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Bracegirdle L, Stubbs M, Rahman R, Jackson AIR, Burton-Papp HC, Chambers R, Gupta S, Grocott MPW, Dushianthan A. Organisation and delivery of a dedicated multidisciplinary prone ventilation team in the intensive care unit: Strategies and lessons from COVID-19. PLoS One 2023; 18:e0296379. [PMID: 38153940 PMCID: PMC10754430 DOI: 10.1371/journal.pone.0296379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND COVID-19 placed immense strain on healthcare systems, necessitating innovative responses to the surge of critically ill patients, particularly those requiring mechanical ventilation. In this report, we detail the establishment of a dedicated critical care prone positioning team at University Hospital Southampton in response to escalating demand for prone positioning during the initial wave of the pandemic. METHODS The formation of a prone positioning team involved meticulous planning and collaboration across disciplines to ensure safe and efficient manoeuvrers. A comprehensive training strategy, aligned with national guidelines, was implemented for approximately 550 staff members from a diverse background. We surveyed team members to gain insight to the lived experience. RESULTS A total of 78 full-time team members were recruited and successfully executed over 1200 manoeuvres over an eight-week period. Our survey suggests the majority felt valued and expressed pride and willingness to participate again should the need arise. CONCLUSION The rapid establishment and deployment of a dedicated prone positioning team may have contributed to both patient care and staff well-being. We provide insight and lessons that may be of value for future respiratory pandemics. Future work should explore objective clinical outcomes and long-term sustainability of such services.
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Affiliation(s)
- Luke Bracegirdle
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Matthew Stubbs
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Rezaur Rahman
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Alexander I. R. Jackson
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Helmi C. Burton-Papp
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Robert Chambers
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Sanjay Gupta
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Michael P. W. Grocott
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Ahilanandan Dushianthan
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Dushianthan A, Bracegirdle L, Cusack R, Cumpstey AF, Postle AD, Grocott MPW. Alveolar Hyperoxia and Exacerbation of Lung Injury in Critically Ill SARS-CoV-2 Pneumonia. Med Sci (Basel) 2023; 11:70. [PMID: 37987325 PMCID: PMC10660857 DOI: 10.3390/medsci11040070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/17/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023] Open
Abstract
Acute hypoxic respiratory failure (AHRF) is a prominent feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) critical illness. The severity of gas exchange impairment correlates with worse prognosis, and AHRF requiring mechanical ventilation is associated with substantial mortality. Persistent impaired gas exchange leading to hypoxemia often warrants the prolonged administration of a high fraction of inspired oxygen (FiO2). In SARS-CoV-2 AHRF, systemic vasculopathy with lung microthrombosis and microangiopathy further exacerbates poor gas exchange due to alveolar inflammation and oedema. Capillary congestion with microthrombosis is a common autopsy finding in the lungs of patients who die with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome. The need for a high FiO2 to normalise arterial hypoxemia and tissue hypoxia can result in alveolar hyperoxia. This in turn can lead to local alveolar oxidative stress with associated inflammation, alveolar epithelial cell apoptosis, surfactant dysfunction, pulmonary vascular abnormalities, resorption atelectasis, and impairment of innate immunity predisposing to secondary bacterial infections. While oxygen is a life-saving treatment, alveolar hyperoxia may exacerbate pre-existing lung injury. In this review, we provide a summary of oxygen toxicity mechanisms, evaluating the consequences of alveolar hyperoxia in COVID-19 and propose established and potential exploratory treatment pathways to minimise alveolar hyperoxia.
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Affiliation(s)
- Ahilanandan Dushianthan
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Luke Bracegirdle
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Rebecca Cusack
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Andrew F Cumpstey
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Anthony D Postle
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P W Grocott
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Bracegirdle L, Jackson A, Beecham R, Burova M, Hunter E, Hamilton LG, Pandya D, Morden C, Grocott MPW, Cumpstey A, Dushianthan A. Dynamic blood oxygen indices in mechanically ventilated COVID-19 patients with acute hypoxic respiratory failure: A cohort study. PLoS One 2022; 17:e0269471. [PMID: 35687543 PMCID: PMC9187096 DOI: 10.1371/journal.pone.0269471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Acute hypoxic respiratory failure (AHRF) is a hallmark of severe COVID-19 pneumonia and often requires supplementary oxygen therapy. Critically ill COVID-19 patients may require invasive mechanical ventilation, which carries significant morbidity and mortality. Understanding of the relationship between dynamic changes in blood oxygen indices and clinical variables is lacking. We evaluated the changes in blood oxygen indices–PaO2, PaO2/FiO2 ratio, oxygen content (CaO2) and oxygen extraction ratio (O2ER) in COVID-19 patients through the first 30-days of intensive care unit admission and explored relationships with clinical outcomes.
Methods and findings
We performed a retrospective observational cohort study of all adult COVID-19 patients in a single institution requiring invasive mechanical ventilation between March 2020 and March 2021. We collected baseline characteristics, clinical outcomes and blood oxygen indices. 36,383 blood gas data points were analysed from 184 patients over 30-days. Median participant age was 59.5 (IQR 51.0, 67.0), BMI 30.0 (IQR 25.2, 35.5) and the majority were men (62.5%) of white ethnicity (70.1%). Median duration of mechanical ventilation was 15-days (IQR 8, 25). Hospital survival at 30-days was 72.3%. Non-survivors exhibited significantly lower PaO2 throughout intensive care unit admission: day one to day 30 averaged mean difference -0.52 kPa (95% CI: -0.59 to -0.46, p<0.01). Non-survivors exhibited a significantly lower PaO2/FiO2 ratio with an increased separation over time: day one to day 30 averaged mean difference -5.64 (95% CI: -5.85 to -5.43, p<0.01). While all patients had sub-physiological CaO2, non-survivors exhibited significantly higher values. Non-survivors also exhibited significantly lower oxygen extraction ratio with an averaged mean difference of -0.08 (95% CI: -0.09 to -0.07, p<0.01) across day one to day 30.
Conclusions
As a novel cause of acute hypoxic respiratory failure, COVID-19 offers a unique opportunity to study a homogenous cohort of patients with hypoxaemia. In mechanically ventilated adult COVID-19 patients, blood oxygen indices are abnormal with substantial divergence in PaO2/FiO2 ratio and oxygen extraction ratio between survivors and non-survivors. Despite having higher CaO2 values, non-survivors appear to extract less oxygen implying impaired oxygen utilisation. Further exploratory studies are warranted to evaluate and improve oxygen extraction which may help to improve outcomes in severe hypoxaemic mechanically ventilated COVID-19 patients.
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Affiliation(s)
- Luke Bracegirdle
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Alexander Jackson
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, Hampshire, United Kingdom
| | - Ryan Beecham
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Maria Burova
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Elsie Hunter
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Laura G. Hamilton
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Darshni Pandya
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Clare Morden
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Michael P. W. Grocott
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, Hampshire, United Kingdom
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, Hampshire, United Kingdom
- * E-mail:
| | - Andrew Cumpstey
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, Hampshire, United Kingdom
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, Hampshire, United Kingdom
| | - Ahilanandan Dushianthan
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, Hampshire, United Kingdom
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, Hampshire, United Kingdom
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Richardson A, Bracegirdle L, McLachlan SIH, Chapman SR. Use of a three-dimensional virtual environment to teach drug-receptor interactions. Am J Pharm Educ 2013; 77:11. [PMID: 23459131 PMCID: PMC3578324 DOI: 10.5688/ajpe77111] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 08/14/2012] [Indexed: 05/14/2023]
Abstract
Objective. To determine whether using 3-dimensional (3D) technology to teach pharmacy students about the molecular basis of the interactions between drugs and their targets is more effective than traditional lecture using 2-dimensional (2D) graphics.Design. Second-year students enrolled in a 4-year masters of pharmacy program in the United Kingdom were randomly assigned to attend either a 3D or 2D presentation on 3 drug targets, the β-adrenoceptor, the Na(+)-K(+) ATPase, and the nicotinic acetylcholine receptor.Assessment. A test was administered to assess the ability of both groups of students to solve problems that required analysis of molecular interactions in 3D space. The group that participated in the 3D teaching presentation performed significantly better on the test than the group who attended the traditional lecture with 2D graphics. A questionnaire was also administered to solicit students' perceptions about the 3D experience. The majority of students enjoyed the 3D session and agreed that the experience increased their enthusiasm for the course.Conclusions. Viewing a 3D presentation of drug-receptor interactions improved student learning compared to learning from a traditional lecture and 2D graphics.
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MESH Headings
- Computer Graphics
- Computer-Assisted Instruction
- Education, Pharmacy/methods
- Educational Measurement
- England
- Humans
- Imaging, Three-Dimensional
- Learning
- Ligands
- Molecular Conformation
- Personal Satisfaction
- Pharmaceutical Preparations/chemistry
- Pharmaceutical Preparations/metabolism
- Pharmacology/education
- Problem Solving
- Program Evaluation
- Protein Conformation
- Receptors, Adrenergic, beta/chemistry
- Receptors, Adrenergic, beta/drug effects
- Receptors, Adrenergic, beta/metabolism
- Receptors, Nicotinic/chemistry
- Receptors, Nicotinic/drug effects
- Receptors, Nicotinic/metabolism
- Sodium-Potassium-Exchanging ATPase/metabolism
- Structure-Activity Relationship
- Students, Pharmacy/psychology
- Surveys and Questionnaires
- Teaching/methods
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Affiliation(s)
- Alan Richardson
- School of Pharmacy, Keele University, Keele, United Kingdom.
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