Positioning the role of qSOFA for screening and prognostication in critically ill medical and surgical patients with suspected sepsis

The global magnitude of sepsis coupled with the unacceptably high attendant mortality continues to fuel universal efforts to improve its early detection and the assessment of severity of disease in the pursuit of improving clinical outcomes. The quick Sequential Organ Failure Assessment (qSOFA) score was introduced in conjunction with the Sepsis-3 definition – the intention being that a positive qSOFA score would serve as a screening tool for sepsis and for predicting poor outcomes in such patients. The qSOFA score is based on three variables: a Glasgow Coma Score <15, a respiratory rate ≥22 breaths per minute, and a systolic blood pressure ≤100 mmHg. The simultaneous presence of two of these variables indicates a positive qSOFA. There is no directive on how to gauge change in mentation at baseline for patients with altered mental status. The appeal of qSOFA score is related to it being immediately calculated without additional investigations and the ease of its derivation.http://www.ajtccm.org.za/index.php/SARJam2022Critical Car

'Acute kidney injury predictive models : advanced yet far from application in resource-constrained settings.'

DATA AVAILABILITY : No data are associated with this article.Acute kidney injury (AKI) remains a significant cause of morbidity and mortality in hospitalized patients, particularly critically ill patients. It poses a public health challenge in resource-constrained settings due to high administrative costs. AKI is commonly misdiagnosed due to its painless onset and late disruption of serum creatinine, which is the gold standard biomarker for AKI diagnosis. There is increasing research into the use of early biomarkers and the development of predictive models for early AKI diagnosis using clinical, laboratory, and imaging data. This field note provides insight into the challenges of using available AKI prediction models in resource-constrained environments, as well as perspectives that practitioners in these settings may find useful.http://f1000research.comam2023Critical Car

Quantifying the burden of the post-ICU syndrome in South Africa : a scoping review of evidence from the public health sector

BACKGROUND. The post-ICU syndrome (PICS) comprises unexpected impairments in physical, cognitive, and mental health after intensive care unit (ICU) discharge, and is associated with a diminished health-related quality of life (HRQOL). A Cochrane review recommended more research in this field from low- and middle-income countries. OBJECTIVE. This review aims to examine the extent and nature of publications in the field of PICS in the South African (SA) public health sector. Findings of available local research are contextualised through comparison with international data. METHODS. A comprehensive literature search strategy was employed. Inclusion criteria comprised publications enrolling adult patients following admission to SA public hospital ICUs, with the aim to study the main elements of PICS (ICU-acquired neuromuscular weakness, neurocognitive impairment, psychopathology and HRQOL). RESULTS. Three studies investigated physical impairment, 1 study psychopathology, and 2 studies HRQOL. Recommended assessment tools were utilised. High rates of attrition were reported. Neuromuscular weakness in shorter-stay patients had recovered at 3 months. Patients who were ventilated for ≥5 days were more likely to be impaired at 6 months. The study on psychopathology reported high morbidity. The HRQOL of survivors was diminished, particularly in patients ventilated for ≥5 days. CONCLUSION. This review found a paucity of literature evaluating PICS in the SA public health sector. The findings mirror those from international studies. Knowledge gaps pertaining to PICS in medical, surgical and HIV-positive patients in SA are evident. No publications on neurocognitive impairment or the co-occurrence of PICS elements were identified. There is considerable scope for further research in this field in SA.http://www.sajcc.org.zadm2022Critical Car

Antiretroviral therapy non-adherence among HIV- positive patients presenting to an emergency department in Johannesburg, South Africa: associations and reasons

BACKGROUND. Suboptimal antiretroviral therapy (ART) adherence is associated with viral resistance, opportunistic infections and increased mortality. OBJECTIVES. To determine the rates of ART non-adherence and its associations, and also the reasons for ART non-adherence, among HIV-positive patients presenting to a major central hospital emergency department (ED). METHODS. Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 7 July 2017 and 18 October 2018 were prospectively enrolled. Self-reported adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire (ACTG-AQ). RESULTS. Of the 1 224 consecutive HIV-positive participants enrolled, 761 (75.2%) were on ART at the time of ED presentation. Of these, 245 (32.2%) were non-adherent as per the ACTG-AQ. Participants not yet on ART prior to ED presentation had significantly higher in-hospital mortality than participants on ART (odds ratio 1.69; 95% confidence interval 1.21 - 2.34; p=0.002). Younger age, male sex, CD4 count <100 cells/µL, lack of viral suppression, a high National Early Warning Score 2 (≥7 points) and length of hospital stay ≥7 days were significantly associated with ART non-adherence (p<0.05). Forgetfulness (13.9%) and lack of social support, depression/stress/mental illness, and lack of money for transport to collect medications (9.9% each) were the most common reasons given for ART non-adherence. CONCLUSIONS. Of HIV-positive patients presenting to the ED, a high proportion were either not yet initiated on ART or ART non-adherent. HIV programmes should focus on HIV-positive ED attendees with the aim of identifying high-risk patients and providing adequate ART adherence supporthttp://www.samj.org.zadm2022Critical Car

Is there a role for melatonin in the ICU?

In the last decade, there have been significant developments in the understanding of the hormone melatonin in terms of its physiology, regulatory role and potential utility in various domains of clinical medicine. Melatonin’s purported properties include, among others, regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As such, its role has been explored specifically in the critical care setting in terms of many of these properties. This review addresses the physiological basis for considering melatonin in the critical care setting as well as the current evidence pertaining to its potential utility.http://www.sajcc.org.zadm2022Critical Car

SARS-CoV-2 infection prevalence in healthcare workers and administrative and support staff: The first-wave experience at three academic hospitals in the Tshwane district of Gauteng Province, South Africa

BACKGROUND : The availability of well and functional healthcare workers (HCWs) and support staff is pivotal to a country’s ability to manage the COVID-19 pandemic effectively. While HCWs have been identified as being at increased risk for acquisition of SARS-CoV-2 infection, there is a paucity of data pertaining to South African (SA) HCW-related infection rates. Global and provincial disparities in these numbers necessitate local data in order to mitigate risks. OBJECTIVES : To ascertain the overall SARS-CoV-2 infection rates and outcomes among all hospital staff at three hospitals in the Tshwane district of Gauteng Province, SA, and further determine associations with the development of severe COVID-19 disease. METHODS : This retrospective audit was conducted across three academic hospitals in the Tshwane district for the period 1 June - 31 August 2020. Deidentified data from occupational health and safety departments at each hospital were used to calculate infection rates. A more detailed analysis at one of the three hospitals included evaluation of demographics, work description, possible source of SARS-CoV-2 exposure (community or hospital), comorbidities and outcomes. RESULTS : The period prevalence of SARS-CoV-2 infections ranged from 6.1% to 15.4% between the three hospitals, with the average period prevalence being 11.1%. The highest incidence of SARS-CoV-2 infections was observed among administrative staff (2.8 cases per 1 000 staff days), followed by nursing staff (2.7 cases per 1 000 staff days). Medical doctors had the lowest incidence of 1.1 cases per 1 000 staff days. SARS-CoV-2 infections were categorised as either possibly community or possibly healthcare facility acquired for 26.6% and 73.4% of the infections, respectively. The administrative group had the highest proportion of possible community-acquired infections (41.8%), while doctors had the lowest (6.1%). The mean age of individuals with mild and severe disease was 41 years and 46.1 years, respectively (p=0.004). The presence of comorbidities was significantly associated with severity of disease (p=0.002). CONCLUSIONS : This study highlights that hospital staff, including administrative staff, are clearly at high risk for acquisition of SARS-CoV-2 infection during a surge.South African Society of Anaesthesiologists, Acacia Branchhttp://www.samj.org.zadm2022AnaesthesiologyCritical Car

Profile of presentation of HIV-positive patients to an emergency department in Johannesburg, South Africa

BACKGROUND: Despite improved availability and better access to antiretroviral therapy (ART), approximately 36% of human immunodeficiency virus (HIV)-positive South Africans are still not virally suppressed. Objective: The aim of this study was to describe the patterns of presentation of HIV-positive patients to a major central hospital emergency department (ED). METHODS: In this prospectively designed study, consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) adult ED were enrolled between 07 July 2017 and 18 October 2018. RESULTS: A total of 1224 participants were enrolled. Human immunodeficiency virus was newly diagnosed in 212 (17.3%) patients, 761 (75.2%) were on ART, 245 (32.2%) reported ART non-adherence, 276 (22.5%) had bacterial pneumonia, 244 (19.9%) had tuberculosis (TB), 86 (7.0%) had gastroenteritis, 205 (16.7%) required intensive care unit admission, 381 (31.1%) were admitted for ≥ 7 days and 166 (13.6%) died. With regard to laboratory parameters, CD4 cell count was < 100 cell/mm3 in 527 (47.6%) patients, the viral load (VL) was > 1000 copies/mL in 619 (59.0%), haemoglobin was < 11 g/dL in 636 (56.3%), creatinine was > 120 μmol/L in 294 (29.3%), lactate was > 2 mmol/L in 470 (42.0%) and albumin was < 35 g/L in 633 (60.8%). CONCLUSION: Human immunodeficiency virus-positive patients presenting to the CMJAH ED demonstrated a high prevalence of opportunistic infections, required a prolonged hospital stay and had high mortality rates. There is a need to improve the quality of ART services and accessibility to care.http://www.sajhivmed.org.za/index.php/hivmeddm2022Critical Car

Predictors of prolonged hospital stay in HIV-positive patients presenting to the emergency department

BACKGROUND: Prolonged hospitalization places a significant burden on healthcare resources. Compared to the general population, hospital length of stay (LOS) is generally longer in HIV-positive patients. We identified predictors of prolonged hospital length of stay (LOS) in HIV-positive patients presenting to an emergency department (ED). METHODS: In this cross-sectional study, HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED were prospectively enrolled between 07 July 2017 and 18 October 2018. Data was subjected to univariate and multivariate logistic regression to determine parameters associated with a higher likelihood of prolonged hospital LOS, defined as ≥7 days. RESULTS: Among the 1224 participants that were enrolled, the median (IQR) LOS was 4.6 (2.6–8.2) days, while the mean (SD) LOS was 6.9 (8.2) days. On multivariate analysis of the data, hemoglobin 120 μmol/L (OR 1.85, p = 0.000), cryptococcal meningitis (OR 2.45, p = 0.015) and bacterial meningitis (OR 4.83, p = 0.002) were significantly associated with a higher likelihood of LOS ≥7 days, while bacterial pneumonia (OR 0.35, p = 0.000) and acute gastroenteritis (OR 0.40, p = 0.025) were significantly associated with a lower likelihood of LOS ≥7 days. CONCLUSION: Various clinical and laboratory parameters are useful in predicting prolonged hospitalization among HIV-positive patients presenting to the ED. These parameters may be useful in guiding clinical decision making and directing the allocation of resources.http://www.plosone.orgpm2022Critical Car

Predictors of in-hospital mortality among HIV-positive patients presenting with an acute illness to the emergency department

OBJECTIVES : Despite better access to antiretroviral therapy (ART) over recent years, HIV remains a major global cause of mortality. The present study aimed to identify predictors of in-hospital mortality among HIV-positive patients presenting to an emergency department (ED). METHODS : In this cross-sectional study, HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 07 July 2017 and 18 October 2018 were prospectively enrolled. Data were compared between participants who survived to hospital discharge and those who died. The data were further subjected to univariate and multivariate logistic regression analyses to determine variables that were associated with in-hospital mortality. RESULTS : Of a total of 1224 participants, the in-hospital mortality was 13.6% (n = 166). On multivariate analysis, respiratory rate > 20 breaths/min [odds ratio (OR) = 1.90, P = 0.012], creatinine > 120 μmol/L (OR = 1.97, P = 0.006), oxygen saturation 2 mmol/L (OR = 4.83, P = 0.000) and cryptococcal meningitis (OR = 6.78, P = 0.000) were significantly associated with in-hospital mortality. CONCLUSIONS : Routine clinical and laboratory parameters are useful predictors of in-hospital mortality in HIV-positive patients presenting to the ED with an acute illness. These parameters may be of value in guiding clinical decision-making, directing the appropriate use of resources and influencing patient disposition, and may also be useful in developing an outcome prediction tool.http://www.wileyonlinelibrary.com/journal/hivhj2022Critical Car

The role of laboratory testing in hospitalised and critically ill COVID-19-positive patients

The COVID-19 pandemic has placed healthcare resources around the world under immense pressure. South Africa, given the condition of its healthcare system, is particularly vulnerable. There has been much discussion around rational healthcare utilisation, ranging from diagnostic testing and personal protective equipment to triage and appropriate use of ventilation strategies. There has, however, been little guidance around use of laboratory tests once COVID-19 positive patients have been admitted to hospital. We present a working guide to rational laboratory test use, specifically for COVID-19, among hospitalised patients, including the critically ill. The specific tests, the reasons for testing, their clinical usefulness, timing and frequency are addressed. We also provide a discussion around evidence for the use of these tests from a clinical perspective.The Critical Care Society of Southern Africahttp://www.sajcc.org.za/index.php/SAJCCam2021Critical Car