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OBJECTIVE The use of remote real-time continuous glucose monitoring (CGM) in the hospital has rapidly emerged to preserve personal protective equipment and reduce potential exposures during coronavirus disease 2019 (COVID-19). RESEARCH DESIGN AND METHODS We linked a hybrid CGM and point-of-care (POC) glucose testing protocol to a computerized decision support system for continuous insulin infusion and integrated a validation system for sensor glucose values into the electronic health record. We report our proof-of-concept experience in a COVID-19 intensive care unit. RESULTS All nine patients required mechanical ventilation and corticosteroids. During the protocol, 75.7% of sensor values were within 20% of the reference POC glucose with an associated average reduction in POC of 63%. Mean time in range (70–180 mg/dL) was 71.4 ± 13.9%. Sensor accuracy was impacted by mechanical interferences in four patients. CONCLUSIONS A hybrid protocol integrating real-time CGM and POC is helpful for managing critically ill patients with COVID-19 requiring insulin infusion.

Aim During the pandemic of coronavirus disease 2019 (COVID‐19), the physicians are using various off‐label therapeutics to manage COVID‐19. We undertook a cross‐sectional survey to study the current variation in therapeutic strategies for managing severe COVID‐19 in India. Methods From January 4 to January 18, 2021, an online cross‐sectional survey was conducted among physicians involved in the management of severe COVID‐19. The survey had three sections: 1. Antiviral agents, 2. Immunomodulators, and 3. Adjuvant therapies. Results 1055 respondents (from 24 states and five union territories), of which 64.2% were consultants, 54.3% working in private hospitals, and 39.1% were from critical care medicine completed the survey. Remdesivir (95.2%), antithrombotics (94.2%), corticosteroids (90.3%), vitamins (89.7%) and empirical antibiotics (85.6%) were the commonly used therapeutics. Ivermectin (33%), convalescent plasma (28.6%) and favipiravir (17.6%) were other antiviral agents used. Methylprednisolone (50.2%) and dexamethasone (44.1%) were preferred corticosteroids and at a dose equivalent of 8 mg of dexamethasone phosphate (70.2%). There was significant variation among physicians from different medical specialities in the use of favipiravir, corticosteroids, empirical antibiotics and vitamins. Conclusion There is a considerable variation in the physicians’ choice of therapeutic strategies for the management of severe COVID‐19 in India, as compared with the available evidence.

Introduction: During the COVID-19 pandemic, we implemented a protocol combining continuous glucose monitoring (CGM) with a computerized intravenous insulin infusion algorithm to care for patients with severe COVID-19. Objective: To examine glucose trends surrounding cardiac arrest events to evaluate the performance of CGM sensors during severe clinical instability. Methods: We reviewed eight cases of patients with type 2 diabetes diagnosed with COVID-19 requiring ICU care on IV insulin and CGM therapy experiencing severe clinical decompensation leading to cardiac arrest. Index events (cardiac arrest) were identified by staff documentation in the electronic health record. Clinical characteristics, mean arterial pressure (MAP), and point-of-care (POC) glucose values surrounding the index event were collected. CGM data was paired with MAP and POC glucose values. Rapid declines in the glucose trend [rate of change (ROC) ≥3mg/dl/min] were identified during this time of clinical instability. Results: The mean age of patients was 61.3±13.8 years. All patients were treated with steroid therapy, vasopressors, and mechanical ventilation. 62.5% were on CRRT. Four (50%) patients had sudden cardiac arrest and drop in MAP, while the other four patients had a more prolonged decline in MAP prior to cardiac arrest. CGM values in those with sudden arrest showed an abrupt decline (≥3mg/dl/min) an average of 16.7±13.7 min following cardiac arrest. Rapid down trending of CGM values in those with prolonged hypotension occurred on average about 6 hours prior to cardiac arrest. During these episodes, the CGM values stopped correlating with POC tests. Conclusions: Real-time CGM in critically-ill patients may provide clinical information beyond glucose control. Rapid declines in CGM values (≥3mg/dl/min) not correlating with POC glucose testing are associated with both sudden and prolonged changes in arterial pressure. Disclosure J. Hester: None. G. M. Davis: None. F. J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Research Support; Self; Dexcom, Inc., Merck & Co., Inc. M. Rabinovich: None. N. Poindexter: None. S. Tekwani: None.

Background Patients with sepsis are at risk for developing sepsis-induced cardiomyopathy (SIC). Previous studies offer inconsistent results regarding the association of SIC and mortality. This study sought to assess whether SIC is linked to mortality in patients with sepsis and to evaluate predictors of the development of SIC. Methods In this retrospective study, patients admitted to the medical intensive care unit with a diagnosis of sepsis in the absence of acute coronary syndrome were included. SIC was identified using transthoracic echocardiogram and was defined by a new-onset decline in left ventricular ejection fraction (LVEF) of up to 50% or a decline of at least 10% in LVEF relative to baseline in patients with a history of heart failure with reduced EF. Multivariable logistic regression analysis was performed using the R software program (R Foundation for Statistical Computing). Results Of the 359 patients in the final analysis, 19 (5.3%) had SIC, and eight (42.1%) of these 19 patients and 60 (17.6%) of the 340 patients in the non-SIC group died. SIC was associated with an increased risk for all-cause in-hospital mortality (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.15-18.69; P=0.03). Independent predictors for the development of SIC were albumin level (OR, 0.47; 95% CI, 0.23-0.93; P=0.03) and culture positivity (OR, 8.47; 95% CI, 2.24-55.61; P=0.006). Concomitant right ventricular hypokinesis was noted in 13 (68.4%) of the 19 SIC patients. Conclusion SIC was associated with an increased risk for all-cause in-hospital mortality. Low albumin level and culture positivity were independent predictors of SIC.

The rate of unplanned ICU readmissions is often considered a measure of hospital performance. However, the degree to which these readmissions are preventable and the causes of preventable readmissions are unknown, creating uncertainty about the feasibility and value of reducing ICU readmission rates. To inform this issue, we sought to determine the frequency and underlying causes of potentially preventable ICU readmissions.Retrospective cohort study.Urban, academic medical center in the mid-Atlantic United States.Adult patients discharged alive from their first ICU admission with an unplanned readmission within 48 hours of discharge.Each patient's medical chart was reviewed by two independent investigators who rated each readmission's preventability according to standardized scale and assessed the etiology of both preventable and nonpreventable readmissions. We assessed concordance between raters using the κ statistic and resolved disagreements through iterative discussion. Of 136 readmissions in the final analysis, 16 (11.8%; 95% CI, 6.9-18.4) were considered preventable and 120 (88.2%; 95% CI, 81.5-93.1) were considered nonpreventable. Of nonpreventable readmissions, 67 were due to a new clinical problem and 53 were due to an existing clinical problem. Among preventable readmissions, six were attributable to system errors, six were attributable to management errors, two were attributable to procedural events, one was attributable to a diagnostic error, and one was attributable to a medication error. Compared to nonpreventable readmissions, preventable readmissions tended to have shorter index ICU lengths of stay (2 vs 3 d; p = 0.05) and a shorter duration of time on the ward prior to readmission (16.6 vs 23.6 hr; p = 0.05).The majority of early ICU readmissions are nonpreventable, raising important concerns about ICU readmission rates as a measure of hospital performance.

Source Citation Cao B, Wang Y, Wen D, et al. A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. N Engl J Med. 2020;382:1787-99. 32187464

Ultrastructural observations reveal a continuous interstitial matrix connection between the endocrine and exocrine pancreas, which is lost due to fibrosis in rodent models and humans with type 2 diabetes mellitus (T2DM). Widening of the islet-exocrine interface appears to result in loss of desmosomes and adherens junctions between islet and acinar cells and is associated with hypercellularity consisting of pericytes and inflammatory cells in T2DM pancreatic tissue. Organized fibrillar collagen was closely associated with pericytes, which are known to differentiate into myofibroblasts-pancreatic stellate cells. Of importance, some pericyte cellular processes traverse both the connecting islet-exocrine interface and the endoacinar interstitium of the exocrine pancreas. Loss of cellular paracrine communication and extracellular matrix remodeling fibrosis in young animal models and humans may result in a dysfunctional insulino-acinar-ductal-incretin gut hormone axis, resulting in pancreatic insufficiency and glucagon-like peptide deficiency, which are known to exist in prediabetes and overt T2DM in humans.

Background Previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilator support on outcomes. We evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. Methods Objective: The objective was to evaluate the effect of early application of prone position on mortality in patients with severe ARDS. Design: The PROSEVA group conducted a multicenter, prospective, randomized controlled trial. Setting: Patients with ARDS were recruited from 26 ICUs in France and one ICU in Spain. Subjects: The subjects were critically ill patients admitted to the ICU with respiratory failure requiring mechanical ventilation for severe ARDS. Severe ARDS criteria - an arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio of less than 150 mm Hg, an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume of about 6 mL per kilogram of predicted body weight - were confirmed after 12 to 24 hours of mechanical ventilation in the participating ICUs. Subjects were eligible after 12 to 24 hours of stabilization and were randomly assigned to either the prone group or the supine group. Intervention: Four hundred sixty-six patients with severe ARDS underwent prone position ventilation of at least 16 hours or ventilation in the supine position. Patients assigned to the prone group were manually turned in standard ICU beds to the prone position within the first hour of random assignment and were placed prone for at least 16 consecutive hours. Standard ventilator protocols and weaning protocols were implemented for study participants. Outcomes: The primary outcome was the proportion of patients who died from any cause within 28 days after random assignment. Results In total, 237 patients were assigned to the prone group and 229 patients were assigned to the supine group. The 28-day mortality rates were 16% in the prone group and 32.8% in the supine group (P