BackgroundOptimal decision-making regarding who to admit to critical care in pandemic situations remains unclear. We compared age, Clinical Frailty Score (CFS), 4C Mortality Score and hospital mortality in two separate COVID-19 surges based on the escalation decision made by the treating physician.MethodsA retrospective analysis of all referrals to critical care during the first COVID-19 surge (cohort 1, March/April 2020) and a late surge (cohort 2, October/November 2021) was undertaken. Patients with confirmed or high clinical suspicion of COVID-19 infection were included. A senior critical care physician assessed all patients regarding their suitability for potential intensive care unit admission. Demographics, CFS, 4C Mortality Score and hospital mortality were compared depending on the escalation decision made by the attending physician.Results203 patients were included in the study, 139 in cohort 1 and 64 in cohort 2. There were no significant differences in age, CFS and 4C scores between the two cohorts. Patients deemed suitable for escalation by clinicians were significantly younger with significantly lower CFS and 4C scores compared with patients who were not deemed to benefit from escalation. This pattern was observed in both cohorts. Mortality in patients not deemed suitable for escalation was 61.8% in cohort 1 and 47.4% in cohort 2 (p<0.001).ConclusionsDecisions who to escalate to critical care in settings with limited resources pose moral distress on clinicians. 4C score, age and CFS did not change significantly between the two surges but differed significantly between patients deemed suitable for escalation and those deemed unsuitable by clinicians. Risk prediction tools may be useful in a pandemic to supplement clinical decision-making, even though escalation thresholds require adjustments to reflect changes in risk profile and outcomes between different pandemic surges.
Pregnancy is a normal physiological state with hyperdynamic circulation that is characterised by important physiological changes, many of which take place in the cardiovascular system. Few patients with physiological bradycardia may, in the second trimester, feel symptomatic as their blood pressure drops due to a reduction in systemic vascular resistance however, treatment is rarely required. Pathological bradycardia in pregnant women is rare and usually secondary to either Congenital heart block, Myocarditis, or Severe Hypocalcaemia with an incidence as low as 1:20 000 women. Authors present a rare case of severe bradycardia during peripartum period who required LSCS in view of IUGR with Anhydroamnios. On admission her general condition was good her pulse was 42 beats per mins and BP was 170/100 mm of Hg with 1+ protinuria. A clinical impression of preeclampsia was made. ECG showed sinus bradycardia with no irregularity. 2 DEcho showed no structural lesion in the heart and normal functional capacity so dilated peripartum cardiomyopathy was ruled out. Her serum electrolytes were normal and serum calcium and magnesium was markedly reduced which was corrected. Post operatively on day 4 pulse was mor than 60 and she was transferred out of ICU. The ECG performed on day 6 was normal.
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