Results of the home mechanical ventilation national program among adults in Chile between 2008 and 2017.

BACKGROUND: Home mechanical ventilation (HMV) is a viable and effective strategy for patients with chronic respiratory failure (CRF). The Chilean Ministry of Health started a program for adults in 2008. METHODS: This study examined the following data from a prospective cohort of patients with CRF admitted to the national HMV program: characteristics, mode of admission, quality of life, time in the program and survival. RESULTS: A total of 1105 patients were included. The median age was 59 years (44-58). Women accounted for 58.1% of the sample. The average body mass index (BMI) was 34.9 (26-46) kg/m2. A total of 76.2% of patients started HMV in the stable chronic mode, while 23.8% initiated HMV in the acute mode. A total of 99 patients were transferred from the children's program. There were 1047 patients on non-invasive ventilation and 58 patients on invasive ventilation. The median baseline PaCO2 level was 58.2 (52-65) mmHg. The device usage time was 7.3 h/d (5.8-8.8), and the time in HMV was 21.6 (12.2-49.5) months. The diagnoses were COPD (35%), obesity hypoventilation syndrome (OHS; 23.9%), neuromuscular disease (NMD; 16.3%), non-cystic fibrosis bronchiectasis or tuberculosis (non-CF BC or TBC; 8.3%), scoliosis (5.9%) and amyotrophic lateral sclerosis (ALS; 5.24%). The baseline score on the Severe Respiratory Insufficiency questionnaire (SRI) was 47 (± 17.9) points and significantly improved over time. The lowest 1- and 3-year survival rates were observed in the ALS group, and the lowest 9-year survival rate was observed in the non-CF BC or TB and COPD groups. The best survival rates at 9 years were OHS, scoliosis and NMD. In 2017, there were 701 patients in the children's program and 722 in the adult´s program, with a prevalence of 10.4 per 100,000 inhabitants. CONCLUSION: The most common diagnoses were COPD and OHS. The best survival was observed in patients with OHS, scoliosis and NMD. The SRI score improved significantly in the follow-up of patients with HMV. The prevalence of HMV was 10.4 per 100,000 inhabitants. Trial registration This study was approved by and registered at the ethics committee of North Metropolitan Health Service of Santiago, Chile (N° 018/2021).

Hospitalizations in patients with idiopathic pulmonary fibrosis.

BACKGROUND: Hospitalizations are common among patients with idiopathic pulmonary fibrosis (IPF). We investigated the impact of hospitalizations on outcomes in patients with IPF. METHODS: The IPF-PRO Registry is an observational US registry that enrolled patients with IPF that was diagnosed or confirmed at the enrolling center in the previous 6 months. Associations between patient characteristics and hospitalization, and between hospitalization and mortality, were analyzed using Cox regression models. RESULTS: A total of 1002 patients with IPF were enrolled into the IPF-PRO Registry. Over a median follow-up time of 23.7 months (maximum: 67.0 months), 568 patients (56.7%) had at least one hospitalization. Of these patients, 319 (56.2%) had at least one respiratory-related hospitalization and 120 (21.1%) had at least one hospitalization with ventilatory support. Younger age (HR 0.68 [95% CI 0.55, 0.84] per 5-year increase for patients < 62 years), lower BMI (0.96 [0.93, 0.98] per 1-point increase), lower FVC % predicted (0.90 [0.83, 0.97] per 10% increase), oxygen use at rest (2.85 [2.18, 3.72]) and history of pulmonary hypertension (2.02 [1.37, 2.96]) at enrollment were associated with an increased risk of respiratory-related hospitalization during follow-up. In a multivariable model, there was an eightfold increase in the risk of mortality during hospitalization or within 90 days of discharge compared with outside of this period. The risk of mortality associated with a respiratory hospitalization or a hospitalization with ventilatory support was even greater. CONCLUSIONS: Data from the IPF-PRO Registry demonstrate that hospitalizations are common among patients with IPF. The risk of mortality during hospitalization or within 90 days of discharge was high, particularly among patients who were hospitalized for a respiratory cause or received ventilatory support. Trial registration ClinicalTrials.gov, NCT01915511. Registered 5 August 2013, https://clinicaltrials.gov/ct2/show/NCT01915511.

Increased circulating cytokeratin 19 fragment levels in preterm neonates receiving mechanical ventilation are associated with poor outcome.

Invasive mechanical ventilation and oxygen toxicity are postnatal contributors to chronic lung disease of prematurity, also known as bronchopulmonary dysplasia (BPD). Cyfra 21-1 is a soluble fragment of cytokeratin 19, which belongs to the cytoskeleton stabilizing epithelial intermediate filaments. As a biomarker of structural integrity, Cyfra 21-1 might be associated with airway injury and lung hypoplasia in neonates. Serum Cyfra 21-1 concentrations for 80 preterm and 80 healthy term newborns were measured within 48 h after birth. Preterm infants with the combined endpoint BPD/mortality had significantly higher Cyfra 21-1 levels compared with those without fulfilling BPD/mortality criteria (P = 0.01). Also, severe RDS (>grade III) was associated with higher Cyfra levels (P = 0.01). Total duration of oxygen therapy was more than five times longer in neonates with high Cyfra 21-1 levels (P = 0.01). Infants with higher Cyfra 21-1 values were more likely to receive mechanical ventilation (50% vs. 17.5%). However, the duration of mechanical ventilation was similar between groups. The median Cyfra value was 1.93 ng/mL (IQR: 1.68-2.53 ng/mL) in healthy term neonates and 8.5 ng/mL (IQR: 3.6-16.0 ng/mL) in preterm infants. Using ROC analysis, we calculated a Cyfra cutoff > 8.5 ng/mL to predict BPD/death with an AUC of 0.795 (P = 0.004), a sensitivity of 88.9%, and a specificity of 55%. Mortality was predicted with a cutoff > 17.4 ng/mL (AUC: 0.94; P = 0.001), a sensitivity of 100%, and a specificity of 84%. These findings suggest that Cyfra 21-1 concentration might be useful to predict poor outcome in premature infants.

Decreased in-hospital mortality associated with aspirin administration in hospitalized patients due to severe COVID-19.

Hypercoagulability and thrombosis caused by coronavirus disease 2019 (COVID-19) are related to the higher mortality rate. Because of limited data on the antiplatelet effect, we aimed to evaluate the impact of aspirin add-on therapy on the outcome of the patients hospitalized due to severe COVID-19. In this cohort study, patients with a confirmed diagnosis of severe COVID-19 admitted to Imam Hossein Medical Center, Tehran, Iran from March 2019 to July 2020 were included. Demographics and related clinical data during their hospitalization were recorded. The mortality rate of the patients was considered as the primary outcome and its association with aspirin use was assessed. Nine hundred and ninety-one patients were included, of that 336 patients (34%) received aspirin during their hospitalization and 655 ones (66%) did not. Comorbidities were more prevalent in the patients who were receiving aspirin. Results from the multivariate COX proportional model demonstrated a significant independent association between aspirin use and reduction in the risk of in-hospital mortality (0.746 [0.560-0.994], p = 0.046). Aspirin use in hospitalized patients with COVID-19 is associated with a significant decrease in mortality rate. Further prospective randomized controlled trials are needed to assess the efficacy and adverse effects of aspirin administration in this population.

Mortality in mechanically ventilated patients with COVID-19: a systematic review.

Introduction: The use of mechanical ventilation associated with acute hypoxemic respiratory failure, the most common complication in critically ill COVID-19 patients, defines a high risk population that requires specific consideration of outcomes and treatment practices.Areas covered: This review evaluates existing information about mortality rates and effectiveness of antiviral, immune-modulating, and anticoagulation treatments in COVID-19 patients who received mechanical ventilation. The mortality rate and follow-up periods in patients receiving mechanical ventilation ranged widely. Antivirals, including remdesivir and convalescent plasma, have shown no definitive mortality benefit in this population despite positive results in other COVID-19 patients. Dexamethasone was associated with an absolute reduction in 28-day mortality by 12.3% (95% CI, 6.3 to 17.6), after adjusting for age. Reduced mortality has been demonstrated with tocilizumab use alongside corticosteroids. Evidence is inconclusive for therapeutic anticoagulation, and further studies are needed to determine the comparative benefit of prophylactic anticoagulation.Expert opinion: Significant variation and high mortality rates in mechanically ventilated patients necessitate more standardized outcome measurements, increased consideration of risk factors to reduce intubation, and improved treatment practices. Anticoagulation and dexamethasone should be incorporated in the treatment of patients receiving invasive mechanical ventilation, while more rigorous studies are required for other potential treatments.

Preexisting respiratory diseases and clinical outcomes in COVID-19: a multihospital cohort study on predominantly African American population.

BACKGROUND: Comorbidities play a key role in severe disease outcomes in COVID-19 patients. However, the literature on preexisting respiratory diseases and COVID-19, accounting for other possible confounders, is limited. The primary objective of this study was to determine the association between preexisting respiratory diseases and severe disease outcomes among COVID-19 patients. Secondary aim was to investigate any correlation between smoking and clinical outcomes in COVID-19 patients. METHODS:  This is a multihospital retrospective cohort study on 1871 adult patients between March 10, 2020, and June 30, 2020, with laboratory confirmed COVID-19 diagnosis. The main outcomes of the study were severe disease outcomes i.e. mortality, need for mechanical ventilation, and intensive care unit (ICU) admission. During statistical analysis, possible confounders such as age, sex, race, BMI, and comorbidities including, hypertension, coronary artery disease, congestive heart failure, diabetes, any history of cancer and prior liver disease, chronic kidney disease, end-stage renal disease on dialysis, hyperlipidemia and history of prior stroke, were accounted for. RESULTS:  A total of 1871 patients (mean (SD) age, 64.11 (16) years; 965(51.6%) males; 1494 (79.9%) African Americans; 809 (43.2%) with ≥ 3 comorbidities) were included in the study. During their stay at the hospital, 613 patients (32.8%) died, 489 (26.1%) needed mechanical ventilation, and 592 (31.6%) required ICU admission. In fully adjusted models, patients with preexisting respiratory diseases had significantly higher mortality (adjusted Odds ratio (aOR), 1.36; 95% CI, 1.08-1.72; p = 0.01), higher rate of ICU admission (aOR, 1.34; 95% CI, 1.07-1.68; p = 0.009) and increased need for mechanical ventilation (aOR, 1.36; 95% CI, 1.07-1.72; p = 0.01). Additionally, patients with a history of smoking had significantly higher need for ICU admission (aOR, 1.25; 95% CI, 1.01-1.55; p = 0.03) in fully adjusted models. CONCLUSION:  Preexisting respiratory diseases are an important predictor for mortality and severe disease outcomes, in COVID-19 patients. These results can help facilitate efficient resource allocation for critical care services.

Respiratory mechanics behavior after heart surgery: an experimental study

Changes in ventilatorymechanics and their consequent pulmonary complications are common after surgical procedures, particularly in cardiac surgery (CS), and may be associated with both preoperative history and surgical circumstances. This study aims to compare ventilatory mechanics in the moments before and after cardiac surgery (CS), describing how pulmonary complications occurred. An experimental, uncontrolled study was conducted, of the before-and-after type, and with a descriptive and analytical character. It was carried out in a private hospital in the city of Salvador, Bahia, Brazil, and involved 30 adult patients subjected to CS. In addition to clinical and epidemiological variables, minute volume (VE), respiratory rate (RR), tidal volume (VT), forced vital capacity (FVC), maximum inspiratory pressure (MIP), and peak expiratory flow (PEF) were also recorded. Data were collected in the following moments: preoperative (PRE-OP) period, immediate postoperative (IPO) period, and 1stpostoperative day (1stPOD). The sample was aged 48.1 ± 11.8 years old and had a body mass index of 25.5 ± 4.9 kg m-2; 60% of the patients remained on mechanical ventilation for less than 24 hours (17.5 [8.7-22.9] hours). There was a significant reduction in VT, FVC, MIP and PEF when PRE-OP versus IPO, and PRE-OP versus 1stPOD were compared (p < 0.05). There were no significant changes between IPO and the 1stPOD. The highest incidence of pulmonary complications involved pleural effusion (50% of the patients). This study showed that patients subjected to CS present significant damage to ventilatory parameters after the surgery, especially in the IPO period and on the 1stPOD. It is possible that the extension of this ventilatory impairment has led to the onset of postoperative pulmonary complications.

Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients.

OBJECTIVES/HYPOTHESIS: To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN: Retrospective case series. METHODS: All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS: A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS: Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2469-E2474, 2021.

Clinical characteristics, outcomes and prognosticators in adult patients hospitalized with COVID-19.

BACKGROUND: COVID-19 is a novel disease caused by SARS-CoV-2. METHODS: We conducted a retrospective evaluation of patients admitted with COVID-19 to one site in March 2020. Patients were stratified into 3 groups: survivors who did not receive mechanical ventilation (MV), survivors who received MV, and those who received MV and died during hospitalization. RESULTS: There were 140 hospitalizations; 22 deaths (mortality rate 15.7%), 83 (59%) survived and did not receive MV, 35 (25%) received MV and survived; 18 (12.9%) received MV and died. Thee mean age of each group was 57.8, 55.8 and 72.7 years, respectively (P = .0001). Of those who received MV and died, 61% were male (P = .01). More than half the patients (n = 90, 64%) were African American. First measured d-dimer >575.5 ng/mL, procalcitonin > 0.24 ng/mL, lactate dehydrogenase >445.6 units/L, and brain natriuretic peptide (BNP) >104.75 pg/mL had odds ratios of 10.5, 5, 4.5 and 2.9, respectively for MV (P < .05 for all). Peak BNP >167.5 pg/mL had an odds ratio of 6.7 for inpatient mortality when mechanically ventilated (P = .02). CONCLUSIONS: Age and gender may impact outcomes in COVID-19. D-dimer, procalcitonin, lactate dehydrogenase and BNP may serve as early indicators of disease trajectory.

Cancer and Coronavirus Disease (COVID-19): Comorbidity, Mechanical Ventilation, and Death Risk.

BACKGROUND: The presence of comorbidity poses a major clinical challenge in the care and treatment of COVID-19 patients. Moreover, having one or more comorbidities could be a life-threatening situation in COVID-19 patients. Cancer is substantially associated with significant morbidity and mortality in COVID-19 patients. However, there is not sufficient data to conclude that cancer patients have a higher risk of COVID-19 infection. In this study, we reviewed cancer comorbidity and risk of mechanical ventilation or death in patients with confirmed COVID-19. METHODS: A comprehensive systematic search was performed on PubMed, Scopus, Web of Science, SciELO, and CNKI, to find articles published until August 01, 2020. All relevant case series, case reports, systematic and narrative reviews, meta-analyses, and prospective and retrospective studies that reported clinical characteristics and epidemiological information of cancer patients infected with COVID-19 were included in the study. RESULTS: A total of 12 cohort studies exclusively on cancer patients with confirmed COVID-19 were selected. CONCLUSIONS: According to the findings of this study, cancer was not among the most prevalent underlying diseases in patients with confirmed COVID-19. Moreover, cancer patients infected with COVID-19 had the lowest risk of mechanical ventilation or death than the non-cancer infected patients.

Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?

OBJECTIVES: To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery. METHODS: Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared. RESULTS: Of 717 infants (median age: 4 months, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group. CONCLUSIONS: FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.

Adverse events related to mechanical ventilation in a pediatric intensive care unit / Eventos adversos relacionados à ventilação mecânica em uma unidade de terapia intensiva pediátrica

ABSTRACT Objective: To identify the prevalence and factors associated with adverse events (AE) related to invasive mechanical ventilation in patients admitted to the Pediatric Intensive Care Unit (PICU) of a tertiary public hospital. Methods: This is a cross-sectional study from July 2016 to June 2018, with data collected throughout patients' routine care in the unit by the care team. Demographic, clinical and ventilatory characteristics and adverse events were analysed. The logistic regression model was used for multivariate analysis regarding the factors associated with AE. Results: Three hundred and six patients were included, with a total ventilation time of 2,155 days. Adverse events occurred in 66 patients (21.6%), and in 11 of those (16.7%) two AE occurred, totalling 77 events (36 AE per 1000 days of ventilation). The most common AE was post-extubation stridor (25.9%), followed by unplanned extubation (16.9%). Episodes occurred predominantly in the afternoon shift (49.3%) and associated with mild damage (54.6%). Multivariate analysis showed a higher occurrence of AE associated with length of stay of 7 days or more (Odds Ratio [OR]=2.6; 95% confidence interval [95%CI] 1.49-4.66; p=0.001). Conclusions: The results of the present study show a significant number of preventable adverse events, especially stridor after extubation and accidental extubation. The higher frequency of these events is associated with longer hospitalization.

RESUMO Objetivo: Identificar a prevalência e os fatores associados a eventos adversos (EA) relacionados à ventilação mecânica (VM) invasiva em pacientes internados na Unidade de Terapia Intensiva Pediátrica (UTIP) de hospital público terciário. Métodos: Trata-se de estudo transversal realizado entre julho de 2016 e junho de 2018, com dados coletados ao longo da rotina de atendimento dos pacientes na unidade pela equipe assistencial. Neste estudo, foram analisados características demográficas, clínicas, ventilatórias e os EA ocorridos. O modelo de regressão logística foi utilizado para análise multivariada quanto aos fatores associados aos EA. Resultados: Neste estudo, foram incluídos 306 pacientes, com tempo de ventilação total de 2.155 dias. Ocorreram EA em 66 pacientes (21,6%), dos quais 11 (16,7%) sofreram dois EA, totalizando 77 eventos (36 EA por mil dias de ventilação). O EA mais comum foi o estridor pós-extubação (25,9%), seguido da extubação não planejada (16,9%). Os episódios ocorreram predominantemente no turno da tarde (49,3%) e associados a grau de dano leve (54,6%). Na análise multivariada, observou-se maior ocorrência de EA associado a tempo de internação igual ou superior a sete dias (Odds Ratio [OR]=2,6, intervalo de confiança de 95% [IC95%)]1,49-4,66, p=0,001). Conclusões: Evidenciou-se número significativo de EA que podem ser prevenidos, destacando-se o estridor pós-extubação e a extubação acidental, com ocorrência mais frequentemente associada ao maior tempo de internação.

Síndrome de dificultad respiratoria aguda en niños: duración de la ventilación y supervivencia / Acute respiratory distress syndrome in children: duration of ventilation and survival

Introducción: El síndrome de dificultad respiratoria aguda es una enfermedad que cursa con hipoxemia severa, poco frecuente en las unidades de cuidados intensivos pediátricos, pero con elevada mortalidad. Objetivo: Determinar la relación entre variables demográficas y clínicas con la duración de la ventilación mecánica y la supervivencia en niños con síndrome de dificultad respiratoria aguda. Métodos: Estudio retrospectivo de los pacientes ingresados en 15 unidades de cuidados intensivos pediátricos, con diagnóstico de síndrome de dificultad respiratoria aguda. Se evaluaron variables demográficas, las formas clínicas del síndrome de dificultad respiratoria aguda, duración de la ventilación mecánica y la supervivencia. Las variables cualitativas se expresaron en valores absolutos y porcentajes, las variables cuantitativas se analizaron con la prueba ji-cuadrada de Pearson y comparación de medias. Resultados: Se registraron 282 pacientes, de ellos 63,7 por ciento menores de seis años, el 54,4 por ciento del sexo masculino y el 51,1 por ciento de piel blanca. Las formas clínicas pulmonares prevalecieron (58,1 por ciento) y se correlacionaron (p= 0,022) con la supervivencia, la mediana de la duración de la ventilación mecánica fue de 10 días. Existió relación (p= 0,000) entre la duración de la ventilación y la mortalidad. Se registró una mortalidad global de 40,78 por ciento, (n= 115). Conclusiones: El síndrome de dificultad respiratoria aguda tiene mayor incidencia en los menores de seis años y en las formas clínicas pulmonares que se relacionan con una mayor supervivencia, la cual se eleva en la medida que aumentan los días de ventilación mecánica(AU)

ABSTRACT Introduction: The acute respiratory distress syndrome is a disease that evolves with severe hypoxemia, and it is not frequent in pediatric intensive care units, but it has high mortality rates. Objective: To determine the relation between demographic and clinical variables with the mechanical ventilation and survival in children with acute respiratory distress syndrome. Methods: Retrospective study in patients admitted in 15 pediatric intensive care units with diagnosis of acute respiratory distress syndrome. There was an assessment of the demographic variables, the clinical forms of this syndrome, the duration of mechanical ventilation and the survival rates. Qualitative variables were presented in absolute values and percentages, and were analyzed with the Pearson´s ji-square test and means comparison. Results: 282 patients were recorded, 63.7 percent of them were under 6 years old, 54.4 percent were males and 51.1 percent were white. Pulmonary clinical forms prevailed (58,1 percent) and were correlated (p= 0,022) with the survival rates, and the mean of mechanical ventilation´s duration was of 10 days. There was relation (p= 0,000) between the duration of ventilation and mortality. It was recorded a total mortality of 40.78 percent (n= 115). Conclusions: Acute respiratory distress syndrome has higher incidence in children under 6 years and in the pulmonary clinical forms that are related with a higher survival, which increases in the same way that mechanical ventilation´s amount of days do(AU)

Effectiveness of remdesivir in patients with COVID-19 under mechanical ventilation in an Italian ICU.

BACKGROUND: Remdesivir is a prodrug with in vitro activity against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Its clinical efficacy in patients with COVID-19 under mechanical ventilation remains to be evaluated. METHODS: This study includes patients under mechanical ventilation with confirmed SARS-CoV-2 infection admitted to the ICU of Pesaro hospital between 29 February and 20 March 2020. During this period, remdesivir was provided on a compassionate use basis. Clinical characteristics and outcome of patients treated with remdesivir were collected retrospectively and compared with those of patients hospitalized in the same time period. RESULTS: A total of 51 patients were considered, of which 25 were treated with remdesivir. The median (IQR) age was 67 (59-75.5) years, 92% were men and symptom onset was 10 (8-12) days before admission to ICU. At baseline, there was no significant difference in demographic characteristics, comorbidities and laboratory values between patients treated and not treated with remdesivir. Median follow-up was 52 (46-57) days. Kaplan-Meier curves showed significantly lower mortality among patients who had been treated with remdesivir (56% versus 92%, P < 0.001). Cox regression analysis showed that the Charlson Comorbidity Index was the only factor that had a significant association with higher mortality (OR 1.184; 95% CI 1.027-1.365; P = 0.020), while the use of remdesivir was associated with better survival (OR 3.506; 95% CI 1.768-6.954; P < 0.001). CONCLUSIONS: In this study the mortality rate of patients with COVID-19 under mechanical ventilation is confirmed to be high. The use of remdesivir was associated with a significant beneficial effect on survival.

COVID-19-Associated Critical Illness-Report of the First 300 Patients Admitted to Intensive Care Units at a New York City Medical Center.

BACKGROUND: The first confirmed case of novel coronavirus (2019-nCoV) infection in the United States was reported from the state of Washington in January, 2020. By March, 2020, New York City had become the epicenter of the outbreak in the United States. METHODS: We tracked all patients with confirmed coronavirus-19 (COVID-19) infection admitted to intensive care units (ICU) at Montefiore Medical Center (Bronx, NY). Data were obtained through manual review of electronic medical records. Patients had at least 30 days of follow-up. RESULTS: Our first 300 ICU patients were admitted March 10 through April 11, 2020. The majority (60.7%) of patients were men. Acute respiratory distress syndrome (ARDS) was documented in 91.7% of patients; 91.3% required mechanical ventilation. Prone positioning was employed in 58% of patients and neuromuscular blockade in 47.8% of mechanically-ventilated patients. Neither intervention was associated with decreased mortality. Vasopressors were required in 77.7% of patients. Acute kidney injury (AKI) was present on admission in 40.7% of patients, and developed subsequently in 36.0%; 50.9% of patients with AKI received renal replacement therapy (RRT). Overall 30-day mortality rate was 52.3%, and 55.8% among patients receiving mechanical ventilation. In univariate analysis, higher mortality rate was associated with increasing age, male sex, hypertension, obesity, smoking, number of comorbidities, AKI on presentation, and need for vasopressor support. A representative multivariable model for 30-day mortality is also presented, containing patient age, gender, body mass index, and AKI at admission. As of May 11, 2020, 2 patients (0.7%) remained hospitalized. CONCLUSIONS: Mortality in critical illness associated with COVID-19 is high. The majority of patients develop ARDS requiring mechanical ventilation, vasopressor-dependent shock, and AKI. The variation in mortality rates reported to date likely reflects differences in the severity of illness of the evaluated populations.

Daño renal agudo en pacientes con ventilación mecánica invasiva, Guantánamo 2018-2019 / Acute kidney injury in patients with invasive mechanical ventilation in Guantanamo, 2018-2019

RESUMEN Introducción: El daño renal agudo es una complicación frecuente en las Unidades de Terapia Intensiva, sobre todo en pacientes con ventilación mecánica. Objetivo: Caracterizar el daño renal agudo en los pacientes tratados con ventilación mecánica invasiva en la Unidad de Terapia Intensiva del Hospital General Docente "Dr. Agostinho Neto" durante el periodo 2108-2019. Método: Se realizó un estudio descriptivo, retrospectivo y longitudinal, que se aprobó por el Comité de Ética. El universo de estudio se constituyó por el total de pacientes con este diagnóstico según la clasificación Acute Kidney Injury Network (AKIN). Se estudiaron las características de los pacientes (necesidad y duración de la VAM, necesidad de hemodiálisis, estado al egreso) y del daño renal agudo (estadio y etiología). Resultados: El 47,5 % de los pacientes tratados con este soporte vital presentó un daño renal agudo, sobre todo los que la demandaron por siete o más días (68,4 %). El riesgo de muerte fue superior en los pacientes que requirieron ventilación mecánica o hemodiálisis. En los pacientes con daño renal estadio 2 y 3 de la clasificación que se utilizó presentaron un riesgo tres veces o más superior comparado con los que no necesitaron estas terapias. La sepsis (69,4 %) fue la principal causa del daño renal agudo. Conclusiones: El uso de ventilación mecánica invasiva y la presentación de un daño renal agudo son condiciones con una fuerte asociación, juntas y separadas se correlacionan con la mortalidad.

ABSTRACT Introduction: Acute kidney injury is a very common complication in the intensive care units, especially in patients with invasive mechanical ventilation. Objective: To characterize acute kidney damage in patients with invasive mechanical ventilation in the intensive care unit at the General Teaching Hospital ¨Dr. Agostinho Neto¨ within the period 2018-2019. Method: A descriptive, retrospective and longitudinal study approved by the Ethics Committee was carried out. The study population was constituted by the total of patients with the diagnosis, according to the Acute Kidney Injury Network (AKIN). Characteristics and variables like: reason for the invasive mechanical ventilation, its duration, hemodialysis, and status of the patient at time of discharge were taken into account, along with the characteristics of the kidney injury (stages and etiology). Results: 47.5 % of the patients treated with life support showed acute kidney injury, especially the ones with more than a week of mechanical ventilation (68.4 %). The risk of death was higher in the patients with mechanical ventilation and hemodialysis. In the patients with stage 2 and 3 of the scale used for kidney injury presented 3 times more risk compared to those who did not require these treatments. Sepsis was the main cause of acute kidney injury (69.4 %). Conclusions: the use of invasive mechanical ventilation and acute kidney injury are deeply related to each other, both of them constitute main issues in the variables of mortality.

Early Neonatal Oxygen Exposure Predicts Pulmonary Morbidity and Functional Deficits at 1 Year.

OBJECTIVE: To evaluate the predictive value of cumulative oxygen exposure thresholds over the first 2 postnatal weeks, linking them to bronchopulmonary dysplasia (BPD) and 1-year pulmonary morbidity and lung function in extremely low gestational age newborns. STUDY DESIGN: Infants (N = 704) enrolled in the Prematurity and Respiratory Outcomes Program, a multicenter prospective cohort study, that survived to discharge were followed through their neonatal intensive care unit hospitalization to 1-year corrected age. Cumulative oxygen exposure (OxygenAUC14) thresholds were derived from univariate models of BPD, stratifying infants into high-, intermediate-, and low-oxygen exposure groups. These groups were then used in multivariate logistic regressions to prospectively predict post-prematurity respiratory disease (PRD), respiratory morbidity score (RMS) in the entire cohort, and pulmonary function z scores (N = 108 subset of infants) at 1-year corrected age. RESULTS: Over the first 14 postnatal days, infants exposed to high oxygen averaged ≥33.1% oxygen, infants exposed to intermediate oxygen averaged 29.1%-33.1%, and infants exposed to low oxygen were below both cutoffs. In multivariate models, infants exposed to high oxygen showed increased PRD and RMS, whereas infants exposed to intermediate oxygen demonstrated increased moderate/severe RMS. Infants in the high/intermediate groups had decreased forced expiratory volume at 0.5 seconds/forced vital capacity ratio. CONCLUSIONS: OxygenAUC14 establishes 3 thresholds of oxygen exposure that risk stratify infants early in their neonatal course, thereby predicting short-term (BPD) and 1-year (PRD, RMS) respiratory morbidity. Infants with greater OxygenAUC14 have altered pulmonary function tests at 1 year of age, indicating early evidence of obstructive lung disease and flow limitation, which may predispose extremely low gestational age newborns to increased long-term pulmonary morbidity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01435187.

Noncardiac determinants of death and intensive care morbidity in adult congenital heart disease surgery.

OBJECTIVES: Predicting perioperative morbidity and mortality in cardiac surgery for adult congenital heart disease is challenging because it encompasses a wide spectrum of disease. There is a paucity of published outcome data, and there are no perioperative risk score calculators for this population group. We set out to identify robust determinants of morbidity and mortality in this patient population under going cardiac surgery. METHODS: We collected data on 20 socioeconomic and pathophysiologic variables in 784 consecutive adults with congenital heart disease who underwent cardiac surgery between 2004 and 2015 at a single center. Using logistic regression, we sought to identify which of these factors were associated with the primary composite adverse outcome of in-hospital mortality, prolonged ventilation exceeding 7 days, and severe acute renal failure requiring dialysis. Secondary outcome analysis identified variables that were significant predictors for 1-year mortality. RESULTS: Composite adverse outcome occurred in 54 of 784 patients (6.9%). Significant predictors of the composite adverse outcome by multivariate regression include Mayo End-Stage Liver Disease modified score, cognitive impairment, number of chest wall incisions from previous cardiac surgery, body mass index, and cardiac anatomic category. Two survivors of the composite adverse outcome died within a few weeks postdischarge. Only 657 of 784 patients had 1-year follow-up data; 40 of 657 patients died at 1 year. One-year mortality was predicted by anticoagulation, Mayo End-Stage Liver Disease modified score, and anatomic category. CONCLUSIONS: Recognition and quantification of noncardiac comorbidities preoperatively predict the risk of adverse events and mortality in addition to cardiac anatomic factors.

Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality.

BACKGROUND: "Lung-protective ventilation" describes a ventilation strategy involving low tidal volumes (VTs) and/or low driving pressure/plateau pressure and has been associated with improved outcomes after mechanical ventilation. We evaluated the association between intraoperative ventilation parameters (including positive end-expiratory pressure [PEEP], driving pressure, and VT) and 3 postoperative outcomes: (1) PaO2/fractional inspired oxygen tension (FIO2), (2) postoperative pulmonary complications, and (3) 30-day mortality. METHODS: We retrospectively analyzed adult patients who underwent major noncardiac surgery and remained intubated postoperatively from 2006 to 2015 at a single US center. Using multivariable regressions, we studied associations between intraoperative ventilator settings and lowest postoperative PaO2/FIO2 while intubated, pulmonary complications identified from discharge diagnoses, and in-hospital 30-day mortality. RESULTS: Among a cohort of 2096 cases, the median PEEP was 5 cm H2O (interquartile range = 4-6), median delivered VT was 520 mL (interquartile range = 460-580), and median driving pressure was 15 cm H2O (13-19). After multivariable adjustment, intraoperative median PEEP (linear regression estimate [B] = -6.04; 95% CI, -8.22 to -3.87; P < .001), median FIO2 (B = -0.30; 95% CI, -0.50 to -0.10; P = .003), and hours with driving pressure >16 cm H2O (B = -5.40; 95% CI, -7.2 to -4.2; P < .001) were associated with decreased postoperative PaO2/FIO2. Higher postoperative PaO2/FIO2 ratios were associated with a decreased risk of pulmonary complications (adjusted odds ratio for each 100 mm Hg = 0.495; 95% CI, 0.331-0.740; P = .001, model C-statistic of 0.852) and mortality (adjusted odds ratio = 0.495; 95% CI, 0.366-0.606; P < .001, model C-statistic of 0.820). Intraoperative time with VT >500 mL was also associated with an increased likelihood of developing a postoperative pulmonary complication (adjusted odds ratio = 1.06/hour; 95% CI, 1.00-1.20; P = .042). CONCLUSIONS: In patients requiring postoperative intubation after noncardiac surgery, increased median FIO2, increased median PEEP, and increased time duration with elevated driving pressure predict lower postoperative PaO2/FIO2. Intraoperative duration of VT >500 mL was independently associated with increased postoperative pulmonary complications. Lower postoperative PaO2/FIO2 ratios were independently associated with pulmonary complications and mortality. Our findings suggest that postoperative PaO2/FIO2 may be a potential target for future prospective trials investigating the impact of specific ventilation strategies for reducing ventilator-induced pulmonary injury.

Myasthenic crisis demanding mechanical ventilation: A multicenter analysis of 250 cases.

OBJECTIVE: To determine demographic characteristics, clinical features, treatment regimens, and outcome of myasthenic crisis (MC) requiring mechanical ventilation (MV). METHODS: Analysis of patients who presented with MC between 2006 and 2015 in a German multicenter retrospective study. RESULTS: We identified 250 cases in 12 participating centers. Median age at crisis was 72 years. Median duration of MV was 12 days. Prolonged ventilation (>15 days) depended on age (p = 0.0001), late-onset myasthenia gravis (MG), a high Myasthenia Gravis Foundation of America Class before crisis (p = 0.0001 for IVb, odds ratio [OR] = infinite), number of comorbidities (>3 comorbidities: p = 0.002, OR 2.99), pneumonia (p = 0.0001, OR 3.13), and resuscitation (p = 0.0008, OR 9.15). MV at discharge from hospital was necessary in 20.5% of survivors. Patients with early-onset MG (p = 0.0001, OR 0.21), thymus hyperplasia (p = 0.002, OR 0), and successful noninvasive ventilation trial were more likely to be ventilated for less than 15 days. Noninvasive ventilation in 92 cases was sufficient in 38%, which was accompanied by a significantly shorter duration of ventilation (p = 0.001) and intensive care unit (ICU) stay (p = 0.01). IV immunoglobulins, plasma exchange, and immunoadsorption were more likely to be combined sequentially if the duration of MV and the stay in an ICU extended (p = 0.0503, OR 2.05). Patients who received plasma exchange or immunoadsorption as first-line therapy needed invasive ventilation significantly less often (p = 0.003). In-hospital mortality was 12%, which was significantly associated with the number of comorbidities (>3) and complications such as acute respiratory distress syndrome and resuscitation. Main cause of death was multiorgan failure, mostly due to sepsis. CONCLUSION: Mortality and duration of MC remained comparable to previous reports despite higher age and a high disease burden in our study. Prevention and treatment of complications and specialized neurointensive care are the cornerstones in order to improve outcome.