The potential impact of Covid-19 on the capacity of routine laboratory tests to detect heparin-induced thrombocytopenia.

In Covid-19, anticoagulation with heparin is often administered to prevent or treat thromboembolic events. Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin treatment, caused by heparin-dependent, platelet activating anti-platelet factor 4 (PF4)/heparin antibodies. Diagnosis of HIT is based on the combination of clinical parameters, allowing to determine the pretest probability, and laboratory testing for anti-PF4/heparin antibodies and confirmatory functional assays, such as the heparin-induced platelet activation (HIPA) test.We report the case of a patient with severe Covid-19 pneumonia requiring ECMO treatment, who developed recurrent clotting of the ECMO filter and a drop in platelet count under heparin treatment. He was therefore suspected to have HIT and the anticoagulation was switched to argatroban. Despite high clinical probability and high titres of anti-PF4/heparin antibodies, the functional HIPA test was negative. Nevertheless, argatroban was continued rather than to reinstate anticoagulation with heparin. Reevaluation 7 days later then demonstrated a strongly positive functional HIPA test and confirmed the diagnosis of HIT. Under anticoagulation with argatroban the patient gradually improved and was finally weaned off the ECMO.In conclusion, this case highlights the critical importance of clinical judgement, exploiting the 4 T score, given that Covid-19 patients may present a different pattern of routine laboratory test results in HIT diagnostics. The possibility of a false negative HIPA test has to be considered, particularly in early phases of presentation. In cases of a discrepancy with high clinical probability of HIT and/or high titre anti-PF4/heparin antibodies despite a negative HIPA test, a reevaluation within 3 to 5 days after the initial test should be considered in order to avoid precipitant reestablishment of unfractionated heparin, with potentially fatal consequences

Physiology education for intensive care medicine residents: A 15-minute interactive peer-led flipped classroom session.

INTRODUCTION In acute care medicine, knowledge of the underlying (patho)-physiology is of paramount importance. This may be especially relevant in intensive care medicine, where individual competence and proficiency greatly depend on knowledge and understanding of critical care physiology. In settings with time constraints such as intensive care units (ICUs), time allotted to education is often limited. We evaluated whether introduction of a short, interactive, peer-led flipped classroom session is feasible and can provide ICU residents with a better understanding of critical care physiology. MATERIALS AND METHODS Using the flipped classroom concept, we developed a 15-minute peer-led interactive "physiology education" session to introduce a total of 44 residents to critical care physiology. Using a nine-item electronic survey with open questions and a five-point Likert scale, we analysed the overall concept with regard to feasibility, motivation, and subjective learning of critical care physiology. RESULTS The overall rate of response to the survey was 70.5% (31/44). The residents reported that these sessions sparked their interest (p = 0.005, Chi square 10.52), and that discussion and interaction during these sessions had promoted their knowledge and understanding. Both novice and experienced residents reported that new knowledge was imparted (both p<0.0001, Chi-square 32.97 and 25.04, respectively). CONCLUSIONS In an environment with time constraints such as the ICU, a 15-minute, interactive, peer-led flipped classroom teaching session was considered feasible and generally appeared useful for teaching critical care physiology to ICU residents. Responses to questions on questionnaires indicated that teaching sessions sparked interest and increased motivation. This approach may theoretically induce a modification in professional behaviour and promote self-directed learning. We therefore support the use of peer-led flipped classroom training sessions in the ICU. Whether these sessions result in improved ICU care should be addressed in subsequent studies

Teaching End-of-Life Communication in Intensive Care Medicine: Review of the Existing Literature and Implications for Future Curricula.

OBJECTIVES End-of-life (EOL) situations are common in the intensive care unit (ICU). Poor communication in respective situations may result in conflict and/or post-traumatic stress disorder in patients' next of kin. Thus, training for EOL communication seems pivotal. Primary objective of the current report was to identify approaches for educational programs in the ICU with regard to EOL communication as well as to conclude on implications for future curricula. MATERIALS AND METHODS A literature review in MEDLINE, EMBASE, and PsychINFO was performed. A total of 3484 articles published between 2000 until 2016 were assessed for eligibility. Nine articles reporting on education in EOL communication in the ICU were identified and analyzed further. RESULTS The duration of EOL workshops ranged from 3 hours to 3 days, with several different educational methods being applied. Mounting data suggest improved comfort, preparedness, and communication performance in EOL providers following specific EOL training. Due to missing data, the effect of EOL training programs on respective patients' next of kin remains unclear. CONCLUSION Few scientific investigations focus on EOL communication in intensive care medicine. The available evidence points to increased comfort and EOL communication performance following specific individual EOL training. Given the general importance of EOL communication, we suggest implementation of educational EOL programs. When developing future educational programs, educators should consider previous experience of participants, clearly defined objectives based on institutional needs, and critical care society recommendations to ensure best benefit of all involved parties

Interventions in Post-Intensive Care Syndrome-Family: A Systematic Literature Review.

OBJECTIVES Data show that family members of ICU patients may have high levels of anxiety, depression, posttraumatic stress disorders, and/or complicated grief. This was previously referred to as post-intensive care syndrome-family. We systematically review randomized controlled trials for post-intensive care syndrome-family. DATA SOURCES Systematic research in databases (Pubmed, EMBASE, PsycINFO, CINHAL for articles published between January 2000 and October 2019). STUDY SELECTION Interventions in randomized controlled trials for post-intensive care syndrome-family in relatives of adult ICU patients. DATA EXTRACTION Review, quality assessment, and risk assessment for bias of eligible publications were performed along recommended guidelines for each investigation. Quality assessment graded studies into "strong" (n = 5), "moderate" (n = 4), and "weak" (n = 2). DATA SYNTHESIS Out of 2,399 publications, 11 investigations were found eligible (3,183 relatives of ICU patients). Studies addressed interventions during ICU stay (n = 6), during the post-ICU period (n = 4), or both (n = 1). Two studies included relatives of dying/deceased patients. One study implemented end-of-life conferences and showed reduced prevalence of posttraumatic stress disorder (45% vs 69%; p = 0.01), anxiety (45% vs 67%; p = 0.02), and depression (29% vs 56%; p = 0.003). Family conferences with a physician and proactive participation of a nurse reduced anxiety-scores (p = 0.01) without reducing anxiety prevalence (33.3% vs 52.3%; p = 0.08). Other studies failed to improve symptoms or reduce prevalence of post-intensive care syndrome-family. Interestingly, condolence letters may even increase prevalence of posttraumatic stress disorder (52.4% vs 37.1%; p = 0.03). Meetings without the presence of ICU physicians were shown to increase Impact of Event Scale-Revised scores (25.9 vs 21.3; p = 0.0495). CONCLUSIONS Only few data are available on interventions for post-intensive care syndrome-family. It appears that proactive communication and provision of information seems pivotal for post-intensive care syndrome-family treatment. Interestingly, some interventions may even worsen post-intensive care syndrome-family. In the light of the relevance of post-intensive care syndrome-family in daily ICU care, more high-quality data seems urgently needed

Journal Club sessions in the Intensive Care Unit: a conceptual framework.

Journal Club sessions are regarded highly effective tools for continued medical education. They aim to keep participants up to date with the current available literature and may enhance one's critical reading, interpretation, and discussion skills. Thus, Journal Clubs should be implemented as part of educational curricula in intensive care medicine. Here, we provide a conceptual framework that may support medical educators and programme directors to successfully implement structured Journal Club sessions. Moreover, we discuss the technical aspects and future perspectives of respective educational formats

In sechs Wochen hat sich die Welt verändert: COVID-19.

In six weeks the world has changed: COVID-19 - Family-centered care in the intensive care unit Abstract. Background and problem definition: The admission of patients to an intensive care unit is extremely stressful for relatives during the COVID-19 pandemic, as they are not allowed to visit their family members due to a visitation restriction. OBJECTIVES To describe the experience of relatives during the COVID-19 pandemic and to derive support information for health professionals. METHODS Qualitative analysis of three written testimonies of relatives whose family members were hospitalized with COVID-19 or other disease at intensive care unit. RESULTS Relatives report the sudden, unexpected occurrence of the disease. "It was there, out of nowhere, hits the heart of life, doesn't just go away, does what it wants. It is an unknown virus that we have to get to know very closely." The ban on visiting was harsh, it made her faint. The first visit was an indescribable joy. Knowing how the family member was and that the health care professionals were taking professional and empathetic care of the sick person were the only things the relatives could hold on to. DISCUSSION Relatives were reassured when they experienced a high level of commitment on the part of health professionals and received repeated comprehensible information by phone. Limitations and transfer: Restrictions on visits depend on national legislation. Measures such as video calls can also be useful outside of a pandemic to build relationships with relatives