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Background: This study looked at the characteristics and outcomes of critically ill patients with confirmed influenza A (H1N1) pdm09 infection in the Western Balkans in the post-pandemic period. Materials and Methods: This retrospective observational study of medical records and associated data collected during the post-pandemic period included all mechanically ventilated adult patients of two university-affiliated hospitals of the Western Balkans between 1 January and 31 March 2019 who had influenza A (H1N1) pdm09 infection confirmed by real-time reverse transcriptase-polymerase chain reaction from nasopharyngeal swab specimens and respiratory secretions. Results: The study included 89 patients, 49 males (55.1%), aged 56.09 ± 12.64 years. The median time from shift from hospital time to intensive care unit was 1 day (range: 1–2). In the post-pandemic period, cases observed in this study were found to have the following comorbidities: cardiovascular diseases in 44 (49.4%) patients and diabetes in 21 (23.6%) patients. Thirty-one patients (34.8%) in this study were obese. All 89 patients (100%) experienced some degree of acute respiratory distress syndrome, and 39 (44%) had multiorgan failure. Eighty-three patients (93%) were intubated and mechanically ventilated, 6 (7%) received non-invasive mechanical ventilation, 12 (13%) were treated with vvECMO and 36 (40%) received renal replacement therapy. Vasoactive support was needed by 56 (63%) patients. The median duration of mechanical ventilation was 9 (6–15.5) days. The hospital mortality rate was 44%. Conclusion: Critically ill patients with confirmed influenza A (H1N1) pdm09 infection in the post-pandemic season were older, required vasoactive drugs more often, and there was a trend of higher survival compared to H1N1 infection patients in the previous pandemic seasons.

Background/Aim. Acinetobacter is one of the most common causes of nosocomial infections, especially ventilatorassociated pneumonia (VAP). Considering the increased presence of multidrug-resistant microorganisms and the lack of novel antibiotics, colistin merged as the last-resort antibiotic for life threatening nosocomial infections. Intravenous use of antibiotics is accepted as a gold standard for the treatment of pneumonia, but additional administration of inhaled antibiotics in the treatment of VAP has shown to be advantageous in some clinical trials. The aim of this study was to investigate the effect of inhalatory colistin as an adjunct to intravenous colistin on the survival of patients with VAP caused by Acinetobacter species. Methods. We conducted a retrospective study to evaluate the efficacy of combination of inhalatory and intravenous colistin vs. intravenous colistin alone in 69 patients in the Intensive Care Units (ICU) with VAP caused by Acinetobacter baumannii. The patients were treated in the ICU at the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica (Serbia) in the period from January, 2013 to March, 2018. Baseline demographic data, severity of the disease, comorbidities, colistin regimen and length of the treatment were collected. The primary outcome was 28-day mortality. Results. Twenty seven of total 69 (39.1%) patients received combined intravenous and inhalatory colistin. Forty two (60.9%) patients received only intravenous colistin. Compared to the combined use of the drug (intravenous and inhalatory colistin), patients receiving intravenous colistin alone had a significantly increased risk of death during 28 days [25.9% vs. 61.9%, respectively; odds ratio (OR) 4.464, 95% confidence interval (CI) 1.539?2.925; p = 0.006]. Length of colistin use (> 7 days) was also associated with reduced survival (OR 0.22; 95% CI 0.080?0.606; p = 0.003). After adjusting for baseline severity of the illness (APACHE score) and length of colistin treatment, patients receiving only intravenous colistin had greater 28-day mortality rate compared to patients receiving both intravenous and inhalatory colistin (OR 6.305; 95% CI 1.795?22.153; p = 0.004). Conclusion. Our results suggest that adding inhalatory to intravenous colistin might be beneficial in the treatment of VAP caused by Acinetobacter species.

In many areas of the world, critical care providers caring for COVID-19 patients lacked specific knowledge and were exposed to the abundance of new and unfiltered information. With support from the World Health Organization, we created a multimodal tele-education intervention to rapidly share critical care knowledge related to COVID-19 targeting providers in a region of Southeastern Europe. We delivered 60-minute weekly interactive tele-education sessions over YouTube TM between March and May 2020, supplemented by a dedicated webpage. The intervention was reinforced using a secure social media platform (Viber TM) providing continuous rapid knowledge exchange among faculty and learners. A high level of engagement was observed with over 2,000 clinicians participating and actively interacting over a six-week period. Surveyed participants were highly satisfied with the intervention. Tele-education interventions using social media platforms are feasible, low-cost, and effective methods to share knowledge during the COVID-19 pandemic.

Pneumonia is the leading infectious cause of death worldwide. While inflammation is critically important in host response to microbial invasion, exaggerated inflammation can damage the lungs, contributing to respiratory failure and mortality. Corticosteroids are effective in reducing inflammation and can also cause immune suppression. Presently, clinicians are unable to reliably distinguish between exaggerated and appropriate immune response and thus cannot rapidly identify patients most likely to benefit from adjunctive corticosteroids. In this review, we propose a biomarker-guided, precision medicine approach to corticosteroid treatment, aimed to give these medications at appropriate dose and time and only to patients who have exaggerated inflammation.

Background: Systemic thrombolytic therapy is not recommended for patients with intermediate-risk pulmonary embolism (PE) because of major bleeding and intracranial bleeding overcomes the benefit of...

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of mortality worldwide but the data on ICU outcomes are limited to high income settings. Aim: To determine the outcomes of COPD patients admitted to ICUs in middle income countries (MICs). Methods: A secondary analysis of CERTAIN (Checklist For Early Recognition And Treatment of Acute Illness) trial. The ICU patients with main discharge diagnosis of COPD in 27 ICUs from 12 MICs (9 upper-MICs and 3 lower-MICs according to World Bank classification) were included in the analysis. Results: From total 3365 admissions, 184 were diagnosed with COPD (5.5%). There were 118 (64.1%) men, mean age was 68 (±14) years and BMI 24 (IQR 22-28) kg/m2. One hundred and fifty-three patients (83%) received mechanical ventilation (median 4 days, IQR 2-12). Palliative care was provided at some point in 48 (26.6%) patients. Median number of ICU days was 6 (IQR 3-13). ICU mortality was 25% and 28-days mortality 34%. There were no differences in ICU mortality between upper-MICS and lower-MICS (31/134, 23.3% vs.15/50, 30.0%, p=0.34) but significant differences between the countries were observed (Figure 1). Conclusions: Although COPD represents minority of total ICU patients in MICs these patients have high mortality rates that are comparable to previous reports from developed countries. The mortality rates varied across different geographical regions but were not associated with income levels.

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals. Grading of asthma based on clinical presentation is going from acute severe asthma over life threatening asthma to near fatal asthma There are only a few diagnostic methods that we can use for patients with severe form of asthma because. This is because of severity of disease which disables them to complete usually used diagnostic tests. Treatment of patients with severe form of asthma is difficult. Today we have precisely defined criteria for hospital admission, so we will not waste time to decide whether patient is of general ward, high dependence unit or intensive care unit. Thanks to latest GINA recommendations we updated about treatment procedures for each patient based on severity of disease. It is extremely important to choose adequate therapy as soon as possible, because we do not have big margin for an error. Therapy should be based on latest GINA recommendation.

Conclusion Influenza 2009 H1N1 infection in three southeast European ICUs affected predominantly healthy young patients and was associated with rapid deterioration after hospital admission and severe respiratory and multiorgan failure. These emerging ICUs provided contemporary ICU services, resulting in case-fatality rate comparable to reports from well-established ICU settings. After the first cases of human influenza A H1N1 infection were observed in Mexico in April 2009 (1), the infection quickly spread to Europe, Asia, and both Americas, which is why the World Health Organization (WHO) declared level 6 pandemic alert on June 11, 2009 (2). Up to February 2010, influenza A H1N1 virus was confirmed in more than 212 countries and caused more than 15 000 deaths (3). Compared with seasonal influenza, pandemic 2009 H1N1 influenza A has affected a great number of young, previously healthy patients and caused significant health and economic burden even in developed countries. So far, several studies have reported their experience with critically ill patients with 2009 H1N1 influenza in North America, South America, Asia, Australia, and Europe (1,4-12). A few studies have so far reported on H1N1 patients' characteristics and outcome in low-income and developing countries with limited ICU resources (1,8-12), and none on that in the west Balkans. The ICUs in these countries are mainly run by physicians who lack formal ICU training. Furthermore, until only recently non-surgical critically ill patients in these ICUs had limited access to mechanical ventilation and other life support interventions. However, over the past five years, three university hospitals in Bosnia and Herzegovina and Serbia have established multidisciplinary medical ICUs and most of critically ill patients with H1N1 influenza A infection in the region were admitted to these units. The aim of this study was to describe characteristics and outcomes of mechanically ventilated adult patients with 2009 H1N1 influenza A infection treated in these ICUs.

Critical care is a complicated, high risk, resource-dependent environment. Developing countries face common barriers to delivering quality emergent care due to the lack of supplies, coordination, infrastructure, technology, and human resources (e.g., competency-based education, multi-disciplinary staff and access to the most recent literature).(1) More importantly, the capacity to provide care for critically ill patients in intensive care units (ICUs) of low-income countries is unknown. Most developing countries lack published data on ICU capacity.(2) Importantly, a previous observational study aimed to assess the worldwide burden of critical illness, but only an insignificant sample (2 of 730 centers) of ICUs in low-income countries was taken into account.(3) Poor access to material resources and skilled personal pose a significant barrier to care improvement. Indeed, severity-of-illness-adjusted mortality is inversely related to gross national income.(3) Nevertheless, a recent survey performed by the CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and INjury; www.icertain.org) Investigators network in 15 ICUs from 11 lowand middle-income countries showed that 77% of ICUs singled out lack of protocols and trained staff, which are the most important barriers to improving the care and outcomes of critically ill patients as opposed to cost-dependent variables, such as equipment or supplies.(1) Basic resources, such as standardized supportive care and trained personnel have been cited as instrumental in changing the outcomes for catastrophic/challenging diseases, such as the Ebola virus disease in resource-limited settings.(4)

Background: Timely and appropriate care is the key to achieving good outcomes in acutely ill patients, but the effectiveness of critical care may be limited in resource-limited settings.Objectives: This study sought to understand how to implement best practices in intensive care units (ICU) in low- and middle-income countries (LMIC) and to develop a point-of-care training and decision-support tool.Methods: An internationally representative group of clinicians performed a 22-item capacity-and-needs assessment survey in a convenience sample of 13 ICU in Eastern Europe (4), Asia (4), Latin America (3), and Africa (2), between April and July 2012. Two ICU were from low-income, 2 from low-middle-income, and 9 from upper-middle-income countries. Clinician respondents were asked about bed capacity, patient characteristics, human resources, available medications and equipment, access to education, and processes of care.Results: Thirteen clinicians from each of 13 hospitals (1 per ICU) responded. Surveyed hospitals had median of 560 (interquartile range [IQR]: 232, 1,200) beds. ICU had a median of 9 (IQR: 7, 12) beds and treated 40 (IQR: 20, 67) patients per month. Many ICU had 1 staff member with some formal critical care training (n = 9, 69%) or who completed Fundamental Critical Care Support (n = 7, 54%) or Advanced Cardiac Life Support (n = 9, 69%) courses. Only 2 ICU (15%) used any kind of checklists for acute resuscitation. Ten (77%) ICU listed lack of trained staff as the most important barrier to improving the care and outcomes of critically ill patients.Conclusions: In a convenience sample of 13 ICU from LMIC, specialty-trained staff and standardized processes of care such as checklists are frequently lacking. ICU needs-assessment evaluations should be expanded in LMIC as a global priority, with the goal of creating and evaluating context-appropriate checklists for ICU best practices.HighlightsIn intensive care units from low- and middle-income countries, trained staff and processes of care such as checklists are frequently lacking even as access to intensive care unit resources is reasonable.A better understanding of existing intensive care units' capacity and evaluation of interventions to bring context-appropriate best practices to the bedside of critically ill patients should be a global priority.

Processes to ensure world-wide best-practice for critical care delivery are likely to minimize preventable death, disability and costly complications for any healthcare system's sickest patients, but no large-scale efforts have so far been undertaken towards these goals. The advances in medical informatics and human factors engineering have provided possibility for novel and user-friendly clinical decision support tools that can be applied in a complex and busy hospital setting. To facilitate timely and accurate best-practice delivery in critically ill patients international group of intensive care unit (ICU) physicians and researchers developed a simple decision support tool: Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). The tool has been refined and tested in high fidelity simulated clinical environment and has been shown to improve performance of clinical providers faced with simulated emergencies. The aim of this international educational intervention is to implement CERTAIN into clinical practice in hospital settings with variable resources (included those in low income countries) and evaluate the impact of the tool on the care processes and patient outcomes. To accomplish our aims, CERTAIN will be uniformly available on either mobile or fixed computing devices (as well as a backup paper version) and applied in a standardized manner in the ICUs of diverse hospitals. To ensure the effectiveness of the proposed intervention, access to CERTAIN is coupled with structured training of bedside ICU providers.