SCCM Resource Library-Impact of COVID-19 on Patients and Nursing

Video Transcription

This is Julie Graham, and I'm going to be reviewing an article that pertains to the impact of COVID-19 in patients in nursing, specifically as it relates to acute kidney  injury in patients hospitalized with COVID-19. This is from an in-press article that is available online prior to publication through PubMed for free. Hello.  I'm Julie Graham, and I'm going to be presenting a systematic review and meta-analysis conducted  by a nurse-led team, Passone et al., which is available for free on PubMed prior to publication. It's currently in press, according to at least the time of this recording.  This meta-analysis is, in English, translated to Occurrence of Acute Kidney Injury in Adult Patients Hospitalized with COVID-19, a Systematic Review and Meta-Analysis.  All right, a little background here. Many of you who are clinically active may have noticed a relationship between kidney  injury, acute kidney injury observed in patients hospitalized with COVID-19-related respiratory failure and an associated increased risk of mortality.  The relationship between acute kidney injury and respiratory failure in COVID-19-positive patients is yet to be fully understood.  There are certain observations that we know and can infer, but really the full scope remains unknown at this point.  And the impact to nursing is significant, as the National Institute of Health recommends  that continuous renal replacement therapy, or CRRT, over intermittent hemodialysis in patients with AKI who are COVID-19-positive.  And that is for the purpose of reducing exposure and frequency for nursing at the bedside. So you can see here on the right the author's flow map of their process for retrieval of  articles and following the PRISMA guidelines. That's the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, which is a best  practice guideline for a selection of literature for systematic review and meta-analysis.  Studies that were included were studies published up to June 2020, so early studies from five databases in English, Portuguese, and Spanish. This was a RN-led team.  Acute kidney injury was identified using the Kidney Disease Improving Global Outcomes, the KDIGO best practice scoring criteria. And this was hospitalized patients with COVID-19.  The primary outcomes included incidence, secondary outcome was mortality, and this also included an estimation of renal replacement therapy risk.  30 studies included in review following our mentioned guidelines, of which 28 were then included in the meta-analysis.  Okay, looking at some of our findings, data were assessed for a total of 18,043 cases.  The acute kidney injury estimate incidence overall and in the ICU was 9.2 and 32.6, respectively.  AKI estimate incidence in the elderly patients with acute respiratory distress syndrome was significantly higher at 22.9%.  Patients with secondary infection, AKI estimates increased to 31.6%, and the estimate incidence  of patients that required renal replacement therapy was 3.2%, and estimate AKI mortality was 50.4%, respectively.  Now you can see, looking at the ranges, there's quite a lot of variability in terms of these rates. So understandably, there was a considerable amount of limitations to this review.  These were all very early studies. There was a high degree of heterogeneity amongst the studies, and also a high degree of variability in outcomes.  The independent bias analysis was done by two authors using validated instruments. Risk of bias as AKI and AKI risk was not part of the initial study's design.  There's a risk of publication bias. A lot of those early studies included case reviews and observational studies among the earliest publications.  Rigor of analysis is demonstrated in the PRISMA flow diagram, and studies did not address identification of mitigation of some of these confounding factors.  So discussion of findings. Cytokine storm comes up as a theme with consequent endothelial damage, mitochondrial dysfunction, oxidative stress, hypovolemia, and hypercoagulability.  So we can infer the risk of organ damage in the context of cytokine storm. There's also direct viral damage to the ACE2 receptors, as this is the receptor by which  the coronavirus attaches itself. So disrupting the ACE2 receptor prevents our body's own restorative systems in terms of healing damaged cells and infected cells.  Proteinuria and hematuria were often the initial presenting signs in acute kidney injury, and  in older age and in secondary infection, as we had seen, was associated with a considerable increased risk of AKI.  Acute myocardial injury is evidenced by elevated serum troponin, demonstrated in association with WIRTH's outcomes, including AKI and ARDS.  And among ICU admissions, 26.7 needed CRRT. Mortality for patients with CRRT in the context of having a COVID positive diagnosis has been reported at 100%. So a couple of questions.  Given what we gleaned from the findings in the discussion, how can these findings be applied in the clinical setting?  And in particular, in terms of decision making, when we see the risk of mortality associated  with patients requiring CRRT in the context of having also a COVID positive presentation?  And then how could further research make these findings more meaningful, perhaps with consideration to some of the limitations of the study?  So implications specifically for nursing. Extracorporeal therapies are recommended for cytokine removal and organ support.  However, these therapies are resource intensive in terms of equipment, in terms of skilled staff to manage the equipment and monitor and support patients.  Per the National Institutes of Health, COVID treatment guidelines, CRRT is recommended as we discussed, over HD to prevent exposure to dialysis teams.  And more robust research studies are needed to further understand this phenomena and signs of early identification to prevent that deterioration. Okay, so one last question.  Care during the pandemic has predominantly been deferred to nursing care, while other caregivers can often remain outside of the negative pressure rooms to prevent exposure.  So this presents somewhat of a moral dilemma. Does it add, and I've framed the question this way, does it add insult to injury that  nurses on top of overwhelming surges that have led to PTSD have become metaphorically lambs to the slaughter?  So in closing, I wanted to share with you some anecdotes from my personal experience at our hospital in Southern California.  We're a border facility and that led to us being very significantly impacted by COVID-19. We lost many patients, we learned many lessons.  These pictures are from a year ago at the one year anniversary of the virus. And at that time, we came together to mourn the loss of almost 400 patients at that time,  including three of our own staff members.  And I can say after being secluded for a year and seeing so much loss, I really was able to understand how healing it is to come together and grieve the loss of these individuals.  And references are listed here. And to wrap up, thank you so much for allowing me to share this story and be part of the Society of Clinical Care Medicine Nursing Year in Review.  Thank you very much.

Video Summary

A nurse reviews a meta-analysis on the impact of COVID-19 on patients with acute kidney injury in nursing settings. The study finds that the incidence of acute kidney injury in COVID-19 patients is 9.2% overall and 32.6% in ICU. Elderly patients with acute respiratory distress syndrome have a higher incidence at 22.9%. Patients with secondary infection have an increased incidence of 31.6% and estimated mortality is 50.4%. The review acknowledges limitations such as the variability in outcomes and the need for further research. The nurse highlights the implications for nursing, including the use of continuous renal replacement therapy and the need for early identification and prevention of deterioration.

Asset Subtitle

Administration, Infection, Quality and Patient Safety, 2022

Asset Caption

This session will highlight the latest research, lessons learned, and changes taking place in critical care nursing practice, research, and/or education during the past year. Below are links to articles and additional information that will be discussed in Year in Review: Nursing. Innovations in Nursing Research Nesbitt J, Mitarai T, Chan GK, et al. Effect of emergency critical care nurses and emergency department boarding tome on in-hospital mortality in critically ill patients. Am J Emerg Med 2021;41:120-124. Doi:10.1016/j.ajem.2020.12.067. Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients - ScienceDirect or via Pub Med Impact of COVID-19 on Patients and Nursing Passoni R, Lordani TVA, Peres LAB, Carvalho ARDS. Ocurrencia de lesión renal aguda en pacientes adultos hospitalizados con COVID-19: revisión sistemática y metanálisis [Occurrence of acute kidney injury in adult patients hospitalized with COVID-19: A systematic review and meta-analysis]. Nefrologia (Engl Ed). 2021 Sep 20. doi: 10.1016/j.nefro.2021.09.002. Epub ahead of print. PMID: 34566228; PMCID: PMC8450067. Occurrence of acute kidney injury in adult patients hospitalized with COVID-19: A systematic review and meta-analysis - ScienceDirect The National Institutes of Health (NIH) COVID-19 treatment guidelines: https://www.covid19treatmentguidelines.nih.gov/critical-care/acute-kidney-injury/ Titratable Medications and The Joint Commission (TJC) Update Davidson JE, Doran N, Petty, A, et al. Survey of nurses' experiences applying The Joint Commission's medication management titration standards. Am J Crit Care 2021;30(5):365-374. https://doi.org/10.4037/ajcc2021716 https://aacnjournals.org/ajcconline/article/30/5/365/31549/Survey-of-Nurses-Experiences-Applying-The-Joint Davidson J, Chechel L, Chavez J, et al. Thematic analysis of nurses' experiences with The Joint Commission's medication management titration standards. Am J Crit Care 2021;30(5):375-384. https://doi.org/10.4037/ajcc2021280 https://aacnjournals.org/ajcconline/article/30/5/375/31550/Thematic-Analysis-of-Nurses-Experiences-With-The Firth S 'Forced to Lie': Med titration standards put critical care nurses on shaky ground. MedPage Today September 2, 2021https://www.medpagetoday.com/washington-watch/washington-watch/94342 McLean B, Chechel L. Nurses need to take the lead on medication titration. Am Nurse September 8, 2021https://www.myamericannurse.com/nurses-need-to-take-the-lead-on-medication-titration/ Rincon T. Where's the evidence guiding updated titration standards? MedPage Today September 27, 2021 Where's the Evidence Guiding Updated Titration Standards? | MedPage Today

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Infection

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Nursing

Tag Evidence Based Medicine

Tag COVID-19

Year 2022

Keywords

nurse

meta-analysis

COVID-19

acute kidney injury

nursing settings

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