ICU-acquired weakness, diaphragm dysfunction and long-term outcomes of critically ill patients

Effect of High Protein Normocaloric Nutrition on Skeletal Muscle Wasting in Critically Ill Mechanically Ventilated Patients: A Randomized Double-blind Study

Background and aims

Muscle wasting in critically ill patients is associated with poor outcomes. During intensive care unit (ICU) stay, delivering appropriate nutritional support helps minimize muscle loss. We sought to evaluate the impact of high-dose protein on muscle thickness and cross-sectional area (CSA), as well as to track changes in muscle echogenicity and pennation angle (PA) using bedside ultrasound in this population.

Patients and methods

We conducted a randomized, prospective, double-blind trial in which 30 patients mechanically ventilated for more than 48 hours and receiving enteral feed were enrolled. Patients were divided into two groups, and all patients received enteral feeds with total calories of about 25 kcal/kg/day. In the high-protein feed (HPF) group, patients were targeted to receive 1.5 gm/kg/day of protein, whereas in the standard feed (SF) group, patients received 1 gm/kg/day of protein. After ICU admission, muscle thickness, CSA, echogenicity, and PA were measured in all mechanically ventilated patients on days 1, 3, 5, and 7 using bedside ultrasound. The right lower limb vastus lateralis (VL) and the medial head of the gastrocnemius were investigated.

Results

We found a progressive decrease in muscle mass from day 1 to day 7 in all patients. Our study showed that muscle thickness and CSA were significantly higher in the HPF group than the SF group over 7 days, whereas muscle echogenicity and PA changes were not statistically significant.

Conclusion

High-protein feeds prevent muscle wasting in critically ill patients compared to patients receiving SFs during the first week of ICU stay. The qualitative muscle parameters, like muscle echogenicity and PA changes, were not significant.

How to cite this article

Parasuraman V, Anand RK, Khanna P, Shanmugam R, Ray BK. Effect of High Protein Normocaloric Nutrition on Skeletal Muscle Wasting in Critically Ill Mechanically Ventilated Patients: A Randomized Double-blind Study. Indian J Crit Care Med 2025;29(5):431-440.

Enhancing early mobilization in critically ill patients through multidisciplinary rounds: A process-focused observational study

BACKGROUNDS

Early mobilization (EM) is vital for critically ill patients, yet various barriers hinder its implementation in daily critical care practice. This study aimed to explore the impact of multidisciplinary rounds (MDR) on the initiation of EM.

METHODS

We conducted a retrospective, process-focused observational study in the medical/surgical intensive care unit (ICU) of a tertiary university medical center in Tokyo, Japan, including 301 patients who received physical therapy (PT) during their ICU stay. MDR implementation commenced in October 2016, followed by a year-long initiative to enhance awareness about the importance of EM. Patients admitted between April 2015 and September 2016 were categorized into the pre-MDR group (Phase 1, n = 110), while those admitted from October 2017 to March 2019 formed the post-MDR group (Phase 2, n = 191).

RESULTS

EM practice was significantly increased in Phase 2, compared to Phase 1 (39.8% vs. 20.9%; p = 0.001), particularly among mechanically ventilated patients (33.8% vs. 9.3%; p < 0.001). The median time from ICU admission to PT initiation was significantly reduced in Phase 2 (3.0 vs. 6.0 days, p < 0.001). Additionally, PT consultations significantly increased from 9.2% to 16.5% (χ2 = 27.75, p < 0.001). MDR was associated with an 84% higher likelihood of initiating EM (adjusted relative risk 1.84, 95% CI 1.30-2.61).

CONCLUSIONS

MDR played a pivotal role in enhancing the initiation of EM for ICU patients, highlighting its significance in overcoming barriers to EM.

Respiratory and limb muscles' ability to repeatedly generate maximal isometric strength in patients with intensive care unit-acquired weakness: an observational study

BACKGROUND

Intensive care unit-acquired weakness (ICU-Aw) is a prevalent complication in critically ill patients, affecting both limb and respiratory muscles, individually or concurrently. The precise mechanisms by which muscle weakness influences the distinct functional roles of each muscle group remain to be fully elucidated. The objective of this study was to compare the time course evolution of inspiratory and quadriceps muscles strength during repeated maximal isometric contractions in patients with limb muscles and inspiratory muscles weakness.

METHODS

A single-center, observational study was conducted in critically ill patients after extubation, presenting with both inspiratory and limb muscle weakness (defined as maximal inspiratory pressure (Pimax) < 30 cmH2O and an MRC score < 48). The patients' ability to sustain maximal voluntary effort was measured using electronic manometers and dynamometers, with repeated efforts performed 10 times. Following each measurement, a 10-second rest period was observed, and strength measurements were repeated to evaluate recovery.

RESULTS

A total of 20 patients (90% male, mean age 61 ± 10 years, SAPS II score 28 ± 17) were included. The mean first maximal inspiratory pressure was 32.6 ± 17 cmH2O, and the mean first quadriceps maximal force was 135 ± 90 Newtons (N). Investigation revealed a decline in quadriceps muscle force of -15.45 ± 28.61 N (95% CI: -28.84 to -2.05) while inspiratory muscles demonstrated stability (mean difference: 1.75 ± 7.57 cmH2O (95% CI: -1.80 to 5.30)). A statistically significant interaction between time and muscle group was identified (p = 0.0017), suggesting a different time course evolution of maximal voluntary strength between muscle groups. After a one-minute recovery, significant improvement in quadriceps strength was observed (p = 0.009), while no statistically significant change was detected in inspiratory muscle strength (p = 0.16).

CONCLUSIONS

The results of this study indicate potential disparities in the maximum force maintenance capacity between the quadriceps muscles and inspiratory muscles in patients with ICU-acquired weakness.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov Identifier NCT05396066.

A comprehensive overview of fixed-volume hemorrhage effects in New Zealand White rabbit models

Background

Hemorrhagic shock is a life-threatening condition resulting from acute blood loss, leading to compromised tissue perfusion and organ dysfunction. Currently, the guidelines for categorizing and managing hemorrhagic shock in pets are based on protocols developed for humans.

Aim

This study employed New Zealand White rabbits as an animal model to systematically evaluate the physiological and biochemical responses to fixed-volume hemorrhage, aiming to establish its role in inducing shock and significant physiological alterations.

Methods

A total of 21 New Zealand White rabbits, weighing 2-3 kg, were subjected to controlled hemorrhage by withdrawing 30%-35% of their total blood volume via the auricular artery using a 24-G IV catheter over 15 minutes. Parameters were assessed at baseline and 45 minutes post-induction.

Results

Hemorrhage induced significant increases in heart rate and respiratory rate, reflecting compensatory mechanisms to maintain perfusion during shock. The mean arterial pressure and blood pressure significantly declined, consistent with hemorrhagic shock. Oxygen saturation initially decreased but partially recovered over time. All hematological variables decreased. Coagulopathy was indicated by prolonged prothrombin time and activated partial thromboplastin time. Elevated lactate levels indicate a shift to anaerobic metabolism due to hypoxia. The increased levels of interleukin-10 and tumor necrosis factor-alpha suggested an adaptive anti-inflammatory response to mitigate excessive inflammation.

Conclusion

Fixed-volume hemorrhage in New Zealand White rabbits induces the physiological changes characteristic of hemorrhagic shock, providing valuable insights into the pathophysiological response to acute blood loss.

Co-infection of SARS-CoV-2 and influenza A/B among patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) is a public health problem and may result in co-infection with other pathogens such as influenza virus. This review investigates the co-infection of SARS-CoV-2 and influenza A/B among patients with COVID-19.

METHODS

This meta- analysis included 38 primary studies investigating co-infection of SARS-CoV-2 with influenza in confirmed cases of COVID-19. The global online databases were used to identify relevant studies published between December 2019 and July 2024. Data analysis was performed using STATA Ver. 17 software, and standard errors of prevalence were calculated using the binomial distribution formula. Heterogeneity of study results was evaluated using the I-square and Q index, and publication bias was examined using the Begg's and Egger's tests, as well as funnel plot. A random effects model was used to determine prevalence rates, and a forest plot diagram was used to present results with 95% confidence intervals. In addition, sensitivity analyses were performed to check the impact of each primary study on the overall estimate.

RESULT

The analysis found that the prevalence of influenza in co-infected patients at 95% confidence interval using a random effect model was 14% (95% CI: 8-20%). Significant heterogeneity was observed in the random-effects model for influenza A, 11% (95% CI: 5-18%) and B, 4% (95% CI: 2-7%) in co-infected patients. The highest prevalence of influenza A/B (21%), influenza A (17%) and influenza B (20%) was shown in Asia and Europe respectively. Subgroup analysis by study year showed that the co-prevalence of COVID-19 and influenza A/B was similar in the pre-2021 and post-2021 time periods, at 14% (95% CI: 5-23%) for pre-2021 and 6-22% for 2021 and post-2021. Also, the overall prevalence of influenza A and B in COVID-19 patients is 11% and 4%, and there was no significant difference between the time periods before and after 2021. Meta-regression with a random-effects model showed that the variables location, year group, and total patients showed only 2.71% of very high heterogeneity (I² = 99.92%), and none of these variables had a significant effect on the co-prevalence of COVID-19 and influenza A/B (p > 0.05). Also, meta-regression results showed that these variables had no significant effect on influenza A and B prevalence (p > 0.05) and showed only a small proportion of the very high heterogeneity (I² = 99.72%), (I² = 68.78%). In our study, Egger's test indicated that there was publication bias or small study effects in this meta-analysis (p = 0.0000).

CONCLUSION

The combination of SARS-CoV-2 with influenza and other respiratory viruses requires the best treatment protocols to reduce the severity of the disease. In this approach, high vaccination coverage against seasonal influenza and SARS-CoV-2 could reduce the risk of co-infection in the recent pandemic.

Contribution and evolution of respiratory muscles function in weaning outcome of ventilator-dependent patients

BACKGROUND

The present study was designed to investigate the evolution and the impact of respiratory muscles function and limb muscles strength on weaning success in prolonged weaning of tracheotomized patients. The primary objective was to determine whether the change in respiratory muscles function and limb muscles strength over the time is or is not associated with weaning success.

METHODS

Tracheotomized patients who were ventilator dependent upon admission at a weaning center were eligible. Diaphragm function was assessed with the phrenic nerve stimulation technique and with ultrasound to measure the diaphragm thickening fraction (TFdi) and diaphragm excursion (EXdi). Global respiratory muscle function was assessed with the maximal inspiratory pressure (MIP) and the forced vital capacity (FVC). Limb muscle strength was measured with the Medical Research Council Score (MRC). Measurements were made on a weekly basis. Patients were compared according to their outcome at discharge: complete weaning, partial weaning or death.

RESULTS

Among the 60 patients who were enrolled, 30 patients finally achieved complete weaning, 20 had partial weaning and 10 died. At 6 months, 6 patients were lost of follow-up, 33 achieved complete weaning, 10 had partial weaning and 11 died. In median, 2 (1-9) assessments were performed per patient. Diaphragm dysfunction was present in all patients with a median Ptr,stim of 5.5 cmH2O (3.0-7.5). Ptr,stim, MIP, TFdi and EXdi at admission were not different between patients who achieved complete weaning and their counterparts. At discharge of the weaning center, MIP, Ptr,stim and EXdi significantly increased in patients who achieved complete weaning. The MRC score significantly increased only in patients with complete weaning. At discharge, diaphragm dysfunction was highly prevalent even in patients with complete weaning (Ptr,stim < 11 cmH2O in n = 11 (37%)).

CONCLUSION

Respiratory muscle function and limb muscles strength are severely impaired in patients with prolonged weaning from mechanical ventilation. Significant improvement of diaphragm ultrasound indices was associated with successful weaning from mechanical ventilation and ICU-acquired weakness upon admission was significantly associated with good outcome suggesting that it was an amendable determinant of weaning failure in this population.

Deciphering the multifaceted role of microRNAs in hepatocellular carcinoma: Integrating literature review and bioinformatics analysis for therapeutic insights

Hepatocellular carcinoma (HCC) poses a significant global health challenge, necessitating innovative therapeutic strategies. MicroRNAs (miRNAs) have emerged as pivotal regulators of HCC pathogenesis, influencing key processes such as self-renewal, angiogenesis, glycolysis, autophagy, and metastasis. This article integrates findings from a comprehensive literature review and bioinformatics analysis to elucidate the role of miRNAs in HCC. We discuss how dysregulation of miRNAs can drive HCC initiation, progression, and metastasis by modulating various signaling pathways and target genes. Moreover, leveraging high-throughput technology and bioinformatics tools, we identify key miRNAs involved in multiple cancer hallmarks, offering insights into potential combinatorial therapeutic strategies. Through our analysis considering p-values and signaling pathways associated with key features, we unveil miRNAs with simultaneous roles across critical cancer characteristics, providing a basis for the development of high-performance biomarkers. The microRNAs, miR-34a-5p, miR-373-3p, miR-21-5p, miR-214-5p, miR-195-5p, miR-139-5p were identified to be shared microRNAs in stemness, angiogenesis, glycolysis, autophagy, EMT, and metastasis of HCC. However, challenges such as miRNA stability and delivery hinder the translation of miRNA-based therapeutics into clinical practice. This review underscores the importance of further research to overcome existing barriers and realize the full potential of miRNA-based interventions for HCC management.

Latent Trajectories of Activities of Daily Living Disability and Associated Factors Among Adults with Post-Intensive Care Syndrome One Week After ICU Discharge

Objective

To identify the latent trajectories of activities of daily living (ADL) disability and the influential factors among adults with post-intensive care syndrome (PICS).

Methods

We evaluated five-time longitudinal data about PICS diagnosed in 434 of 593 assessed patients (73.19%). Disability was measured by the Barthel index scale, which grades individuals according to how difficult it is to carry out ADL. We utilized the growth mixture model (GMM) to identify latent trajectories and associated factors.

Results

Two groups with distinct trajectories of ADL disability were identified, including the Severe Disability Sustained Group and the Disability Recovery Group. People who were of advanced age transferred to another hospital for treatment, or had cognitive impairment or depression were more likely to be classified into the Severe Disability Sustained Group (P < 005).

Conclusion

There are two potential trajectories of ADL disability in patients with PICS, which are the severe disability persistence group and the disability recovery group. Improvement in cognitive impairment or depression may contribute to recovery from disability, transfer to hospital or advanced age may not be conducive to recovery of ADL ability, and disability may last longer.

Higher protein intake may benefit in patients with prolonged mechanical ventilation

Background

Patients with prolonged mechanical ventilation (PMV) is usually associated with muscle wasting and diaphragm weakness, resulting in high medical costs and mortality. Adequate energy and protein intake were beneficial in sarcopenia patients. We aimed to investigate the impact of protein intake in weaning parameters in patients with PMV.

Materials and methods

We enrolled patients with PMV (mechanical ventilation ≥6 h/day for ≥21 days) from a respiratory care center (RCC) of a tertiary medical center from December 2020 to October 2022, and classified them into weaning success and weaning failure groups. The patients' characteristics, nutrition records, weaning parameters and outcomes were analyzed.

Results

A total of 289 patients were included (mean age 73.5 years). Of the 289 patients, 149 were weaned successfully and 140 were not. The average protein intake was higher in the weaning success group than in the weaning failure group (1.22 ± 0.320 versus 0.99 ± 0.332 g/kg/day, p < 0.001). No significant differences were noted in the average calorie intake and whey protein intake between the two groups. RSBI <90 breaths/min/L (OR = 2.38, p = 0.045), serum albumin at 4th week ≥3 g/dL (OR = 2.89, p = 0.027), daily protein intake ≥1.01 g/kg/day (OR = 8.10, p < 0.001), PaO2/FiO2 (PF) ratio ≥ 300 (OR = 2.56, p = 0.027) were independent predictors for weaning from ventilator. Weak positive correlations were found between average protein intake with PF ratio (r = 0.1576, p = 0.0227) and PaO2 (r = 0.13359, p = 0.0497).

Conclusion

Daily protein intake had positively correlated with PF ratio and had independently benefit for weaning in patients with PMV.

Evaluation of Secondary Bacterial Infections and Determination of Antibiogram Susceptibility Testing in Hospitalized Patients with COVID-19

Background & Objective

COVID-19 is a global pandemic that has caused an increase in hospitalization rates and high mortality. Secondary bacterial infections in hospitalized patients are one of the common complications of this viral disease. Due to the increased prevalence of antibiotic resistance, treating these patients is challenging. Therefore, this study aimed to evaluate the secondary bacterial infection and antimicrobial sensitivity test in hospitalized patients with COVID-19 in a tertiary hospital.

Methods

In this retrospective descriptive study, all patients with COVID-19 who were admitted to Shahid Modares Hospital (Tehran-Iran) from October 2020 to March 2021 with positive culture results for bacterial infections, were assessed. The significance level was lower than 0.05.

Results

Ninety-seven patients with a mean age of 65.23 ± 16.72 years were assessed. The male patients accounted for 58.8% of the patients, while 41.2% were female. The ICU admitted patients with critical COVID-19 severity accounted for 59.8%, while 40.2% were hospitalized in the ward with a severe form of the disease. Age, length of hospitalization, and mortality rate were significantly higher in patients with ICU admission (all P-values<0.05). The most antibiotic-resistant bacteria were Klebsiella pneumoniae (32.98%). ICU admission showed a significantly higher rate in patients who were resistant to Cefotaxime, Ceftriaxone, Gentamicin, and Co-trimoxazole compared to the patients who were hospitalized in the ward (all P-values<0.05).

Conclusion

Secondary bacterial infection in hospitalized patients with COVID-19 may lead to high mortality.

Burnout experience among healthcare workers post third COVID-19 wave in India; findings of a cross-sectional study

Background

The pandemic exacerbated burnout experienced by healthcare personnel, whose mental health had long been a public health concern before COVID-19. This study used the Copenhagen burnout inventory (CBI) tool to assess burnout and identify predictors among Indian healthcare workers managing COVID-19.

Methods

A cross-sectional study was conducted from June to December 2022, after the third pandemic wave. A web-based, fillable Google form was used to recruit COVID-19 management professionals from multiple Jaipur district hospitals. Healthcare professionals provided socio-demographic, work-related, and CBI scores. Multiple linear regression was used to control for model covariant independent variables.

Results

We evaluated the responses of a total of 578 participants with a mean age of 36.59 ± 9.1 years. Based on the CBI cut-off score of 50, 68.1% reported burnout. A total of 67.5%, 56.4%, and 48.6% of healthcare workers reported work-related, personal, and patient-related burnout, respectively. High burnout scores were significantly associated with the nursing profession (β = 7.89, 95% CI; 3.66, 12.11, p < 0.0001). The p-value indicates the probability of observing the data if the null hypothesis is true, and the confidence interval shows the range within which we can be 95% confident that the true effect lies. An independent relationship exists between male gender and higher personal-related burnout scores (β = 4.45, 95% CI 1.9-6.9).

Conclusion

This study identified key indicators that need further emphasis and the need for organizational and individual-level burnout monitoring in healthcare delivery sectors. Health workers continue to experience burnout due to a combination of personal, professional, and patient-related factors. This underscores the need for targeted organizational and individual interventions. The findings also suggest that the CBI tool could identify healthcare worker burnout risk groups.

Accelerometer-derived movement features as predictive biomarkers for muscle atrophy in neurocritical care: a prospective cohort study

BACKGROUND

Physical inactivity and subsequent muscle atrophy are highly prevalent in neurocritical care and are recognized as key mechanisms underlying intensive care unit acquired weakness (ICUAW). The lack of quantifiable biomarkers for inactivity complicates the assessment of its relative importance compared to other conditions under the syndromic diagnosis of ICUAW. We hypothesize that active movement, as opposed to passive movement without active patient participation, can serve as a valid proxy for activity and may help predict muscle atrophy. To test this hypothesis, we utilized non-invasive, body-fixed accelerometers to compute measures of active movement and subsequently developed a machine learning model to predict muscle atrophy.

METHODS

This study was conducted as a single-center, prospective, observational cohort study as part of the MINCE registry (metabolism and nutrition in neurointensive care, DRKS-ID: DRKS00031472). Atrophy of rectus femoris muscle (RFM) relative to baseline (day 0) was evaluated at days 3, 7 and 10 after intensive care unit (ICU) admission and served as the dependent variable in a generalized linear mixed model with Least Absolute Shrinkage and Selection Operator regularization and nested-cross validation.

RESULTS

Out of 407 patients screened, 53 patients (age: 59.2 years (SD 15.9), 31 (58.5%) male) with a total of 91 available accelerometer datasets were enrolled. RFM thickness changed - 19.5% (SD 12.0) by day 10. Out of 12 demographic, clinical, nutritional and accelerometer-derived variables, baseline RFM muscle mass (beta - 5.1, 95% CI - 7.9 to - 3.8) and proportion of active movement (% activity) (beta 1.6, 95% CI 0.1 to 4.9) were selected as significant predictors of muscle atrophy. Including movement features into the prediction model substantially improved performance on an unseen test data set (including movement features: R2 = 79%; excluding movement features: R2 = 55%).

CONCLUSION

Active movement, as measured with thigh-fixed accelerometers, is a key risk factor for muscle atrophy in neurocritical care patients. Quantifiable biomarkers reflecting the level of activity can support more precise phenotyping of ICUAW and may direct tailored interventions to support activity in the ICU. Studies addressing the external validity of these findings beyond the neurointensive care unit are warranted.

TRIAL REGISTRATION

DRKS00031472, retrospectively registered on 13.03.2023.

Cerebellitis following COVID-19 infection: A case-based systematic review and pooled analysis

Background

The COVID-19 pandemic has been linked to neurological complications, including Cerebellitis. This study aims to investigate the clinical features, and consequences of Cerebellitis following COVID-19 infection, informing medical management strategies.

Methods

A systematic search was conducted through PubMed, Web of Science, Embase, ProQuest, and Cochrane databases from January 2018 to September 12, 2023, on cases post-COVID-19. Demographics, clinical characteristics, and diagnostic techniques were analyzed using descriptive statistics. Chi-Square tests assessed associations between diagnoses and treatments, with visualizations including heatmaps and scatter plots.

Results

After the final Screening, the analysis of 18 cases revealed Cerebellitis post-COVID-19 spanned 9 countries, predominantly from the USA (27.8 %), with a mean patient age of 40.1 years (±24.6). Males comprised 94.4 % of cases. Common underlying conditions included hypertension (22.2 %) and diabetes (11.1 %). Neurological symptoms presented on average 15.15 ± 12.7 days post-COVID-19 infection. A moderate negative correlation (r = -0.358) was observed between age and symptom onset. Blood and CSF biomarkers showed weak correlations with symptom onset intervals. Treatment efficacy varied, with most cases achieving symptom-free outcomes. The Chi-Square test for diagnosis-treatment associations yielded a p-value of 0.089, and for follow-up outcomes, a p-value of 0.283, indicating no significant statistical associations.

Conclusion

This systematic review highlights increased reports of Cerebellitis in males in their fourth decade of life, with the highest comorbidities being vascular diseases. Marker assessments show a decrease in CSF protein in half of patients, along with complete recovery following combination treatment with antivirals and steroids in acute Cerebellitis.

Intensive care unit-acquired weakness - preventive, and therapeutic aspects; future directions and special focus on lung transplantation

In this editorial, comments are made on an interesting article in the recent issue of the World Journal of Clinical Cases by Wang and Long. The authors describe the use of neural network model to identify risk factors for the development of intensive care unit (ICU)-acquired weakness. This condition has now become common with an increasing number of patients treated in ICUs and continues to be a source of morbidity and mortality. Despite identification of certain risk factors and corrective measures thereof, lacunae still exist in our understanding of this clinical entity. Numerous possible pathogenetic mechanisms at a molecular level have been described and these continue to be increasing. The amount of retrievable data for analysis from the ICU patients for study can be huge and enormous. Machine learning techniques to identify patterns in vast amounts of data are well known and may well provide pointers to bridge the knowledge gap in this condition. This editorial discusses the current knowledge of the condition including pathogenesis, diagnosis, risk factors, preventive measures, and therapy. Furthermore, it looks specifically at ICU acquired weakness in recipients of lung transplantation, because - unlike other solid organ transplants- muscular strength plays a vital role in the preservation and survival of the transplanted lung. Lungs differ from other solid organ transplants in that the proper function of the allograft is dependent on muscle function. Muscular weakness especially diaphragmatic weakness may lead to prolonged ventilation which has deleterious effects on the transplanted lung - ranging from ventilator associated pneumonia to bronchial anastomotic complications due to prolonged positive pressure on the anastomosis.

The impact of nursing workforce skill-mix on patient outcomes in intensive care units in Victoria, Australia

Objective

This article aims to examine the impact of nursing workforce skill-mix (percentage of critical care registered nurses [CCRN]) in the intensive care unit (ICU) during a patient's stay.

Design

Registry linked cohort study of the Australian and New Zealand Intensive Care Society Adult Patient Database and the Critical Health Resources Information System using real-time nursing workforce data.

Settings

Fifteen public and 5 private hospital ICUs in Victoria, Australia.

Participants

There were 16,618 adult patients admitted between 1 December 2021 and 30 September 2022.

Main outcome measures

Primary outcome: in-hospital mortality. Secondary outcomes: in-ICU mortality, development of delirium, pressure injury, duration of stay in-ICU and hospital, after-hours discharge from ICU and readmission to ICU.

Results

In total, 6563 (39.5%) patients were cared for in ICUs with >75% CCRN, 7695 (46.3%) in ICUs with 50-75% CCRN, and 2360 (14.2%) in ICUs with <50% CCRN. In-hospital mortality was 534 (8.1%) vs. 859 (11.2%) vs. 252 (10.7%) respectively. After adjusting for confounders, patients cared for in ICUs with 50-75% CCRN (adjusted OR 1.21 [95% CI 1.02-1.45]) were more likely to die compared to patients in ICUs with >75% CCRN. A similar but non-significant trend was seen in ICUs with <50% CCRN (adjusted OR 1.21 [95% CI 0.94-1.55]), when compared to patients in ICUs with >75% CCRN. In-ICU mortality, delirium, pressure injuries, after-hours discharge and ICU length of stay were lower in ICUs with CCRN>75%.

Conclusion

The nursing skill-mix in ICU impacts outcomes and should be routinely monitored. Health system regulators, hospital administrators and ICU leaders should ensure nursing workforce planning and education align with these findings to maximise patient outcomes.

Low-Medium and High-Intensity Inspiratory Muscle Training in Critically Ill Patients: A Systematic Review and Meta-Analysis

Background and objectives: Mechanical ventilation is often used in intensive care units to assist patients' breathing. This often leads to respiratory muscle weakness and diaphragmatic dysfunction, causing weaning difficulties. Inspiratory muscle training (IMT) has been found to be beneficial in increasing inspiratory muscle strength and facilitating weaning. Over the years, different protocols and devices have been used. Materials and Methods: The aim of this systematic review and meta-analysis was to investigate the effectiveness of low-medium (LM-IMT) and high-intensity (H-IMT) threshold inspiratory muscle training in critically ill patients. A systematic literature search was performed for randomized controlled trials (RCTs) in the electronic databases Google Scholar, PubMed, Scopus, and Science Direct. The search involved screening for studies examining the effectiveness of two different intensities of threshold IMT in critically ill patients published the last 10 years. The Physiotherapy Evidence Database (PEDro) scale was chosen as the tool to assess the quality of studies. A meta-analysis was performed where possible. Results: Fourteen studies were included in the systematic review, with five of them having high methodological quality. Conclusions: When examining LM-IMT and H-IMT though, neither was able to reach statistically significant improvement in their maximal inspiratory pressure (MIP), while LM-IMT reached it in terms of weaning duration. Additionally, no statistical difference was noticed in the duration of mechanical ventilation. The application of IMT is recommended to ICU patients in order to prevent diaphragmatic dysfunction and facilitate weaning from mechanical ventilation. Therefore, further research as well as additional RCTs regarding different protocols are needed to enhance its effectiveness.

Breath-by-breath comparison of a novel percutaneous phrenic nerve stimulation approach with mechanical ventilation in juvenile pigs: a pilot study

About one in three critically ill patients requires mechanical ventilation (MV). Prolonged MV, however, results in diaphragmatic weakness, which itself is associated with delayed weaning and increased mortality. Inducing active diaphragmatic contraction via electrical phrenic nerve stimulation (PNS) not only provides the potential to reduce diaphragmatic muscular atrophy but also generates physiological-like ventilation and therefore offers a promising alternative to MV. Reasons why PNS is not yet used in critical care medicine are high procedural invasiveness, insufficient evidence, and lack of side-by-side comparison to MV. This study aims to establish a minimal-invasive percutaneous, bilateral electrode placement approach for sole PNS breathing and thereby enable, for the first time, a breath-by-breath comparison to MV. Six juvenile German Landrace pigs received general anesthesia and orotracheal intubation. Following the novel ultrasound-guided, landmark-based, 4-step approach, two echogenic needles per phrenic nerve were successfully placed. Stimulation effectiveness was evaluated measuring tidal volume, diaphragmatic thickening and tomographic electrical impedance in a breath-by-breath comparison to MV. Following sufficient bilateral phrenic nerve stimulation in all pigs, PNS breaths showed a 2.2-fold increase in diaphragmatic thickening. It induced tidal volumes in the lung-protective range by negative pressure inspiration and improved dorso-caudal regional ventilation in contrast to MV. Our study demonstrated the feasibility of a novel ultrasound-guided, percutaneous phrenic nerve stimulation approach, which generated sufficient tidal volumes and showed more resemblance to physiological breathing than MV in a breath-by-breath comparison.

Diaphragm ultrasound in patients with prolonged weaning from mechanical ventilation

Background

Several publications have examined diaphragmatic ultrasound using two-dimensional (2D) parameters in the context of weaning from mechanical ventilation (MV) and extubation. However, the studied cohorts had rather short duration of ventilation. Examinations on patients with prolonged weaning after long-term ventilation were missing. It was the aim of this study to assess of the diaphragm and peripheral musculature of patients undergoing prolonged weaning creating a chronological sequence of ultrasonic parameters during the course of weaning.

Methods

This study was carried out as a monocentric, prospective observational cross-sectional study. Patients in prolonged weaning who were transferred to a specialized weaning unit were eligible for inclusion if they were ventilated invasively by means of an endotracheal tube or tracheal cannula and if their expected treatment period was at least 5 days. Diaphragmatic function and one representative peripheral muscle were examined in 50 patients between March 2020 and April 2021. The 2D sonographic parameters of diaphragm and diaphragmatic function consisted of diaphragmatic thickness (Tdi) at the end of inspiration and expiration, the fractional thickening (FT) and the diaphragmatic excursion. Additionally, the M. quadriceps femoris was sonographically assessed at two locations. The difference of measurements between the first and the last measuring timepoint were examined using the Wilcoxon signed-rank test. For a longer chronological sequence, the Friedman's rank sum test with subsequent Wilcoxon-Nemenyi-McDonald-Thompson test for multiple comparisons was carried out.

Results

Fifty patients with prolonged weaning were included. The median duration of MV before transfer to the weaning unit was 11.5 [interquartile range (IQR) 10] days. Forty-one patients could be assessed over the full course of weaning, with 38 successfully weaned. Within these 41 patients, the sonographic parameters of the diaphragm slightly increased over the course of weaning indicating an increase in thickness and mobility. Especially parameters which represented an active movement reached statistical significance, i.e., inspiratory Tdi when assessed under spontaneous breathing [begin 3.41 (0.99) vs. end 3.43 (1.31) mm; P=0.01] and diaphragmatic excursion [begin 0.7 (0.8) vs. end 0.9 (0.6) cm; P=0.01]. The presence of positive end-expiratory pressure (PEEP) and pressure support did not influence the sonographic parameters significantly. The M. quadriceps femoris, in contrast, decreased slightly but constantly over the time [lower third: begin 1.36 (0.48) vs. end 1.28 (0.36) cm; P=0.054].

Conclusions

The present study is the first one to longitudinally analyse diaphragmatic ultrasound in patients with prolonged weaning. Sonographic assessment showed that Tdi and excursion increased over the course of prolonged weaning, while the diameter of a representative peripheral muscle decreased. However, the changes are rather small, and data show a wide dispersion. To allow a potential, standardized use of diaphragm ultrasound for diagnostic decision support in prolonged weaning, further studies in this specific patient group are required.

Critical illness-associated limb and diaphragmatic weakness

PURPOSE OF REVIEW

In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW).

RECENT FINDINGS

In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW.

SUMMARY

This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.

Early Mobilization and Rehabilitation of Critically-Ill Patients

Post-intensive care unit (ICU) syndrome may occur after ICU treatment and includes ICU-acquired weakness (ICU-AW), cognitive decline, and mental problems. ICU-AW is muscle weakness in patients treated in the ICU and is affected by the period of mechanical ventilation. Diaphragmatic weakness may also occur because of respiratory muscle unloading using mechanical ventilators. ICU-AW is an independent predictor of mortality and is associated with longer duration of mechanical ventilation and hospital stay. Diaphragm weakness is also associated with poor outcomes. Therefore, pulmonary rehabilitation with early mobilization and respiratory muscle training is necessary in the ICU after appropriate patient screening and evaluation and can improve ICU-related muscle weakness and functional deterioration.

Speckle tracking echocardiography for diagnosis of right ventricular failure in children with totally corrected tetralogy of Fallot in Sulaimani, Iraq

Objectives

The study was aimed at using speckle tracking echocardiography as a novel technique to diagnose right ventricular failure (RVF) in children with total correction of tetralogy of Fallot (TOF) through surgery.

Methods

A quasi-experimental study was performed at the Children's Heart Hospital of Sulaimani for 9 months. A total of 150 children with completely repaired TOF were enrolled to investigate RVF. Conventional echocardiographic data were recorded, including right ventricular (RV) ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), and RV end-systolic and diastolic volume (RVESV and RVEDV). Additionally, speckle tracking was performed for the regional and longitudinal strain and strain rate in four-chamber apical view. RVF diagnosis was determined on the basis of electrocardiography measurement of P-wave dispersion, T-wave dispersion, and QRS duration.

Results

Children with repaired TOF who were diagnosed with RVF through conventional echocardiography exhibited abnormalities with respect to children with normal RV function, including a TAPSE of 1.3 ± 0.11 cm, RVEF of 35.5 ± 6.72, RVESV of 69.8 ± 15.13 ml, RVEDV of 110.1 ± 14.13 ml, MPI of 0.60 ± 0.12, and Pmax of 52.4 ± 14.08. The use of speckle tracking in RVF diagnosis revealed a relatively lower longitudinal strain and strain rate (-12.1 ± 2.3 and -0.9 ± 0.3, respectively) in the children with RVF. Moreover, longitudinal right ventricular strain was positively correlated with TAPSE (r = 0.656) and EF (r = 0.675), and negatively correlated with RVEDV (r = -0.684), RVESV (r = -0.718), MPI (r = -0.735), and Pmax (r = -0.767).

Conclusions

The application of speckle tracking with the longitudinal RV strain and strain rate to estimate RV function in children with repaired TOF is a new advanced method that, compared with conventional echo, significantly improves the diagnosis of regional myocardial deformations and cardiac muscle motion velocity.

Safety and effectiveness of neuromuscular electrical stimulation in cardiac surgery: A systematic review

BACKGROUND

Lack of mobilization and prolonged stay in the intensive care unit (ICU) are major factors resulting in the development of ICU-acquired muscle weakness (ICUAW). ICUAW is a type of skeletal muscle dysfunction and a common complication of patients after cardiac surgery, and may be a risk factor for prolonged duration of mechanical ventilation, associated with a higher risk of readmission and higher mortality. Early mobilization in the ICU after cardiac surgery has been found to be low with a significant trend to increase over ICU stay and is also associated with a reduced duration of mechanical ventilation and ICU length of stay. Neuromuscular electrical stimulation (NMES) is an alternative modality of exercise in patients with muscle weakness. A major advantage of NMES is that it can be applied even in sedated patients in the ICU, a fact that might enhance early mobilization in these patients.

AIM

To evaluate safety, feasibility and effectiveness of NMES on functional capacity and muscle strength in patients before and after cardiac surgery.

METHODS

We performed a search on Pubmed, Physiotherapy Evidence Database (PEDro), Embase and CINAHL databases, selecting papers published between December 2012 and April 2023 and identified published randomized controlled trials (RCTs) that included implementation of NMES in patients before after cardiac surgery. RCTs were assessed for methodological rigor and risk of bias via the PEDro. The primary outcomes were safety and functional capacity and the secondary outcomes were muscle strength and function.

RESULTS

Ten studies were included in our systematic review, resulting in 703 participants. Almost half of them performed NMES and the other half were included in the control group, treated with usual care. Nine studies investigated patients after cardiac surgery and 1 study before cardiac surgery. Functional capacity was assessed in 8 studies via 6MWT or other indices, and improved only in 1 study before and in 1 after cardiac surgery. Nine studies explored the effects of NMES on muscle strength and function and, most of them, found increase of muscle strength and improvement in muscle function after NMES. NMES was safe in all studies without any significant complication.

CONCLUSION

NMES is safe, feasible and has beneficial effects on muscle strength and function in patients after cardiac surgery, but has no significant effect on functional capacity.

Protein and energy intake in intensive care unit survivors during the first year of recovery: A descriptive cohort study

BACKGROUND

Many intensive care unit (ICU) survivors suffer long-term health issues that affect their quality of life. Nutrition inadequacy can limit their rehabilitation potential. This study investigates nutrition intake and support during ICU admission and recovery.

METHODS

In this prospective cohort study, 81 adult ICU patients with stays ≥48 h were included. Data on dietary intake, feeding strategies, baseline and ICU characteristics, and 1-year outcomes (physical health and readmission rates) were collected. The number of patients achieving 1.2 gram per kilogram per day of protein and 25 kilocalories per kilogram per day at 3 months, 6 months, and 12 months after ICU admission was recorded. The impact of dietary supplementation during the year was assessed. Baseline characteristics, intake barriers, and rehabilitation's influence on nutrition intake at 12 months were evaluated, along with the effect of inadequate intake on outcomes.

RESULTS

After 12 months, only 10% of 60 patients achieved 1.2 g/kg/day protein intake, whereas 28% reached the advised 25 kcal/kg/day energy target. Supplementary feeding significantly increased protein intake at 3, 6, and 12 months (P = 0.003, P = 0.012, and P = 0.033, respectively) and energy intake at 3 months (P = 0.003). A positive relation was found between female sex and energy intake at 12 months after ICU admission (β = 4.145; P = 0.043) and taste issues were independently associated with higher protein intake (β = 0.363; P = 0.036). However, achieving upper-quartile protein or energy intake did not translate into improved physical health outcomes.

CONCLUSION

Continuous and improved nutrition care is urgently needed to support patients in reaching nutrition adequacy.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Illness Weakness, Polyneuropathy and Myopathy: Diagnosis, treatment, and long-term outcomes

BACKGROUND

Severe weakness associated with critical illness (CIW) is common. This narrative review summarizes the latest scientific insights and proposes a guide for clinicians to optimize the diagnosis and management of the CIW during the various stages of the disease from the ICU to the community stage.

MAIN BODY

CIW arises as diffuse, symmetrical weakness after ICU admission, which is an important differentiating factor from other diseases causing non-symmetrical muscle weakness or paralysis. In patients with adequate cognitive function, CIW can be easily diagnosed at the bedside using manual muscle testing, which should be routinely conducted until ICU discharge. In patients with delirium or coma or those with prolonged, severe weakness, specific neurophysiological investigations and, in selected cases, muscle biopsy are recommended. With these exams, CIW can be differentiated into critical illness polyneuropathy or myopathy, which often coexist. On the general ward, CIW is seen in patients with prolonged previous ICU treatment, or in those developing a new sepsis. Respiratory muscle weakness can cause neuromuscular respiratory failure, which needs prompt recognition and rapid treatment to avoid life-threatening situations. Active rehabilitation should be reassessed and tailored to the new patient's condition to reduce the risk of disease progression. CIW is associated with long-term physical, cognitive and mental impairments, which emphasizes the need for a multidisciplinary model of care. Follow-up clinics for patients surviving critical illness may serve this purpose by providing direct clinical support to patients, managing referrals to other specialists and general practitioners, and serving as a platform for research to describe the natural history of post-intensive care syndrome and to identify new therapeutic interventions. This surveillance should include an assessment of the activities of daily living, mood, and functional mobility. Finally, nutritional status should be longitudinally assessed in all ICU survivors and incorporated into a patient-centered nutritional approach guided by a dietician.

CONCLUSIONS

Early ICU mobilization combined with the best evidence-based ICU practices can effectively reduce short-term weakness. Multi-professional collaborations are needed to guarantee a multi-dimensional evaluation and unitary community care programs for survivors of critical illnesses.

Survival outcomes and mobilization during venovenous extracorporeal membrane oxygenation: a retrospective cohort study

Introduction

Venovenous extracorporeal membrane oxygenation (V-V ECMO) can be considered in critically ill patient in severe pulmonary failure. However, the mobilization of patients on V-V ECMO can be challenging due to logistic and safety concerns. This study aimed to investigate whether 30 days survival was improved in patients who were mobilized during V-V ECMO support.

Methods

We conducted a retrospective cohort all-comer study that included all patients cannulated for V-V ECMO at a single center. Patients with a V-V ECMO duration below 24 h were excluded from the analysis. The patients were grouped based on the ICU mobility scale documented during V-V ECMO support. The primary endpoint was 30 days survival, and secondary endpoints included weaning from ECMO and mechanical ventilation, as well as hospital survival.

Results

A total of 343 patients were included in the study, with a median age of 56 years and 32% were female. Among them, 28% had chronic lung disease. The ICU mobilization scale ≥2 during ECMO was documented in 62/343 (18%) patients. There were no significant differences in age, gender and preexisting lung disease. Duration of ICU stay (13.1 vs. 15.6 days), time on ECMO (186 vs. 190 h) and mechanical ventilation (11.2 vs. 13.6 days) were slightly shorter in patients with ICU mobility scale <2 compared to those with ≥2 (all p = 0.0001). However, patients with ICU mobilization scale ≥2 showed significantly better 30 days survival (71.0 vs. 48.0%, OR 2.6 (1.5 to 4.8), p = 0.0012) compared to those with <2. In the ≥2 mobility scale group, a significantly higher number of patients were successfully weaned from the ventilator (61.3 vs. 46.6%, OR 1.8 (1.0 to 3.2), p = 0.049). A stronger correlation was observed between more intense mobilizations, such as being in a standing position (OR 5.0 (1.7 to 14.0), p = 0.0038), and higher 30 days survival.

Conclusion

The findings of this study suggest that active mobilization during V-V ECMO support is associated with improved 30 days survival and successful weaning from the respirator. Incorporating mobilization as part of the therapeutic approach during ECMO support may offer potential benefits for critically ill patients.

Sonometric assessment of cough predicts extubation failure: SonoWean-a proof-of-concept study

BACKGROUND

Extubation failure is associated with increased mortality. Cough ineffectiveness may be associated with extubation failure, but its quantification for patients undergoing weaning from invasive mechanical ventilation (IMV) remains challenging.

METHODS

Patients under IMV for more than 24 h completing a successful spontaneous T-tube breathing trial (SBT) were included. At the end of the SBT, we performed quantitative sonometric assessment of three successive coughing efforts using a sonometer. The mean of the 3-cough volume in decibels was named Sonoscore.

RESULTS

During a 1-year period, 106 patients were included. Median age was 65 [51-75] years, mainly men (60%). Main reasons for IMV were acute respiratory failure (43%), coma (25%) and shock (17%). Median duration of IMV at enrollment was 4 [3-7] days. Extubation failure occurred in 15 (14%) patients. Baseline characteristics were similar between success and failure extubation groups, except percentage of simple weaning which was lower and MV duration which was longer in extubation failure patients. Sonoscore was significantly lower in patients who failed extubation (58 [52-64] vs. 75 [70-78] dB, P < 0.001). After adjustment on MV duration and comorbidities, Sonoscore remained associated with extubation failure. Sonoscore was predictive of extubation failure with an area under the ROC curve of 0.91 (IC95% [0.83-0.99], P < 0.001). A threshold of Sonoscore < 67.1 dB predicted extubation failure with a sensitivity of 0.93 IC95% [0.70-0.99] and a specificity of 0.82 IC95% [0.73-0.90].

CONCLUSION

Sonometric assessment of cough strength might be helpful to identify patients at risk of extubation failure in patients undergoing IMV.

Guideline on multimodal rehabilitation for patients with post-intensive care syndrome

BACKGROUND

Intensive Care Unit (ICU) survivors often experience several impairments in their physical, cognitive, and psychological health status, which are labeled as post-intensive care syndrome (PICS). The aim of this work is to develop a multidisciplinary and -professional guideline for the rehabilitative therapy of PICS.

METHODS

A multidisciplinary/-professional task force of 15 healthcare professionals applied a structured, evidence-based approach to address 10 scientific questions. For each PICO-question (Population, Intervention, Comparison, and Outcome), best available evidence was identified. Recommendations were rated as "strong recommendation", "recommendation" or "therapy option", based on Grading of Recommendations, Assessment, Development and Evaluation principles. In addition, evidence gaps were identified.

RESULTS

The evidence resulted in 12 recommendations, 4 therapy options, and one statement for the prevention or treatment of PICS.

RECOMMENDATIONS

early mobilization, motor training, and nutrition/dysphagia management should be performed. Delirium prophylaxis focuses on behavioral interventions. ICU diaries can prevent/treat psychological health issues like anxiety and post-traumatic stress disorders. Early rehabilitation approaches as well as long-term access to specialized rehabilitation centers are recommended. Therapy options include additional physical rehabilitation interventions. Statement: A prerequisite for the treatment of PICS are the regular and repeated assessments of the physical, cognitive and psychological health in patients at risk for or having PICS.

CONCLUSIONS

PICS is a variable and complex syndrome that requires an individual multidisciplinary, and multiprofessional approach. Rehabilitation of PICS should include an assessment and therapy of motor-, cognitive-, and psychological health impairments.

A wastewater-based risk index for SARS-CoV-2 infections among three cities on the Canadian Prairie

Wastewater surveillance (WWS) is useful to better understand the spreading of coronavirus disease 2019 (COVID-19) in communities, which can help design and implement suitable mitigation measures. The main objective of this study was to develop the Wastewater Viral Load Risk Index (WWVLRI) for three Saskatchewan cities to offer a simple metric to interpret WWS. The index was developed by considering relationships between reproduction number, clinical data, daily per capita concentrations of virus particles in wastewater, and weekly viral load change rate. Trends of daily per capita concentrations of SARS-CoV-2 in wastewater for Saskatoon, Prince Albert, and North Battleford were similar during the pandemic, suggesting that per capita viral load can be useful to quantitatively compare wastewater signals among cities and develop an effective and comprehensible WWVLRI. The effective reproduction number (Rt) and the daily per capita efficiency adjusted viral load thresholds of 85 × 106 and 200 × 106 N2 gene counts (gc)/population day (pd) were determined. These values with rates of change were used to categorize the potential for COVID-19 outbreaks and subsequent declines. The weekly average was considered 'low risk' when the per capita viral load was 85 × 106 N2 gc/pd. A 'medium risk' occurs when the per capita copies were between 85 × 106 and 200 × 106 N2 gc/pd. with a rate of change <100 %. The start of an outbreak is indicated by a 'medium-high' risk classification when the week-over-week rate of change was >100 %, and the absolute magnitude of concentrations of viral particles was >85 × 106 N2 gc/pd. Lastly, a 'high risk' occurs when the viral load exceeds 200 × 106 N2 gc/pd. This methodology provides a valuable resource for decision-makers and health authorities, specifically given the limitation of COVID-19 surveillance based on clinical data.

Course of recovery of respiratory muscle strength and its associations with exercise capacity and handgrip strength: A prospective cohort study among survivors of critical illness

BACKGROUND

Mechanical ventilation affects the respiratory muscles, but little is known about long-term recovery of respiratory muscle weakness (RMW) and potential associations with physical functioning in survivors of critical illness. The aim of this study was to investigate the course of recovery of RMW and its association with functional outcomes in patients who received mechanical ventilation.

METHODS

We conducted a prospective cohort study with 6-month follow-up among survivors of critical illness who received ≥ 48 hours of invasive mechanical ventilation. Primary outcomes, measured at 3 timepoints, were maximal inspiratory and expiratory pressures (MIP/MEP). Secondary outcomes were functional exercise capacity (FEC) and handgrip strength (HGS). Longitudinal changes in outcomes and potential associations between MIP/MEP, predictor variables, and secondary outcomes were investigated through linear mixed model analysis.

RESULTS

A total of 59 participants (male: 64%, median age [IQR]: 62 [53-66]) were included in this study with a median (IQR) ICU and hospital length of stay of 11 (8-21) and 35 (21-52) days respectively. While all measures were well below predicted values at hospital discharge (MIP: 68.4%, MEP 76.0%, HGS 73.3% of predicted and FEC 54.8 steps/2m), significant 6-month recovery was seen for all outcomes. Multivariate analyses showed longitudinal associations between older age and decreased MIP and FEC, and longer hospital length of stay and decreased MIP and HGS outcomes. In crude models, significant, longitudinal associations were found between MIP/MEP and FEC and HGS outcomes. While these associations remained in most adjusted models, an interaction effect was observed for sex.

CONCLUSION

RMW was observed directly after hospital discharge while 6-month recovery to predicted values was noted for all outcomes. Longitudinal associations were found between MIP and MEP and more commonly used measures for physical functioning, highlighting the need for continued assessment of respiratory muscle strength in deconditioned patients who are discharged from ICU. The potential of targeted training extending beyond ICU and hospital discharge should be further explored.

A systematic review on impact of SARS-CoV-2 infection

Innumerable pathogens including RNA viruses have catastrophic pandemic propensity, in turn, SARS-CoV-2 infection is highly contagious. Emergence of SARS-CoV-2 variants with high mutation rate additionally codifies infectious ability of virus and arisen clinical imputations to human health. Although, our knowledge of mechanism of virus infection and its impact on host system has been substantially demystified, uncertainties about the emergence of virus are still not fully understood. To date, there are no potentially curative drugs are identified against the viral infection. Even though, drugs are repurposed in the initial period of infection, many are significantly negative in clinical trials. Moreover, the infection is dependent on organ status, co-morbid conditions, variant of virus and geographic region. This review article aims to comprehensively describe the SARS-CoV-2 infection and the impacts in the host cellular system. This review also briefly provides an overview of genome, proteome and metabolome associated risk to infection and the advancement of therapeutics in SARS-CoV-2 infection management.

Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement

Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.

Out of Chaos Leaders Emerged

COVID-19 had a major influence on nursing with the pandemic resulting in changes in the work environment while experiencing physical and emotional challenges such as moral distress, fear for self and family and dealing with the unknown. However, during this period, nurses demonstrated extraordinary resilience, crafted innovations in clinical practice, communication and support, providing leadership in the health service and in the nursing profession.

Application of Neuromuscular Blockers in Patients with ARDS in ICU: A Retrospective Study Based on the MIMIC-III Database

BACKGROUND

Although neuromuscular blocker agents (NMBAs) are recommended by guidelines as a treatment for ARDS patients, the efficacy of NMBAs is still controversial. Our study aimed to investigate the association between cisatracurium infusion and the medium- and long-term outcomes of critically ill patients with moderate and severe ARDS.

METHODS

We performed a single-center, retrospective study of 485 critically ill adult patients with ARDS based on the Medical Information Mart for Intensive Care III (MIMIC-III) database. Propensity score matching (PSM) was used to match patients receiving NMBA administration with those not receiving NMBAs. The Cox proportional hazards model, Kaplan-Meier method, and subgroup analysis were used to evaluate the relationship between NMBA therapy and 28-day mortality.

RESULTS

A total of 485 moderate and severe patients with ARDS were reviewed and 86 pairs of patients were matched after PSM. NMBAs were not associated with reduced 28-day mortality (hazard ratio (HR) 1.44; 95% CI: 0.85~2.46; p = 0.20), 90-day mortality (HR = 1.49; 95% CI: 0.92~2.41; p = 0.10), 1-year mortality (HR = 1.34; 95% CI: 0.86~2.09; p = 0.20), or hospital mortality (HR = 1.34; 95% CI: 0.81~2.24; p = 0.30). However, NMBAs were associated with a prolonged duration of ventilation and the length of ICU stay.

CONCLUSIONS

NMBAs were not associated with improved medium- and long-term survival and may result in some adverse clinical outcomes.

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

BACKGROUND

The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation.

METHODS

This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008-2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003-2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation.

RESULTS

We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8).

CONCLUSION

Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.

Reconfiguring the social organization of work in the intensive care unit: Changed relationships and new roles during COVID-19

The COVID-19 pandemic caused hospitals to make changes to workflow that exacerbated emotional exhaustion and burnout among health care workers. This article examines one of those changes, restricted visitation, showing how it changed the social organization of work by upending established interactional patterns and relationships between health care workers, patients, and patients' families. Based on 40 interviews with intensive care unit (ICU) workers in units that were full of COVID-19 patients and had fully restricted visitation, study findings show that staff took on emotional support roles with patients that had typically been done by families at the bedside. They also faced increased anger, distrust, and misunderstandings from families who were not allowed to see their dying loved one. With each other, staff bonded together with dark humor and candid talk about the scale of deaths, constructing a shared understanding and solidarity amidst the tragedy of the pandemic.

Bacterial Superinfection and Antibiotic Management in Patients with COVID-19 Admitted to Intensive Care Medicine in Central Iran: A Follow-Up Study

Background

Bacterial superinfections are one of the crucial challenges in patients with coronavirus disease 2019 (COVID-19) that are associated with a high mortality rate. The current study was designed to assess bacterial superinfections and antibiotic management in COVID-19 patients admitted to intensive care unit (ICU).

Material and Methods

Seventy-three adult intubated patients with COVID-19 were included in a cross-sectional study. The lung aspirate samples were collected in two stages and assessed for bacterial growth by standard methods. Antimicrobial susceptibility testing was performed using the Kirby-Bauer method as recommended by the Clinical Laboratory Standard Institute guideline (2021 edition). Also, demographic and clinical data were collected. The statistical analysis was done by chisquare test and Student's t-test, and a P value <0.05 was considered significant.

Results

Forty men and thirty-three women with a mean age of 64.78 ± 13.90 have included in our study. The mean length of hospitalization and stay in ICU were 18.77 ± 12.94 and 13.51 ± 9.83 days, respectively; 84.9% of cases died. Thirty-three patients had a bacterial superinfection mainly caused by Klebsiella spp and Acinetobacter spp; 21.2% of piperacillin/tazobactam consumers' patients survived that; the differences were significant (p = 0.034). A significant relationship was seen between superinfection and length of hospital stay until intubation (p = 0.033).

Conclusion

Bacterial superinfection and mortality rates were relatively high in COVID-19 patients admitted to ICU. According to the results, using beta-lactam/beta-lactamase inhibitors antibiotics in hospitalized patients in ICU can effectively control superinfection.

Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients-The mNUTRIC Score is an Independent Predictor

Background

The expiratory abdominal skeletal muscles are an important component of the respiratory muscle pump, and their reduced thickness has been associated with difficult weaning. There is no objective score that may help clinicians to predict expiratory abdominal muscle thinning.

Patients and methods

This was a single-center retrospective study on 81 patients undergoing weaning from mechanical ventilation. The thickness of the four abdominal expiratory muscles-rectus abdominis (RA), internal oblique (IO), external oblique (EO), and transversus abdominis (TA) on the day of the first spontaneous breathing trial (SBT), was obtained. The various parameters of the patients with thinner RA, IO, EO, and TA below the determined thickness cut-off values, predicting difficult weaning was analyzed.

Results

Modified nutritional risk in critically ill (mNUTRIC) score was found to be an independent predictor of thinner IO muscle after logistic regression analysis [p = 0.001, adjusted OR 2.33, 95% CI (1.394-3.892)]. The mNUTRIC score was also an independent predictor of thinner EO (p = 0.014, adjusted OR 1.57) and RA muscle (p = 0.002, adjusted OR 1.69). The mNUTRIC cutoff score ≥4 predicted thinner IO (AUC 0.813, p < 0.001 sensitivity 71%, specificity 77%) and thinner EO (AUC 0.738, p < 0.001, 71% sensitivity, 67% specificity). The mNUTRIC score ≥3 predicted that at least one out of the four abdominal expiratory muscles will be thin (AUC 0.849, p < 0.001, 95% CI [0.763-0.935], sensitivity 87.5%, specificity 59%).

Conclusion

The mNUTRIC score is an independent predictor of thinner abdominal expiratory muscles in mechanically ventilated critically ill patients.

How to cite this article

Vishwas P, Amara V, Maddani SS, Chaudhuri S, Podder S. Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients-The mNUTRIC Score is an Independent Predictor. Indian J Crit Care Med 2023;27(1):8-15.

Neuromuscular blockade in mechanically ventilated pneumonia patients with moderate to severe hypoxemia: A multicenter retrospective study

BACKGROUND/PURPOSE

The benefit of neuromuscular blockades (NMBs) in critically ill patients receiving mechanical ventilation remains uncertain. Therefore, we aimed to investigate whether NMB use is associated with improved survival of mechanically ventilated pneumonia patients with moderate to severe hypoxemia.

METHODS

This retrospective multicenter study was conducted at five university-affiliated hospitals. Data of pneumonia patients aged 18 years and older who received mechanical ventilation between January 1, 2011, and December 31, 2020, were analyzed.

RESULTS

In a total of 1,130 patients, the mean patient age was 73.1 years (SD±12.6), and the overall mortality rate at 30 d was 29.5% (n = 333). NMB users had a higher 30 d mortality rate than NMB nonusers (33.9% vs. 26.8%, P = 0.014). After PS matching, the 30 d mortality rate was not significantly different between NMB users and nonusers (33.4% vs. 27.8%, p = 0.089). However, 90 d mortality rate was significantly increased in NMB users (39.7% vs. 31.9%, p = 0.021). Univariable Cox proportional hazard regression analyses showed that NMB use ≥ 3 d was significant risk factor for the 90 d mortality than those with < 3 d use (90 d mortality HR 1.39 [95% CI: 1.01-1.91], P = 0.045).

CONCLUSIONS

NMB use was not associated with lower 30 d mortality among mechanically ventilated pneumonia patients with moderate to severe hypoxemia. Rather, NMB users had higher 90 d mortality, furthermore, and NMB use ≥ 3 d was associated with a higher risk of long-term mortality compared to NMB use < 3 d. Therefore, care should be taken to avoid extended use of NMB in critically ill pneumonia patients during mechanical ventilation.

Early glycaemic variability increases 28-day mortality and prolongs intensive care unit stay in critically ill patients with pneumonia

OBJECTIVE

This study aimed to evaluate the effect of early glycaemic variability (GV) on 28-day mortality in critically ill patients with pneumonia.

PATIENTS AND METHODS

This single-centre retrospective study included patients admitted to the intensive care unit (ICU) due to pneumonia between 2018 and 2019. A total of 282 patients (mean age, 68.6 years) with blood sugar test (BST) results measured more than three times within 48 h after hospitalization and haemoglobin A1c (HbA1c) levels recorded within 2 months were enrolled. Coefficient of variation (CV) was calculated using the BST values. The effects of GV on 28-day mortality and prolonged ICU stay (>14 days) were also assessed.

RESULTS

The mean age was 60.6 years (male to female ratio, 2.5:1). The 28-day mortality rate was 31.6% (n = 89) and was not different according to the presence of diabetes (DM vs. non-DM) or HbA1c levels (≥7.5 vs. <7.5%; both p > .05). However, the mortality rate was significantly higher in patients with high GV (CV ≥ 36%) than in those with low GV (CV < 36%; 37.5 vs. 25.4%, p = .028). The risk of mortality in patients with high GV was prominent in the subgroups with DM or low HbA1c levels. Among the surviving patients (n = 193), 44 remained in the ICU for more than 14 days. Compared to low GV, high GV was associated with a higher rate of prolonged ICU stay, although not statistically significant (27.8 vs. 18.5%, p = .171). After adjusting for the severity of illness and treatment strategy, CV was an independent risk factor for 28-day mortality (hazard ratio [HR], 1.01, p = .04) and prolonged ICU stay (odds ratio, 1.02; p = .04).

CONCLUSIONS

High GV within 48 h of ICU admission was associated with an increased 28-day mortality risk and prolonged ICU stay. Early phase GV should be carefully managed in critically ill patients with pneumonia.KEY MESSAGESThe presence of diabetes or HbA1c alone is insufficient to predict 28-day mortality and prolonged ICU stay in critically ill patients with pneumonia.High glycaemic variability (GV) within 48 h of ICU admission increases 28-day mortality and prolongs ICU stay, which is consistent after adjusting for severity of illness and treatment strategy.Patients with high GV, especially those with DM or low HbA1c levels (<7.5%) should be more carefully treated to reduce mortality.

Cardiovascular Magnetic Resonance in Children with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19: Institutional Protocol-Based Medium-Term Follow-up Study

Multisystem inflammatory syndrome in children (MIS-C) secondary to COVID-19 infection in previously healthy children often results in subtle but persistent echocardiographic abnormalities despite complete clinical recovery. This study was done to investigate medium-term cardiovascular outcomes of patients with MIS-C using cardiovascular magnetic resonance imaging (CMR). This is a single-center retrospective study of patients aged less than 21 years, diagnosed with MIS-C who received an outpatient CMR, around 6 months after discharge. CMR was done in patients with significant troponin leak or depressed LVEF. CMR performed on a GE Signa HDxt 1.5 Tesla magnet with a myocarditis protocol. Diagnosis of myocarditis was determined by the original Lake Louise Criteria. There were 21 patients with a median age of 11 years, (IQR 8-13 years), who underwent CMR at median follow-up duration of 6 months (IQR 5-7 months). At the peak of illness during admission, there were 95.2% patients with abnormal Troponin I and BNP. By echocardiogram, 76.2% had left ventricular systolic dysfunction and 9.5% had coronary ectasia, which all resolved by 6 months. By CMR, there were five patients (23.8%) with abnormal left atrial volume, one patient (4.8%) with an abnormal indexed left ventricular end-diastolic volume, and three patients (15%) with abnormal LVEF. There was no evidence of myocardial edema in T2-weighted image sequence. There were three patients with persistent late gadolinium enhancement (14.3%). Follow-up CMR is a useful tool in diagnosing subtle myocardial abnormalities and guide necessity for future follow-up.

Assessment of drugs administered in the Middle East as part of the COVID-19 management protocols

The pandemic spread of coronavirus (COVID-19) has been reported first at the end of 2019. It continues disturbing various human aspects with multiple pandemic waves showing more fatal novel variants. Now Egypt faces the sixth wave of the pandemic with controlled governmental measures. COVID-19 is an infectious respiratory disease-causing mild to moderate illness that can be progressed into life-threatening complications based on patients- and variant type-related factors. The symptoms vary from dry cough, fever to difficulty in breathing that required urgent hospitalization. Most countries have authorized their national protocols for managing manifested symptoms and thus lowering the rate of patients' hospitalization and boosting the healthcare systems. These protocols are still in use even with the development and approval of several vaccines. These protocols were instructed to aid home isolation, bed rest, dietary supplements, and additionally the administration of antipyretic, steroids, and antiviral drugs. The current review aimed to highlight the administered protocols in the Middle East, namely in Egypt and the Kingdom of Saudi Arabia demonstrating how these protocols have shown potential effectiveness in treating patients and saving many soles.

[German S1 Guideline Long-/Post-COVID]

The German Society of Pneumology initiated 2021 the AWMF S1 guideline Long COVID/Post-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendations describe current Long COVID/Post-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an explicit practical claim and will be developed and adapted by the author team based on the current increase in knowledge.

The Relative Risk of Toxico-Clinical Parameters with respect to Poisoning Severity and Outcomes in Patients with Acute Poisoning

Background

Complications or death risk factors is necessary for better monitoring and treatment. The aim of this study was to define the relative risk of toxico-clinical parameters with regard to poisoning severity and outcomes in patients with acute poisoning.

Materials and Methods

This cross-sectional study entailed of patients with acute poisoning admitted to the poisoning emergency center of khorshid hospital, Isfahan, Iran from December 2018 until March 2019. Patients (n = 300) were categorized into four groups (minor, moderate, severe, and fatal poisoning) based on severity. Multivariate logistic regression analysis was employed to calculate the odds ratio (OR) as the estimate of the relative risk of the different variables for the poisoning severity and outcomes prediction.

Results

In the minor group, opioids/opiates, alcohols, and benzodiazepines (14.7%) were the most prevalent poisoning, multidrug (23.3%) was in the moderate and severe groups and finally, pesticides poisoning (23%) was most common in the fatal group. The predictive factors for poisoning severity were pre-hospital antidote administration [OR, (95%CI); P value) [7.08 (1.77-28.34); 0.006]; loss of consciousness [4.38 (1.84-10.42), 0.001]; abnormal ECG [4.56 (1.65-12.56); 0.003]; and time interval of poisoning to admission in the hospital [1.15 (1.02-1.28); 0.01). Patients without complications was observed in 49.7% of subjects. Patients with the loss of consciousness [66.06 (2.41-180.07); 0.01); underlying disease [3.65 (1.09-12.24); 0.03]; abnormal respiration [1.14 (1.02-1.27); 0.02); have had a greater risk of complications and death.

Conclusion

Important factors for poisoning severity and/or outcome were loss of consciousness, pre-hospital antidote administration, abnormal ECG or respiration, underlying disease, and delay to presentation to hospital.

Automatic detection of Covid-19 from chest X-ray and lung computed tomography images using deep neural networks and transfer learning

The world has been undergoing the most ever unprecedented circumstances caused by the coronavirus pandemic, which is having a devastating global effect in different aspects of life. Since there are not effective antiviral treatments for Covid-19 yet, it is crucial to early detect and monitor the progression of the disease, thereby helping to reduce mortality. While different measures are being used to combat the virus, medical imaging techniques have been examined to support doctors in diagnosing the disease. In this paper, we present a practical solution for the detection of Covid-19 from chest X-ray (CXR) and lung computed tomography (LCT) images, exploiting cutting-edge Machine Learning techniques. As the main classification engine, we make use of EfficientNet and MixNet, two recently developed families of deep neural networks. Furthermore, to make the training more effective and efficient, we apply three transfer learning algorithms. The ultimate aim is to build a reliable expert system to detect Covid-19 from different sources of images, making it be a multi-purpose AI diagnosing system. We validated our proposed approach using four real-world datasets. The first two are CXR datasets consist of 15,000 and 17,905 images, respectively. The other two are LCT datasets with 2,482 and 411,528 images, respectively. The five-fold cross-validation methodology was used to evaluate the approach, where the dataset is split into five parts, and accordingly the evaluation is conducted in five rounds. By each evaluation, four parts are combined to form the training data, and the remaining one is used for testing. We obtained an encouraging prediction performance for all the considered datasets. In all the configurations, the obtained accuracy is always larger than 95.0%. Compared to various existing studies, our approach yields a substantial performance gain. Moreover, such an improvement is statistically significant.

Weaning and extubation from neonatal mechanical ventilation: an evidenced-based review

Mechanical ventilation is a lifesaving treatment used to treat critical neonatal patients. It facilitates gas exchange, oxygenation, and CO2 removal. Despite advances in non-invasive ventilatory support methods in neonates, invasive ventilation (i.e., ventilation via an endotracheal tube) is still a standard treatment in NICUs. This ventilation approach may cause injury despite its advantages, especially in preterm neonates. Therefore, it is recommended that neonatologists consider weaning neonates from invasive mechanical ventilation as soon as possible. This review examines the steps required for the neonate's appropriate weaning and safe extubation from mechanical ventilation.

Chronic critical illness and post-intensive care syndrome: from pathophysiology to clinical challenges

Background

Post‐intensive care syndrome (PICS) encompasses physical, cognition, and mental impairments persisting after intensive care unit (ICU) discharge. Ultimately it significantly impacts the long‐term prognosis, both in functional outcomes and survival. Thus, survivors often develop permanent disabilities, consume a lot of healthcare resources, and may experience prolonged suffering. This review aims to present the multiple facets of the PICS, decipher its underlying mechanisms, and highlight future research directions.

Main text

This review abridges the translational data underlying the multiple facets of chronic critical illness (CCI) and PICS. We focus first on ICU-acquired weakness, a syndrome characterized by impaired contractility, muscle wasting, and persisting muscle atrophy during the recovery phase, which involves anabolic resistance, impaired capacity of regeneration, mitochondrial dysfunction, and abnormalities in calcium homeostasis. Second, we discuss the clinical relevance of post-ICU cognitive impairment and neuropsychological disability, its association with delirium during the ICU stay, and the putative role of low-grade long-lasting inflammation. Third, we describe the profound and persistent qualitative and quantitative alteration of the innate and adaptive response. Fourth, we discuss the biological mechanisms of the progression from acute to chronic kidney injury, opening the field for renoprotective strategies. Fifth, we report long-lasting pulmonary consequences of ARDS and prolonged mechanical ventilation. Finally, we discuss several specificities in children, including the influence of the child’s pre-ICU condition, development, and maturation.

Conclusions

Recent understandings of the biological substratum of the PICS’ distinct features highlight the need to rethink our patient trajectories in the long term. A better knowledge of this syndrome and precipitating factors is necessary to develop protocols and strategies to alleviate the CCI and PICS and ultimately improve patient recovery.

A novel algorithm for detection of COVID-19 by analysis of chest CT images using Hopfield neural network

BACKGROUND

Widely spread of the COVID-19 virus has put the whole world in jeopardy. At this moment, using new techniques to detect and treat this novel disease is of significance or maybe the first priority of many scientists and researchers throughout the world.

PURPOSE

To present a new algorithm for detecting the novel coronavirus 2019 using chest CT images with high accuracy.

MATERIALS AND METHODS

In this study, we looked at the newly-presented data and detection methods of this disease using chest CT; then, a new neural network algorithm was presented to recognize the COVID-19 symptoms. A mathematical model is used to enhance the accuracy of masking, and a high accuracy Hopfield Neural Network (HNN) is used for finding symptoms. A dataset of CT scans, including 12 pattern images, was trained by this neural network, and 295CT images from three different datasets were tested via the model.

RESULTS

The sensitivity and specificity of the model for detecting COVID-19 in test data were 97.4% (149 of 153) and 98.6% (140 of 142) respectively. Also, the sensitivity and specificity of the model for detecting CAP (community-acquired pneumonia) in test data were 97.3% (106 of 109) and 99.5% (185 of 186) respectively, and, the sensitivity and specificity of the model for detecting non-pneumonia patients were 100% (33 of 33) and 98.5% (258 of 262) respectively.

CONCLUSION

This new algorithm can potentially help detect the novel Coronavirus patients using CT images.