Use of CytoSorb in the emergency department-high dependency unit: A case report and a mini review

Circulating inflammatory mediators and cytokines play a pivotal role in the progression of sepsis, leading in turn to septic shock, organ failure and resistance to standard therapy. Blood purification therapies may be adjuvant treatment for severe sepsis, but results have been shown to be so far controversial. Recently, CytoSorb has achieved promising outcomes on reduction of cytokine blood levels, improvement of clinical parameters and mortality in sepsis, as well as in other acute conditions. It is mostly used in Intensive Care Unit (ICU), in isolated hemoperfusion, or inserted in other circuits in addition to Continuous Renal Replacement Therapy (CRRT), heart-lung machines and extracorporeal membrane oxygenation. We report a case of septic shock occurred in our Emergency Department-High Dependency Unit (ED-HDU), resistant to standard therapy and improved after CytoSorb, so avoiding ICU hospitalization.

Comparison of Low-Versus High-Dose Steroids in the Clinical Outcome of Hospitalized COVID-19 Patients

(1) Objectives: Patients with COVID-19 infection have been given various formulations and dosages of steroids over the last year and a half. This study aims to compare the effects of different formulations and doses of steroids on the 30 day in-hospital clinical outcome of patients with severe COVID-19 infection. (2) Material and Methods: An analysis of a retrospective cohort was carried out on patients with severe COVID-19 infection in a high-dependency unit (HDU) between February and July 2021. In total, 557 patients were included in this study. Patients who did not receive steroids (124) were excluded. Patients were divided into three groups based on dosages of steroids (Dexamethasone = 6 mg/day, Dexamethasone > 6 mg/day, and Methylprednisolone = 500 mg/day), given for 10 days. First, clinical outcome was evaluated on the 10th day of steroid administration in relation to mode of oxygen delivery. Then, Kaplan–Meier analysis was employed to determine 30 day in-hospital survival in relation to the use of steroid. (3) Results: Three groups were statistically equal according to biochemical characteristics. After 10 days of Methylprednisolone = 500 mg/day vs. Dexamethasone = 6 mg/day, 10.9% vs. 6.2% of patients required invasive ventilation (p = 0.01). The 30 day in-hospital mortality was lowest, 3%, in individuals receiving Dexamethasone = 6 mg/day, compared to 3.9% in individuals receiving Dexamethasone > 6 mg/day and 9.9% in individuals receiving Methylprednisolone = 500 mg/day, respectively. The median elapsed time was longer than 28 days between admission and outcome for Dexamethasone = 6 mg/day, compared to 18 days for Dexamethasone > 6 mg/day and 17 days for Methylprednisolone = 500 mg/day (p = < 0.0001). Dexamethasone = 6 mg/day was found to be a positive predictor of clinical outcome in COVID-19 patients on regression analysis. (4) Conclusions: Low-dose Dexamethasone (6 mg/day) is more effective than high-dose Dexamethasone and Methylprednisolone in improving the survival outcome of severe COVID-19 cases.

Prolidase deficiency in an infant with an incidental finding of methaemoglobinaemia

A 4-week-old boy presented to the hospital with symptoms of diarrhoea and vomiting initially thought to be due to cow’s milk allergy. He was discharged with extensively hydrolysed formula. The patient represented with worsening of symptoms with metabolic acidosis and was screened and treated for sepsis. However, his condition deteriorated further and he developed methaemoglobinaemia. He was transferred to the high dependency unit and was given two doses of methylene blue. Further investigations were carried out, including rapid trio exome sequencing, which identified a homozygous pathogenic Peptidase D (PEPD) variant (c.978G>A, p.(Trp326*)). This was consistent with a diagnosis of prolidase deficiency.

Impact of establishing a respiratory high dependency unit for SCAP patients on the therapeutic effect, prognosis, and expenditure: a retrospective case-control study

Objective: To explore the effects of establishing high dependency unit (HDU) on the prognosis, outcome, and expenditure of patients with severe community acquired pneumonia (SCAP).Method: Data pertaining to 108 SCAP patients were retrieved from the respiratory intensive care unit (RICU) of the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. Of these, 87 qualified the study-selection criteria and were divided into HDU group (treated in HDU after discharge from RICU prior to transfer to normal unit) (n=40) and normal group (not treated in the HDU) (n=47). General condition of patients, APACHE II and SOFA scores, duration of mechanical ventilation, hospital infection, intensive care unit syndrome, length of stay, and expenditure were compared between the two groups.Outcome: There was no significant between-group difference with respect to noninvasive ventilation time, oxygenation index, or APACHE II and SOFA scores at admission or discharge from RICU (P>0.05). Fourteen patients in the HDU group received invasive ventilation; the mean invasive ventilation time (176±160 h) was not significantly different from that in the normal group (206±179 h). The period of sequential noninvasive ventilation in the HDU group (135±82 h) was significantly shorter than that in the normal group (274±182 h, P<0.05). HDU group had shorter length of stay in hospital and RICU, and incurred lesser expenditure than patients in the normal group (P<0.05).Conclusion: Patients in HDU group had almost the same therapeutic effect with shorter length of stay in hospital and RICU, and lesser expenditure.

182 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams

Introduction A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients. Method Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated. Results In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges. Conclusions By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.

347 Read the First Page: An Audit on Medicine Reconciliation in General Surgery Inpatients at London District General Hospital

Aim Medication-related incidents occur more frequently when medicine reconciliation happens more than 24 hours after admission. The National Institute for Health and Care Excellence recommends a complete reconciliation within 24 hours of admission. General Surgery is a busy specialty with a high patient turnover rate. Hence, this audit was conducted to assess the extent of a problem and mitigate it. Method Every adult General Surgery inpatient who were admitted for over 24 hours were included. Patients on intensive care or high dependency unit were excluded. Drug charts were reviewed every Thursday for nine weeks between October and December 2020. Data from the first three weeks were used to establish baseline. Three interventions were introduced, each lasting two weeks. Any significant harm to patients due to incomplete reconciliation was recorded. Results At baseline (n = 100), 38.0% of patients had incomplete reconciliation. This significantly reduced to 23.4% (n = 64, p-value=0.037) between Weeks 4 and 5 after baseline data was presented at a team meeting and posters were put up. Allowing pharmacists to flag up missing medications on a daily job’s list did not significantly reduce the incompletion rate (23.0%, n = 74, p-value&gt;0.999). Finally, performing a medicine reconciliation ward round on Weeks 8 and 9 further reduced the incompletion rate to 2.8% (n = 74, p-value=0.001). One significant harm was noted on Week 1. Conclusions Medicine reconciliation is a vital aspect of patient safety. Raising awareness of the issue significantly reduced the incompletion rate. However, the most effective intervention is conducting a medicine reconciliation ward round.

Severe Maternal Morbidity: Admission Shift From Intensive Care Unit to Obstetric High-dependency Unit

Background: To study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU).Methods: This is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend.Results: A total of 40 412 women delivered and 447 (11.1‰) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 15.9‰ in 2016 and then dropped to 6.7‰ in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P<0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P<0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac disease (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). After adjusting for the proportion of high-risk pregnancies, the establishment of HDU reduced 20% of ICU admission (aOR = 0.804, 95% CI =0.666-0.972).Conclusions: The introduction of HDU helps to reduce ICU utilization in obstetric population.