Mortality in COVID-19 patients receiving systemic anticoagulant: A systematic review and meta-analysis
Abstract
Background: Coronavirus disease 2019 (COVID-19)/Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is a pandemic disease that quickly spreads throughout the world. There are no definitive therapeutic recommendations that give benefit results until recently. Recent studies suggest that coagulopathy is one of the complications of COVID-19 that increases the mortality rate regardless of the severity. This systematic review and meta-analysis aims to explore the association between systemic anticoagulant use and mortality in COVID-19 patients with various clinical conditions.
Methods: We performed a comprehensive search from several databases. The anticoagulant used in this study comprises of systemic anticoagulants such as low molecular weight heparin (LMWH) or others. The primary outcome was all-cause mortality related to anticoagulant use in COVID-19 patients. The meta-analysis was performed to see the significance of anticoagulants in decreasing the mortality rate of COVID-19 patients.
Results: 7064 patients were analyzed from 7 studies. The meta-analysis showed that systemic anticoagulant use was related with lower mortality rate (RR 0.70 [0.51, 0.97], p<0.03; I2: 87%, p<0.00001). The systematic review reported that 4 of 7 studies favor decreasing the mortality rate in COVID-19 patients administered with systemic anticoagulants.
Conclusion: Systemic use of anticoagulants was associated with a lower mortality rate in COVID-19 patients. Further studies are needed for better causation explanation. The implication of this study is to measure the mortality impact of systemic anticoagulant use in COVID-19 patients.
Post-sternotomy mediastinitis: What the intensivist needs to know
Abstract
Deep sternal wound infection (DSWI) is a dreaded complication after cardiac surgery, which dramatically increases health costs, in addition to high morbidity and mortality. The diagnosis and treatment of post-sternotomy mediastinitis (PSM) is a professional challenge. The aim of this current narrative mini review, we will consider epidemiology, implicit risk factors, the basis of diagnosis, preoperative, intraoperative, and postoperative prevention, and antimicrobial procedures, as well as the management of an optimal antimicrobial policy including an antimicrobial switch therapy.
Antibiotic cost represents a significant part of hospital budgets all over the world and more when the cost falls directly on the patient in those health systems that do not cover assistance and treatment. The management of switch therapy is not yet well known in patients with mediastinitis and it is common to find some objection in its use due to the change from long-acting intravenous antimicrobial antibiotics to oral regimen in this type of patients, most of them with high hospitalization rates.
Optic nerve and transcranial doppler ultrasonography for diagnosing increased intracranial pressure in adult traumatic brain injury patients: A systematic review and meta-analysis
Abstract
Objective: To evaluate the accuracy of ultrasonography to assess the increase of intracranial pressure by assessing optic nerve sheath diameter (ONSD) and transcranial Doppler (TCD), consisting of the black box (BB) model, arterial diastolic flow velocity (FVd), critical closing pressure (CrCp), and pulsatility index (PI) as parameters, in adult traumatic brain injury (TBI) patients.
Methods: A systematic search through the electronic databases including Medline through PubMed and Embase for studies evaluating the use of optic nerve and TCD USG to evaluate increased intracranial pressure (ICP) compared with the invasive method. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the risk of bias.
Results: Ten studies consisting of 727 patients were included in this study. The overall pooled sensitivity and specificity for the prediction of elevated ICP by measuring ONSD were 94% (95% CI: 89%-97%) and 88% (95% CI: 81%-95%), respectively. Positive and negative likelihood ratios were 12.7 (95% CI: 6.6-25.3; Cochran Q-statistic =14.6; p=0.04) and 0.06 (95% CI: 0.03-0.10; Cochran Q-statistic =14.1; p=0.05), respectively. All I2 values were >0.50. The area under the receiver operating characteristic (ROC) curve was 0.92 (95% CI: 0.81-0.98) as shown in the summary ROC (sROC) plot. A meta-analysis could not be performed for the TCD subgroup due to several incomplete sensitivity and specificity data and differences in the evaluated parameters. Four studies evaluated the role of TCD with mixed results. In one study, averaging the parameters of TCD displayed favorable results.
Conclusion: ONSD can be used as a parameter to evaluate the increase of ICP in TBI patients. BB model, FVd, and CrCp are potential promising parameters of TCD ultrasonography for noninvasive ICP estimation as opposed to PI. However, more studies with complete accuracy results are required in the future.
Future views on nanonutrition for critically ill patients: The role of extra virgin olive oil nanoemulsion in sepsis enteral nutrition
Abstract
Enteral nutrition (EN) can maintain the structure and function of the gastrointestinal mucosa better than parenteral nutrition. Early intervention by enteral nutrition in critically ill patient may help the patient from fatality of multiple organ failure. Oral nutrition is an attempt to provide a physiological nutrition that is expected to trigger the immune system, prevent blood stream infection from the intravenous route, and reduce cost of therapy. One of the problems that inhibits supply of enteral nutrition in critically ill patients is absorption disorders that cause the body’s nutritional needs to be hampered. Administration of extra virgin olive oil (EVOO) in the form of nanoemulsion is expected to improve pharmacokinetics and pharmacodynamics in those patients. EVOO is one functional food that has a lot of health benefits. Nanoemulsion-based delivery systems are proven to increase utilization of lipophilic bioactive components in food, personal care, cosmetic, and pharmaceutical applications. So far, there is no report describes the use of enteral nanonutrition in critically ill patients. This review discusses the perspective view of using EVOO nanoemulsion to care the critically ill patients.
Early mobilization of the critically ill patient: Literature systematic review
Abstract
Introduction: The immobility and prolonged bed rest, to which the critically ill patient admitted to the intensive care unit, is subjected harmful and have potential adverse effects, especially on the musculoskeletal system and, consequently, on motor functionality.
Objectives: To characterize the impact of early mobilization on the critical patient admitted to an intensive care unit.
Method: Systematic review of the literature that used the PI[C]OD methodology to compile the research question, which led to the search in the EBSCOHost search engine, in the CINAHL Complete and MEDLINE Complete databases, for the identification of studies published between 2016 and 2019. Four systematic reviews of the literature and three randomized controlled trials were selected. This review considered the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation. Levels of evidence were secured by the levels of evidence from The Joanna Briggs Institute and methodological quality was analyzed using the Critical Appraisal Skills Program.
Results: Most of the articles included in this review point to the benefits of early mobilization in intensive care units, mainly for the improvement of motor functionality and functional capacity, and only one revision, due to the poor quality of the articles included, is inconclusive to the benefits of this intervention in this population.
Conclusions: Early mobilization is a feasible, beneficial, and safe intervention for the critical patient admitted to an intensive care unit. However, due to the lack of studies on the subject and the limitations of the studies analyzed, it is suggested that more quantitative studies, with more representative samples, be carried out.
A primary biomarker examination in preventing progressivity of acute respiratory distress syndrome: the role of surfactant protein-D in sepsis induced ARDS
Abstract
Sepsis is one of the most unreachable conditions of hospitalization and a major contributor to hospital mortality, representing a major worldwide health burden. Sepsis is a syndrome characterized by an irregular host response to pathogens invasion, which involving hemodynamic changes that lead to multiple life-threatening organ dysfunctions. Among the injured organs, the lung is the first and most frequent organ to fail. Acute respiratory distress syndrome (ARDS) develops with many serious medical disorders. At least, mortality is 40% and there is no specific therapy. ARDS is an acute inflammatory process in the lung caused by infection direct or indirectly to the alveolar-capillary membrane. Currently, ARDS is diagnosed based on a combination of clinical and physiological variables. In this article, we will review the current understanding of surfactant protein-D as one of many biomarkers in ARDS diagnosis.
The primary, secondary, and tertiary brain injury
Abstract
Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity and mortality all over the world. The knowledge and understanding of pathophysiology of TBI are the priority as a basic to develop therapeutic opportunities and allow improvement of outcome for TBI patients. In TBI, primary damage occurs at the time of impact and the damage is preventable but not treatable. The process will continue caused following trauma due to complicating processes. Secondary brain insults have been found in many patients of severe TBI. This insult continues, which involves complex molecular and genes cascades, and is not fully understood. Chronic microglia activation and epigenetic mechanism were potential entry point in third brain damage processes. We suggest that treatment of tertiary insults might be ameliorate chronic complication of severe TBI patients.
Advances of hemodynamic monitoring and the current state of fluid resuscitation in clinical practice
Abstract
Fluid resuscitation remains the most common and the most debated intervention for critically ill patients. Fluid resuscitation is recommended as a principal therapy in various critical care guidelines, despite the low quality of evidence backing its safety. Fluid overload may lead to a lot of adverse effects, necessitating a reliable method to predict the patient’s hemodynamic response to fluid resuscitation. This review summarizes various hemodynamic monitoring techniques developed over the years and their role in guiding fluid resuscitation, such as the Swan-Ganz catheter, transpulmonary thermodilution, Doppler ultrasound, and impedance cardiography. Each of these techniques comes with differing advantages and shortcomings, as well the appropriate clinical settings in which these techniques can be applied. Existing protocols, which recommend fluid resuscitation as well as evidences pointing against its clinical safety are also discussed.
Hydrocortisone, vitamin C, and thiamine as treatment of septic shock combined with cardiogenic shock: a case report and literature review
Abstract
Objective: To determine whether the concomitant administration of vitamin C, hydrocortisone, and thiamine improves sepsis-related organ failure assessment (SOFA) score and mortality in a patient with septic and cardiogenic shock, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), gram negative bacteremia, cardiomyopathy, disseminated intravascular coagulation (DIC), and 95% mortality on presentation.
Design: A case report and literature review.
Setting: Surgical Intensive Care Unit at NYU Winthrop Hospital.
Patient: Patient with 95% mortality received appropriate treatment for septic and cardiogenic shock with no clinical improvement.
Intervention: Hydrocortisone 50 mg intravenous push (IVP) every 6 hours for four days, vitamin C 1,500 mg IV every 6 hours for four days, and thiamine 200 mg intravenous piggyback (IVPB) every 12 hours for four days.
Conclusion: Our patient had a remarkable survival of what was thought to be indefinite mortality with the intervention of vitamin C, hydrocortisone, and thiamine. The administration of the vitamin C protocol warrants a randomized controlled trial to change management of septic shock and mortality. We are very optimistic that it will show similar results yielding a significant decrease in mortality rates in patients with septic shock.
Anesthesia and intensive care management in acute ischemic stroke patient
Abstract
Acute ischemic stroke is a brain functional disorder, which cause high disability and mortality rate worldwide, the second most common cause of dementia, and the third leading cause of death. It has enormous clinical, social, and economic implications and demands a significant effort from both basic scientists and clinicians in the quest for understanding the underlying pathomechanisms and producing suitable preventive measures and successful therapies. Management of acute ischemic stroke has been revolutionized by the introduction of several interventions, such as prehospital and stroke unit care, intravenous tissue plasminogen activator therapy within 4.5 hours of stroke onset, aspirin therapy within 48 hours of stroke onset, decompressive craniectomy for supratentorial malignant hemispheric cerebral infarct, and more recently endovascular therapy for anterior circulating stroke. Also, special attention in management of vital systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose. In line with this, the role of neuroanesthesiologists and neuro critical care in managing acute ischemic stroke become more prominent.
Analysis of sepsis and septic shock 3- and 6-hour management at resuscitation room in Dr. Soetomo General Hospital
Abstract
Objective: To provide a record of the implementation and outcome of surviving sepsis campaign 2016 at Dr. Soetomo General Hospital, Surabaya, Indonesia, such as 3- and 6-hour sepsis bundle compliance as a baseline and the Sepsis-related Organ Failure Assessment (SOFA) score after 48 hours of treatment. SOFA values were used to predict mortality in the hospital.
Design: This was an observational experimental study that used cross sectional design.
Setting: Resuscitation room in Dr. Soetomo General Hospital.
Patients and participants: A purposive sample was taken of patients older than 17-year-old suspected with sepsis or septic shock according to diagnosis criteria from Surviving Sepsis Campaign (SSC) 2016. Thirty-two patients, consist of 24 male and 8 female patients were included.
Interventions: After patients were suspected of sepsis or septic shock according to diagnosis criteria from SSC 2016, they were treated with 3- and 6-hour sepsis bundle, then the data were collected with questionnaire.
Measurements and results: We found 75% of patients received a 3-hour sepsis bundle in <3 hours, and 50% of patients had 6-hour sepsis bundle in <6 hours. The compliance rate of 3- and 6-hour sepsis and septic shock bundles reached 46.88%. SOFA scores before and after 48-hour management of sepsis had a significant increase with p=0.001 (p<0.05).
Conclusions: There were significant decreasing of SOFA values in baseline and 48 hours after the management of sepsis and septic shock in 81.25% patients (n=26). This result suggests that management of sepsis based on SSC 2016 contribute to the improvement of the patient's condition and better prognosis.
Profile of children with rabies dog bites: Manado experience, Indonesia
Abstract
Background: Rabies is an infectious viral disease that is almost always fatal following the onset of clinical signs. Forty percent of all human rabies occur in children <14-year-old. In up to 99% of rabies virus is transmitted by dogs.
Objective: To determine the mortality risk factor of children with rabies dog bites in Prof. Dr. RD Kandou Hospital, Manado, from 2012-2016.
Methods: We performed a retrospective cohort study of all pediatric patients with rabies dog bites. Rabies was diagnosed via detection of nucleoprotein from dogs brain using fluorescent antibody test (FAT). We used chi-square test and calculated odd ratio using software SPSS 23.0 to determine the mortality risk factor of patients with rabies dog bites, considering p value <0.05 as significant.
Results: During the study period, 38 children came with rabies dog bites (71.1% were boys). Incubation period range from 1 week to 4 years. Most common bites location was hand. Symptoms associated with rabies mortality were hydrophobia (OR 143, 95% CI 11.78-1735.96, p=0.0001), photophobia (OR 19.6, 95% CI 2.04-181.93, p=0.002), and hypersalivation (100% mortality, p=0.0001). Post-exposure vaccination associated with mortality of patients (OR 0.003, 95% CI 0.000-0.056, p=0.0001).
Conclusion: Hypersalivation, hydrophobia, and photophobia are major risk factors of rabies dog bites mortality. Post-exposure vaccination is important to prevent rabies infection after a high-risk bite.
Multivessel spontaneous coronary arterial dissection. Usefulness of angio-CT during follow-up
Abstract
Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of myocardial ischemia associated with a high mortality rate. Its aetiology, incidence and pathogenesis are still unknown. It is characterized by the presence of a hematoma and/or the separation of the different layers in the arterial wall, causing vessel lumen stenosis. The clinical manifestation depends on the extent and limitation of the blood flow caused by the dissection, and it varies from an asymptomatic presentation to acute myocardial infarction (50-75%), sudden cardiac death (0.5%) or heart failure.
The optimal ICU organizational structure
A variety of intensive care units (ICU) staffing models exist, which to a large extent are based on local practice and economic factors rather than cost-effectiveness and the quality of care delivered. The organizational structure of ICU in the United States are usually classified according to two types of models, namely a low- or high intensity model, or an open- or closed ICU model. (1,2) In a low-intensity ICU, patients are managed by non-intensivists, however an intensivist may be consulted on some cases (open model), whereas in a high-intensity model intensivists are consulted on all patients (open model) or the intensivist assumes responsibility for the patient and directs all aspects of the care (closed model). The closed ICU structure is the predominant model in almost all Western nations. (3,4) There are significant organizational differences between open and closed ICU. Open units are those in which admission of patients to the ICU is uncontrolled and management of the patients is at the discretion of each attending physician (not an intensivist). Admissions are based on a first-come, first-served basis. As the attending of record does not have the time nor skills to provide “comprehensive critical care” he/she "portions off" the patients' care to a number of organ specific sub-specialists.