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12th August 2021
Among critically ill patients, intravenous fluids (IV) are used for intravascular volume replacement. Administration of such fluids is extremely common and it has been estimated that every day, over 20% of patients within an intensive care setting receive fluid therapy. In general terms, fluid therapy is required for several indications including impaired tissue perfusion, low cardiac output and abnormal vital signs, e.g., blood pressure, heart rate or urine output. The most commonly used IV fluid is saline solution (0.9% sodium chloride) although in recent years, there has been emerging evidence that IV fluids other than saline in critically ill patients may have a more favourable impact on mortality. Balanced IV fluids, for example, have been designed to be more aligned with the composition of serum and may have some advantages over saline. For example, one study in patients with sepsis, concluded that resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality. In a 2018 study among critically ill adults, the use of a balanced crystalloid rather than saline, produced a lower rate of death compared to saline. The use of a balanced solution rather than saline has several other potential advantages, particularly in relations to adverse effects, since saline contains a higher concentration of chloride ions and has been associated with a hyperchloraemic metabolic acidosis and acute kidney injury.
However, the overall benefit of using a balanced IV fluid rather than saline is not always superior. For instance, the use of a balanced crystalloid did not reduce the incidence of acute kidney injury compared to saline within an intensive care unit (ICU). In trying to provide much needed clarity, the Balanced Solution versus Saline in Intensive Care Study (BaSICS) by a Brazilian group of clinicians was undertaken to compare the effectiveness and safety of balanced crystalloids compared with saline in critically ill patients. This trial undertaken at 75 intensive care units in Brazil, randomised patients admitted to an ICU to either saline or a balanced solution and the primary outcome was 90-day survival.
A total of 10,520 critically ill patients with a mean age of 61.1 years (44.2% female), were randomised to either balanced fluids or saline and patients in both groups received a median of 1.5 litres of fluid during the first day of enrolment. Of the whole cohort, 60.6% of patients had hypotension or vasopressor use and 44.3% required mechanical ventilation at enrolment. Within 90 days of enrolment, 26.4% of those assigned to balance fluids died compared to 27.2% given saline (adjusted hazard ratio, aHR = 0.97, 95% CI 0.90 – 1.05, p = 0.47).
The authors concluded that despite the potential advantages of balanced crystalloids over saline, there were no apparent mortality benefits.
Zampieri F et al. Effect of Intravenous Fluid Treatment with a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients. The BaSICS Randomised Clinical Trial. JAMA 2021
9th August 2021
Patients are hospitalised with COVID-19 because of breathing difficulties due to a lack of oxygen as the virus induces damage in the lungs. Among those who deteriorate further, respiratory failure leads to the need for invasive ventilation within critical care units. Early in the pandemic, the increasing number of severely ill patients placed an enormous strain on critical care units, prompting the need to explore viable alternatives to invasive ventilation. Possible alternatives that could help to reduce the need for invasive mechanical ventilation include continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO). The use of CPAP and HFNO have been perceived as attractive alternative treatment options although there is a lack of data on whether either CPAP or HFNO are clinically effective in comparison to conventional oxygen in reducing the need for intubation. This led the Recovery-respiratory Support collaborators from Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK, to undertake an open-label, randomised trial among hospitalised patients with COVID-19. The study was designed to evaluate the effectiveness of either CPAP, HFNO or conventional oxygen, in hospitalised patients with acute respiratory failure caused by COVID-19. All adult patients (18 years and older) with acute respiratory failure, deemed suitable for tracheal intubation if treatment escalation was required, were included in the study. The treating clinician randomised between CPAP, HFNO or conventional oxygen and patients were followed-up throughout their hospital stay. The primary outcome was a composite of tracheal intubation or mortality within 30 days of randomisation.
During a 13-month period, 1,272 patients were randomised, 380 (29.9%) to CPAP, 417 (32.8%) to HFNO and the remainder to conventional oxygen therapy. The mean age of participants was 57.4 years (66.4% male) and 65.3% were of white ethnicity. The need for tracheal intubation occurred in 36.3% of CPAP patients and 44.4% of those receiving conventional oxygen, giving an adjusted odds ratio (OR) of 0.72 (95% CI 0.53–0.96, p = 0.03). For HFNO in comparison to conventional oxygen, there was no significant difference with an adjusted OR of 0.97 (95% CI 0.73–1.29, p = 0.85). With respect to 30-day mortality, there was no difference between CPAP and conventional oxygen (OR = 0.91, 95% CI 0.59–1.39) or for HFNO and oxygen (OR = 0.96, 95% CI 0.64–1.45).
The authors concluded that their data clearly demonstrated that the use CPAP reduced the need for tracheal intubation compared with the use of conventional oxygen. However, they also noted that neither CPAP or HFNO led to a reduction in mortality.
Perkins GD et al. An adaptive randomised controlled trial of non-invasive respiratory strategies in acute respiratory failure patients with COVID-19. MedRxiv 2021
23rd July 2021
Healthcare workers are three times more likely to become infected with COVID-19 compared to community individuals. Nevertheless, during viral epidemic outbreaks, an additional burden to healthcare staff is the impact on their mental wellbeing that accompanies the associated increased workload, leading to stress and anxiety. With thousands of patients across the globe developing more severe infection, there has been much focus on management within intensive care units. Such units are a highly demanding environment with staff continually exposed to traumatic and stressful events and a study from 2007, revealed a higher incidence of post-traumatic stress disorder (PTSD) among intensive care nursing staff. Given the high levels of 28-day mortality among patients with COVID-19, this undoubtedly further increases the mental health burden of intensive care staff. However, there is a lack of data specifically examining the mental wellbeing of intensive care staff.
Using an online survey, a team from the Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, Imperial College, London, UK, sought to gain a better understanding of the mental health burden experienced by intensive care staff. The overall aim was to establish the prevalence of indices of depression, insomnia, and PTSD, which the authors suspected would be high among intensive care staff. The survey was conducted among all healthcare professionals working within the intensive care environment and distributed across the UK, France, Italy, Belgium, Egypt, Taiwan and Mainland China.
For the survey, three previously validated questionnaires were included: the two-item patient health questionnaire (PHQ-2) which sought to grade depression severity, an 8-item Athens Insomnia scale (AIS-8) and the 10-item trauma screening questionnaire (TSQ). The corresponding cut-off values for these questionnaires are 3 (PHQ-2), 8 (AIS-8) and 6 (TSQ). As well as these questionnaires, the authors included a series of general questions on wellbeing.
The final cohort included 515 responses from seven different countries and the majority of respondents were female (73%), of white ethnicity (73%) and aged 31–40 years (43.3%). Interestingly, 5.8% of respondents reported a pre-existing mental health condition. Just over half (52.4%) were nurses, with the remainder being senior (13.8%), residents/fellows (8.9%) and junior (6.4%) doctors, physiotherapists and others. Furthermore, nearly two-thirds (60.2%) had been re-deployed from another specialty and only a third (33.8%) were normally based within an intensive care ward.
The median scores were 2, 10 and 3 for PHQ-2, AIS-8 and TSQ respectively. Overall, 37.3%, 78.6% and 27.7% of participants had scores for PHQ-2, AIS-8 and TSQ respectively, that were above the thresholds for each condition. Across the different countries, 16–44% of respondents exceeded the threshold for depression, 60–80% for insomnia and 17–35% for PTSD.
The authors concluded that the COVID-19 pandemic had created a significant mental health burden for intensive care staff and recommended that all such staff have access to mental wellbeing resources, especially given the possibility of further surges in the rates of infection in the future.
Ezzat A. The global mental health burden of COVID-19 on critical care staff. Br J Nurs 2021