception to 2020. A single reviewer screened available literature against eligibility criteria then cross-checked by a second reviewer. Data were abstracted from relevant publications and results were narratively synthesised through application of a biopsychosocial model.Results: Twenty-five studies were identified for inclusion. Characteristics were categorised as biological, psychological, or social and contextual. Overarching outcomes were also considered. Results demonstrated that characteristics were complex and interwoven between domains. Results were grouped into four key themes: 1) An increased worldwide demand for intensive care, 2) ADL performance, 3) HRQOL, and 4) Consideration of social and contextual characteristics. No studies were found to detail the role of occupational therapists working with post-intensive care survivors.Conclusions: The complex and interwoven nature of post-intensive care syndrome highlights the need to consider a holistic rehabilitation approach. Considering the COVID-19 pandemic, occupational therapists have the potential to play an increased role during the post-intensive care period to reduce the global healthcare burden and improve patient outcomes. Future research is needed to determine the best model of care to support occupational therapists working with survivors of critical illness.Trial Registration: NA

Functional morphometry to estimate the alveolar surface area by using a premature baboon model

The main respiratory pathophysiological process following premature birth is the delayed or arrested alveolar development which translates to a smaller alveolar surface area (S­A). Histological morphometry is the gold standard method to measure the SA but requires invasive tissue sampling or the removal of the whole organ for analysis. Alternatively, the SA could be measured in living subjects by "functional morphometry" using Fick's first law of diffusion and non-invasive measurements of the ventilation perfusion ratio (VA/Q). We herein aim to describe a novel functional morphometric method to measure SA using a premature baboon model. We used both functional morphometry and post-mortem histological morphometry to measure SA in 11 premature baboons born at 135 days who received intensive care treatment for 14 days. For the calculation of the SA by functional morphology we measured the septal wall thickness using microscopy, the alveolar arterial oxygen gradient using concurrent measurements of arterial pressure of O2 and CO2 and pulmonary perfusion using echocardiography and integrated Doppler signals. The median (IQR) SA using functional morphometry was 3,100 (2,080-3,640) cm2 and using histological morphometry was 1,034 (634-1,210) cm2 (left lung only). The SA measured by functional morphometry was not related to the SA measured by histological morphometry. Following linear regression analysis, the VA/Q significantly predicted the histologically measured SA (R2=0.659,p=0.002). In conclusion, functional measurements of ventilation to perfusion ratio could be used to estimate the alveolar surface area in prematurely born baboons and the ventilation perfusion ratio was the main determinant of the alveolar surface area.

Distinct characteristics of multisystem inflammatory syndrome in children in Poland

During the winter months of 2020/2021 a wave of multisystem inflammatory syndrome in children (MIS-C) emerged in Poland. We present the results of a nationwide register aiming to capture and characterise MIS-C with a focus on severity determinants. The first MIS-C wave in Poland was notably high, hence our analysis involved 274 children. The group was 62.8% boys, with a median age of 8.8 years. Besides one Asian, all were White. Overall, the disease course was not as severe as in previous reports, however. Pediatric intensive care treatment was required for merely 23 (8.4%) of children, who were older and exhibited a distinguished clinical picture at hospital admission. We have also identified sex-dependent differences; teenage boys more often had cardiac involvement (decreased ejection fraction in 25.9% vs. 14.7%) and fulfilled macrophage activation syndrome definition (31.0% vs. 15.2%). Among all boys, those hospitalized in pediatric intensive care unit were significantly older (median 11.2 vs. 9.1 years). Henceforth, while ethnicity and sex may affect MIS-C phenotype, management protocols might be not universally applicable, and should rather be adjusted to the specific population.

Re-Print- Artificial Respiration in Severe COVID-19 Cases: A Beneficial or Deleterious Treatment

The world over artificial respiration is employed as one of the intensive care treatment measures in severe cases of COVID-19 because of the significant respiratory distress patients develop. Nevertheless, the outcome is poor. Lethality varies from country to country and clinic to clinic between 50% and 90%. So the question arises as to whether the use of oxygen can be a risk factor in the treatment of acute inflammatory diseases in general and of COVID-19 in particular. Oxidative stress is the first and oldest step of cellular defense and starts before the activation of the immune system. This leads to an increase of intracellular oxygen in the mitochondria, followed by an elevated electron flow and the formation of superoxide as well as other reactive oxygen species and reactive nitrogen species. Superoxide reacts with nitric oxide, which is always present in inflammation, forming peroxynitrite, the strongest inducer of oxidative stress. This step induces the activation of nuclear factor kB, followed by the production of proinflammatory cytokines. The elevated levels of inducible nitric oxide synthase keep this cycle running. High amounts of superoxide have to be compensated and catabolized by manganese-superoxide dismutase 2 into hydrogen peroxide and in a second step by catalase into water. When using artificial respiration, these steps are accelerated considerably in the inflamed tissue of the lung, leading to a significant increase of the electron flow as well as an elevation of superoxide, oxidative stress, and water. As SARS-CoV-2 generally induces the production of proteins (and not only those necessary for viral reproduction), the water will remain in the tissue, causing edema and thus a wet lung syndrome associated with a growing oxygen diffusion distance to red blood cells. Ultimately, patients do not suffocate in spite of, but because of, the presence of high levels of oxygen. The limited number of patients who survive this deleterious treatment describe it as having had a sensation of drowning. The reasons will be discussed.

Evaluation of the effect of clinical characteristics and intensive care treatment methods on the mortality of covid-19 patients aged 80 years and older

Background Older adults have an increased risk of mortality from Coronavirus disease 2019 (Covid-19). Despite the high number of publications on the topic of Covid-19 pandemic, few studies have focused on the intensive care treatments of Covid-19 patients aged 80 years and older. The goal of our study is to investigate the effect of the intensive care treatments on the mortality of Covid-19 patients aged 80 years and older based on their clinical features, laboratory findings and the intensive care treatments methods. Methods The data of 174 patients aged 80 years and older treated from Covid-19 in intensive care unit were assessed retrospectively. The patients were divided into two groups as survivor and non-survivor. The effects of age, gender, length of stay, comorbid diseases, laboratory values, thoracic computed tomography findings, having invasive mechanical ventilation (IMV), high flow nasal cannula (HFNC) and/or non-invasive mechanical ventilation (NIMV), hemodiafiltration (HDF), anti-cytokines and plasma therapy on mortality have been investigated. Results The mean age and mean values of CRP, PCT, Ferritin, LDH were statistically significantly high in the non-survivor group. The mortality rate of the patients who had IMV was also statistically significantly higher compared to patients who had HFNC and/or NIMV. Albumin level and the rate of treatment with HFNC and/or NIMV were statistically significantly low in non-survivor group compared to the Survivor group. Conclusion ICU treatments may be beneficial for the Covid-19 patients aged 80 years and older. Increased age, high levels of CRP, PCT, ferritin, and having IMV are detected as poor outcome markers.

Collateral effects and mortality of kidney transplant recipients during the COVID-19 pandemic

Background: Collateral effects and consequences of the coronavirus disease 19 (COVID-19) pandemic on kidney transplant recipients remain widely unknown. Methods: This retrospective cohort study examines changes in admission rates, incidences of diseases leading to hospitalization, in-patient procedures, and maintenance medication in long-term kidney transplant recipients with functioning graft during the early COVID-19 pandemic in Germany. Data derived from a nationwide health insurance database. Analysis was performed from March 15th to September 30th and compared the years 2019 and 2020. Effects on mortality and adverse allograft events were compared to COVID-19 attributed effects. Results: 7,725 patients were included in the final analysis. Admissions declined in 2020 by 17% with a main dip during a 3-month lockdown (-31%) but without a subsequent rebound. Incidences for hospitalization did not increase for any investigated disease entities, while decreasing trends were noted for non-COVID-19 pulmonary and urogenital infections (incidence rate ratio 0.8, 95%-CI 0.62-1.03, and 0.82, 95%-CI 0.65-1.04, respectively). Non-COVID-19 hospital stays were 0.6 days shorter (p = 0.034) and not complicated by increased dialysis, ventilation, or intensive care treatment rates. In-hospital and 90-day mortality remained stable. Incidence of severe COVID-19 requiring hospitalization was 0.09 per 1,000 patient-days and in-hospital mortality was 9.2%. 31% of patients with calcineurin-inhibitor medication and without being hospitalized for COVID-19 reduced doses by at least 25%, which was associated with an increased allograft rejection risk (adjusted hazard ratios 1.29, 95%-CI 1.02-1.63). COVID-19 caused 16.9% of all deaths but had no significant association with allograft rejections. All-cause mortality remained stable (rate ratio 1.15, 95%-CI 0.91-1.46), also when restricting analysis to patients with no or outpatient-treated COVID-19 (0.97, 95%-CI 0.76-1.25). Conclusion: Despite significant collateral effects, mortality remained unchanged during the early COVID-19 pandemic. Considerable temporary reductions in admissions are safe whereas reducing immunosuppression results in increased allograft rejection risk.