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   Table of Contents - Current issue
April-June 2022
Volume 12 | Issue 2
Page Nos. 59-117

Online since Friday, June 24, 2022

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What's New in Critical Illness and Injury Science? Delirium, COVID-19, and critical illness p. 59
Andrew C Miller
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Intensive care unit delirium in patients with severe COVID-19: A prospective observational cohort study p. 61
Ryan J Smith, Christian Lachner, Vijay P Singh, Rodrigo Cartin-Ceba
Background: Delirium is common in patients with severe coronavirus disease-19 (COVID-19). The purpose of our study was to determine whether severe COVID-19 is an independent risk factor for the development of delirium in patients treated in the intensive care unit (ICU). Methods: This prospective observational cohort study involved 162 critically ill patients admitted to a multidisciplinary ICU during 2019 and 2020. A validated screening tool was used to diagnose delirium. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. After univariate analysis, a multivariate logistic regression analysis was performed to determine independent risk factors associated with the development of delirium. Results: In our study population, 50 (31%) patients developed delirium. A total of 39 (24.1%) tested positive for COVID-19. Initial analysis showed COVID-19 to be more prevalent in those patients that developed delirium (40% vs. 17%; P = 0.003). Multivariate analysis showed opioid use (odds ratio [OR]: 24 [95% confidence intervals (CI): 16–27]; P ≤ 0.001), benzodiazepine use (OR: 23 [95% CI: 16–63] P = 0.001), and estimated mortality based on acute physiology and chronic health evaluation IV score (OR: 1.04 [95% CI: 1.01–1.07] P = 0.002) to be independently associated with delirium development. COVID-19 (OR: 1.44 [95% CI: 0.13–10.6]; P = 0.7) was not found to be associated with delirium. Conclusion: Delirium is prevalent in critically ill patients admitted to the ICU, including those with COVID-19. However, after adjustment for important covariates, we found in this cohort that COVID-19 was not an independent risk factor for delirium.
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Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter observational study p. 70
Nada S Alqadheeb, Mai S Hashhoush, Abdulrahman M Alharthy, Nasir Nasim Mahmood, Zahra A Alfardan, Rashid Amin, Khalid A Maghrabi, Mohammed A Almaani, Mahmoud S Alyamany, Farhan Zayed Alenezi, Abdulrahman R Alruwaili, Kasim H Alkhatib, Asia S Rugaan, Faisal S Eltatar, Haifa M Algethamy, Abdullah M Abudayah, Alaa E Ghabashi, Galal B ElRakaiby, Khalid F Alkatheeri, Mohammed I Alarifi, Yousef A Al Mubarak, Nadia H Ismail, Israa H Alnajdi, Mohammed Elrazi I. Ahmed, Mariam A Alansari, Ahmed O Alenazi, Osama M Almuslim
Background: Delirium in critically ill patients is independently associated with poor clinical outcomes. There is a scarcity of published data on the prevalence of delirium among critically ill patients in Saudi Arabia. Therefore, we sought to determine, in a multicenter fashion, the prevalence of delirium in critically ill patients in Saudi Arabia and explore associated risk factors. Methods: A cross-sectional point prevalence study was conducted on January 28, 2020, at 14 intensive care units (ICUs) across 3 universities and 11 other tertiary care hospitals in Saudi Arabia. Delirium was screened once using the Intensive Care Delirium Screening Checklist. We excluded patients who were unable to participate in a valid delirium assessment, patients admitted with traumatic brain injury, and patients with documented dementia in their medical charts. Results: Of the 407 screened ICU patients, 233 patients were enrolled and 45.9% were diagnosed with delirium. The prevalence was higher in mechanically ventilated patients compared to patients not mechanically ventilated (57.5% vs. 33.6%; P < 0.001). In a multivariate model, risk factors independently associated with delirium included age (adjusted odds ratio [AOR], 1.021; 95% confidence interval [CI], 1.01–1.04; P = 0.008), mechanical ventilation (AOR, 2.39; 95% CI, 1.34–4.28; P = 0.003), and higher severity of illness (AOR, 1.01; 95% CI, 1.001–1.021; P = 0.026). Conclusion: In our study, delirium remains a prevalent complication, with distinct risk factors. Further studies are necessary to investigate long-term outcomes of delirium in critically ill patients in Saudi Arabia.
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Mortality in patients receiving prolonged invasive mechanical ventilation time in the emergency department: A retrospective cohort study p. 77
Sorravit Savatmongkorngul, Chaiyaporn Yuksen, Napathom Sunsuwan, Pungkawa Sricharoen, Chetsadakon Jenpanitpong, Konwachira Maijan, Sorawich Watcharakitpaisan, Parama Kaninworapan
Background: Patients waiting for intensive care unit (ICU) admission cause emergency department (ED) crowding and have an increased risk of mortality and length of stay (LOS) in hospital, which increase the hospitalization cost. This study aimed to investigate the correlation between mortality and invasive mechanical ventilation (IMV) time in patients in the ED. Methods: A retrospective cohort study was conducted in patients who received IMV in the ED of Ramathibodi Hospital. The correlation between mortality at 28 days after intubation and IMV time in the ED was analyzed. The cutoff time was analyzed to determine prolonged and nonprolonged IMV times. ICU ventilation time, length of ICU stay, and LOS in the hospital were also analyzed to determine their correlations between IMV time in the ED. Results: In this study, 302 patients were enrolled, 71 died, and 231 survived 28 days after receiving IMV in the ED. We found that the duration of >12 h of IMV in the ED increased the 28-day mortality rate by 1.98 times (P = 0.036). No correlations were found between IMV time in the ED and ventilation time in the ICU, length of ICU stay, and LOS in the hospital. Conclusion: More than 12 h of IMV time in the ED correlated with mortality at 28 days after initiation of IMV. No associations were found between prolonged IMV time in the ED with ventilation time in the ICU, length of ICU stay, and LOS in the hospital.
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Surveillance study of bloodstream infections, antimicrobial use, and resistance patterns among intensive care unit patients: A retrospective cross-sectional study p. 82
Mera A Ababneh, Mohammad Al Domi, Abeer M Rababa'h
Background: Bloodstream infections (BSIs) are one of the most critical illnesses requiring intensive care unit (ICU) admission. This study assessed patterns of antimicrobial use and resistance in ICU patients with BSIs. Methods: Inpatients admitted to the ICU and who received at least one antimicrobial agent between January 1, 2017, and December 31, 2019, were included in the study. Electronic patients' medical records were used to collect patients' demographic, clinical, and microbiological data. Results: A total of 1051 patients were enrolled in the study, where 650 patients (61.84%) were treated with three or more antimicrobial agents. The most frequently used antimicrobials were piperacillin/tazobactam followed by teicoplanin, meropenem, and levofloxacin. The most predominant multidrug-resistant pathogens were Acinetobacter baumannii, followed by Escherichia coli, Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumonia, and Pseudomonas aeruginosa. Conclusions: The administration of the antimicrobials among ICU patients was highly based on a combination of three or more broad-spectrum agents. MDR pathogens were found to be highly prevalent among ICU patients with BSI. Therefore, we suggest recommending that hospital policies should apply the antimicrobial stewardship protocols, infection control, and implement antimicrobial de-escalation protocol to reduce the harm pressure of antimicrobial resistance.
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Acute kidney injury in critically ill adults: A cross-sectional study p. 91
Mohamed M. A. ElSeirafi, Hasan M. S. N. Hasan, Kannan Sridharan, Mohamed Qasim Toorani, Sheikh Abdul Azeez Pasha, Zafar Mohiuddin, Sana Alkhawaja
Background: Wide differences in the estimates of acute kidney injury (AKI) have been reported in studies from various parts of the world. Due to dearth of data from the region, we carried out the present study to assess the incidence and the associated factors for AKI in our critically ill population. Methods: A prospective, observational study in critically ill adults who developed AKI was carried out. The diagnosis of AKI was attained by AKI Network (AKIN) criteria. The key details collected included details related to demographics, APCAHE score, concomitant diagnoses, whether mechanical ventilation was provided or not, radiological findings, drugs with potential nephrotoxicity, requirement of renal replacement therapy (RRT), whether recovered from AKI and time taken for recovery, duration of stay in the intensive care unit, and outcome (died/alive). Results: One hundred patients out of the total 560 with an incidence of 17.9% developed AKI. Forty-five had Stage 1, 22 had Stage 2, and 33 had Stage 3 AKI, and a significantly higher mortality was observed with Stage 3 AKIN Class compared to Stages 1 and 2. Two-thirds of the patients had septic shock, while 29 had contrast-induced nephropathy. Ninety-five patients received at least one drug with potential nephrotoxicity. Sixty-three patients recovered from AKI episodes. Only 29 patients underwent RRT of which 41% died. Conclusion: We observed an incidence of 17.9% for AKI in our critically ill patients. The estimates from this study will serve as a baseline for future studies in the region.
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Hematological manifestations of COVID-19 acute respiratory distress syndrome patients and the impact of thrombocytopenia on disease outcomes: A retrospective study p. 95
Meltem Simsek, Fatma Yildirim, Irem Karaman, Halil İbrahim Dural
Background: Platelet count is a simple and readily available biomarker, in which thrombocytopenia was shown to be independently associated with disease severity and risk of mortality in the critical coronavirus disease-19 (COVID-19) patients. The aim of this study was to investigate the impact of thrombocytopenia on disease progression in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) admitted to a medical intensive care unit (ICU). Methods: COVID-19-associated ARDS patients in our research hospitals' ICU were retrospectively investigated. Patients were divided into two groups as thrombocytopenic (<150 × 109/ml) patients on admission or those who developed thrombocytopenia during ICU follow-up (Group 1) and those without thrombocytopenia during ICU course and follow-up (Group 2). Results: The median platelet count of all patients was 240 × 109/ml, and the median D-dimer was 1.16 mg/ml. On admission, 32 (18.3%) patients had thrombocytopenia. The mean platelet count of Group 1 was 100.0 ± 47.5 × 109/ml. Group 1 was older and their Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scores were higher. Group 1 had lower hemoglobin, neutrophil, and lymphocyte counts and higher ferritin and procalcitonin level. Invasive mechanical ventilation was more commonly needed, and disseminated intravascular coagulation (DIC) was more frequently observed in Group 1. The ICU and hospital length of stay of Group 1 was longer with higher mortality. Conclusion: Patients with thrombocytopenia had increased inflammatory markers, frequency of DIC, duration of ICU stay, and mortality. The presence of thrombocytopenia may reflect the progression of COVID-19 toward an unfavorable outcome.
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Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution p. 101
Jin Bong Ye, Jin Young Lee, Jin Suk Lee, Se Heon Kim, Hanlim Choi, Yook Kim, Soo Young Yoon, Young Hoon Sul, Jung Hee Choi
Background: We aimed to investigate the outcomes after delayed management of ≥ Grade II blunt traumatic thoracic aortic injury (BTAI). Methods: Between January 2005 and December 2019, we retrospectively reviewed the medical records of 21 patients with ≥ Grade II thoracic aortic injury resulting from blunt trauma. Twelve patients underwent observation for the injury, whereas nine patients were transferred immediately after the diagnosis. Patients were divided into a nonoperative management group (n = 7) and delayed repair group (n = 5) based on whether they underwent thoracic endovascular aneurysm repair or surgery. Results: The most common dissection type was DeBakey classification IIIa (n = 9). Five patients underwent delayed surgery (including aneurysm repair), with observation periods ranging from 1 day to 36 months. The delayed repair group exhibited higher injury severity scores than the nonoperative management group (n = 7). The nonoperative management group was followed-up with blood pressure management without a change in status for a period ranging from 3 to 96 months. Conclusions: Our findings indicated that conservative management may be appropriate for select patients with Grade II/III BTAI, especially those exhibiting hemodynamic stability with anti-impulse therapy and minimally sized pseudoaneurysms. However, further studies are required to identify the risk factors for injury progression and long-term outcomes.
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Medication errors in Jordan: A systematic review p. 106
Abeer M Rababah, Afrah Nabil Mardini, Mera A Ababneh, Mohammad Rababa, Maisan Hayajneh
Medication errors (MEs) present a significant issue in health care area, as they pose a threat to patient safety and could occur at any stage of the medication use process. The objective of this systematic review was to review studies reporting the rates, prevalence, and/or incidence of various MEs in different health care clinical settings in Jordan. We searched PubMed, HINARI, Google, and SCOPUS for relevant published studies. We included observational, cross-sectional or cohort studies on MEs targeting adults in different health-care settings in Jordan. A total of 411 records were identified through searching different databases. Following the removal of duplicates, screening of title, abstract and full-text screening, 24 papers were included for the final review step. Prescribing errors was the most common error reported in the included studies, where it was reported in 15 studies. The prevalence of prescribing errors ranged from 0.1% to 96%. Two studies reported unintentional discrepancies and documentation errors as other types of MEs, where the prevalence of unintentional discrepancies ranged from 47% to 67.9%, and the prevalence of documentation errors ranged from 33.7% to 65%. In conclusion, a wide variation was found between the reviewed studies in the error prevalence rates. This variation may be due to the variation in the clinical settings, targeted populations, methodologies employed. There is an imperative need for addressing the issue of MEs and improving drug therapy practice among health-care professionals by introducing education and training.
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Approach to new-onset facial nerve palsy in a critically ill patient: A case report p. 115
Saumitra Misra, Saurabh Kumar, Nitin Rai, Sai Saran
Lower motor type of facial nerve palsy (Bell's palsy) is one of the most common types of facial nerve palsy, with well-defined management with steroids and antivirals for patients attending outpatient clinics. The diagnosis and management of facial nerve palsy in critically ill patients require an individualized approach, as there may be many other causes like soft-tissue compression due to facial edema which can occur as a complication of prone ventilation and severe subcutaneous emphysema. This report highlights the challenges in the management of new-onset facial nerve palsy diagnosed in the intensive care unit (ICU) for a patient on mechanical ventilation, and creates a necessity for a standard operating protocol for the management of such scenarios in ICU.
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