Comparison between standard Vs. Escalated dose venous thromboembolism (VTE) prophylaxis in critically ill patients with COVID-19: A two centers,observational study

IntroductionThe risk of mortality in patients with COVID-19 was found to be significantly higher in patients who experienced thromboembolic events. Thus, several guidelines recommend using prophylactic anticoagulants in all COVID-19 hospitalized patients. However, there is uncertainty about the appropriate dosing regimen and safety of anticoagulation in critically ill patients with COVID-19. Thus, this study aims to compare the effectiveness and safety of standard versus escalated dose pharmacological venous thromboembolism (VTE) prophylaxis in critically ill patients with COVID-19.MethodsA two-center retrospective cohort study including critically ill patients aged ≥ 18-years with confirmed COVID-19 admitted to the intensive care unit (ICU) at two tertiary hospitals in Saudi Arabia from March 1st, 2020, until January 31st, 2021. Patients who received either Enoxaparin 40 mg daily or Unfractionated heparin 5000 Units three times daily were grouped under the “standard dose VTE prophylaxis and patients who received higher than the standard dose but not as treatment dose were grouped under ”escalated VTE prophylaxis dose“. The primary outcome was the occurance of thrombotic events, and the secondary outcomes were bleeding, mortality, and other ICU-related complications.ResultsA total of 758 patients were screened; 565 patients were included in the study. We matched 352 patients using propensity score matching (1:1). In patients who received escalated dose pharmacological VTE prophylaxis, any case of thrombosis and VTE were similar between the two groups (OR 1.22;95 %CI 0.52–2.86; P = 0.64 and OR 0.75; 95% CI 0.16–3.38; P = 0.70 respectively). However, the odds of minor bleeding was higher in patients who received escalated VTE prophylaxis dose (OR 3.39; 95% CI 1.08–10.61; P = 0.04). There was no difference in the 30-day mortality nor in-hospital mortality between the two groups (HR 1.17;95 %CI0.79–1.73; P = 0.43 and HR 1.08;95 %CI 0.76–1.53; P = 0.83, respectively).ConclusionEscalated-dose pharmacological VTE prophylaxis in critically ill patients with COVID-19 was not associated with thrombosis, or mortality benefits but led to an increased risk of minor bleeding. This study supports previous evidence regarding the optimal dosing VTE pharmacological prophylaxis regimen for critically ill patients with COVID-19.     

Identification of factors affecting meropenem pharmacokinetics in critically ill patients: Impact of inflammation on clearance

IntroductionThe purpose of this study was to explore factors influencing meropenem pharmacokinetics (PKs) in critically ill patients by developing a population PK model and to determine the optimal dosing strategy.MethodsThis prospective observational study involved 12 critically ill patients admitted to the intensive care unit and treated with meropenem 1 g infused over 1 h every 8 h. Blood samples were collected on days 1, 2, and 5 immediately prior to dosing, and at 1, 2, 4, and 6 h after the start of infusion. Population PK parameters were estimated using nonlinear mixed-effects model software.ResultsMeropenem PK was adequately described using a two-compartment model. Typical values of total and inter-compartmental clearance were 9.30 L/h and 9.70 L/h, respectively, and the central and peripheral compartment volumes of distribution were 12.61 L and 7.80 L, respectively. C-reactive protein (CRP) was identified as significant covariate affecting total meropenem clearance. The probability of target attainment (PTA) predicted by Monte Carlo simulations varied according to the patients’ CRP. The PTA of 100% time above the minimum inhibitory concentration ≤2 mg/L for bacteria was achieved after a dose of 1 and 2 g infused over 4 h every 8 h in patients with CRP of 30 and 5 mg/dL, respectively.ConclusionThe findings of this study suggest that CRP might be helpful in managing meropenem dosing in critically ill patients. Higher doses and extended infusion may be required to achieve optimal pharmacodynamic targets.     

情境体验教学在临床急重症护理带教中的运用

目的分析情境体验教学在临床急重症护理带教中的运用效果。方法以2017年7月-2019年7月在我院实习的60名临床急重症护理实习生作为本次研究对象,通过双盲选法将60名护理实习生随机分为对照组(n=30)和研究组(n=30),对照组护理实习生的带教模式为传统护理带教,研究组护理实习生的带教模式为情境体验教学,比较两组护理实习生带教结束后的理论知识考核成绩、实操技能考核成绩以及护理能力评分差异。结果在理论知识考核成绩方面,对照组最终成绩明显低于研究组(P <0.05),在实操技能考核成绩方面,对照组最终成绩明显低于研究组(P <0.05)。在急救处置能力评分方面、护患沟通能力评分方面以及组织协调能力评分方面,对照组评分均明显低于研究组(P <0.05)。结论将情境体验教学模式应用于临床急重症护理带教中,不仅能够有效提高临床带教质量,同时还有利于进一步提升护理实习生的急救护理能力,具有良好的临床带教应用价值。     

血液净化技术在危重患者治疗中的应用进展

近年来血液净化技术不断发展，新模式和新材料不断涌现。在多种病因导致的危重患者中，血液净化均可以发挥重要的治疗作用。特别是对于内环境严重紊乱的危重患者，血液净化已经成为重要的生命支持手段。因为连续性血液净化技术对血流动力学影响较小，在危重患者的治疗中更具有优势。免疫吸附等新技术的出现，对一些危重患者的原发病也有很好的治疗效果。但是目前还存在抗凝剂选择、容量控制等需要进一步研究的问题。     

番泻叶在危重患者便秘治疗中的应用分析

目的探讨对于危重患者便秘治疗中采取番泻叶进行应用的临床效果分析。方法选取2017年1月—2017年12月进行治疗的危重患者共80例,按照治疗方式不同随机分为对照组与试验组,其中所选对照组患者采取常规西药进行治疗,试验组患者采取番泻叶结合西药进行治疗,观察2组患者临床疗效、首次排便、便秘严重程度评分等资料数据对比。结果根据试验数据可知,试验组患者在采取番泻叶结合西药进行治疗后临床疗效(92.50%)与对照组患者采取常规药物治疗的临床疗效(77.50%)存在统计学差异(P<0.05),所选2组患者治疗前各项数据比较不存在统计学差异(P>0.05),干预后排便间隔时间、便秘严重程度评分与便秘患者生存质量表与对照组患者数据对比后存在统计学差异(P<0.05)。结论对于危重患者采取番泻叶结合常规西药治疗,可有效提高患者临床治疗效果,大大提高患者首次排便的时间,改善排便间隔时间,保证消化道规律运行,大大减轻患者便秘严重程度的同时,有效提高患者的生活质量,有效的保护患者肠道功能,减轻肠胃压力,值得临床广泛推广实践。     

四川省危重型新型冠状病毒肺炎3例死亡病例分析

目的 分析危重型新型冠状病毒肺炎死亡病例的临床特征,提高对重症病例诊治的认识。方法 收集2020年1月—5月成都市公共卫生临床医疗中心接诊的危重型新型冠状病毒肺炎死亡病例资料,回顾性分析其临床资料和影像学特征。结果 3例危重型COVID-19死亡病例均有冠心病、伴或不伴肺部疾病、肾功能障碍等基础疾病,均有发热、咳嗽、咳痰症状,入院APACHEⅡ评分和PSI评分均为高危,实验室检查结果提示肌酸激酶、肌钙蛋白、脑钠肽、C-反应蛋白及血清淀粉样蛋白A明显升高,而T淋巴细胞计数明显下降,胸部影像学提示双肺磨玻璃斑片影。入院后给予积极的抗病毒、抗细菌、增强免疫治疗及有创机械通气呼吸支持。3例患者均并发脓毒性休克及多器官功能衰竭综合征等严重并发症,起病到死亡的平均时间为13.7 d。结论 高龄、合并心脏病等基础疾病、免疫功能低下者是危重型新型冠状病毒肺炎死亡的高危人群。     

Patient's Perspectives on the Notion of a Good Death: A Systematic Review of the Literature

ContextThere is no clear definition of what constitutes a good death or its features. Patients, caregivers, physicians, and relatives have different notions of a good death. Discussions have been driven by academic perspectives, with little research available on the patients' perspectives.ObjectivesTo explore the notions of a good death from the patients' perspective.MethodsA systematic literature search was conducted up to November 2017 using CINAHL®, MEDLINE®, EMBASE®, and PsycINFO® databases. Search terms used were “quality of death,” “good death,” “quality of dying,” or “good dying.” Scientific empirical studies that included the exploration of the notion of a good death in adult patients with advanced and life-threatening diseases were selected separately by two researchers. Hawker's et al. criteria were used to assess the quality of articles. The analysis was conducted using a thematic analysis.ResultsTwo thousand six hundred and fifty two titles were identified; after elimination of duplicates, screening, and final selection, 29 relevant publications remained for analysis. Sample populations included patients with terminal diseases (AIDS, cardiovascular disease, and cancer). Core elements for a “good death” included control of pain and symptoms, clear decision-making, feeling of closure, being seen and perceived as a person, preparation for death, and being still able to give something to others; whereas other factors such as culture, financial issues, religion, disease, age, and life circumstances were found to shape the concept across groups. Studies agree on the individuality of death and dying while revealing a diverse set of preferences, regarding not only particular attributes but also specific ways in which they contribute to a good death.ConclusionsAlthough sharing common core elements, patients' notions of good death are individual, unique, and different. They are dynamic in nature, fluctuating within particular groups and during the actual process of dying. Formal and informal caregivers should carefully follow-up and respect the patient's individual concepts and preferences regarding death and dying, while attending to shared core elements, to better adjust clinical decisions.