Association between longitudinal changes in phase angle and mortality rate in adults critically ill with COVID-19: A retrospective cohort study.

BACKGROUND: Phase angle (PhA) obtained by bioelectrical impedance analysis (BIA) works as a predictor of clinical outcomes. Specific cutoff values for longitudinal changes and their relationship with clinical outcomes are still undetermined for patients with critical illness. Thus, the aim of this study was to analyze the association between longitudinal changes in PhA during intensive care unit (ICU) stay and all-cause 90-day mortality in patients critically ill with COVID-19. METHODS: This was a retrospective cohort study of adults critically ill with COVID-19 undergoing invasive mechanical ventilation with a length of stay >14 days. BIA was performed at ICU admission and at days 7 and 14 of ICU stay; PhA and hydration parameters were collected. Differences between survivors and nonsurvivors were assessed. Longitudinal changes were evaluated using repeated-measures analysis of variance. A receiver operating characteristics curve for PhA declined (%) during the first 14 days, and all-cause 90-day mortality was performed. Survival probability was reported using hazard ratios (HR). RESULTS: One-hundred nine patients were included. The change in the value of PhA was close to 17.1%. Nonsurvivors had a higher prevalence of individuals with a decrease in PhA >22.2% (area under the curve = 0.65) in the first 14 days in comparison with survivors (70% vs 34.8%, P < 0.01). PhA decrease >22.2% at 14 days was a significant predictor of all-cause 90-day mortality (HR = 2.2, 95% CI 1.71-3.6, P = 0.04). CONCLUSION: Changes in PhA are associated with all-cause 90-day mortality. Future studies should be directed to interventions to prevent changes in this nutrition marker.

Clinical and epidemiological factors related to mortality due to septic shock in a pediatric intensive care unit.

INTRODUCTION: Septic shock is a potentially life-threatening condition. The aim of this study was to identify clinical and epidemiological factors associated with mortality in pediatric patients admitted to a pediatric intensive care unit (PICU) with septic shock. MATERIALS AND METHODS: A retrospective comparative case series study was conducted with children aged 1 month to 14 years with septic shock from 2018 to 2020 in a PICU in Lima, Peru. Patients were divided into deceased and survivor groups based on their condition at discharge from the PICU. The influence of each variable on mortality was assessed using a logistic regression model. RESULTS: A total of 174 patients were included in the study, with 51 (29.3%) fatalities. Deceased patients, compared to survivors, were older, had a higher incidence of oncological disease (31.4% vs. 14.6%; p = 0.011), more frequently presented with hemoglobin ≤ 9 g/dL (44% vs. 28%; p = 0.043), lactate > 2 mmol/L (70% vs. 44%; p = 0.002), platelets ≤ 150 (×103)/µL (77% vs. 42%; p < 0.001), and pH ≤ 7.1 (31% vs. 6%; p < 0.001). In the logistic regression model, factors related to mortality were having a pH ≤ 7.1 (odds ratio [OR] = 8.95; 95% confidence interval [CI]: 2.52-31.75) and platelets ≤ 150 (×103)/µL (OR = 3.89; 95% CI: 1.40-10.84). CONCLUSIONS: Factors associated with mortality in pediatric patients with septic shock were a pH ≤ 7.1 and platelets ≤ 150 (×103)/µL in the assessments conducted upon admission to the PICU.

INTRODUCCIÓN: El shock séptico es una condición potencialmente mortal. El objetivo del estudio fue identificar factores clínicos y epidemiológicos relacionados con la mortalidad en pacientes que ingresaron por shock séptico a una Unidad de Cuidados Intensivos Pediátricos (UCIP). MÉTODOS: Estudio retrospectivo tipo serie de casos comparativos con niños de 1 mes a 14 años hospitalizados por shock séptico del 2018 al 2020 en una UCIP de Lima en Perú. Los pacientes fueron divididos en fallecidos y vivos según su condición al alta de la Unidad. La influencia de cada variable sobre la mortalidad fue evaluada mediante un modelo de regresión logística. RESULTADOS: Ingresaron 174 pacientes al estudio, fallecieron 51 (29.3%). Los fallecidos en comparación con los vivos fueron de mayor edad, tuvieron más casos oncológicos (31.4% vs. 14.6%; p = 0.011), presentaron con mayor frecuencia hemoglobina ≤ 9 g/dL (44% vs. 28%; p = 0.043), lactato > 2 mmol/L (70% vs. 44%; p = 0.002), plaquetas ≤ 150 (×103)/µL (77% vs. 42%; p < 0.001) y pH ≤ 7,1 (31% vs. 6%; p < 0.001). En la regresión logística ajustada los factores que se relacionaron con la mortalidad fueron tener un pH ≤ 7,1 (OR = 8.95; IC 95%: 2.52 a 31.75) y plaquetas ≤ 150 (×103)/µL (OR = 3.89; IC 95%: 1.40 a 10.84). CONCLUSIONES: Los factores relacionados con la mortalidad en pacientes hospitalizados por shock séptico fueron tener un pH ≤ 7.1 y plaquetas ≤ 150 (×103)/µL en los controles realizados al ingreso de la UCIP.

Towards better mortality prediction in cancer patients in the ICU: a comparative analysis of prognostic scales: systematic literature review.

OBJECTIVE: To evaluate the predictive ability of mortality prediction scales in cancer patients admitted to intensive care units (ICUs). DESIGN: A systematic review of the literature was conducted using a search algorithm in October 2022. The following databases were searched: PubMed, Scopus, Virtual Health Library (BVS), and Medrxiv. The risk of bias was assessed using the QUADAS-2 scale. SETTING: ICUs admitting cancer patients. PARTICIPANTS: Studies that included adult patients with an active cancer diagnosis who were admitted to the ICU. INTERVENTIONS: Integrative study without interventions. MAIN VARIABLES OF INTEREST: Mortality prediction, standardized mortality, discrimination, and calibration. RESULTS: Seven mortality risk prediction models were analyzed in cancer patients in the ICU. Most models (APACHE II, APACHE IV, SOFA, SAPS-II, SAPS-III, and MPM II) underestimated mortality, while the ICMM overestimated it. The APACHE II had the SMR (Standardized Mortality Ratio) value closest to 1, suggesting a better prognostic ability compared to the other models. CONCLUSIONS: Predicting mortality in ICU cancer patients remains an intricate challenge due to the lack of a definitive superior model and the inherent limitations of available prediction tools. For evidence-based informed clinical decision-making, it is crucial to consider the healthcare team's familiarity with each tool and its inherent limitations. Developing novel instruments or conducting large-scale validation studies is essential to enhance prediction accuracy and optimize patient care in this population.

Clinical Characteristics of Hospitalized Patients With COVID-19 and Their Association With the Progression to Critical Illness and Death: A Single-Center Retrospective Study From Northwestern Mexico.

OBJECTIVE: The objective of this study was to associate the epidemiological and clinical characteristics of patients hospitalized for COVID-19 with the progression to critical illness and death in northwestern Mexico. METHODS: From March to October 2020, we collected the demographic and clinical characteristics of 464 hospitalized patients from northwestern Mexico. RESULTS: Sixty-four percent (295/464) of the patients became critically ill. Age, occupation, steroid and antibiotic use at previous hospitalization, and underlying diseases (hypertension, obesity, and chronic kidney disease) were associated with critical illness or death (p: < 0.05). No symptoms were associated with critical illness. However, the parameters such as the heart rate, respiratory rate, oxygen saturation, and diastolic pressure and the laboratory parameters such as the glucose, creatinine, white line cells, hemoglobin, D-dimer, and C-reactive protein, among others, were associated with critical illness (p: < 0.05). Finally, advanced age, previous hospital treatment, and the presence of one or more underlying diseases were associated with critical illness and death (p: < 0.02). CONCLUSIONS: Several epidemiological (e.g., age and occupation) and clinical factors (e.g., previous treatment, underlying diseases, and vital signs and laboratory parameters) were associated with critical illness and death in patients hospitalized with COVID-19. These data provide us with possible markers to avoid critical illness or death from COVID-19 in our region.

Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting.

Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.

Refeeding syndrome risk at ICU admission is an independent predictor of ICU readmission but it is not associated with mortality or length of stay in critically ill patients.

OBJECTIVES: This study evaluated the association between refeeding syndrome (RFS) risk and intensive care unit (ICU)/in-hospital mortality and length of stay (LOS) and ICU readmission in critically ill patients. METHODS: This secondary analysis of a cohort study included patients aged ≥ 18 years admitted at ICU 24 h before data collection. We evaluated RFS risk based on the National Institute for Health and Clinical Excellence (NICE), stratifying it into four categories (no, low, high, and very-high risk). SETTING: Five adult ICUs in Brazil. MAIN OUTCOME MEASURES: ICU/in-hospital mortality and LOS and ICU readmission data were obtained from electronic medical records analysis, following patients until discharge (alive or not). RESULTS: The study involved 447 patients, categorized into no (19.2 %), low (28.6 %), high (48.8 %), and very-high (3.4 %) RFS risk groups. No significant differences emerged between the two groups (at RFS risk and no RFS risk) regarding the ICU death ratio (34.3 % versus 23.4 %) and LOS (5 versus 4 days), respectively. In contrast, patients at RFS risk experienced higher in-hospital mortality rates (34.3 % versus 23.4 %) prolonged hospital LOS (21 days versus 17 days), and increased ICU readmission rates (15 % versus 8.4 %) than patients without RFS risk. After adjusting for age and Sequential Organ Failure Assessment (SOFA) Score, we found no association between RFS risk and increased mortality in the ICU or hospital. Also, there was no significant association between RFS risk and prolonged LOS in the ICU or hospital setting. However, patients identified as at risk of RFS showed nearly double the odds of ICU readmission (Odds ratio, 1.90; 95 % CI 1.02-3.43). CONCLUSIONS: This study found no significant association between RFS risk and increased mortality in both the ICU and hospital settings, nor was there a significant association with prolonged LOS in the ICU or hospital among critically ill patients. However, patients at risk of RFS exhibited nearly double the odds of ICU readmission. IMPLICATIONS FOR CLINICAL PRACTICE: Our findings may contribute to understanding risks associated with ICU readmissions, highlighting the complexity of discharge decision-making through comprehensive assessments.

Daily compliance of the ABCDEF liberation bundle for patients in the intensive care unit: A retrospective descriptive study / Cumplimiento diario del bundle ABCDEF de liberación de los pacientes de cuidados intensivos: estudio descriptivo retrospectivo.

Introduction: Implementing the ABCDEF bundle has demonstrated improved outcomes in patients with critical illness. This study aims to describe the daily compliance of the ABCDEF bundle in a Chilean intensive care unit. Methods: Retrospective observational study of electronic clinical records of nursing, physiotherapy, and medical professionals who cared for patients over 18 years of age, admitted to an intensive care unit for at least 24 hours, with or without mechanical ventilation. Daily bundle compliance was determined by considering the daily records for each element: Assess pain (element A), both spontaneous awakening trials (element B1) and spontaneous breathing trials (element B2), choice of sedation (element C), delirium assessment (element D), early mobilization (element E), and family engagement (element F). Results: 4165 registered bundle elements were obtained from nursing (47%), physiotherapy (44%), and physicians (7%), including 1134 patient/days (from 133 patients). Elements E and C showed 67 and 40% compliance, while D, A, and B2 showed 24, 14 and 11%, respectively. For B1 and F, 0% compliance was achieved. Compliance was higher in patients without mechanical ventilation for A and E, while it was similar for D. Conclusions: Early mobilization had the highest compliance, while spontaneous awakening trials and family engagement had absolute non-compliance. Future studies should explore the reasons for the different degrees of compliance per bundle element in clinical practice.

Introducción: La implementación del ABCDEF ha demostrado mejores resultados en los pacientes críticos. El objetivo de este trabajo es identificar el cumplimiento del registro diario del ABCDEF en una unidad de cuidados intensivos chilena. Métodos: Estudio observacional retrospectivo de los registros clínicos electrónicos de profesionales de enfermería, kinesiología y medicina que trataron a pacientes mayores de 18 años, hospitalizados en una unidad de cuidados intensivos durante al menos 24 horas, con o sin requerimiento de ventilación mecánica. Se determinó el cumplimiento diario del considerando la presencia del registro en la ficha clínica de cada elemento: evaluación del dolor (elemento A), prueba de interrupción de la sedación (elemento B1) y ventilación espontánea (elemento B2), elección de la sedación (elemento C), evaluación del (elemento D), movilización temprana (elemento E) y empoderamiento de la familia (elemento F). Resultados: Se obtuvieron 4165 elementos del registrados provenientes de enfermería (47%), kinesiología (44%) y medicina (7%), incluyendo 1134 días/paciente (133 pacientes). Los elementos E y C mostraron un cumplimiento del 67 y 40%, mientras que D, A, y B2 mostraron 24, 14 y 11%, respectivamente. Para B1 y F se obtuvo 0% de cumplimiento. El cumplimiento fue mayor en los pacientes sin ventilación mecánica para A y E, mientras que para D fue similar. Conclusiones: La movilización temprana fue el elemento con mayor cumplimiento, mientras que las pruebas de interrupción de sedación y el empoderamiento de la familia tuvieron incumplimiento absoluto. Futuros estudios deberían explorar las razones que expliquen los diferentes grados de cumplimiento por elemento del en la práctica clínica.

Cumplimiento diario del bundle ABCDEF de liberación de los pacientes de cuidados intensivos: estudio descriptivo retrospectivo / Daily compliance of the ABCDEF liberation bundle for patients in the intensive care unit: A retrospective descriptive study

Introducción La implementación del ABCDEF ha demostrado mejores resultados en los pacientes críticos. El objetivo de este trabajo es identificar el cumplimiento del registro diario del ABCDEF en una unidad de cuidados intensivos chilena. Métodos Estudio observacional retrospectivo de los registros clínicos electrónicos de profesionales de enfermería, kinesiología y medicina que trataron a pacientes mayores de 18 años, hospitalizados en una unidad de cuidados intensivos durante al menos 24 horas, con o sin requerimiento de ventilación mecánica. Se determinó el cumplimiento diario del considerando la presencia del registro en la ficha clínica de cada elemento: evaluación del dolor (elemento A), prueba de interrupción de la sedación (elemento B1) y ventilación espontánea (elemento B2), elección de la sedación (elemento C), evaluación del (elemento D), movilización temprana (elemento E) y empoderamiento de la familia (elemento F). Resultados Se obtuvieron 4165 elementos del registrados provenientes de enfermería (47%), kinesiología (44%) y medicina (7%), incluyendo 1134 días/paciente (133 pacientes). Los elementos E y C mostraron un cumplimiento del 67 y 40%, mientras que D, A, y B2 mostraron 24, 14 y 11%, respectivamente. Para B1 y F se obtuvo 0% de cumplimiento. El cumplimiento fue mayor en los pacientes sin ventilación mecánica para A y E, mientras que para D fue similar. Conclusiones La movilización temprana fue el elemento con mayor cumplimiento, mientras que las pruebas de interrupción de sedación y el empoderamiento de la familia tuvieron incumplimiento absoluto. Futuros estudios deberían explorar las razones que expliquen los diferentes grados de cumplimiento por elemento del en la práctica clínica.

Introduction Implementing the ABCDEF bundle has demonstrated improved outcomes in patients with critical illness. This study aims to describe the daily compliance of the ABCDEF bundle in a Chilean intensive care unit. Methods Retrospective observational study of electronic clinical records of nursing, physiotherapy, and medical professionals who cared for patients over 18 years of age, admitted to an intensive care unit for at least 24 hours, with or without mechanical ventilation. Daily bundle compliance was determined by considering the daily records for each element: Assess pain (element A), both spontaneous awakening trials (element B1) and spontaneous breathing trials (element B2), choice of sedation (element C), delirium assessment (element D), early mobilization (element E), and family engagement (element F). Results 4165 registered bundle elements were obtained from nursing (47%), physiotherapy (44%), and physicians (7%), including 1134 patient/days (from 133 patients). Elements E and C showed 67 and 40% compliance, while D, A, and B2 showed 24, 14 and 11%, respectively. For B1 and F, 0% compliance was achieved. Compliance was higher in patients without mechanical ventilation for A and E, while it was similar for D. Conclusions Early mobilization had the highest compliance, while spontaneous awakening trials and family engagement had absolute non-compliance. Future studies should explore the reasons for the different degrees of compliance per bundle element in clinical practice.

Movilización activa temprana versus cuidado habitual activo en sujetos críticos: revisión sistemática y metaanálisis / Early active mobilization versus active usual care in critically ill subjects: a systematic review and meta-analysis

RESUMEN Objetivo: Evaluar el efecto de la movilización activa temprana (MAT) en comparación con el cuidado habitual activo (CHA) en sujetos adultos críticamente enfermos respecto de la fuerza muscular y del estado funcional. Materiales y métodos: Se realizó una revisión sistemática con metaanálisis. Se incluyeron ensayos clínicos aleatorizados que compararon la MAT con el CHA en sujetos >18 años, de ambos sexos, en estado crítico durante o después del período de ventilación mecánica en la unidad de cuidados intensivos (UCI). La búsqueda se realizó en las bases de datos Cochrane, Medline/Pubmed, Embase (Elsevier), SciELO, LILACS/BVS, www.controlled-trials.com/, clinicaltrials.gov/ y www.who.int/ictrp/en/. Se analizó el riesgo de sesgo mediante la herramienta RoB 1. Se generó una síntesis cualitativa y cuantitativa (metaanálisis) de los resultados. Registro: OSF: https://bit.ly/430fF72. Resultados: Se incluyeron siete estudios, con un total de 1905 sujetos. La mayoría de los sujetos eran del sexo masculino (57 %) y tenían entre 54 y 66 años. Los desenlaces reportados mostraron baja certeza de evidencia, según la Clasificación de la valoración, desarrollo y evaluación de las recomendaciones (GRADE, por sus siglas en inglés). En el metaanálisis del estado funcional al alta hospitalaria, se observó un efecto a favor del grupo MAT, con una diferencia de medias estandarizada de 0,26 (IC 95 % 0,11 - 0,41) y baja heterogeneidad (I2 = 0 %). Conclusión: Con una baja certeza de evidencia, el efecto de la MAT en sujetos adultos críticamente enfermos en la UCI podría mejorar el estado funcional al alta hospitalaria en comparación con el CHA.

ABSTRACT Objective: To evaluate the effect of early active mobilization (EAM) compared to active usual care (AUC) in critically ill adult subjects regarding muscle strength and functional status. Materials and methods: A systematic review with meta-analysis were conducted. Randomized clinical trials comparing EAM with AUC in subjects >18 years of age, of both sexes, in critical condition during or after the period of mechanical ventilation in the intensive care unit (ICU) were included. The search was performed in the Cochrane, Medline/Pubmed, Embase (Elsevier), SciELO, LILACS/BVS, www.controlled-trials.com/, clinicaltrials.gov/, and www.who.int/ictrp/en/ databases. Bias risk was assessed using the RoB 1 tool. A qualitative and quantitative synthesis (meta-analysis) of the results was generated. Registration: OSF: https://bit.ly/430fF72. Results: Seven studies were included in this review, comprising a total of 1905 subjects. The majority of subjects were male (57 %) and aged between 54 and 66 years. The reported outcomes showed low certainty of evidence, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. In the meta-analysis of functional status at hospital discharge, a favorable effect was observed in the EAM group, with a standardized mean difference of 0.26 (95 % CI 0.11 - 0.41) and low heterogeneity (I2 = 0 %). Conclusion: With low certainty of evidence, the effect of EAM on critically ill adult subjects in the ICU may improve functional status at hospital discharge compared to AUC.

Nutrition adequacy in the late period of the acute phase is associated with a lower risk of 30-day mortality in critically ill patients: A prospective cohort study.

BACKGROUND: The provision of nutrition support for critically ill patients in the early phase of intensive care unit (ICU) admission plays a vital role in their recovery. However, there is still debate regarding the impact of nutrition adequacy of critical illness phases. We aimed to investigate whether nutrition adequacy in the acute phase (early and late periods) is associated with 30-day mortality in critically ill patients. METHODS: We prospectively collected nutrition and clinical data from critically ill patients receiving exclusive enteral nutrition (EN) within the first 10 days of ICU admission. EN was classified as adequate when ≥80% of the prescribed EN was administered. Directed acyclic graphs were constructed to identify the minimum set of adjustment variables required to control for confounding factors. The relationships between energy and protein intake and 30-day mortality were assessed using the Cox regression analysis. RESULTS: A total of 119 patients were evaluated (70 years old, 56.3% male, and 68.1% with medical admission). The 30-day mortality rate was 23%. After adjusting for confounders, in the late period (days 5-10), energy adequacy (hazard ratio [HR] = 0.960; 95% CI, 0.937-0.984) and protein adequacy (HR = 0.960; 95% CI, 0.937-0.982) were predictors of 30-day mortality. No associations were observed in the early period (days 1-4) of the acute phase. CONCLUSION: In critically ill patients, nutrition adequacy (≥80% EN) during days 5-10 in the ICU was associated with a lower risk of 30-day mortality.

Effects of exercise interventions on functioning and health-related quality of life following hospital discharge for recovery from critical illness: A systematic review and meta-analysis of randomized trials.

OBJECTIVE: This systematic review and meta-analysis aimed to analyze the published randomized controlled trials (RCTs) that investigated the effects of exercise interventions on functioning and health-related quality of life following hospital discharge for recovery from critical illness. DESIGN: Systematic review and meta-analysis of RCTs. DATA SOURCES: We searched PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, PEDro data base, and SciELO (from the earliest date available to January 2023) for RCTs that evaluated the effects of physical rehabilitation interventions following hospital discharge for recovery from critical illness. REVIEW METHODS: Study quality was evaluated using the PEDro Scale. Mean differences (MDs), standard MDs (SMD), and 95% confidence intervals (CIs) were calculated. RESULTS: Fourteen studies met the study criteria, including 1259 patients. Exercise interventions improved aerobic capacity SMD 0.2 (95% CI: 0.03-0.3, I2 = 0% N = 880, nine studies, high-quality evidence), and physical component score of health-related quality of life MD 3.3 (95% CI: 1.0-5.6, I2 = 57%, six studies N = 669, moderate-quality evidence). In addition, a significant reduction in depression was observed MD -1.4 (95% CI: -2.7 to -0.1, I2 = 0% N = 148, three studies, moderate-quality evidence). No serious adverse events were reported. CONCLUSION: Exercise intervention was associated with improvement of aerobic capacity, depression, and physical component score of health-related quality of life after hospital discharge for survivors of critical illness.

A Predictive Model for Thiamine Responsive Disorders Among Infants and Young Children: Results from a Prospective Cohort Study in Lao People's Democratic Republic.

OBJECTIVE: To develop a predictive model for thiamine responsive disorders (TRDs) among infants and young children hospitalized with signs or symptoms suggestive of thiamine deficiency disorders (TDDs) based on response to therapeutic thiamine in a high-risk setting. STUDY DESIGN: Children aged 21 days to <18 months hospitalized with signs or symptoms suggestive of TDD in northern Lao People's Democratic Republic were treated with parenteral thiamine (100 mg daily) for ≥3 days in addition to routine care. Physical examinations and recovery assessments were conducted frequently for 72 hours after thiamine was initiated. Individual case reports were independently reviewed by three pediatricians who assigned a TRD status (TRD or non-TRD), which served as the dependent variable in logistic regression models to identify predictors of TRD. Model performance was quantified by empirical area under the receiver operating characteristic curve. RESULTS: A total of 449 children (median [Q1, Q3] 2.9 [1.7, 5.7] months old; 70.3% exclusively/predominantly breastfed) were enrolled; 60.8% had a TRD. Among 52 candidate variables, those most predictive of TRD were exclusive/predominant breastfeeding, hoarse voice/loss of voice, cyanosis, no eye contact, and no diarrhea in the previous 2 weeks. The area under the receiver operating characteristic curve (95% CI) was 0.82 (0.78, 0.86). CONCLUSIONS: In this study, the majority of children with signs or symptoms of TDD responded favorably to thiamine. While five specific features were predictive of TRD, the high prevalence of TRD suggests that thiamine should be administered to all infants and children presenting with any signs or symptoms consistent with TDD in similar high-risk settings. The usefulness of the predictive model in other contexts warrants further exploration and refinement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03626337.

Single-nucleotide polymorphisms related to vitamin D metabolism and severity or mortality of COVID-19: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to verify the association between single-nucleotide polymorphisms (SNPs) in vitamin D-related genes and the severity or mortality of coronavirus disease 19 (COVID-19). We systematically searched PubMed, BVS/Bireme, Scopus, Embase, and Web of Science for relevant studies published until November 24, 2023. Twelve studies were included. Thirty-one SNPs related to four genes were studied (VDR, 13 SNPs; GC, 6 SNPs; DHCR7/NADSYN1, 6 SNPs; CYP2R1, 6 SNPs). Eight SNPs were examined in two or more studies (VDR rs731236, rs2228570, rs1544410, rs7975232, rs739837, rs757343, rs11568820, and rs4516035). Meta-analysis showed a significant association between the VDR rs1544410 Bb + bb genotype and b allele and an increased odds of developing severe/critical COVID-19 (Bb + bb vs. BB = 2 studies, OR = 1.73, 95% confidence interval (CI): 1.16-2.57, P = 0.007, I2 = 0%; b allele vs. B allele = 2 studies, OR = 1.31, 95% CI: 1.03-1.67; P = 0.03; I2 = 0%). Regarding the mortality rate, VDR rs731236 TT-genotype, TT + Tt genotype, and T allele; VDR rs1544410 bb-genotype, Bb + bb genotype, and b allele; VDR rs7975232 AA-genotype, AA + Aa genotype, and A allele; and VDR rs2228570 ff-genotype, Ff + ff genotype, and f allele were associated with increased odds of death due to COVID-19. In conclusion, the present study suggests that SNPs rs1544410 may serve as a predictive biomarker for COVID-19 severity and rs731236, rs1544410, rs7975232, and rs2228570 as predictive biomarkers for COVID-19 mortality. More well-designed studies involving a larger number of COVID-19 patients are required to validate and replicate these findings.

Epidemiology of Tracheostomized Adult Patients Admitted to Specialized Weaning Centers After Acute COVID-19.

BACKGROUND: Epidemiological data on patients with COVID-19 referred to specialized weaning centers (SWCs) are sparse, particularly in low- and middle-income countries. Our aim was to describe clinical features, epidemiology, and outcomes of subjects admitted to SWCs in Argentina. METHODS: We conducted a prospective, multi-center, observational study between July 2020-December 2021 in 12 SWCs. We collected demographic characteristics, laboratory results, pulmonary function, and dependence on mechanical ventilation at admission, decannulation, weaning from mechanical ventilation, and status at discharge. A multiple logistic model was built to predict home discharge. RESULTS: We enrolled 568 tracheostomized adult subjects after the acute COVID-19 phase who were transferred to SWCs. Age was 62 [52-71], males 70%, Charlson comorbidity index was 2 [0-3], and length of stay in ICU was 42 [32-56] d. Of the 315 ventilator-dependent subjects, 72.4% were weaned, 427 (75.2%) were decannulated, and 366 subjects (64.5%) were discharged home. The mortality rate was 6.0%. In multivariate analysis, age (odds ratio 0.30 [95% CI 0.16-0.56], P < .001), Charlson comorbidity index (odds ratio 0.43 [95% CI 0.22-0.84], P < .01), mechanical ventilation duration in ICU (odds ratio 0.80 [95% CI 0.72-0.89], P < .001), renal failure (odds ratio 0.40 [95% CI 0.22-0.73], P = .003), and expiratory muscle weakness (odds ratio 0.35 [95% CI 0.19-0.62], P < .001) were independently associated with home discharge. CONCLUSIONS: Most subjects with COVID-19 transferred to SWCs were weaned, achieved decannulation, and were discharged to home. Age, high-comorbidity burden, prolonged mechanical ventilation in ICU, renal failure at admission, and expiratory muscle weakness were inversely associated with home discharge.

Phase angle as a prognostic indicator in critically ill children: A systematic review.

Phase angle (PhA) may reflect the integrity of cellular membranes, hydration status, and total body cell mass. Studies have shown that PhA can be used as a good predictor for evaluation of disease severity in critically ill adults. However, there is a lack of studies assessing the association between PhA and clinical outcomes in critically ill children. This systematic review described the association between PhA at pediatric intensive care unit (PICU) admission with clinical outcomes in critically ill children. The search was conducted using PubMed/Medline, Scopus, Web of Science, EMBASE and LILACS until July 22, 2022. Studies that evaluate the association between PhA at PICU admission in critically ill children and clinical outcomes were eligible. Data regarding population, study design, setting, bioelectrical impedance analysis (BIA) protocol used, PhA classification, and outcome analysis were extracted. Risk of bias was assessed by Newcastle-Ottawa Scale. Among the 4669 articles screened, five prospective studies were included. The studies have shown association between lower values of PhA at PICU admission with longer PICU and hospital length of stay, duration of mechanical ventilation, septic shock, and higher mortality risk. Small sample size, different clinical conditions, and methodological differences of the studies regarding BIA equipment and cutoffs of PhA were observed. Although the studies have limitations, the PhA has a potential role in predicting clinical outcomes in critically ill children. Larger studies with standardized PhA protocols and other relevant clinical outcomes are necessary.

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up / Desmascarando as consequências ocultas: sequelas pós-unidade de terapia intensiva, planejamento da alta e acompanhamento a longo prazo

ABSTRACT A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

RESUMO Parcela significativa de indivíduos que enfrentaram doença crítica sofre de síndrome pós-cuidados intensivos, caracterizada por comprometimento novo ou exacerbado da função física, cognitiva ou de saúde mental. Além disso, os sobreviventes geralmente apresentam maior risco de consequências adversas, como infecção, eventos cardiovasculares maiores, reinternação e taxas de mortalidade elevadas, durante os meses após a hospitalização. Esses achados reforçam a necessidade urgente de prevenção e manejo eficazes da deterioração da saúde a longo prazo no ambiente de cuidados intensivos. Embora haja poucas evidências conclusivas de ensaios clínicos randomizados bem desenhados, potenciais intervenções incluem estratégias como limitação da sedação, mobilização precoce, presença da família durante a internação na unidade de terapia intensiva, implementação de programas de transição multidisciplinares (da unidade de terapia intensiva para a enfermaria e do hospital para o domicílio) e acompanhamento especializado após a alta hospitalar. Esta revisão objetiva fornecer um resumo conciso da literatura médica recente sobre os desfechos a longo prazo após doenças críticas e destacar potenciais abordagens para prevenir e abordar a deterioração da saúde de sobreviventes de cuidados intensivos.

Evaluation of oxidative stress level: reactive oxygen species, reduced glutathione, and D-dimer in patients hospitalized due to COVID-19.

Elevated D-dimer levels at hospital admission may also indicate a higher likelihood of progressing to a severe or critical state. This study aimed to assess reactive oxygen species (ROS), non-enzymatic antioxidant reduced glutathione (GSH), and D-dimer levels in COVID-19 patients upon admission, examining their association with mortality outcomes. Data was collected from the medical records of 170 patients hospitalized in a referral hospital unit between March 2020 and December 2021. Patients were divided into two groups: the ward bed group (n = 87), comprising 51% with moderate clinical conditions, and the intensive care unit (ICU) group (n = 83), comprising 49% with severe conditions. The mean age was 59.4 years, with a male predominance of 52.4%. The overall death rate was 43%, with 30.6% in the moderate group and 69.4% in the severe group. The average time from symptom onset to hospitalization was 6.42 days. Results showed that non-survivors had high D-dimer and ROS counts, longer ICU stays, and worse saturation levels at admission. In conclusion, elevated ROS and D-dimer levels may contribute to worse outcomes in critically ill patients, potentially serving as specific and sensitive predictors of poor outcomes upon admission.

Decrease in the intensive care unit-acquired weakness with a multicomponent protocol implementation: A quasi-experimental clinical trial / Disminución de la debilidad muscular adquirida en una unidad de cuidados intensivos con la implementación de un protocolo multicomponente: ensayo clínico cuasiexperimental

Introduction: Intensive care unit-acquired weakness is a frequent complication that affects the prognosis of critical illness during hospital stay and after hospital discharge. Objectives: To determine if a multicomponent protocol of early active mobility involving adequate pain control, non-sedation, non-pharmacologic delirium prevention, cognitive stimulation, and family support, reduces intensive care unit-acquired weakness at the moment of discharge. Materials and methods: We carried out a non-randomized clinical trial in two mixed intensive care units in a high-complexity hospital, including patients over 14 years old with invasive mechanical ventilation for more than 48 hours. We compared the intervention ­the multicomponent protocol­ during intensive care hospitalization versus the standard care. Results: We analyzed 82 patients in the intervention group and 106 in the control group. Muscle weakness acquired in the intensive care unit at the moment of discharge was less frequent in the intervention group (41.3% versus 78.9%, p<0.00001). The mobility score at intensive unit care discharge was better in the intervention group (median = 3.5 versus 2, p < 0.0138). There were no statistically significant differences in the invasive mechanical ventilation-free days at day 28 (18 versus 15 days, p<0.49), and neither in the mortality (18.2 versus 27.3%, p<0.167). Conclusion: A multi-component protocol of early active mobility significantly reduces intensive care unit-acquired muscle weakness at the moment of discharge.

Introducción: La debilidad adquirida en las unidades de cuidados intensivos es una complicación frecuente de los pacientes con enfermedades críticas, que puede tener un impacto negativo en su pronóstico a corto y a largo plazo. OBJETIVOS: Evaluar si la utilización de un protocolo multicomponente, que incluye movilidad activa temprana, manejo efectivo del dolor, reducción de la sedación, medidas no farmacológicas para prevenir el delirium, estimulación cognitiva y apoyo familiar, puede disminuir la incidencia de debilidad adquirida en las unidades de cuidados intensivos al momento del egreso del paciente. Materiales y métodos: Se trata de un ensayo clínico, no aleatorizado, en dos unidades de cuidados intensivos mixtas de un hospital de tercer nivel. Los participantes fueron pacientes mayores de 14 años con ventilación mecánica invasiva por más de 48 horas. Se aplicó como intervención un protocolo multicomponente y como control se utilizó el cuidado usual o estándar. RESULTADOS: Ingresaron 188 pacientes al estudio, 82 al grupo de intervención y 106 al grupo control. La tasa de debilidad adquirida en las unidades de cuidados intensivos al egreso de la unidad fue significativamente menor en el grupo de intervención (41,3 % versus 78,9 %, p<0,00001). La mediana del puntaje de movilidad al momento del alta de la unidad de cuidados intensivos fue mayor en el grupo de intervención (3,5 versus 2, p<0,0138). No se encontraron diferencias estadísticamente significativas en las medianas de días libres de respiración mecánica asistida, ni de unidad de cuidados intensivos al día 28, tampoco en la tasa de mortalidad general al egreso del hospital (18 versus 15 días, p<0,49; 18,2 % versus 27,3 %, p<0,167). CONCLUSIONES: Un protocolo multicomponente que incluía movilidad activa temprana tuvo un impacto significativo en la reducción de la debilidad adquirida en las unidades de cuidados intensivos al egreso en comparación con el cuidado estándar.

Intensive glucose control in critically ill adults: a protocol for a systematic review and individual patient data meta-analysis / Controle intensivo da glicose em adultos em estado grave: um protocolo de revisão sistemática e metanálise de dados individuais de pacientes

ABSTRACT Objective: The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults. Data sources: MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published trial-level data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available. Methods: Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of ≤ 120mg/dL (≤ 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge. Primary endpoint: In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used. Discussion: This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?' Protocol version 0.4 - 06/26/2023 PROSPERO registration: CRD42021278869

RESUMO Objetivo: Não está claro qual é a meta ideal de concentração de glicose no sangue em pacientes em estado grave. Realizaremos uma revisão sistemática e uma metanálise com dados agregados e de pacientes individuais de estudos controlados e randomizados, comparando o controle intensivo da glicose com o controle liberal da glicose em adultos em estado grave. Fontes de dados: MEDLINE®, Embase, Cochrane Central Register of Clinical Trials e registros de ensaios clínicos (Organização Mundial da Saúde, clinical trials.gov). Os autores dos estudos qualificados serão convidados a fornecer dados individuais de pacientes. Os dados publicados em nível de ensaio qualificado que não apresentem alto risco de viés serão incluídos em uma metanálise de dados agregados se os dados individuais de pacientes não estiverem disponíveis. Métodos: Critérios de inclusão: ensaios clínicos controlados e randomizados que recrutaram pacientes adultos, com meta de glicemia ≤ 120mg/dL (≤ 6,6mmol/L) comparada a uma meta de concentração de glicemia mais alta com insulina intravenosa em ambos os grupos. Estudos excluídos: aqueles com meta de glicemia no limite superior no grupo de intervenção > 120mg/dL (> 6,6mmol/L), ou em que o controle intensivo de glicose foi realizado apenas no período intraoperatório, e aqueles em que a perda de seguimento excedeu 10% até a alta hospitalar. Desfecho primário: Mortalidade intra-hospitalar durante a admissão hospitalar. Desfechos secundários: Mortalidade e sobrevida em outros momentos, duração da ventilação mecânica invasiva, agentes vasoativos e terapia de substituição renal. Utilizaremos metanálise bayesiana de efeito randômico e modelos bayesianos hierárquicos para dados individuais de pacientes. Discussão: Essa revisão sistemática com dados agregados e de pacientes individuais abordará a questão clínica: Qual é a melhor meta de glicose no sangue de pacientes graves em geral? Protocolo versão 0.4 - 26/06/2023 Registro PROSPERO: CRD42021278869

Delirium severity and outcomes of critically ill COVID-19 patients / Gravidade do delirium e desfechos de pacientes críticos com COVID-19

ABSTRACT Objective: To investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes. Methods: This prospective cohort study was performed in two tertiary intensive care units in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of intensive care unit stay using the Richmond Agitation Sedation Scale, Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Confusion Method Assessment for Intensive Care Unit-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality. Results: Among the 277 COVID-19 patients included, delirium occurred in 101 (36.5%) during the first 7 days of intensive care unit stay, and it was associated with a higher length of intensive care unit stay in days (IQR 13 [7 - 25] versus 6 [4 - 12]; p < 0.001), higher hospital mortality (25.74% versus 5.11%; p < 0.001) and additional higher one-year mortality (5.3% versus 0.6%, p < 0.001). Delirium was classified by CAM-ICU-7 in terms of severity, and higher scores were associated with higher in-hospital mortality (17.86% versus 34.38% versus 38.46%, 95%CI, p value < 0.001). Severe delirium was associated with a higher risk of progression to coma (OR 7.1; 95%CI 1.9 - 31.0; p = 0.005) and to mechanical ventilation (OR 11.09; 95%CI 2.8 - 58.5; p = 0.002) in the multivariate analysis, adjusted by severity and frailty. Conclusion: In patients admitted with COVID-19 in the intensive care unit, delirium was an independent risk factor for the worst prognosis, including mortality. The delirium severity assessed by the CAM-ICU-7 during the first week in the intensive care unit was associated with poor outcomes, including progression to coma and to mechanical ventilation.

RESUMO Objetivo: Investigar como a gravidade do delirium afeta pacientes graves com COVID-19 e sua associação com os desfechos. Métodos: Estudo de coorte prospectivo realizado em duas unidades de terapia intensiva terciárias no Rio de Janeiro (RJ). Os pacientes com COVID-19 foram avaliados diariamente durante os primeiros 7 dias de internação na unidade de terapia intensiva usando a escala de agitação e sedação de Richmond, a Confusion Assessment Method for Intensive Care Unit (CAM-ICU) e a Confusion Assessment Method for Intensive Care Unit-7 (CAM-ICU-7). A gravidade do delirium foi correlacionada com os desfechos e a mortalidade em 1 ano. Resultados: Entre os 277 pacientes com COVID-19 incluídos, o delirium ocorreu em 101 (36,5%) durante os primeiros 7 dias de internação na unidade de terapia intensiva e foi associado a maior tempo de internação na unidade de terapia intensiva em dias (IQ: 13 [7 - 25] versus 6 [4 - 12]; p < 0,001), maior mortalidade hospitalar (25,74% versus 5,11%; p < 0,001) e maior mortalidade em 1 ano (5,3% versus 0,6%, p < 0,001). O delirium foi classificado pela CAM-ICU-7 em termos de gravidade, e escores maiores foram associados à maior mortalidade hospitalar (17,86% versus 34,38% versus 38,46%, IC95%, valor de p < 0,001). O delirium grave foi associado a um risco maior de progressão ao coma (RC de 7,1; IC95% 1,9 - 31,0; p = 0,005) e à ventilação mecânica (RC de 11,09; IC95% 2,8 - 58,5; p = 0,002) na análise multivariada, ajustada por gravidade e fragilidade Conclusão: Em pacientes internados com COVID-19 na unidade de terapia intensiva, o delirium foi fator de risco independente para o pior prognóstico, incluindo mortalidade. A gravidade do delirium avaliada pela CAM-ICU-7 durante a primeira semana na unidade de terapia intensiva foi associada a desfechos desfavoráveis, incluindo a progressão ao coma e à ventilação mecânica.