Spiritual care in critically ill patients during COVID-19 pandemic

IntroductionSpiritual care has a positive influence when patients are subjected to serious illnesses, and critically ill situations such as the case of the COVID-19 pandemic.PurposeThe purpose of this study was to investigate the perceptions and attitudes of nurses working at critical care units and emergency services in Spain concerning the spiritual care providing to patients and families during the COVID-19 pandemic.MethodsA qualitative investigation was carried out using in-depth interviews with 19 ICU nursing professionals.FindingsDuring the pandemic, nurses provided spiritual care for their patients. Although they believed that spirituality was important to help patients to cope with the disease, they do not had a consensual definition of spirituality. Work overload, insufficient time and lack of training were perceived as barriers for providing spiritual healthcare.DiscussionThese results support the role of spirituality in moments of crisis and should be considered by health professionals working in critical care settings.     

Secondary bloodstream infection in critically ill patients with COVID-19

ObjectiveSecondary infection, especially bloodstream infection, is an important cause of death in critically ill patients with COVID-19. We aimed to describe secondary bloodstream infection (SBI) in critically ill adults with COVID-19 in the intensive care unit (ICU) and to explore risk factors related to SBI.MethodsWe reviewed all SBI cases among critically ill patients with COVID-19 from 12 February 2020 to 24 March 2020 in the COVID-19 ICU of Jingmen First People''s Hospital. We compared risk factors associated with bloodstream infection in this study. All SBIs were confirmed by blood culture.ResultsWe identified five cases of SBI among the 32 patients: three with Enterococcus faecium, one mixed septicemia (E. faecium and Candida albicans), and one C. parapsilosis. There were no significant differences between the SBI group and non-SBI group. Significant risk factors for SBI were extracorporeal membrane oxygenation, central venous catheter, indwelling urethral catheter, and nasogastric tube.ConclusionsOur findings confirmed that the incidence of secondary infection, particularly SBI, and mortality are high among critically ill patients with COVID-19. We showed that long-term hospitalization and invasive procedures such as tracheotomy, central venous catheter, indwelling urethral catheter, and nasogastric tube are risk factors for SBI and other complications.     

新型冠状病毒肺炎危重症患者营养治疗专家建议

当前抗击新型冠状病毒疫情进入决战阶段,危重症患者的营养治疗是降低病死率的关键措施。为了进一步提高危重症患者的营养治疗效果,现结合抗疫前线的临床经验,就危重症患者的营养代谢特点、营养筛查、营养治疗目标量、营养方案和途径的选择,以及营养监测方法等方面做出总结和建议,为危重症患者的救治提供参考。     

Challenges in hyperglycemia management in critically ill patients with COVID-19

Hyperglycemia is commonly associated with adverse outcomes especially in patients requiring intensive care unit stay. Data from the corona virus disease 2019 (COVID-19) pandemic indicates that individuals with diabetes appear to be at similar risk for COVID-19 infection to those without diabetes but are more likely to experience increased morbidity and mortality. The proposed hypothesis for hyperglycemia in COVID-19 include insulin resistance, critical illness hyperglycemia (stress- induced hyperglycemia) secondary to high levels of hormones like cortisol and catecholamines that counteract insulin action, acute cytokine storm and pancreatic cell dysfunction. Diabetic patients are more likely to have severe hyperglycemic complications including diabetic ketoacidosis and hyperosmolar hyperglycemic state. Management of hyperglycemia in COVID-19 is often complicated by use of steroids, prolonged total parenteral or enteral nutrition, frequent acute hyperglycemic events, and restrictions with fluid management due to acute respiratory distress syndrome. While managing hyperglycemia special attention should be paid to mode of insulin delivery, frequency of glucose monitoring based on patient and caregiver safety thereby minimizing exposure and conserving personal protective equipment. In this article we describe the pathophysiology of hyperglycemia, challenges encountered in managing hyperglycemia, and review some potential solutions to address them.     

重症新型冠状病毒肺炎患者营养支持治疗的专家建议

2019年12月以来,一种新型冠状病毒导致的感染在我国突发,截止目前,我国累计确诊病例已超7万例。2020年2月7日,国家卫生健康委将新型冠状病毒感染的肺炎暂命名为“新型冠状病毒肺炎”(简称:新冠肺炎,Novel Coronavirus Pneumonia,NCP);2020年2月11日,世界卫生组织将新型冠状病毒引发的疾病命名为“COVID-19”(Corona Virus Disease 2019)。     

PICC导管应用于3例新冠肺炎危重症患者的护理

本文回顾了三例危重症新冠肺炎患者,在重症监护隔离病房应用经外周置入中心静脉导管 (Peripherally inserted central catheter, PICC)的经验,包括重症患者应用PICC的指征、穿刺点的选择、穿刺的技巧、穿刺后的维护、抗凝状态下PICC的相关并发症。我们认为,包括新冠肺炎在内的、尤其是接受持续抗凝的重症患者,PICC可作为中心静脉通路的首选方案;术前详尽的超声血管评估和穿刺时正确的超声引导能够提高多重个人防护下的穿刺成功率;在不能停止抗凝的极端情况下,护理PICC相比CVC更加便捷,一旦出现穿刺点渗血等并发症,也能相对简单有效地进行处理。综上所述,我们推荐PICC在重症患者中有指征地应用,尤其是需要持续抗凝的患者中,充分发挥PICC的优势,有技巧地使用超声定位和引导,通过护理手段减少和处理PICC相关并发症。     

Enterococcal bloodstream infections in critically ill patients with COVID-19: a case series

BackgroundAn unexpected high prevalence of enterococcal bloodstream infection (BSI) has been observed in critically ill patients with COVID-19 in the intensive care unit (ICU).Materials and methodsThe primary objective was to describe the characteristics of ICU-acquired enterococcal BSI in critically ill patients with COVID-19. A secondary objective was to exploratorily assess the predictors of 30-day mortality in critically ill COVID-19 patients with ICU-acquired enterococcal BSI.ResultsDuring the study period, 223 patients with COVID-19 were admitted to COVID-19-dedicated ICUs in our centre. Overall, 51 episodes of enterococcal BSI, occurring in 43 patients, were registered. 29 (56.9%) and 22 (43.1%) BSI were caused by Enterococcus faecalis and Enterococcus faecium, respectively. The cumulative incidence of ICU-acquired enterococcal BSI was of 229 episodes per 1000 ICU admissions (95% mid-p confidence interval [CI] 172–298). Most patients received an empirical therapy with at least one agent showing in vitro activity against the blood isolate (38/43, 88%). The crude 30-day mortality was 42% (18/43) and 57% (4/7) in the entire series and in patients with vancomycin-resistant E. faecium BSI, respectively. The sequential organ failure assessment (SOFA) score showed an independent association with increased mortality (odds ratio 1.32 per one-point increase, with 95% confidence interval 1.04–1.66, p = .021).ConclusionsThe cumulative incidence of enterococcal BSI is high in critically ill patients with COVID-19. Our results suggest a crucial role of the severity of the acute clinical conditions, to which both the underlying viral pneumonia and the enterococcal BSI may contribute, in majorly influencing the outcome.

KEY MESSAGES

• The cumulative incidence of enterococcal BSI is high in critically ill patients with COVID-19.
• The crude 30-day mortality of enterococcal BSI in critically ill patients with COVID-19 may be higher than 40%.
• There could be a crucial role of the severity of the acute clinical conditions, to which both the underlying viral pneumonia and the enterococcal BSI may contribute, in majorly influencing the outcome.

     

Inadequate prophylactic effect of low-molecular weight heparin in critically ill COVID-19 patients

PurposeThe aim of this study was to investigate potential markers of coagulopathy and the effects of thromboprophylaxis with low-molecular-weight heparin (LMWH) on thromboelastography (TEG) and anti-factor Xa in critically ill COVID-19 patients.Material and MethodsWe conducted a prospective study in 31 consecutive adult intensive care unit (ICU) patients. TEG with and without heparinase and anti-factor Xa analysis were performed. Standard thromboprophylaxis was given with dalteparin (75–100 IU/kg subcutaneously).ResultsFive patients (16%) had symptomatic thromboembolic events. All patients had a maximum amplitude (MA) > 65 mm and 13 (42%) had MA > 72 mm at some point during ICU stay. Anti-factor Xa activity were below the target range in 23% of the patients and above target range in 46% of patients. There was no significant correlation between dalteparin dose and anti-factor Xa activity.ConclusionsPatients with COVID-19 have hypercoagulability with high MA on TEG. The effect of LMWH on thromboembolic disease, anti-factor Xa activity and TEG was variable and could not be reliably predicted. This indicates that standard prophylactic doses of LMWH may be insufficient. Monitoring coagulation and the LMWH effect is important in patients with COVID-19 but interpreting the results in relation to risk of thromboembolic disease poses difficulties.     

Late histopathologic characteristics of critically ill COVID-19 patients: Different phenotypes without evidence of invasive aspergillosis,a case series

PurposePathological data of critical ill COVID-19 patients is essential in the search for optimal treatment options.Material and methodsWe performed postmortem needle core lung biopsies in seven patients with COVID-19 related ARDS. Clinical, radiological and microbiological characteristics are reported together with histopathological findings.Measurement and main resultsPatients age ranged from 58 to 83 years, five males and two females were included. Time from hospital admission to death ranged from 12 to 36 days, with a mean of 20 ventilated days. ICU stay was complicated by pulmonary embolism in five patients and positive galactomannan on bronchoalveolar lavage fluid in six patients, suggesting COVID-19 associated pulmonary aspergillosis. Chest CT in all patients showed ground glass opacities, commonly progressing to nondependent consolidations. We observed four distinct histopathological patterns: acute fibrinous and organizing pneumonia, diffuse alveolar damage, fibrosis and, in four out of seven patients an organizing pneumonia. None of the biopsy specimens showed any signs of invasive aspergillosis.ConclusionsIn this case series common late histopathology in critically ill COVID patients is not classic DAD but heterogeneous with predominant pattern of organizing pneumonia. Postmortem biopsy investigations in critically COVID-19 patients with probable COVID-19 associated pulmonary aspergillosis obtained no evidence for invasive aspergillosis.     

Simulation-based uptraining improves provider comfort in the management of critically ill patients with COVID-19

PurposeThe COVID-19 surge required the deployment of large numbers of non-intensive care providers to assist in the management of the critically ill. Institutions took a variety of approaches to “uptraining” such providers though studies describing methods and effectiveness are lacking.Materials and methodsOne hundred and seventy-five providers underwent a 3 h simulation-based session focused on management of shock, mechanical ventilation, acute respiratory distress syndrome, and critical care ultrasound. All participants were sent surveys to assess their comfort with various aspects of critical care following return to their usual work environments.ResultsOne hundred and eight providers of 175 (62%) completed the survey. Overall, 104/108 responders (96%) felt training either significantly or somewhat improved their knowledge in the management of ICU patients. Responders felt most comfortable in the management of hypoxemia in intubated patients and the management of ventilated patients with acute respiratory distress syndrome (93% strongly agree or agree, and 86% strongly agree or agree, respectively). Fewer responders felt more comfortable using focused echocardiography (70% strongly agree or agree) and lung ultrasonography in following progression of COVID-19 (76% strongly agree or agree).ConclusionsSimulation-based training improved provider comfort in the management of critically ill patients with COVID-19.