Successful management of three patients with autoimmune thrombotic thrombocytopenic purpura with paradigm-changing therapy: Caplacizumab,steroids, plasma exchange,rituximab, and intravenous immunoglobulins (CASPERI)

Autoimmune thrombotic thrombocytopenic purpura (aTTP) is a severe disease caused by the production of autoantibodies against von Willebrand factor (vWF)-cleaving ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin-1 motifs; 13th member of the family). In 2018, caplacizumab was approved for the treatment of patients with acute aTTP in conjunction with plasma exchange (PE) and immunosuppressive therapy. Immunosuppressive standard of care includes mainly steroids whereas rituximab is usually reserved for refractory cases. We report three patients with a first acute episode of aTTP who were successfully treated with a paradigm-changing scheme including standard of care (caplacizumab, steroids and PE) plus upfront therapy with rituximab and intravenous immunoglobulins (CASPERI). Rituximab was added 1–4 days after diagnosis, when ADAMTS13 autoantibodies were detected and intravenous immunoglobulins were administered after performing PE using albumin as replacement solution. Successful outcome was observed in all three patients: platelet recovery (>150 × 10⁹/L) was observed after 3, 4, and 5 days from diagnosis; ADAMTS13 activity >5% and ADAMTS13 autoantibodies were negative after 14, 15, and 21 days from diagnosis. In conclusion, caplacizumab, steroids, PE (using fresh frozen plasma or albumin as replacement solution and adding intravenous immunoglobulins) plus upfront rituximab therapy was a safe and efficient combination to induce remission in case of acute aTTP.     

Comparing the Timeliness of Treatment in Younger vs. Older Patients with ST-Segment Elevation Myocardial Infarction: A Multi-Center Cohort Study

BackgroundST-segment elevation myocardial infarction (STEMI) predominantly affects older adults. Lower incidence among younger patients may challenge diagnosis.ObjectivesWe hypothesize that among patients ≤ 50 years old, emergent percutaneous coronary intervention (PCI) for STEMI is delayed when compared with patients aged > 50 years.MethodsThis 3-year, 10-center retrospective cohort study included emergency department (ED) STEMI patients ≥ 18 years of age treated with emergent PCI. We excluded patients with an electrocardiogram (ECG) completed prior to ED arrival or a nondiagnostic initial ECG. Our primary outcome was door-to-balloon (D2B) time. We compared characteristics and outcomes among younger vs. older STEMI patients, and among age subgroups.ResultsThere were 576 ED STEMI PCI patients, of whom 100 were ≤ 50 years old and 476 were > 50 years old. Median age was 44 years in the younger cohort (interquartile range [IQR] 41–47) vs. 62 years (IQR 57–70) among older patients. Median D2B time for the younger cohort was 76.5 min (IQR 67.5–102.5) vs. 81.0 min (IQR 65.0–105.5) in the older cohort (p = 0.91). This outcome did not change when ages 40 or 45 years were used to demarcate younger vs. older. The younger cohort had a higher prevalence of nonwhite races (38% vs. 21%; p < 0.001) and those currently smoking (36% vs. 23%; p = 0.005). The very young (≤30 years; 6/576) and very old (>80 years; 45/576) had 5.51 and 2.2 greater odds of delays.ConclusionWe found no statistically significant difference in D2B times between patients ≤ 50 years old and those > 50 years old. Nonwhite patients and those who smoke were disproportionately represented within the younger population. The very young and very old had higher odds of D2B times > 90 min.     

Caplacizumab: a change in the paradigm of thrombotic thrombocytopenic purpura treatment

ABSTRACT

Introduction: Immune thrombotic thrombocytopenic purpura (iTTP) is an immune-mediated deficiency in von Willebrand factor-cleaving protease ADAMTS13 allowing unrestrained adhesion of von Willebrand factor multimers to platelets and microthrombosis. Caplacizumab, an anti-von Willebrand factor humanized, bivalent single-domain nanobody preventing its binding to the platelet has been investigated and approved for use in the treatment of iTTP.

Areas covered: The purpose of this article is to summarize the available clinical data on the efficacy and safety of caplacizumab in iTTP and to provide our opinion on the place of caplacizumab in current treatment regimens.

Expert opinion: Caplacizumab is a new drug with a complementary mechanism of action with respect to the standard available therapeutics. It demonstrated efficacy in clinical trials through a faster platelet count normalization and protection of patients from exacerbations and refractoriness. Caplacizumab is well tolerated with minor bleeds as the most important side effect. The efficacy of caplacizumab now needs to be assessed in real-life but definitely, this drug opens hope for a significant improvement in iTTP prognosis at the very early, critical step of the disease.

Trial registration: ClinicalTrials.gov identifier: NCT03922308.

Trial registration: ClinicalTrials.gov identifier: NCT02553317.     

Structured scoring of supporting nursing tasks to enhance early discharge in geriatric rehabilitation: The BACK-HOME quasi-experimental study

IntroductionIn geriatric rehabilitation it is important to have timely discharge of patients, especially if they have low nursing support needs. However, no instruments are available to identify early discharge potential.ObjectiveTo evaluate if weekly scoring of a nursing support scorecard in the evenings/nights and discussing the results in the multidisciplinary team meeting, leads to potential differences in discharge of geriatric rehabilitation patients.DesignQuasi-experimental study with a reference cohort (n = 200) and a Back-Home implementation cohort (n = 283).Setting/ParticipantsPatients in geriatric rehabilitation in the four participating skilled nursing facilities in the Netherlands.MethodsImplementation of the nursing support scorecard during one year consisted of (1) weekly scoring of the scorecard to identify the supporting nursing tasks during the evenings/nights by trained nurses, and (2) discussion of the results in a multidisciplinary team meeting to establish if discharge home planning was feasible. Data on patients’ characteristics and setting before admission were collected at admission; at discharge, the length of stay, discharge destination and barriers for discharge were collected by the nursing staff.ResultsBoth cohorts were comparable with regard to median age, gender [reference cohort: 81 (IQR 75–88) years; 66% females vs. Back-Home cohort 82 (IQR 76–87) years; 71% females] and reasons for admission: stroke (23% vs. 23%), joint replacement (12% vs. 13%), traumatic injuries (31% vs. 34%), and other (35% vs. 30%). Overall, the median length of stay for the participants discharged home in the reference cohort was 56 (IQR 29–81) days compared to 46 (IQR 30–96) days in the Back-Home cohort (p = 0.08). When no home adjustments were needed, participants were discharged home after 50 (IQR 29.5–97) days in the reference cohort, and after 42.5 (IQR 26–64.8) days in the Back-Home cohort (p = 0.03). Reasons for discharge delay were environmental factors (36.7%) and patient-related factors, such as mental (21.5%) and physical capacity (33.9%).ConclusionStructured scoring of supporting nursing tasks for geriatric rehabilitation patients may lead to earlier discharge from a skilled nursing facility to home, if no home adjustments are needed.     

Quality Comparison of the Manual Chest Compression and the Mechanical Chest Compression During Difficult Transport Conditions

BackgroundAlthough there are several studies comparing the quality of manual and mechanical chest compressions, we decided to conduct this study because results of previous studies were not sufficient for us to arrive at a definite conclusion.ObjectiveIn this study, our goal was to evaluate the quality of cardiopulmonary resuscitation (CPR) performed manually and by mechanical chest compression device (MCCD) when removing out-of-hospital cardiac arrest patients from their homes via stairs.MethodsA total of 20 paramedics participated in the study. The patient simulator manikin was moved down the stairs while each of 20 paramedics performed chest compressions, then it was moved down the stairs again 20 times while the MCCD performed chest compressions. Compression depth, compression rate, and hands-on times were recorded and the data were compared.ResultsThe median chest compression rate was 142.0 compressions/min (interquartile [25^th to 75^th percentile] range [IQR] 134.9–148.7 compressions/min) for the paramedics and 102.3 compressions/min for the MCCD (IQR 102.2–102.5 compressions/min) (p < 0.01). The median chest compression depth was 25.2 mm (IQR 23.2–30.9 mm) for the paramedics and 52.0 mm for the MCCD (IQR 51.4–52.6 mm) (p < 0.001). The rate of hands-on time for chest compressions performed by the paramedic participants was 92.0% (IQR 86.5–100%). Hands-on rate of the MCCD was 100% (p = 0.09).ConclusionsIn our study, while carrying the patient simulator manikin to the lower floor, it was found that the MCCD achieved high-quality CPR targets recommended by resuscitation guidelines in terms of compression rate, depth, and hands-on-time.     

Door-To-Triage Time in a Canadian Tertiary-Care Center

BackgroundThe interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional.ObjectiveWe sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada.MethodsData were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period. Demographic information, arrival time (door time), triage time, and Canadian Triage and Acuity Score (CTAS) were collected. DTT was compared across variables using Kruskal-Wallis one-way analysis of variance.ResultsSeven hundred and seventy-five patients were included in the study, representing 82.9% of ambulatory patients. DTT was variable (1–86 min) with a median of 12 min (interquartile range [IQR] 6–21 min). Patients in the 5^th percentile with the longest DTT waited a median of 54 min (IQR 48–63 min). DTT varied across days of the week (p < 0.01); the longest wait was on Monday (median 22 [IQR 11–43] min) and the shortest on Sunday (median 8 [IQR 5–12] min). There was no relationship between DTT and CTAS (p = 0.12).ConclusionsDTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.     

Prophylactic use of platelets in critically ill patients with thrombocytopaenia: A retrospective two-centre observational study

PurposeWe report the use and effect of prophylactic platelet transfusions in critically ill thrombocytopaenic patients, comparing patients with or without bone marrow failure as a cause of thrombocytopaenia.MethodsA retrospective observational study of admissions to three intensive care units (ICU) in the UK. We identified thrombocytopaenic patients who received a platelet transfusion and extracted the platelet count prior and subsequent to platelet transfusion. We grouped patients with or without suspected bone marrow failure, defined by a total white cell count ≤1.0 × 10⁹/L.ResultsOf 11,757 admissions, 399 (3.4%) patients received a platelet transfusion for thrombocytopaenia. The median [IQR] platelet count prior to transfusion in patients without bone marrow failure was 42 [28–64] × 10⁹/L versus 14 [7–24] × 10⁹/L (p < .0001) in those with. The median [IQR] increment in platelets following transfusion was lower in patients with marrow failure (12 [−1−23] × 10⁹/L) compared to those without (18 [5–36] × 10⁹/L) (p = .006).ConclusionsPlatelet transfusions were given at a higher median platelet count than suggested by guidelines. Patients with bone marrow failure were transfused at a lower threshold and experienced a smaller increment in platelet count when compared to patients without marrow failure.     

Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI

BackgroundThe current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI).ObjectiveWe aimed to compare the two paradigms within a single population. We hypothesized that STEMI(–) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization.MethodsWe performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0–2 flow or TIMI 3 flow plus peak troponin T > 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes.ResultsAmong 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(–) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18–7.63), 1.87 (IQR 1.12–5.48), and 0.00 (IQR 0.00–0.08). Median time from arrival to catheterization was 41 min (IQR 23–86 min) for STEMI(+) OMI compared with 437 min (IQR 85–1590 min) for STEMI(–) OMI (p < 0.001). STEMI(+) OMI was more likely than STEMI(–) OMI to undergo catheterization within 90 min (76% vs. 28%; p < 0.001).ConclusionsSTEMI(–) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(–) OMI.     

Early and prolonged continuous hypertonic saline infusion in patients with acute liver failure

PurposeTo study patient characteristics, physiological changes, and outcomes associated with prolonged continuous hypertonic saline (HTS) infusion in acute liver failure (ALF).Materials and methodsRetrospective observational cohort study of adult patients with ALF. We collected clinical, biochemical, and physiological data six hourly for the first week, daily until day 30 or hospital discharge, and weekly, when documented, until day 180.ResultsOf 127 patients, 85 received continuous HTS. Compared with non-HTS patients they were more likely to receive continuous renal replacement therapy (CRRT) (p < 0.001) and mechanical ventilation (p < 0.001). Median HTS duration was 150 (Interquartile range (IQR): 84–168) hours, delivering a median 2244 (IQR: 979–4610) mmol sodium load. Median peak sodium concentration was 149 mmol/L vs 138 mmol/L in non-HTS patients (p < 0.001). The median rate of sodium increase with infusion was 0.1 mmol/L/h and median rate of decrease during weaning was 0.1 mmol/L every 6 h. Median lowest pH value was 7.29 vs. 7.35 in non-HTS patients. Survival of HTS patients was 72.9% overall and 72.2% without transplantation.ConclusionsIn ALF patients, the prolonged administration of HTS infusion was not associated with severe hypernatremia or rapid shifts in serum sodium upon commencement, delivery, or weaning.     

The Critical Care Resuscitation Unit Transfers More Patients From Emergency Departments Faster and Is Associated With Improved Outcomes

BackgroundTransfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes.ObjectivesWe hypothesized that an innovative Critical Care Resuscitation Unit (CCRU) would be associated with improved outcomes by reducing transfer times to a quaternary care center and times to interventions for ED patients with critical illnesses.MethodsThis pre–post analysis compared 3 groups of patients: a CCRU group (patients transferred to the CCRU during its first year [July 2013 to June 2014]), a 2011-Control group (patients transferred to any ICU between July 2011 and June 2012), and a 2013-Control group (patients transferred to other ICUs between July 2013 and June 2014). The primary outcome was time from transfer request to ICU arrival. Secondary outcomes were the interval between ICU arrival to the operating room and in-hospital mortality.ResultsWe analyzed 1565 patients (644 in the CCRU, 574 in the 2011-Control, and 347 in 2013-Control groups). The median time from transfer request to ICU arrival for CCRU patients was 108 min (interquartile range [IQR] 74–166 min) compared with 158 min (IQR 111–252 min) for the 2011-Control and 185 min (IQR 122–283 min) for the 2013-Control groups (p < 0.01). The median arrival-to-urgent operation for the CCRU group was 220 min (IQR 120–429 min) versus 439 min (IQR 290–645 min) and 356 min (IQR 268–575 min; p < 0.026) for the 2011-Control and 2013-Control groups, respectively. After adjustment with clinical factors, transfer to the CCRU was associated with lower mortality (odds ratio 0.64 [95% confidence interval 0.44–0.93], p = 0.019) in multivariable logistic regression.ConclusionThe CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.     

Early recognition of sepsis through emergency medical services pre-hospital screening

BackgroundThe Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance.ObjectivesTo determine if pre-hospital sepsis screening improves 3-hour bundle compliance.MethodsProspective implementation of an EMS sepsis screening tool (June 2016–November 2016) was compared to a historical control (August 2015–March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components.ResultsOf 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2–8] vs. 2 [IQR 1–4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0–35] vs. 46 min [IQR 34–57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0–38] vs. 46 min [IQR 27.5–72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44–92] vs. 72 min [IQR 59.5–112], p = 0.26).ConclusionImplementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.     

An evaluation of short anxiety measures for use in the emergency department

BackgroundThe emergency department (ED) is a stressful environment for children. Few studies assess pediatric anxiety in the ED. “Gold standard” for measuring state-anxiety, Spielberger's State-Trait Anxiety Inventory for Children (STAI-C state), is lengthy and of limited use in this setting.ObjectiveThe objective was to evaluate agreement between STAI-C, Likert, and modified Yale Preoperative Anxiety Scale (m-YPAS) and determine if shorter measures may be adequate replacements for STAI-C in the ED.MethodsThis is a secondary analysis of data from a previous observational cohort study of a convenience sample of children 5–17 years old presenting to the ED. Anxiety was measured using STAI-C, Likert, and m-YPAS. Spearman correlations were used to evaluate agreement between STAI-C and the brief scales. A sub-analysis evaluated agreement between scales for children ≥9 years old to assess the impact of age.ResultsEighty children were included. Median (IQR) STAI-C state score was 32.5 (30.0, 37.8). This represents moderate state anxiety with 30% of children exhibiting elevated state anxiety. Median (IQR) Likert score was 2.0 (1.0, 2.0). Correlation between the Likert and STAI-C was moderate (r_s = 0.51; p < 0.0001). Median (IQR) m-YPAS was 28.3 (24.2, 33.3). The m-YPAS and STAI-C were unrelated (r_s = 0.12; p > 0.05). For children ≥9 years old, correlation between Likert and STAI-C remained moderate (r_s = 0.52; p < 0.0001); STAI-C and m-YPAS were unrelated (r_s = 0.10; p > 0.05).ConclusionsChildren in the ED experienced moderate-elevated state anxiety. Likert scale may be an acceptable substitute for STAI-C state. Further studies of this scale will aid in identifying patients with anxiety to facilitate timely management.     

Mean amplitude of glycemic excursions in septic patients and its association with outcomes: A prospective observational study using continuous glucose monitoring

PurposeTo apply continuous glucose monitoring (CGM) and determine the mean amplitude of glycemic excursions (MAGE) in septic patients and to assess the associations of MAGE with outcomes and oxidative stress.Materials and methodsThis study was conducted in adult septic patients expected to require intensive care for >48 h. We continuously measured blood glucose level for the first 48 h in the ICU using FreeStyle Libre®. MAGE was calculated using glycemic information obtained by CGM during the study period of 48 h. The primary outcome was 90-day all-cause mortality. The secondary outcomes were 90-day ICU-free days and the concentration of urinary 8-isoprostaglandinF2α measured 48 h after commencement of the study as a surrogate of oxidative stress.ResultsForty patients were included in this study. Median of MAGE was higher in non-survivors than in survivors: 68.8 (IQR;39.7–97.2) vs. 39.3 (IQR;19.9–53.3), p = 0.02. In multivariate analysis, MAGE was independently associated with 90-day all-cause mortality rate (p = 0.02), urinary 8-isoprostaglandinF2α level (p = 0.03) and 90-day ICU-free survival days (p = 0.03).ConclusionsIn the current study, MAGE for the first 48 h of treatment that was obtained by using CGM was associated with 90-day all-cause mortality, 90-day ICU-free days and urinary 8-isoprostaglandinF2α level in septic patients.     

Impact of patient delay in a modern real world STEMI network

BackgroundThe impact of patient delay on left ventricular ejection fraction (LVEF), when system delay has performance that meets the current recommended guidelines, is poorly investigated.MethodsWe evaluated a cohort of STEMI patients treated with primary percutaneous coronary intervention (pPCI) and with an ECG STEMI diagnosis to wire crossing time (ETW) ≤120 min. Independent predictors of pre-discharge decreased LVEF (≤45%) were analyzed.Results490 STEMI patients with both ETW time ≤120 min and available pre-discharge LVEF were evaluated. Mean age was 64.2 ± 12 years, 76.2% were male, 19.5% were diabetics, 42.7% had and anterior myocardial infarction (MI), and 9.8% were in Killip class III–IV. Median time of patient's response to initial symptoms (patient delay) was 58,5 (IQR 30;157) minutes and median ETW time was 78 (IQR 62–95) minutes. 115 patients (23.4%) had pre-discharge LVEF ≤45%. At multivariable analysis independent predictors of decreased LVEF (≤45%) were anterior MI (OR 4,659, 95% CI 2,618-8,289, p < 0,001), Killip class (OR 1,449, 95% CI 1,090-1,928, p = 0,011) and patients delay above the median (OR 2,030, 95% CI 1,151–3.578, p = 0,014). These independent predictors were confirmed in patients with ETW time ≤90 min.ConclusionsWhen system delay meets the recommended criteria for pPCI, patient delay becomes an independent predictor of pre-discharge LVEF. These findings provide further insights into the potential optimization of STEMI management and identify a target that needs to be improved, considering that still a significant proportion of patients continue to delay seeking medical care.     

Evaluation of ventilator associated events in critically ill patients with invasive mechanical ventilation: A prospective cohort study at a resource limited setting in Northern India

PurposeThe primary aim of this study was to identify the modifiable risk factors for acquiring ventilator associated events (VAE). Secondary aims were to investigate the intensive care unit (ICU) course and impact of VAE on patient outcome.MethodsThis prospective, observational single center cohort study included 247 patients on mechanical ventilation for 4 calendar days at a 20-bed ICU between January 2018–June 2019.ResultsVAE occurred in 59 episodes (rate 11.3 per 1000 ventilator-days). The Ventilator Utilization Ratio (VUR) was 0.57. The median time to onset of VAE was 6 days. Sepsis was the most common reason for initiating patients on invasive mechanical ventilation (IMV). Cumulative fluid balance ≥2 l (Odds Ratio 30.92; 95% CI 9.82–97.37) and greater number of days with vasopressor support (Odds Ratio 1.92; 95% CI 1.57–2.36) within 7 days of initiating IMV were significant risk factors for acquiring VAE (p < 0.001). VAE cases were ventilated for significantly more days (20 vs 14 days, p = 0.001, had longer days of ICU stay (29 vs 18 days; p = 0.002) and higher hospital mortality (p = 0.02). Klebsiella pneumoniae was the most common isolate (N = 28) and 32.1% were colistin resistant.ConclusionsProspective intervention studies are needed to determine if targeting these risk factors can lower VAE rates in our setting.     

Characteristics of pleural effusion due to paradoxical response in patients with pulmonary tuberculosis

BackgroundPatients with pulmonary tuberculosis may present with deterioration of pleural effusion during anti-tuberculosis therapy, referred to as a paradoxical response (PR), with some patients requiring additional intervention. However, PR may be confused with other differential diagnoses, and the predictive factors for recommending additional therapies are unknown. Therefore, this study aimed to reveal useful information for the diagnosis and intervention of PR.MethodsData from human immunodeficiency virus-negative patients with tuberculous pleurisy (n = 210), including 184 patients with pre-existing pleural effusion and 26 patients with PR at Fukujuji Hospital, were retrospectively collected from January 2012 to December 2022 and compared. Furthermore, patients with PR were divided into the intervention group (n = 9) and the no intervention group (n = 17) and were compared.ResultsPatients in the PR group had lower pleural lactate dehydrogenase (LDH) (median 177 IU/L vs. 383 IU/L, p < 0.001) and higher pleural glucose (median 122 mg/dL vs. 93 mg/dL, p < 0.001) levels than those in the preexisting pleural effusion group. Other pleural fluid data were not significantly different. Patients in the intervention group had a shorter duration from the initiation of anti-tuberculosis therapy to the development of PR than patients in the no intervention group (median 19.0 days [interquartile range (IQR): 18.0–22.0] vs. median 37.0 days [IQR: 28.0–58.0], p = 0.012).ConclusionThis study demonstrates that, apart from lower pleural LDH and elevated pleural glucose levels, PR presents with similar features to preexisting pleural effusion and that patients who develop PR faster tend to require intervention.     

Therapeutic plasma exchange in adult critically ill patients with life-threatening SARS-CoV-2 disease: A pilot study

PurposeWe investigated the effect of therapeutic plasma exchange (TPE) on life-threatening COVID-19; presenting as acute respiratory distress syndrome (ARDS) plus multi-system organ failure and cytokine release syndrome (CRS).Materials and methodsWe prospectively enrolled ten consecutive adult intensive care unit (ICU) subjects [7 males; median age: 51 interquartile range (IQR): 45.1–55.9 years old] with life-threatening COVID-19 infection. All had ARDS [PaO2/FiO2 ratio: 110 (IQR): 95.5–135.5], septic shock, CRS and deteriorated within 24 h of ICU admission despite fluid resuscitation, antibiotics, hydroxychloroquine, ARDS-net and prone position mechanical ventilation. All received 5–7 TPE sessions (dosed as 1.0 to 1.5 plasma volumes).ResultsAll of the following significantly normalized (p < 0.05) following the TPE completion, when compared to baseline: Sequential Organ Function Assessment score, PaO2/FiO2 ratio, levels of lymphocytes, total bilirubin, lactate dehydrogenase, ferritin, C-reactive protein and interleukin-6. No adverse effects from TPE were observed. Acute kidney injury and pulmonary embolism were observed in 10% and 20% of patients, respectively. The duration of mechanical ventilation was 9 (IQR: 7 to 12) days, the ICU length of stay was 15 (IQR: 13.2 to 19.6) days and the mortality on day-28 was 10%.ConclusionTPE demonstrates a potential survival benefit and low risk in life-threatening COVID-19, albeit in a small pilot study.     

Structure and process associated with the efficiency of intensive care units in low-resource settings: An analysis of the CHECKLIST-ICU trial database

PurposeCharacteristics of structure and process impact ICU performance and the outcomes of critically ill patients. We sought to identify organizational characteristics associated with efficient ICUs in low-resource settings.Materials and methodsThis is a secondary analysis of a multicenter cluster-randomized clinical trial in Brazil (CHECKLIST-ICU). Efficient units were defined by standardized mortality ratio (SMR) and standardized resource use (SRU) lower than the overall medians and non-efficient otherwise. We used a regularized logistic regression model to evaluate associations between organizational factors and efficiency.ResultsFrom 118 ICUs (13,635 patients), 47 units were considered efficient and 71 non-efficient. Efficient units presented lower incidence rates (median[IQR]) of central line-associated bloodstream infections (4.95[0.00–22.0] vs 6.29[0.00–25.6], p = .04), utilization rates of mechanical ventilation (0.41[0.07–0.73] vs 0.58[0.19–0.82], p < .001), central venous catheter (0.67[0.15–0.98] vs 0.78[0.33–0.98], p = .04), and indwelling urinary catheter (0.62[0.22–0.95] vs 0.76[0.32–0.98], p < .01) than non-efficient units. The reported active surveillance of ventilator-associated pneumonia (OR = 1.72; 95%CI, 1.16–2.57) and utilization of central venous catheters (OR = 1.94; 95%CI, 1.32–2.94) were associated with efficient ICUs.ConclusionsIn low-resource settings, active surveillance of nosocomial infections and the utilization of invasive devices were associated with efficiency, supporting the management and evaluation of performance indicators as a starting point for improvement in ICU.