Major Bleeding in Adults Undergoing Peripheral Extracorporeal Membrane Oxygenation (ECMO): Prognosis and Predictors

Background. Major bleeding has been a common and serious complication with poor outcomes in ECMO patients. With a novel, less-invasive cannulation approach and closer coagulation monitoring regime, the incidence of major bleeding is currently not determined yet. Our study aims to examine the incidence of major bleeding, its determinants, and association with mortality in peripheral-ECMO patients. Method. We conducted a single-center retrospective study on adult patients undergoing peripheral-ECMO between January 2019 and January 2020 at a tertiary referral hospital. Determinants of major bleeding were defined by logistic regression analysis. Risk factors of in-hospital mortality were determined by Cox proportional hazard regression analysis. Results. Major bleeding was reported in 33/105 patients (31.4%) and was associated with higher in-hospital mortality [adjusted hazard ratio (aHR) 3.56, 95% confidence interval (CI) 1.63–7.80, p < 0.001 ). There were no significant difference in age, sex, ECMO indications, ECMO modality, pre-ECMO APACHE-II and SOFA scores between two groups with and without major bleeding. Only APTT >72 seconds [adjusted odds ratio (aOR) 7.10, 95% CI 2.60–19.50, p < 0.001 ], fibrinogen <2 g/L [aOR = 7.10, 95% CI 2.60–19.50, p < 0.001 ], and ACT >220 seconds [aOR = 3.9, 95% CI 1.20–11.80, p = 0.017 ] on days with major bleeding were independent predictors. Conclusions. In summary, major bleeding still had a fairly high incidence and poor outcome in peripheral-ECMO patients. APTT > 72 seconds, fibrinogen < 2 g/L were the strongest predicting factors for major bleeding events.

Incidence and Risk Factors of Ventilator-Associated Pneumonia among Patients with Delirium in the Intensive Care Unit: A Prospective Observational Study

Introduction. The incidence and risk factors for ventilator-related pneumonia (VAP) in patients with delirium are deficient, and there is a lack of in-depth knowledge of the impact of VAP on outcomes in this population. We investigated the incidence, risk factors, and outcomes of VAP in patients with delirium. Materials and Methods. This prospective observational study was performed in a surgical ICU at Be’sat Hospital in Hamadan, Iran, between 2018 and 2019. A total of 108 patients with delirium were identified using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC) and enrolled in this study. The association between VAP and delirium, risk factors, and outcomes (ICU length of stay and ICU mortality) for VAP were investigated using the Cox proportional hazards model and logistic and simple linear regression analyses with a 95% confidence interval. Results. Of 108 delirium patients, 86 patients (79.6%) underwent mechanical ventilation (MV) and 16 patients (18.6%) experienced VAP during ICU stay. The median onset of VAP was 6.5 (IQR 4.2–7.7) days after intubation. Delirium patients with VAP stayed longer in the ICU (21.68 ± 4.26 vs.12.93 ± 1.71, P < 0.001 ) and also had higher ICU mortality (31.25% vs. 0%, P < 0.001 ) than subjects without VAP. According to multivariate cox regression, the expected HR for VAP was 53.5% lower for patients with early-onset delirium than in patients with late-onset delirium (HR: 0.465, 95% CI: 0.241–0.894, P = 0.022 ). However, the expected hazard for VAP was 1.854 times and 4.604 times higher in patients with longer ICU stay (HR: 1.854, 95% CI: 1.689–3.059, P = 0.032 ) and in patients with a prolonged MV duration (HR: 4.604, 95%CI: 1.567–6.708, P = 0.023 ). Conclusion. According to the results, there seems to be an inverse relationship between early onset of delirium and VAP. This finding cannot be conclusively cited, and more studies in this filed should be conducted with a larger sample size. Furthermore, VAP in delirium patients is associated with increases in poor outcomes (higher ICU mortality) and the use of medical resources (longer stay in the ICU and MV duration).

Characteristics of Adult Sepsis Patients in the Intensive Care Units in a Tertiary Hospital in Jordan: An Observational Study

Sepsis is a global health issue that is commonly encountered in the intensive care unit (ICU) and is associated with high morbidity and mortality. Available data regarding sepsis in low- and middle-income countries (LMIC) is lacking compared to higher income countries, especially using updated sepsis definitions. The lack of recent data on sepsis in Jordan prompted us to investigate the burden of sepsis among Jordanian ICU patients. We conducted a prospective cohort study at Jordan University Hospital, a tertiary teaching hospital in the capital, Amman. All adult patients admitted to the adult ICUs between June 2020 and January 2021 were included in the study. Patients’ clinical and demographic data, comorbidities, ICU length of stay (LOS), medical interventions, microbiological findings, and mortality rate were studied. Descriptive and inferential statistics were used to analyse data from patients with and without sepsis. We observed 194 ICU patients during the study period; 45 patients (23.3%) were diagnosed with sepsis using the Sepsis-3 criteria. Mortality rate and median ICU LOS in patients who had sepsis were significantly higher than those in other ICU patients (mortality rate, 57.8% vs. 6.0%, p value < 0.001, resp., and LOS 7 days vs. 4 days, p value < 0.001, resp.). Additionally, sepsis patients had a higher combined number of comorbidities (2.27 ± 1.51 vs. 1.27 ± 1.09, p value < 0.001). The use of mechanical ventilation, endotracheal intubation, and blood transfusions were all significantly more common among sepsis patients. A causative organism was isolated in 68.4% of sepsis patients with a prevalence of Gram-negative bacteria in 77.1% of cases. While the occurrence of sepsis in the ICU in Jordan is comparable to other regions in the world, the mortality rate of sepsis patients in the ICU remains high. Further studies from LMIC are required to reveal the true burden of sepsis globally.

Influence of Spontaneous and Mechanical Ventilation on Frequency-Based Measures of Heart Rate Variability

Frequency-based measures of heart rate variability have been shown to be a useful physiological marker in both clinical and research settings providing insight into the functioning of the autonomic nervous system. Ongoing interactions between the autonomic nervous system control of the heart and lung occurs during each ventilation cycle because of their anatomical position within the closed thoracic cavity. Mechanical ventilation and subsequent removal change the normal ventilator mechanics producing alterations in the tidal volume, intrathoracic pressure, and oxygen delivery. A noninvasive method called heart rate variability (HRV) can be used to evaluate this interaction during ventilation and can be quantified by applying frequency-based measures of the variability between heartbeats. Although HRV is a reliable method to measure alteration of the autonomic nervous system (ANS) function and cardiopulmonary interaction, there have been limited reports concerning the changes in the frequency-based measure of HRV during both spontaneous and mechanical ventilation. The purpose of this methodological study is therefore to describe the physiological influence of both spontaneous and mechanical ventilation on frequency-based measures of HRV.

Prevalence and Trajectory of COVID-19-Associated Hypercoagulability Using Serial Thromboelastography in a South African Population

Introduction. The coagulation abnormalities resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been attributed to inflammation and subsequent cytokine storm. Thromboelastography (TEG) is a point-of-care test used to assess clot formation and degradation in whole blood and is an indicator of the overall real-time coagulopathic state of the patient. Methods. A single-centre, prospective, observational cohort study was conducted in South Africa, analysing the coagulation patterns of 41 patients with hypoxia related to SARS-CoV-2 using serial thromboelastography (TEG) on admission, after 48 hours, and at resolution of hypoxia/day 10. Results: Two-thirds (n = 26) were women. The median age was 61 (IQR 50–67), and the majority (88%) were Black patients. Almost half (22) of the patients were critically ill and ventilated, with median SOFA and SAPS2 scores of 3 and 22 (IQR2-4 and 18–30), respectively. The prevalence of hypercoagulability was 0.54 (95% CI 0.46–0.62), whilst 29/41 (0.71, CI 0.64–0.78)) met the definition of hypofibrinolysis. Differences between the hypercoagulable (HC) and non-hypercoagulable groups remained apparent at 48 hours after anticoagulation. At this time point, the K time was significantly lower ( p ˂ 0,01), and the α-angle ( p ˂ 0,01) and maximum amplitude (MA) ( p ˂ 0,01) were significantly higher in the HC cohort. At resolution of hypoxia, or day 10, only MA was significantly higher in the hypercoagulable group compared to the non-hypercoagulable group (p = 0.01). The initial impairment in fibrinolysis (Ly30), α angle, and MA were significantly associated with mortality, with p values of 0.006, 0.031, and 0.04, respectively. Conclusions. In this South African population, hypercoagulability was a highly prevalent phenomenon in COVID-19 disease. It was typified by hypofibrinolysis and a persistently elevated MA, despite anticoagulation therapy.

Use of mNUTRIC-Score for Nutrition Risk Assessment and Prognosis Prediction in Critically Ill Patients with COVID-19: A Retrospective Observational Study

Introduction. Nutritional risk is highly prevalent in patients with COVID-19. Relevant data on nutritional assessment in the critically ill population are scarce. This study was conducted to evaluate the modified Nutrition Risk in the Critically Ill (mNUTRIC)-Score as a mortality risk factor in mechanically ventilated patients with COVID-19. Methods. We conducted this retrospective observational study in critically ill patients with COVID-19. Patients’ characteristics and clinical information were obtained from electronic medical records. The nutritional risk for each patient was assessed at the time of mechanical ventilation using the mNUTRIC-Score. The major outcome was 28-day mortality. Results. Ninety-eight patients were analyzed (mean age, 57.22 ± 13.66 years, 68.4% male); 46.9% of critically ill COVID-19 patients were categorized as being at high nutrition risk (mNUTRIC-Score of ≥5). A multivariate logistic regression model indicated that high nutritional risk has higher 28-day hospital mortality (OR = 4.206, 95% CI: 1.147–15.425, p = 0.030 ). A multivariate Cox regression analysis showed that high-risk mNUTRIC-Score had a significantly increased full-length mortality risk during hospitalization (OR = 1.991, 95% CI: 1.219–3.252, p = 0.006 ). Conclusion. The mNUTRIC-Score is an independent mortality risk factor during hospitalization in critically ill COVID-19 patients.

Assessment of Metabolic Dysfunction in Sepsis in a Retrospective Single-Centre Cohort

Objective. Our primary aim was to assess selected metabolic dysfunction parameters, both independently and as a complement to the SOFA score, as predictors of short-term mortality in patients with infection admitted to the intensive care unit (ICU). Methods. We retrospectively enrolled all consecutive adult patients admitted to the eight ICUs of Lille University Hospital, between January 2015 and September 2016, with suspected or confirmed infection. We selected seven routinely measured biological and clinical parameters of metabolic dysfunction (maximal arterial lactatemia, minimal and maximal temperature, minimal and maximal glycaemia, cholesterolemia, and triglyceridemia), in addition to age and the Charlson’s comorbidity score. All parameters and SOFA scores were recorded within 24 h of admission. Results. We included 956 patients with infection, among which 295 (30.9%) died within 90 days. Among the seven metabolic parameters investigated, only maximal lactatemia was associated with higher risk of 90-day hospital mortality in SOFA-adjusted analyses (SOFA-adjusted OR, 1.17; 95%CI, 1.10 to 1.25; p < 0.001 ). Age and the Charlson’s comorbidity score were also statistically associated with a poor prognosis in SOFA-adjusted analyses. We were thus able to develop a metabolic failure, age, and comorbidity assessment (MACA) score based on scales of lactatemia, age, and the Charlson’s score, intended for use in combination with the SOFA score. Conclusions. The maximal lactatemia level within 24 h of ICU admission is the best predictor of short-term mortality among seven measures of metabolic dysfunction. Our combined “SOFA + MACA” score could facilitate early detection of patients likely to develop severe infections. Its accuracy requires further evaluation.

Diabetic Ketoacidosis Updates: Titratable Insulin Infusions and Long-Acting Insulin Early

Background. To compare a titratable insulin infusion order set (vs. nontitratable) and early administration of long-acting insulin in adult patients with diabetic ketoacidosis (DKA). Methods. Single health system, retrospective study of adult patients admitted to the intensive care unit (ICU) for DKA. The primary outcomes were insulin infusion duration and ICU/hospital length of stays (LoS). Secondary outcomes included ICU/hospital survival, hypoglycemia, and hypokalemia. Results. 151 patients were included in the titratable versus nontitratable insulin infusion comparison. Patients treated with the titratable insulin had shorter hospitalization (6.4 vs. 10.4 days, p = 0.03 ) and reduced the number hypoglycemic events by over half (20.6% vs. 46.0%, p < 0.01 ). 110 patients were identified to compare overlapping a long-acting insulin for more than 4 h with the insulin infusion versus the standard 1-2 h overlap. Patients who received the insulin early spent over 18 h longer on the infusion ( p < 0.01 ). Conclusions. A titratable insulin infusion added to the institutional DKA order set was associated with fewer days in the hospital and a significant reduction in hypoglycemic events. Furthermore, overlapping the long-acting insulin earlier with the insulin infusion early showed no benefit and could potentially be worse than the standard overlap.

Correlation of Serum Albumin Level to Lung Ultrasound Score and Its Role as Predictors of Outcome in Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study

Background. There is ambiguity in the literature regarding hypoalbuminemia as a cause of extravascular lung water and acute respiratory distress syndrome (ARDS) outcomes. The aim of the study was to determine if low serum albumin on admission leads to lung deaeration and higher lung ultrasound score (LUSS) in ARDS patients. Patients and Methods. It was a prospective observational study in which 110 ARDS patients aged between 18 and 70 years were recruited. Serum albumin level and lung ultrasound score were assessed on the day of ICU admission. Length of ICU stay and hospital mortality were recorded. Results. The mean and standard deviation of serum albumin level in mild, moderate, and severe ARDS was 2.92 ± 0.65 g/dL, 2.91 ± 0.77 g/dL, and 3.21 ± 0.85 g/dL, respectively. Albumin level was not correlated to the global LUSS (Pearson correlation r −0.006, p = 0.949 ) and basal LUSS (r −0.066, p = 0.513 ). The cut-off value of albumin for predicting a prolonged length of ICU stay (≥10 days) in ARDS patients was <3.25 g/dL with AUC 0.623, p < 0.05 , sensitivity of 86.67%, specificity of 45.45%, and 95% confidence interval (CI) [0.513–0.732], and on multivariate analysis it increased the odds of prolonged ICU stay by 8.9 times (Hosmer and Lemeshow p value 0.810, 95% CI [2.760–28.72]). Serum albumin at admission was not a predictor of mortality. LUSS on the day of admission was not useful to predict either a prolonged length of ICU stay or mortality. Basal LUSS contributed about 56% of the global LUSS in mild and moderate ARDS, and 53% in severe ARDS. Conclusion. Serum albumin level was unrelated to LUSS on admission in ARDS patients. Albumin level <3.25 g/dL increased the chances of a prolonged length of ICU stay (≥10 days) but was not associated with an increase in mortality. LUSS on the day of admission could not predict either a prolonged length of ICU stay or mortality. This trial is registered with CTRI/2019/11/021857.

Knowledge, Attitude, and Associated Factors towards Nonpharmacological Pain Management among Nurses Working at Amhara Region Comprehensive Specialized Hospitals, Ethiopia

Background. Nonpharmacological pain management refers to providing pain management intervention that does not involve the use of drugs. Effective management of a patient’s pain is a vital nursing activity, and it needs a nurse’s adequate pain-related knowledge and a favorable attitude. Globally, many studies stated that the lack of knowledge and unfavorable attitude of nurses towards nonpharmacological pain management was the prevailing persistent challenge. Objective. To assess knowledge, attitude, and associated factors towards nonpharmacological pain management among nurses working in Amhara region Comprehensive Specialized Hospitals, Ethiopia, 2021. Method. An institutional-based cross-sectional study was conducted from April to May 30, 2021. A total of 845 nurses were selected using a simple random sampling technique. Data were collected by using a pretested self-administered structured questionnaire. Then, data were checked, coded, and entered into Epi Info version 7.0 and exported to SPSS version 25.0 software for analysis. Results. A total of 775 nurses participated in this study, with a response rate of 91.8%. Of the total participants, 54.2% (95% CI: 50.6–57.9) and 49.8% (95% CI: 46.1–53.2) of nurses had adequate knowledge and a favorable attitude, respectively. The study revealed that educational status (AOR = 3.51 (95% CI: 1.37, 8.99)), years of experience (AOR = 5.59 (95% CI: 2.86, 10.94)), working unit (AOR = 5.61 (95% CI: 2.25, 13.96)), nurse-to-patient ratio (AOR = 2.33 (95% CI: 1.44, 3.78)), and working hours (AOR = 2.15 (95% CI: 1.27, 3.62)) were significantly associated. This finding also revealed that monthly income (AOR = 4.38 (95% CI: 1.64, 11.69)), nurse-to-patient ratio (AOR = 1.89 (95% CI: 1.19, 3.01)), and nurses’ adequate knowledge (AOR = 4.26 (95% CI: 2.91, 6.24)) were significantly associated with the attitude of nurses. Conclusion and Recommendations. More than half and nearly half of the nurses had adequate knowledge and a favorable attitude towards nonpharmacological pain management, respectively. Educational qualification, years of experience, working unit, nurse-to-patient ratio, and prolonged working hours per day were significantly associated with nurse’s adequate knowledge. Monthly income, nurse-to-patient ratio, and nurse’s knowledge were significantly associated with the attitudes of nurses. It is better to give attention to reviewing the nursing curriculum, achieving a standardized nurse-to-patient ratio, recruiting additional nurses, training, and upgrading nurses with continuing education.