Iatrogenic events contributing to paediatric intensive care unit admission
AIMS: To identify the incidence of iatrogenic events leading to paediatric intensive care unit (PICU) admission and to analyse these patients regarding demographic, illness severity and outcome parameters.
MATERIAL AND METHODS: This was a retrospective case series. The computerised charts of all patients admitted to the multidisciplinary, tertiary, 18-bed PICU in 2014 were analysed. Iatrogenic events leading to PICU admission were identified and their preventability assessed. Underlying diseases, causes of iatrogenic events, illness severity at PICU admission, presence of complex chronic conditions, patient origin, length of stay on the PICU and outcome were analysed.
RESULTS: There were 138 admissions associated with iatrogenic events out of 1102 admissions (12.5%). Ninety iatrogenic events led to unplanned admissions and 48 cases concerned scheduled admissions, where the iatrogenic event would have led to PICU admission by itself or caused a second, planned PICU admission for re-operation. Iatrogenic complications during surgery (31% of all iatrogenic events), wrong management decisions / delayed diagnoses (20%) and nosocomial infections (14%) were the categories most often involved. Regarding origin of the patients, the greatest difference between iatrogenic event admissions and non-iatrogenic event admissions was found for the ward (21% vs 11%). The patients admitted for iatrogenic events had a higher mean expected mortality (8.4 vs 4.7%, p = 0.02) and a higher observed PICU mortality (5.8 vs 3.3%, p = 0.15). Of all iatrogenic events, 60.1% were judged to be preventable. The highest preventability rate was found in the categories “nosocomial infections” (100%) and “management decisions / delayed diagnoses” (92.9%).
CONCLUSION: In our setting, the number of PICU admissions associated with iatrogenic events is significant and comparable to adult data on admission to ICU caused by iatrogenic events. The categories with most potential for improvement are nosocomial infections and the wrong management decisions / delayed diagnoses. Focused measures on these iatrogenic events may have a major impact on patient outcome, availability of PICU resources and healthcare costs.
PREPICare: An intelligent, pressure distributing positioning system for critically ill neonates in paediatric intensive care: First insights from a pilot study
Aim and background: Severely ill neonates in paediatric intensive care units (PICU) regularly suffer from support surface-related pressure ulcers, with an incidence of 28% (1, 2). Besides provoking pain and stress for the affected individual, pressure ulcers make treatment of life-threatening illnesses more challenging and considerably prolong the hospital stay. Standard foam mattresses on which the neonates lie may cause pressure peaks causing pressure ulcers. Therefore, we have developed an air-mattress to better distribute the pressure. In this pilot study, we measured for the first time the interface pressures experienced by neonates lying on standard form mattresses and compared them to pressures when our new air-mattress was applied.
Material and methods: A novel laser-welded air-filled mattress with pressure redistributive and peak reductive capacity was developed. In this pilot study, we measured 5 critically ill, sedated, intubated and ventilated neonates. Surface pressures were measured using a textile pressure sensitive mat (Sensomative GmbH) in order to identify zones of elevated pressures for both the standard foam mattress and the air-mattress.
Results: In all 5 neonates elevated pressure values were measured at the occiput, the shoulders and the sacrum (range 15 – 27 mmHg) in comparison to the other body regions for both the foam mattress and the air-mattress. For all neonates the mean of the interface pressures was reduced in the air-filled sequence, compared to foam-mattress, with differences ranging from 9% to 29% (p = 0.03). For all neonates, the average of the 10% highest interface pressure values (number of values 𝒗 = 9451) was reduced in the air-filled sequence, compared to foam mattrass, with differences ranging from 23% to 41% (p = 0.03).
Conclusion: With this pilot study, for the first time the potential benefit of an air-filled surface regarding pressure distribution for critically ill PICU patients in a real life setting has been shown. The air-filled mattress redistributed pressures over a larger area with reduced peak pressure magnitudes compared to the foam mattress. More research and innovation in this field is needed to further ensure safe, as well as patient-adapted, pressure ulcer prevention surfaces development. This is of high relevance to optimize outcome for children treated in this highly vulnerable setting, especially during the early years of life.
Evolution of mortality over time: results from the COVID-19 Swiss hospital surveillance system (CH-SUR)
Introduction and aim
The assessment of COVID-19 associated mortality is crucial to evaluate the impact of the pandemic and to assess the effectiveness of measures. We aimed to investigate trends in COVID-19 related mortality over time in Switzerland, using data from the COVID-19 Hospital-based Surveillance (CH-SUR) database.
CH-SUR is a prospective hospital surveillance system for COVID-19 patients from 21 hospitals. Considering four different time periods corresponding to the different waves of COVID-19 in Switzerland (Spring, Summer, Autumn 2020, Winter 2021), we calculated crude and adjusted mortality rates and performed survival analyses using Fine & Gray survival models accounting for competing risks. Similar models were conducted for patients admitted to ICU.
Results and Discussion
Overall 16,967 episodes and 2,307 deaths were recorded. Crude in-hospital mortality rates were 15.6% in the 1st and 14.4% in the 2nd wave; for ICU patients it was 24% and 31.3% respectively. Patients were slightly older (median 73 vs 63 years), more likely male (59.9 vs 58.5%) and more comorbid (62 vs 60%) in the 2nd than the 1st wave. Dexamethasone use also increased during the second wave. The adjusted risk of death was lower for hospitalised patients during the 2nd compared to the 1st wave (HR 0.75, 95% CI 0.73 – 0.77). In contrast, the risk of death in patients admitted to ICU was higher during the 2nd wave (HR 1.62, 95% CI 1.54 - 1.70) and patients with invasive ventilation also had a higher mortality (HR 2.10, 95% CI 1.99 - 2.20).
The lower mortality in the second wave compared to first wave was not explained by changes in demographic characteristics, but may be explained by more effective patient care. Especially in the western part of Switzerland, ICU capacity in several cantons reached almost its limits during several weeks in the 2nd wave, which might have contributed to the higher mortality of patients in ICU.
Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: an observational study
Background: Status epilepticus (SE) a neurologic emergency with high morbidity and mortality often requires neurointensive care including mechanical ventilation (MV)1-5. Although initially lifesaving and a useful measure to protect airways, intubation carries the risk of side effects and promotes ventilation-associated pneumonia (VAP) during MV that are associated with unfavorable courses of SE 6,7. Despite this, clinicians tend to underestimate the capacity of patients to breath successfully when disconnected from ventilators 8,9. Delayed extubation in neurocritically ill patients not meeting established extubation criteria is critical, as it increases the risk of complications 10.
Aim: To investigate the frequency and clinical associations with adult SE patients requiring MV, and to identify predictors and the impact of prolongated MV after SE termination.
Material and methods: From 2012-2018, SE patients treated on the ICUs at a Swiss academic care center were included. Primary outcomes were frequency and duration of MV, prolonged postictal MV > 24 hours, no return to premorbid neurologic function, and in-hospital death.
Results: Of 262 patients, 42% were ventilated with 24% on prolonged postictal MV. Ventilated patients had a lower Glasgow Coma Score (GCS) at SE onset, higher proportions of nonconvulsive SE and presumed fatal etiologies, and more severe and longer SE. Patients with prolonged postictal MV were extubated at a median of 7 days with 56% not being extubated despite being weaned from MV. Reasons for this delayed extubation were altered consciousness (56%) and lack of airway-protective reflexes (17%). Non-invasive ventilation was performed in 4.6% and re-intubation in 3.7%. Prolonged postictal MV was associated with increased relative risk for death independent of potential confounders (RR 2.7; 95% confidence interval 1.1-6.6; p = 0.02). While at SE onset, decreased GCS and presumed fatal etiology independently predicted prolonged postictal MV, duration of anesthesia did not correlate with prolonged MV.
Conclusions: Our data reveal that prolonged postictal MV is frequent and an independent risk of in-hospital death. Extubation is often delayed for days despite weaning from the ventilator and altered airway-protective reflexes in only few patients. Studies need to investigate whether more rigorous extubation strategies improve outcome.
Initial albuminemia and albumin administration in severely burned patients; do they matter?
Background & aims: During burn shock, the early use of albumin to decrease the fluid requirements, mortality or acute kidney injury (AKI) has always been debated. We hypothesized that early hypoalbuminemia was an independent risk factor for mortality and that early albumin administration was associated with a decrease in mortality, AKI, dialysis and fluid requirements.
Materials and methods: This retrospective, single-center study was conducted in the burn intensive care unit of Lausanne University Hospital between 01.01.2006 and 31.12.2018. Inclusion criteria were age ≥ 14 years and burns > 20 % total body surface area (TBSA). Exclusion criteria were admission > 8h after burn accident, transfer in the first week to another burn unit or withdrawal of therapy during the first 72h.
Results: 141 patients were included, with burns 35 (24-50) %TBSA, age 39 (26-56) years, 68.1% were male and 56.7% had inhalation injury. ABSI score was 8 (7-10). 17 (12%) patients died. Minimal albuminemia in the first 24h was lower in non-survivors (15 (14-20) vs. 24 (19-31) g/l; p < 0.001) and was found to be an independent risk factor for mortality when adjusted for ABSI (p < 0.001) with a best cut-off of 22 g/l to predict mortality (sensitivity 63.6 %; specificity 87.5 %). In univariate analysis, albumin 20% was administered more often to non-survivors (12 (71%) vs. 30 (24%); p < 0.001), in increased quantities (47 (25-58) vs. 30 (10-40) g; p = 0.030) and earlier (9 (5-13) vs. 18 (14-20) h; p < 0.001). AKI was more frequent in albumin recipients (29 (69%) vs. 33 (33%); p < 0.001). The logistic regression model adjusted for ABSI found that albumin administration increased the risk of developing AKI in the first 7 days (OR 1.03 (95% CI 1.00-1.05); p = 0.035), without any significant effect on mortality or fluid requirements. Increased quantities of albumin administered in the first 7 days was associated with higher cumulated fluid balance, even after adjustment for TBSA.
Conclusions: Hypoalbuminemia < 22 g/l in the first 24h was found to be an independent risk factor for mortality. Albumin administration was associated with a increase of AKI, without significant reduction of fluid requirement at 24h, but with an increase of fluid balance on day 7. Our study was underpowered to draw conclusions on mortality and dialysis. In the absence of a prospective study clearly demonstrating a benefit of albumin, its use should remain confined to extreme hypoalbuminemia.
Mental health outcomes of ICU and non-ICU healthcare workers during the COVID-19 outbreak: a cross-sectional study
Intensive care workers are known for their stressful environment and for high
prevalence of mental health outcomes. This study aimed to evaluate how the COVID-
19 pandemic has impacted the mental health and lifestyle habits of intensive care unit
(ICU) healthcare workers (HCW) and then to compare these results with HCW in other
hospital units. Another objective was to understand which associated factors aggravate
their mental health during the COVID-19 outbreak.
From 28 th May to 7 th July 2020, this cross-sectional survey collected sociodemographic
data, lifestyle changes and mental health evaluation as assessed by the
Generalized Anxiety Disorder 7 items (GAD-7), the Patient Health Questionnaire 9
items (PHQ-9), the Peritraumatic Distress Inventory (PDI) and the World Health
Organization Well-Being Index (WHO-5), in the Geneva University Hospitals,
Switzerland. ICU HCW were analyzed for mental health outcomes and lifestyles
changes and then compared to non-ICU HCW. A series of linear regression analysis
were performed to assess factors associated with mental health scores.
A total of 3,461 HCW participated in the study, including 352 ICU HCW. Among ICU
HCW, 145 (41%) showed low well-being, 162 (46%) anxiety symptoms, 163 (46%)
depressive symptoms and 76 (22%) had peritraumatic distress . The mean scores of
GAD-7, PHQ-9 and WHO-5 were more pathologic in ICU HCW rather than in non-ICU
HCW (p < 0.01). Working in the ICU rather than in another department resulted in a
change of eating habits and alcohol consumption (p < 0.01).
Being a woman, the fear of catching and transmitting COVID-19, anxiety of working
with COVID-19 patients, being overloaded with work, eating less, drinking more alcohol
and having trouble sleeping were associated to worse mental health outcomes.
This study confirms the suspicion of high prevalence of anxiety, depression,
peritraumatic distress and low well-being during the first COVID-19 wave among HCW,
especially among ICU HCW and allows the identification of associated risk factors.
Long-term psychological follow-up should be considered for HCW.