A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

Objective: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. Design: A secondary analysis derived from multicenter, observational study. Setting: Critical Care Units. Patients: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. Interventions: Corticosteroids vs. no corticosteroids. Main variables of interest: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. Results: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR = 0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. Conclusion: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

Objetivo: Evaluar si el uso de corticoesteroides (CC) se asocia con la mortalidad en la unidad de cuidados intensivos (UCI) en la población global y dentro de los fenotipos clínicos predeterminados. Diseño: Análisis secundario de estudio multicéntrico observacional. Ámbito: UCI. Pacientes: Pacientes adultos con COVID-19 confirmado ingresados en 63 UCI de España. Intervención: Corticoides vs. no corticoides. Variables de interés principales: A partir del análisis no supervisado de grupos, 3 fenotipos clínicos fueron derivados y clasificados como: A grave, B crítico y C potencialmente mortal. Se efectuó un análisis multivariado después de un propensity optimal full matching (PS) y una regresión ponderada de Cox (HR) y análisis de Fine-Gray (sHR) para evaluar el impacto del tratamiento con CC sobre la mortalidad en la población general y en cada fenotipo clínico. Resultados: Un total de 2.017 pacientes fueron analizados, 1.171 (58%) con CC. Después del PS, el uso de CC no se relacionó significativamente con la mortalidad en UCI (OR: 1,0; IC 95%: 0,98-1,15). Los CC fueron administrados en 298/537 (55,5%) pacientes del fenotipo A y no se observó asociación significativa con la mortalidad (HR = 0,85; 0,55-1,33). Un total de 338/623 (54,2%) pacientes del fenotipo B recibieron CC sin efecto significativo sobre la mortalidad (HR = 0,72; 0,49-1,05). Por último, 535/857 (62,4%) pacientes del fenotipo C recibieron CC. En este fenotipo, se evidenció un efecto protector de los CC sobre la mortalidad HR (0,75; 0,58-0,98). Conclusión: Nuestros hallazgos alertan sobre el uso indiscriminado de CC a dosis moderadas en todos los pacientes críticos con COVID-19. Solamente pacientes con elevado estado de inflamación podrían beneficiarse con el tratamiento con CC.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

OBJECTIVE: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. DESIGN: A secondary analysis derived from multicenter, observational study. SETTING: Critical Care Units. PATIENTS: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. INTERVENTIONS: Corticosteroids vs. no corticosteroids. MAIN VARIABLES OF INTEREST: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. RESULTS: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. CONCLUSION: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

[Influence of a multiple intervention program for hand hygiene compliance in an ICU]. / Influencia de un programa de intervención múltiple en el cumplimiento de la higiene de manos en una unidad de cuidados intensivos.

OBJECTIVE: To assess compliance with hand hygiene (HH) in ICU workers before (P1) and after (P2) implementation of a HH promotion program and distribution of an alcoholic solution for HH, and to analyze factors independently associated to HH before and after patients care. DESIGN: Fifty hours of observational evaluation were carried out during each period of the study (P1 and P2); the number of opportunities for HH (before and after patients care) was registered. Educational program (6 months): poster campaign, educational meetings with staff about HH, and the provision of alcohol hand rubs. SETTING: ICU in a secondary level hospital. PARTICIPANTS: Healthcare workers in the ICU. INTERVENTIONS: A quasi-experimental design was used to evaluate compliance with HH before and after implementation of the educational program. VARIABLES: Dependent variable: HH compliance before-after patients care; independent variables that might be associated to compliance (including the educational program). RESULTS: In P1 there were 338 opportunities for HH both before and after patients care, versus 355 in P2 (before and after patients care). The hand-washing rate was significantly higher in P2 than in P1 (prior to patient care: 45.3% and 34.9%, respectively, and after patient care: 63% and 51.7%, respectively). In the multivariate analysis, the educational program, together with other variables, was significantly associated to HH before and after patients care. CONCLUSION: There was a significant increase in compliance with hand hygiene among the ICU personnel during the educational phase, both before and after patients care.

Influence of a hygiene promotion programme on infection control in an intensive-care unit.

The objectives of this study were to determine the risk factors associated with nosocomial infection (NI) in the intensive-care unit and to assess the influence of a hand-washing promotion programme on the NI rate. Over a 6-month study period (P1), a prospective study of NI cases was performed, and risk factors for NI were analysed. Data were compared with those corresponding to a second period (P2), during which a health workers' hand-washing promotion programme was carried out; alcohol-based solution was also placed at the patients' headboard. Eight hundred and six patients were included (395 patients in P1 and 411 in P2). The mean APACHE II score was 11.41; there were no statistically significant differences in epidemiological or clinical variables between P1 and P2, and there were no differences in risk factors for NI. The rate of infection in P1 was 26%, and that in P2 was 16% (p <0.05). The hand-washing rate was higher in P2 than in P1 (before patient care, 45% and 35%, respectively; after contact with the patient, 63% and 51%, respectively). In the multivariate analysis, only central venous catheterization (>5 days) and tracheostomy were statistically significant risk factors for NI; having been included in the study during P1 or P2 was not statistically associated with NI. In conclusion, there was a significant increase in hand-washing frequency in P2; the incidence of NI during P1 was significantly higher than during P2, but having been included in the study in P1 was not significantly associated with a higher rate of NI; only central venous catheterization (>5 days) and tracheostomy were significantly associated with NI.

[Prognostic significance of the implantation of a temporary pacemaker in patients with acute myocardial infarction]. / Significado pronóstico de la implantación de marcapasos transitorio en pacientes con infarto agudo de miocardio.

OBJECTIVE: Indication of temporary pacemakers in patients during acute myocardial infarction was widely studied in the pre-thrombolytic era without having determined whether the generalization of fibrinolysis might have changed the overall incidence and significance of temporary pacemakers. Our aim was to determine the incidence and the prognostic significance of insertion of temporary pacemakers in patients with acute myocardial infarction. PATIENTS AND METHODS: In a study involving 1,239 patients consecutively admitted to hospital with acute myocardial infarction we studied clinical characteristics and prognosis depending on temporary pacemaker insertion or not. We performed an univariate analysis on in-hospital mortality and those selected variables were introduced in to a logistic regression analysis. RESULTS: A temporary pacemaker was indicated in 55 patients (4.4%), prophylactically in 22% and therapeutically in 78%. Temporary pacemakers were inserted in 55% of the patients with advanced AV block and in the 10% of the patients with bundle-branch block. Pacemaker insertion was associated with higher number of affected leads in the ECG, and higher CK peak, regardless of the association with thrombolysis. The following complications were more often observed in patients with temporary pacemakers: atrial fibrillation, heart failure, right bundle-branch block, advanced atrioventricular block and in-hospital mortality (45.4 vs 10.2%; p < 0.001). Need for a temporary pacemaker was less frequent in patients treated with thrombolytics compared with those not treated (3.0 vs 6.1%; p < 0.02). Pacemaker insertion had an independent value for predicting in-hospital mortality (OR = 5.51; 95% CI, 2.71-11.19). CONCLUSION: The insertion of a temporary pacemaker in acute myocardial infarction is less frequent nowadays than on the pre-thrombolytic era. Pacemaker insertion is associated with higher indices of infarct extension and in-hospital mortality, having independent prognostic value on the in-hospital mortality.

[Local variability in the guidelines for hypertension screening, diagnosis and baseline assessment in 40 health centers]. / Variabilidad en la protocolización de la captación, diagnóstico y valoración inicial del paciente hipertenso en 40 centros de salud.

BACKGROUND: To identify and to compare the recommendations of the currently existing clinical protocols for arterial hypertension (HT) screening, diagnosis and baseline study in the Murcia Region, Spain, in order to assess their validity and reliability. MATERIAL AND METHODS: Structured comparative description of guidelines in Clinical Protocols for HT (n = 40) from all Health Centers in the Region. Comparative description of the Health Centers Clinical Protocols and national and international reference documents regarding HT screening, diagnosis and baseline assessment is performed. RESULTS: Target population for screening ranged from aged > or = 14 years (24 centers) to > 20 (1 center). Screening procedure was not described in 3 centers and screening periodicity varied from 6 months to 5 years, with differences by age and by concurrent risk factors in some protocols. Diagnosis norms differed by age in only 11 protocols; blood pressure (BP) exams for diagnosis varied from 3 to 5 and there were 12 different HT figures for immediate diagnosis and treatment. Baseline study varied greatly; we found a total of 7 recommended items for anamnesis, 11 for physical exam, 19 for blood tests, 4 for urine tests, and 7 for other tests; only the electrocardiogram was common to all protocols. There was also some disagreement in the national and international reference guidelines whose scientific evidence was not always explicitly considered. CONCLUSIONS: There is a wide local variation in norms for HT screening, diagnosis, and baseline study. If the Centers follow their own protocols, the same patient may be or may not be diagnosed depending on the Center he visits; additionally, there would be big differences in the process and resources needed for HT control. This variation casts doubt on the protocols validity and reliability at regional level and underscores the need for critically reviewing the validity of existing protocols.