The Dutch Data Warehouse, a multicenter and full-admission electronic health records database for critically ill COVID-19 patients

Background The Coronavirus disease 2019 (COVID-19) pandemic has underlined the urgent need for reliable, multicenter, and full-admission intensive care data to advance our understanding of the course of the disease and investigate potential treatment strategies. In this study, we present the Dutch Data Warehouse (DDW), the first multicenter electronic health record (EHR) database with full-admission data from critically ill COVID-19 patients. Methods A nation-wide data sharing collaboration was launched at the beginning of the pandemic in March 2020. All hospitals in the Netherlands were asked to participate and share pseudonymized EHR data from adult critically ill COVID-19 patients. Data included patient demographics, clinical observations, administered medication, laboratory determinations, and data from vital sign monitors and life support devices. Data sharing agreements were signed with participating hospitals before any data transfers took place. Data were extracted from the local EHRs with prespecified queries and combined into a staging dataset through an extract-transform-load (ETL) pipeline. In the consecutive processing pipeline, data were mapped to a common concept vocabulary and enriched with derived concepts. Data validation was a continuous process throughout the project. All participating hospitals have access to the DDW. Within legal and ethical boundaries, data are available to clinicians and researchers. Results Out of the 81 intensive care units in the Netherlands, 66 participated in the collaboration, 47 have signed the data sharing agreement, and 35 have shared their data. Data from 25 hospitals have passed through the ETL and processing pipeline. Currently, 3464 patients are included in the DDW, both from wave 1 and wave 2 in the Netherlands. More than 200 million clinical data points are available. Overall ICU mortality was 24.4%. Respiratory and hemodynamic parameters were most frequently measured throughout a patient's stay. For each patient, all administered medication and their daily fluid balance were available. Missing data are reported for each descriptive. Conclusions In this study, we show that EHR data from critically ill COVID-19 patients may be lawfully collected and can be combined into a data warehouse. These initiatives are indispensable to advance medical data science in the field of intensive care medicine.Perioperative Medicine: Efficacy, Safety and Outcome (Anesthesiology/Intensive Care

DE BEHANDELING VAN CHRONISCH HARTFALEN IN DE HUISARTSENPRAKTIJK EN DE ROL VAN IBOPAMINE (INOPAMIL®)

Evidence for the role and importance of neuroendocrine modulation apart from pre- and afterload reduction as hemodynamic properties in the treatment of chronic heart failure (HF) is accumulating. The mainstay of therapy today are diuretics, digoxin and vasodilators, probably preferably converting enzyme inhibitors (CEI). Apart from vasodilating effects, CEI possess favorable neuroendocrine modulating properties. The recent development of the oral dopamine agonist ibopamine increases the possibilities for the treatment of HF. Ibopamine induces vasodilation and favorably influences the neuroendocrine system, with mild beneficial renal effects in patients with HF by different mechanisms compared to other drugs. Several clinical studies have demonstrated the efficacy and safety of ibopamine in the treatment of HF

Esophageal obstruction: An unusual complication of enteral nutrition

Objective: To report an unusual complication of enteral nutrition in an intensive care patient. Design: Case report. Setting: University tertiary referral intensive care unit. Patients: One patient who developed an esophageal obstruction due to gastroesophageal reflux while receiving enteral nutrition. Interventions: Esophageal-gastroscopy for diagnostics and subsequent irrigation and mechanical cleasing resulting in desobstruction. Conclusion: Enteral nutrition through a nasogastric tube is in general a safe means to feed intensive care patients, but may result in esophageal obstruction due to impaction of the feeding compound as a result of gastroesophageal reflux

The use of dopamine and norepinephrine in ICU patients with special reference to renal function

Dopamine is still a very popular drug, used extensively in the intensive care for its presumed salutary renal effects, with a presumed increase in especially renal blood flow and diuresis. Although the effect on renal blood flow are not always present, the routinely measured property of an increased diuresis is clinically apparent in the ICU. However, there is a lack of evidence that these effects influence favourably the outcome of critically ill patients, when dopamine is given 'routinely' at a low dose infusion rate. The data on the effects on splanchnic perfusion are ambiguous. With respect to its use in patients with septic shock, recent evidence strongly suggests that norepinephrine is more effective in restoring blood pressure. Furthermore, in contrast to what is still frequently believed, recent data give convincing evidence that norepinephrine improves renal function (GFR) in the clinical setting. Norepinephrine is therefore according to the authors a pharmacologically sound and safe choice in patients with septic shock after adequate fluid resuscitation

The use of dopamine and norepinephrine in ICU patients with special reference to renal function

Dopamine is still a very popular drug, used extensively in the intensive care for its presumed salutary renal effects, with a presumed increase in especially renal blood flow and diuresis. Although the effect on renal blood flow are not always present, the routinely measured property of an increased diuresis is clinically apparent in the ICU. However, there is a lack of evidence that these effects influence favourably the outcome of critically ill patients, when dopamine is given 'routinely' at a low dose infusion rate. The data on the effects on splanchnic perfusion are ambiguous. With respect to its use in patients with septic shock, recent evidence strongly suggests that norepinephrine is more effective in restoring blood pressure. Furthermore, in contrast to what is still frequently believed, recent data give convincing evidence that norepinephrine improves renal function (GFR) in the clinical setting. Norepinephrine is therefore according to the authors a pharmacologically sound and safe choice in patients with septic shock after adequate fluid resuscitation

Circulatory optimization of the patient with or at risk for shock

We reviewed the current literature on perioperative 'optimization' of the circulation and the circulatory resuscitation goals in critically ill patients after (non-cardiac) surgery, sepsis or trauma, with the help of variables obtained by a pulmonary artery catheter. Optimization goals that include a maximal stroke work to filling pressure relationship, an elevated (supranormal) cardiac output (> 4.5 l/min/m2), an elevated O2 delivery (> 600 ml/min/m2) and uptake (> 150-170 ml/min/m2), may ameliorate or prevent a tissue O2 deficit and may be associated with less organ failures and improved survival in patients with or at risk for shock. However, this policy may not benefit patients with less severe circulatory deterioration or preterminal illness, where an increase in O2 delivery may only load the heart and may not increase systemic O2 uptake. In fact, in the course of trauma or sepsis, boosting O2 delivery may not increase O2 uptake and thereby decrease mortality, if prevented by a severe O2 extraction deficit (high mixed venous O2 saturation) because of maldistribution of blood flow associated with vasodilatation. The latter may prevent, in turn, an improvement in (regional) markers of perfusion inadequacy, including oliguria, a raised gastric to blood PCO2 gradient (tonometry) and lactic acidaemia. In contrast, blocking β-receptors prior to surgery in patients at high risk for cardiac events, rather than for multiple organ failure, may decrease morbidity and mortality after major surgery. The doubt cast on the contribution of the pulmonary artery catheter to the management of critically ill patients has been fed, among others, by studies disproving the survival benefit of the above optimization goals. It is likely that future studies on circulatory optimization goals will include both global and regional tissue perfusion/oxygenation variables, mean arterial blood pressure and heart and renal function. A study on a set of variables to guide treatment is probably hard to perform, but more likely to help defining the usefulness of circulatory optimization, than a study on the value of manipulating only one variable at a time

Zorgprofessionals moeten stuur weer overnemen

This commentary discusses the increasingly observed managerilisation of healthcare. Managerilisation frequently results in a framework of rules, regulations and accompanying time-consuming forms and procedures to guide decision-making. Although likely developed with the best of intentions in mind, this framework may be of limited value and tends to leave healthcare professionals feeling frustrated and distrusted. In addition, overzealous bureaucracy and rigid adherence to protocols may be disadvantageous to patient care and outcomes. Instead, we advocate a renewed focus on common sense and in particular on a renewed trust in healthcare professionals. Their professional judgement is based on many years of education and bedside experience. Hospital management should once again seek to embrace their expertise, while healthcare professionals should actively seek to regain the reins when it comes to delivering healthcare