What factors predict length of stay in the intensive care unit? Systematic review and meta-analysis

Purpose:  Studies have shown that a small percentage of ICU patients have prolonged length of stay (LoS) and account for a large proportion of resource use. Therefore, the identification of prolonged stay patients can improve unit efficiency. In this study, we performed a systematic review and meta-analysis to understand the risk factors of ICU LoS.
Materials and methods:  We searched MEDLINE, Embase and Scopus databases from inception to November 2018. The searching process focused on papers presenting risk factors of ICU LoS. A meta-analysis was performed for studies reporting appropriate statistics.
Results:  From 6906 citations, 113 met the eligibility criteria and were reviewed. A meta-analysis was performed for six factors from 28 papers and concluded that patients with mechanical ventilation, hypomagnesemia, delirium, and malnutrition tend to have longer stay, and that age and gender were not significant factors.
Conclusions:  This work suggested a list of risk factors that should be considered in prediction models for ICU LoS, as follows: severity scores, mechanical ventilation, hypomagnesemia, delirium, malnutrition, infection, trauma, red blood cells, and PaO2:FiO2. Our findings can be used by prediction models to improve their predictive capacity of prolonged stay patients, assisting in resource allocation, quality improvement actions, and benchmarking analysis.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review.

This article by Wiersinga and colleagues was first published online in JAMA in July 2020.
Importance:  The coronavirus disease 2019 (COVID-19) pandemic, due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a worldwide sudden and substantial increase in hospitalizations for pneumonia with multiorgan disease. This review discusses current evidence regarding the pathophysiology, transmission, diagnosis, and management of COVID-19.
Observations:  SARS-CoV-2 is spread primarily via respiratory droplets during close face-to-face contact. Infection can be spread by asymptomatic, presymptomatic, and symptomatic carriers. The average time from exposure to symptom onset is 5 days, and 97.5% of people who develop symptoms do so within 11.5 days. The most common symptoms are fever, dry cough, and shortness of breath. Radiographic and laboratory abnormalities, such as lymphopenia and elevated lactate dehydrogenase, are common, but nonspecific. Diagnosis is made by detection of SARS-CoV-2 via reverse transcription polymerase chain reaction testing, although false-negative test results may occur in up to 20% to 67% of patients; however, this is dependent on the quality and timing of testing. Manifestations of COVID-19 include asymptomatic carriers and fulminant disease characterized by sepsis and acute respiratory failure. Approximately 5% of patients with COVID-19, and 20% of those hospitalized, experience severe symptoms necessitating intensive care. More than 75% of patients hospitalized with COVID-19 require supplemental oxygen. Treatment for individuals with COVID-19 includes best practices for supportive management of acute hypoxic respiratory failure. Emerging data indicate that dexamethasone therapy reduces 28-day mortality in patients requiring supplemental oxygen compared with usual care (21.6% vs 24.6%; age-adjusted rate ratio, 0.83 [95% CI, 0.74-0.92]) and that remdesivir improves time to recovery (hospital discharge or no supplemental oxygen requirement) from 15 to 11 days. In a randomized trial of 103 patients with COVID-19, convalescent plasma did not shorten time to recovery. Ongoing trials are testing antiviral therapies, immune modulators, and anticoagulants. The case-fatality rate for COVID-19 varies markedly by age, ranging from 0.3 deaths per 1000 cases among patients aged 5 to 17 years to 304.9 deaths per 1000 cases among patients aged 85 years or older in the US. Among patients hospitalized in the intensive care unit, the case fatality is up to 40%. At least 120 SARS-CoV-2 vaccines are under development. Until an effective vaccine is available, the primary methods to reduce spread are face masks, social distancing, and contact tracing. Monoclonal antibodies and hyperimmune globulin may provide additional preventive strategies.
Conclusions and Relevance:  As of July 1, 2020, more than 10 million people worldwide had been infected with SARS-CoV-2. Many aspects of transmission, infection, and treatment remain unclear. Advances in prevention and effective management of COVID-19 will require basic and clinical investigation and public health and clinical interventions.
This article is freely available to all via this link

Mechanical assist devices for acute cardiogenic shock

This Cochrane Systematic Review was published during Summer 2020.
Background: Cardiogenic shock (CS) is a state of critical end‐organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra‐aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer‐term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long‐term VAD.
Objectives:  To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock.
Search methods:  We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions.
Selection criteria:  Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra‐aortic balloon pump and inotropic support.
Data collection and analysis:  We performed data collection and analysis according to the published protocol.
Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow‐up), dialysis‐dependent (30 days/end of follow‐up), length of hospital stay and length of intensive care unit stay and major adverse events.
We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta‐analyses for the pre-specified outcomes.
Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs).
Main results:  The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta‐analysis was performed only to assess the 30‐day survival as there were insufficient data to perform any further meta‐analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30‐day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain.
Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting.
We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing.
Authors’ conclusions:  There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.
The full text of this review is available via this link

Critical Care Reviews Newsletter 450 27th July 2020

The Critical Care Reviews Newsletter, provides you with the best critical care research and open access articles from across the medical literature.
The issue includes original research such as “Hydroxychloroquine with or without Azithromycin in Mild-to-Moderate Covid-19.”, guidelines including “Evidence-Based Practical Guidance for the Antithrombotic Management in Patients With Coronavirus Disease (COVID-19) in 2020” and review articles for example “Application of Lung Ultrasound During the COVID-19 Pandemic: A Narrative Review”.
The full text of the issue is available via this link

Critical Care Reviews Newsletter 449 20th July 2020

The Critical Care Reviews Newsletter, provides you with the best critical care research and open access articles from across the medical literature.
The highlights of this week’s edition are the peer reviewed preliminary results from the dexamethasone arm of the RECOVERY trial, the eagerly anticipated results from the STARRT-AKI trial, and health-related quality of life – a 6-month follow-up from the ADRENAL trial; systematic reviews and meta analyses on  tranexamic acid administration in traumatic brain injury & the association of delirium with long-term cognitive decline; and observational studies on the association between universal masking in a health care system and SARS-CoV-2 positivity among health care workers & another preliminary report of an mRNA vaccine against SARS-CoV-2. There are also narrative reviews on temporary circulatory support for cardiogenic shock, continuous‐flow left ventricular assist devices & the evaluation and management of shock in patients with COVID-19; editorials on the Covid-19 vaccine-development multiverse & the United States and the World Health Organization; and commentaries on airborne transmission of SARS-CoV-2, communicating science in the time of a pandemic and improving clinical trial enrollment – in the Covid-19 era and beyond. Finally, correspondence has been published on CRASH 3 & remdesivir for Covid-19.
The full text of the issue is available via this link

Intensive Care Medicine Volume 46 Issue 8 August 2020

To view Intensive Care Medicine’s August issue’s contents page follow this link.
Articles published in this issue include: Epidemiology and burden of sepsis acquired in hospitals and intensive care units: a systematic review and meta-analysis”, “Hospital-level variation in the development of persistent critical illness” and “Mortality and host response aberrations associated with transient and persistent acute kidney injury in critically ill patients with sepsis: a prospective cohort study.”
Articles on COVID 19 these are freely available in full text to everyone.
To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine” though some are available open access.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.
The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Critical Care Reviews Newsletter 448 12th June 2020

The Critical Care Reviews Newsletter, provides you with the best critical care research and open access articles from across the medical literature.
“Once again, this week’s edition is dominated by COVID-19. The highlights are systematic reviews and meta analyses on hospital‑ and ICU‑treated sepsis & sepsis acquired in hospitals and intensive care units; observational studies on persistent symptoms in patients after acute COVID-19, the emerging spectrum of COVID-19 neurology, the association between discharge delay from intensive care and patient outcomes & the prevalence of SARS-CoV-2 in Spain. There are also two COVID-19 – related guidelines on the management of critically ill adults with COVID-19s & antithrombotic management in COVID-19; three excellent COVID-19 – related narrative reviews, including a general review, emerging pharmacological therapies & extrapulmonary manifestations; editorials on critical care journals during the COVID-19 pandemic & when data interpretation should not rely on the magnitude of P values; and commentaries on whether a different approach is required for COVID-19 related ARDS, airborne transmission of COVID-19 & COVID-19 clinical trials; as well as correspondence on frailty in COVID-19 patients & patient-self-inflicted lung injury in COVID-19.
The full text of the issue is available via this link

Critical Care Reviews Newsletter 447 5th June 2020

The highlights of this week’s edition are the pre-print of the randomised controlled trials evaluating antibiotics in non-critically ill paediatric patients with pneumonia, including a fascinating trial comparing antibiotics with placebo, as well as two RCTs investigating vitamin C, thiamine and steroids in sepsis; systematic reviews and meta analyses on glucocorticoids in patients with ARDS (pre RECOVERY) & the use of a checklist for endotracheal intubation; and observational studies on multisystem inflammatory syndrome in U.S. children & the association of premorbid blood pressure with vasopressor infusion duration in patients with shock. There are also guidelines & recommendations on critical care ultrasound competencies & extracorporeal blood purification and organ support in the critically ill patient during the COVID-19 pandemic; narrative reviews on acute ischemic stroke & the treatment of nosocomial pneumonia in the ICU; editorials on anti-NMDA receptor encephalitis & chloroquine: to use or not to use in COVID19 ;commentaries on accelerating the development of SARS-CoV-2 vaccines the PREVENT study; as well as correspondence on COVID-19 phenotypes & rethinking the post-COVID-19 pandemic hospital: more ICU beds or smart monitoring on the wards?.
The full text of the issue is available via this link

Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study

This article from the UK Obstetric Surveillance System SARS-CoV-2 Infection in Pregnancy Collaborative Group was published online in the BMJ (Clinical research ed.) at the end of June 2020.
Objectives:  To describe a national cohort of pregnant women admitted to hospital with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK, identify factors associated with infection, and describe outcomes, including transmission of infection, for mothers and infants.
Design:  Prospective national population based cohort study using the UK Obstetric Surveillance System (UKOSS).
Setting:  All 194 obstetric units in the UK.
Participants:  427 pregnant women admitted to hospital with confirmed SARS-CoV-2 infection between 1 March 2020 and 14 April 2020.
Main Outcome Measures:  Incidence of maternal hospital admission and infant infection. Rates of maternal death, level 3 critical care unit admission, fetal loss, caesarean birth, preterm birth, stillbirth, early neonatal death, and neonatal unit admission.
Results:  The estimated incidence of admission to hospital with confirmed SARS-CoV-2 infection in pregnancy was 4.9 (95% confidence interval 4.5 to 5.4) per 1000 maternities. 233 (56%) pregnant women admitted to hospital with SARS-CoV-2 infection in pregnancy were from black or other ethnic minority groups, 281 (69%) were overweight or obese, 175 (41%) were aged 35 or over, and 145 (34%) had pre-existing comorbidities. 266 (62%) women gave birth or had a pregnancy loss; 196 (73%) gave birth at term. Forty one (10%) women admitted to hospital needed respiratory support, and five (1%) women died. Twelve (5%) of 265 infants tested positive for SARS-CoV-2 RNA, six of them within the first 12 hours after birth.
Conclusions:  Most pregnant women admitted to hospital with SARS-CoV-2 infection were in the late second or third trimester, supporting guidance for continued social distancing measures in later pregnancy. Most had good outcomes, and transmission of SARS-CoV-2 to infants was uncommon. The high proportion of women from black or minority ethnic groups admitted with infection needs urgent investigation and explanation.
This article is freely available to all via this link

Intensive Care Medicine Volume 46 Number 7 July 2020

intensive-care-medicineTo view Intensive Care Medicine’s July issue’s contents page follow this link.
Articles published in this issue include: Managing ICU surge during the COVID-19 crisis: rapid guidelines, “Interventions for oropharyngeal dysphagia in acute and critical care: a systematic review and meta-analysisand “Acute kidney injury in critically ill patients with COVID-19”.
Together with other articles on COVID 19 these are freely available in full text to everyone.
To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine” though some are available open access.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.
The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.