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INTRODUCTION: Acute respiratory distress syndrome (ARDS) related to COVID-19 increased the number of patients requiring prone position ventilation (PPV). The ProSEVA PPV strategy of daily reproning is resource intensive because each complete PPV cycle takes half an hour of work from 4 experienced operators. Therefore the Standard PPV was extended until 24 to 48 hours. In 2021 Douglas et al. propose the Prolonged PPV strategy for COVID-19 ARDS, returning to the supine position only when the patient has stable gas exchange (Fio2< 60% with PEEP< 10cmH2O). This strategy was secure, but they did not compare the clinical outcomes of the Prolonged against the Standard PPV. In this study, we compare the number of PPV cycles and pressure wounds (PWs) in COVID-19 patients with Standard PPV vs. Prolonged PPV. METHOD(S): Quasi-experimental before-and-after study. We included ventilated patients with PPV indication (criteria from the ProSEVA Trial). Between October 1, 2020, to April 30, 2021, patients with indication of PPV received the standard PPV (24 to 48 hs), and patients hospitalized between May 1, 2021, to October 1, 2021, were treated with the Prolonged PPV. For the primary outcome (number of PPV cycles), we compare the proportion of patients with more than 2 PPV cycles in each group. As a sensitivity analysis, we performed a Fine and Gray regression adjusting by confounders, considering death as a competing event, two PPV cycles as the event, and censoring patients with one PPV cycle at ICU discharge. RESULT(S): We included 64 patients in the Standard PPV group and 16 in the Prolonged PPV group. No differences were observed in the number of PPV cycles between groups (patients with more than one cycle: 42.2% [n=27] vs. 62.5% [n=10];p=0.18). These observations were robust to the sensitivity analysis (the adjusted sHR to have two PPV cycles for the Prolonged PPV group was 1.31 [CI95% 0.63-2.71;p=0.46]). Patients in Prolonged PPV had 2.96 (IQR1.98-3.42) days in PPV vs. 1.98 (IQR1.38-2.94) in the Standard PPV (p=0.03). Chest and abdominal PWs were more frequently in the Prolonged PPV group (chest wounds: 5 patients [31.5%] vs 5 [7.8%];p=0.024 - abdominal: 3 [18.8%] vs 2 [3.12%];p=0.02). CONCLUSION(S): The Prolonged PPV increases the time in PPV and the PPV-associated PWs but does not reduce the total PPV cycles.
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INTRODUCTION: The criteria for the COVID-19 patients' selection that benefit most from ECMO therapy are yet to be defined. In this study, we evaluate the predictive performance of the ECMO mortality predictive models in patients with COVID-19. METHOD(S): A retrospective study was performed in two high-complexity hospitals between March 18, 2020, and December 31, 2021. We included patients over 18 years old with COVID-19 infection confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) who received V-V ECMO due to COVID-19-related ARDS. We evaluated the predictive performance (discrimination, calibration, and accuracy) of death prediction of the following predictive models: i) Prediction of Death due to Severe ARDS in V-V ECMO score (PRESERVE);ii) The Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score;iii) Prediction of Survival on ECMO Therapy- Score (PRESET) score, to predict death. Also, we perform a cost-benefit analysis using the health-related quality of life reported by the CESAR TRIAL and the US life expectancy. Besides, we add the mortality predicted probability calculated with the best predictive model to the cost-benefit analysis. Therefore, the cost/QALY formula was: cost/QALY = cost / age-specific life expectancy*health utilitiesz.ast;survival probability. RESULT(S): We included 38 adult patients who received ECMO due to COVID-19. The PRESET score had the highest discrimination (AUROCs 0.81 [CI95% 0.67-0.94]) and the best calibration (Hosmer-Lemeshow test, p=0.6). The optimal threshold for this score was 7 (sensitivity 67%, specificity 89%, accuracy 78%). The cost per QALY in the USA, adjusted to life expectancy, was higher than UDS 100,000 in patients older than 45 years with a PRESET>10. CONCLUSION(S): The PRESET score had the highest predictive performance and could help in the patient's selection that benefits most from this resource-demanding and highly invasive therapy. Also, the addition of the costbenefit analysis output can help decide which patient to place on ECMO therapy, especially in low-resource settings.
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OBJECTIVE: Investigate the predictive value of NEWS2, NEWS-C, and COVID-19 Severity Index for predicting intensive care unit (ICU) transfer in the next 24h. DESIGN: Retrospective multicenter study. SETTING: Two third-level hospitals in Argentina. PATIENTS: All adult patients with confirmed COVID-19, admitted on general wards, excluding patients with non-intubated orders. INTERVENTIONS: Patients were divided between those who were admitted to ICU and non-admitted. We calculated the three scores for each day of hospitalization. VARIABLES: We evaluate the calibration and discrimination of the three scores for the outcome ICU admission within 24, 48h, and at hospital admission. RESULTS: We evaluate 13,768 days of hospitalizations on general medical wards of 1318 patients. Among these, 126 (9.5%) were transferred to ICU. The AUROC of NEWS2 was 0.73 (95%CI 0.68-0.78) 24h before ICU admission, and 0.52 (95%CI 0.47-0.57) at hospital admission. The AUROC of NEWS-C was 0.73 (95%CI 0.68-0.78) and 0.52 (95%CI 0.47-0.57) respectively, and the AUROC of COVID-19 Severity Index was 0.80 (95%CI 0.77-0.84) and 0.61 (95%CI 0.58-0.66) respectively. COVID-19 Severity Index presented better calibration than NEWS2 and NEWS-C. CONCLUSION: COVID-19 Severity index has better calibration and discrimination than NEWS2 and NEWS-C to predict ICU transfer during hospitalization.
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Introduction: One of the great challenges during the COVID-19 pandemic was the management of ventilatory support. Extracorporeal membrane oxygenation (ECMO) was the main strategy for the management of refractory acute respiratory distress syndrome. Objective: Retrospective, multicentre cohort study of adult patients who required extracorporeal membrane oxygenation (ECMO) in participating centers. Clinical and paraclinical characteristics were recorded. A comparison was made between surviving and non-surviving patients. In addition, time from symptom onset to ECMO placement, time from mechanical ventilation, and cannulation were analyzed. Material and methods: Retrospective, multicentre cohort study of adult patients who required extracorporeal membrane oxygenation (ECMO) in participating centers. Clinical and paraclinical characteristics were recorded. A comparison was made between surviving and non-surviving patients. In addition, time from symptom onset to ECMO placement, time from mechanical ventilation, and cannulation were analyzed. Results: Twenty-six patients were included in the analysis. Mortality during ECMO was 42.3% (n = 11) and overall hospital mortality was 65.3% (n = 17). The patient cohort did not differ in terms of sociodemographic characteristics and predictors of mortality at ICU admission between survivors and non-survivors. Mobile ECMO was performed in 10 patients, while 16 were cannulated in situ at the participating centers. The median time from symptom onset to ECMO was 14.5 days (IQR 10.7–21.5), 11 days (IQR 9.5–15.5) in the survivor group, and 17 days (IQR 12.5–27) in non-survivors. The median IMV time was 28.5 (IQR 13–38.25) days. Driving pressure (12 vs 10 cmH2O;p <.01), compliance (37.2 vs 21.4 ml/cmH2O;p <.01), and mechanical power (17.4 vs 11.3 J/min;p =.051) of the respiratory system showed statistically significant differences when comparing survivors and non-survivors, during the 3rd day of ECMO support. Conclusion: In our cohort, mortality after ECMO and after 30 days of hospital stay, was 42.3%, similar to that stated on the extracorporeal life support organization (ELSO) COVID-19 registry dashboard. Information about patients with COVID-19 who required ECMO during the first wave in Argentina was provided in this analysis. © 2022 Asociación Colombiana de Medicina Crítica y Cuidado lntensivo
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Objective Investigate the predictive value of NEWS2, NEWS-C, and COVID-19 Severity Index for predicting intensive care unit (ICU) transfer in the next 24 h. Design Retrospective multicenter study. Setting Two third-level hospitals in Argentina. Patients All adult patients with confirmed COVID-19, admitted on general wards, excluding patients with non-intubated orders. Interventions Patients were divided between those who were admitted to ICU and non-admitted. We calculated the three scores for each day of hospitalization. Variables We evaluate the calibration and discrimination of the three scores for the outcome ICU admission within 24, 48 h, and at hospital admission. Results We evaluate 13,768 days of hospitalizations on general medical wards of 1318 patients. Among these, 126 (9.5%) were transferred to ICU. The AUROC of NEWS2 was 0.73 (95%CI 0.68–0.78) 24 h before ICU admission, and 0.52 (95%CI 0.47–0.57) at hospital admission. The AUROC of NEWS-C was 0.73 (95%CI 0.68–0.78) and 0.52 (95%CI 0.47–0.57) respectively, and the AUROC of COVID-19 Severity Index was 0.80 (95%CI 0.77–0.84) and 0.61 (95%CI 0.58–0.66) respectively. COVID-19 Severity Index presented better calibration than NEWS2 and NEWS-C. Conclusion COVID-19 Severity index has better calibration and discrimination than NEWS2 and NEWS-C to predict ICU transfer during hospitalization.
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We conducted a retrospective cohort study to report the clinical characteristics, incidence and outcomes of patients with severe COVID-19 with acute kidney injury (AKI). One-hundred and sixtytwo intensive care unit (ICU) admitted patients in a tertiary level hospital in the city of Buenos Aires with COVID-19 diagnosis were included. We hypothesized that COVID-19 related AKI would develop in the period of more severe hypoxemia as an early event and late AKI would be more probably related to intensive care unit complications. For this purpose, we divided subjects into two groups: those with early AKI and late AKI, before and after day 14 from symptom onset, respectively. A stepwise multivariate analysis was conducted to find possible AKI predictors. AKI incidence was 43.2% (n = 70) of the total patients admitted into ICU with severe COVID-19, 11.1% (n = 18) required renal replacement therapy. In-hospital mortality was higher (58.6%) for the AKI group. AKI occurred on a median time of 10 (IQR 5.5-17.5) days from symptom onset. A history of hypertension or heart failure, age and invasive mechanical ventilation (IMV) requirement were identified as risk factors. Late AKI (n = 25, 35.7%) was associated with sepsis and nephrotoxic exposure, whereas early AKI occurred closer to the timing of IMV initiation and was more likely to have an unknown origin. In conclusion, AKI is frequent among critically ill patients with severe COVID-19 and it is associated with higher in-hospital mortality.
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Pandemics pose a major challenge for public health preparedness, requiring a coordinated inter- national response and the development of solid containment plans. Early and accurate identification of high-risk patients in the course of the current COVID-19 pandemic is vital for planning and making proper use of available resources. The purpose of this study was to identify the key variables that account for worse outcomes to create a predictive model that could be used effectively for triage. Through literature review, 44 variables that could be linked to an unfavorable course of COVID-19 disease were obtained, including clinical, laboratory, and X-ray variables. These were used for a 2-round modified Delphi processing with 14 experts to select a final list of variables with the greatest predictive power for the construction of a scoring system, leading to the creation of a new scoring system: the COVID-19 Severity Index. The analysis of the area under the curve for the COVID-19 Severity Index was 0.94 to predict the need for ICU admission in the following 24 hours against 0.80 for NEWS-2. Additionally, the digital medical record of the Hospital Italiano de Buenos Aires was electronically set for an automatic calculation and constant update of the COVID-19 Severity Index. Specifically designed for the current COVID-19 pandemic, COVID-19 Severity Index could be used as a reliable tool for strategic planning, organization, and administration of resources by easily identifying hospitalized patients with a greater need of intensive care.
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This retrospective multicentre study analyzes epidemiological characteristics, ventilatory mechanics, ECMO settings and outcomes in adult COVID-19 patients treated with ECMO during the first surge in Argentina. The data is obtained from 26 out of 34 patients (76%), representing 4 out of 7 ECMO centers that treated COVID-19 patients. 49 requests for ECMO were received during the study period but 23 were rejected for clinical reasons. 26 patients received ECMO and entered the analysis. Patients were mainly males (80%), aged 50 (IQR 39-60), APACHE 2 10.5 (IQR7,7-16) SOFA 5.5 (IQR 4-8). Mortality during ECMO support was 42 3% (n = 11) while overall hospital mortality was 65 3% (n = 17). Median time from mechanical ventilation to ECMO was 5 days (IQR 2 5-8) vs median 6 days (RIQ 3 5-10 5);p=0 46 for survivors and non survivors respectively. However, time from symptoms onset to ECMO was 14 5 days (IQR 10 7-21 5);with statistically significant differences between survivors and non-survivors [11 days (IQR 9 5-15 5) vs 17 days [IQR 12 5-27] days;p=0 039). Additionally, survivors were characterized by higher baseline respiratory system compliance 31,8 (29-45) vs 22,5 (17-28,5) p<0.001) lower driving pressure 12 vs 18 p<0.001, lower ferritin levels 600 (399-1146) vs 1604 (772-2384) p:0.04 and higher platelet count 346100 (248850-409800) vs 273400 (172000-308000) p:0.04 Non-survivors were characterized by a longer course of disease pre ECMO, and severe pro-inflammatory profile associated with a more advanced and severe lung damage.
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During the SARSCoV-2 pandemic many drugs have been used as potential treatments in order to improve the clinical outcome and reduce the mortality. But since it is a currently unknown disease, the evidence about efficacy and safety is built as the drugs are prescribed. In this context, intensive pharmacovigilance allows early detection of adverse events, and thereby infer the safety profile of the indication. We conducted an observational, retrospective, single-center study involving adult patients with severe SARS-CoV-2 infection. All adverse events detected in 23 patients in the Intensive Care Unit between March 15 and June 15, 2020 were registered. We describe type and severity of the adverse events and if treatment suspension was needed. The results show a high rate of adverse events (10/23, 43%) in treatment with lopinavir/ritonavir. In most cases early treatment suspension was required. Even though the limitations of our study derived from the small sample size, these results could help in building evidence about the safety of using lopinavir/ritonavir for severe SARS-CoV-2 infection.
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This is an analysis of clinical characteristics, images findings. laboratory variables and respiratory mechanics in patients with coronavirus disease 2019 (COVID-19) during the first month of the pandemic outbreak in Buenos Aires. In this descriptive case study of a single-centre, we included all confirmed cases of COVID-19 hospitalized in intensive care unit (ICU). All cases were confirmed by reverse transcription polymerase chain reaction. A total of 7 patients with confirmed COVID-19 were referred to out ICU. The median age was 71 years (interquartile range 52-75), including 4 men and 3 women. Patients most common clinical manifestations were fever (7), cough (5), asthenia (4) and shortness of breath (3). Among the radiological findings, five of them showed interstitial opacities and one patient had bilateral pulmonary consolidation. Five required invasive mechanical ventilation and multiple prone sessions. None died during hospitalization, although three still remain in the ICU. According to imaging examination, 71.4% showed interstitial opacities and one patient bilateral consolidation. Five patients required invasive mechanical ventilation and multiple prone sessions. None of them died during hospitalization, although three still remain in the ICU.