The trajectory of very old critically ill patients.

The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.

Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19: The CoDEX Randomized Clinical Trial.

Importance: Acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) is associated with substantial mortality and use of health care resources. Dexamethasone use might attenuate lung injury in these patients. Objective: To determine whether intravenous dexamethasone increases the number of ventilator-free days among patients with COVID-19-associated ARDS. Design, Setting, and Participants: Multicenter, randomized, open-label, clinical trial conducted in 41 intensive care units (ICUs) in Brazil. Patients with COVID-19 and moderate to severe ARDS, according to the Berlin definition, were enrolled from April 17 to June 23, 2020. Final follow-up was completed on July 21, 2020. The trial was stopped early following publication of a related study before reaching the planned sample size of 350 patients. Interventions: Twenty mg of dexamethasone intravenously daily for 5 days, 10 mg of dexamethasone daily for 5 days or until ICU discharge, plus standard care (n =151) or standard care alone (n = 148). Main Outcomes and Measures: The primary outcome was ventilator-free days during the first 28 days, defined as being alive and free from mechanical ventilation. Secondary outcomes were all-cause mortality at 28 days, clinical status of patients at day 15 using a 6-point ordinal scale (ranging from 1, not hospitalized to 6, death), ICU-free days during the first 28 days, mechanical ventilation duration at 28 days, and Sequential Organ Failure Assessment (SOFA) scores (range, 0-24, with higher scores indicating greater organ dysfunction) at 48 hours, 72 hours, and 7 days. Results: A total of 299 patients (mean [SD] age, 61 [14] years; 37% women) were enrolled and all completed follow-up. Patients randomized to the dexamethasone group had a mean 6.6 ventilator-free days (95% CI, 5.0-8.2) during the first 28 days vs 4.0 ventilator-free days (95% CI, 2.9-5.4) in the standard care group (difference, 2.26; 95% CI, 0.2-4.38; P = .04). At 7 days, patients in the dexamethasone group had a mean SOFA score of 6.1 (95% CI, 5.5-6.7) vs 7.5 (95% CI, 6.9-8.1) in the standard care group (difference, -1.16; 95% CI, -1.94 to -0.38; P = .004). There was no significant difference in the prespecified secondary outcomes of all-cause mortality at 28 days, ICU-free days during the first 28 days, mechanical ventilation duration at 28 days, or the 6-point ordinal scale at 15 days. Thirty-three patients (21.9%) in the dexamethasone group vs 43 (29.1%) in the standard care group experienced secondary infections, 47 (31.1%) vs 42 (28.3%) needed insulin for glucose control, and 5 (3.3%) vs 9 (6.1%) experienced other serious adverse events. Conclusions and Relevance: Among patients with COVID-19 and moderate or severe ARDS, use of intravenous dexamethasone plus standard care compared with standard care alone resulted in a statistically significant increase in the number of ventilator-free days (days alive and free of mechanical ventilation) over 28 days. Trial Registration: ClinicalTrials.gov Identifier: NCT04327401.

Failure to reduce C-reactive protein levels more than 25% in the last 24 hours before intensive care unit discharge predicts higher in-hospital mortality: a cohort study.

PURPOSE: To discharge a patient from the intensive care unit (ICU) is a complex decision-making process because in-hospital mortality after critical illness may be as high as up to 27%. Static C-reactive protein (CRP) values have been previously evaluated as a predictor of post-ICU mortality with conflicting results. Therefore, we evaluated the CRP ratio in the last 24 hours before ICU discharge as a predictor of in-hospital outcomes. METHODS: A retrospective cohort study was performed in 409 patients from a 6-bed ICU of a university hospital. Data were prospectively collected during a 4-year period. Only patients discharged alive from the ICU with at least 72 hours of ICU length of stay were evaluated. RESULTS: In-hospital mortality was 18.3% (75/409). Patients with reduction less than 25% in CRP concentrations at 24 hours as compared with 48 hours before ICU discharge had a worse prognosis, with increased mortality (23% vs 11%, P = .002) and post-ICU length of stay (26 [7-43] vs 11 [5-27] days, P = .036). Moreover, among hospital survivors (n = 334), patients with CRP reduction less than 25% were discharged later (hazard ratio, 0.750; 95% confidence interval, 0.602-0.935; P = .011). CONCLUSIONS: In this large cohort of critically ill patients, failure to reduce CRP values more than 25% in the last 24 hours of ICU stay is a strong predictor of worse in-hospital outcomes.

Caracterização da resposta a testes cutâneos de hipersensibilidade tardia em pacientes internados na UTI / Characterization of the response to the delayed hypersensitivity: skin tests in ICU patients

Infecções hospitalares estão entre as principais complicações associadas a óbito em Unidade de Terapia Intensiva(UTI). Entretanto, existem poucas ferramentas validadas em UTI para tentar caracterizar o risco de tais complicações. Objetivo: Caracterizar a resposta a testes cutâneos de hipersensibilidade tardia no momento da admissão de pacientes em UTI, relacionando-a ao desenvolvimento de infecção hospitalar. Pacientes e métodos: Foram analisadas as respostas dos testes cutâneos (pápulas formadas) para quatro antígenos: PPD, candidina, tricofitina e estreptoquinase em 78 pacientes, à admissão em UTI. Os pacientes foram divididos em três grupos: A) sem infecção na admissão e durante a internação; B)sem infecção na admissão e que desenvolveram infecção durante a internação; C) infecção diagnosticada na admissão. Foram ainda divididos em: eutróficos, obesos e desnutridos. Resultados: Tanto pacientes que desenvolveram infecção na UTI (24 pacientes) quanto aqueles que já apresentavam infecção à admissão (15 pacientes) apresentaram menor positividade dos testes ao PPD (1,75 e 0,53mm) e à candidina (1,45 e 1,06mm), quando comparados a 34 pacientes que nãodesenvolveram infecção (4,97 para PPD e 4,74mm para candidina)(p<0,05). Observou-se ainda que os 40 desnutridos apresentaram menor positividade à candidina (1,91mm) quando comparados aos 21 eutróficos (3,17mm) (p<0,05). Conclusão: Observamos que pacientes com diagnóstico de infecção à internação em UTI e os que evoluíram para infecção na UTI apresentaram uma menor resposta aos testes cutâneos de hipersensibilidade tardia ao PPD e à candidina. Acreditamos que a aplicação dos testes cutâneos possa ser uma ferramenta útil na avaliação de risco de infecção hospitalar em UTI.

The hospital infections are among the major complications associated with death in the Intensive Care Unit (ICU). However, there are few validated tools in the ICU to try to characterize the risk of such complications. Objective: To characterize the response to skin tests for delayed hypersensitivity at the time of admission of patients inthe ICU and its relation to the development of nosocomial infection. Patients and Methods: We analyzed the responses of skin tests (papules formed) to four antigens: PPD, candidina, trichophytinand streptokinase in 78 patients at the ICU admission. Patients were divided into three groups: A) no infection at admission and during hospitalization; B) without infection on admission and who developed infections during hospitalization; C) infection diagnosed on admission. Patients were further divided into: normal weight, obese and malnourished. Results: The patients that developed infections in the ICU(24 patients) and those that already had infection on admission(15 patients) had lower positivity to PPD (1.75 and 0.53mm) and candidina tests (1.45 and 1.06mm), when they were compared to 34 patients without infection (4.97 for PPD and 4.74mm for candidina) (p<0.05). It was also observed that the 40 malnourished patients had lower positivity for candidina (1.91 mm) when they were compared to 21 normal weight(3,17mm) (p<0.05). Conclusion: We found that patients with a diagnosis of infection at admission in the ICU and who progressed to infection in the ICU had a lower response to skin tests for delayed hypersensitivity to PPD and candidina. We believe that the application of skin tests may be a useful tool in assessing risk of nosocomial infection in ICU.