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1.
Res Social Adm Pharm ; 17(1): 1853-1858, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33317764

RESUMEN

BACKGROUND: The practical experiences of active pharmacists involved in managing critically ill patients with coronavirus disease 2019 (COVID-19) have been rarely reported. OBJECTIVE: This work aimed to share professional experiences on medication optimization and provide a feasible reference for the pharmaceutical care of critically ill patients with COVID-19. METHODS: This study was conducted in a COVID-19-designated hospital in China. A group of dedicated clinical pharmacists participated in multidisciplinary rounds to optimize the treatments for critically ill patients with COVID-19. Consensus on medication recommendations was reached by a multidisciplinary team through bi-daily discussion. Related drug, classification, cause, and adjustment content for recommendations were recorded and reviewed. RESULTS: A total of 111 medication recommendations were supplied for 22 out of 33 (56.7%) critically ill patients from 1 February 2020 to 18 March 2020, and 106 (95.5%) of these were accepted. Among these recommendations, 64 (67.7%), 32 (28.8%), and 15 (13.5%) were related to antibiotics and antifungals, antiviral agents, and other drugs, respectively. Recommendation types significantly differed for different anti-infectives (p < 0.05). For antibiotics and antifungals, treatment effectiveness accounted for 60.9% of recommendation types, with 15 (38.5%) cases related to untreated infections. For antiviral agents, adverse drug events were the most common recommendation types (84.4%), with 20 (74.1%) cases related to liver function dysfunction. Discontinuation of suspected antiviral agents (66.7%) was usually recommended after the occurrence of adverse events that may progress and bring poor outcomes. CONCLUSION: Forceful and extensive on-ward participation is recommended for clinical pharmacists in managing critically ill patients. Our experiences highlight the need for special attention toward untreated infections and adverse events related to antiviral agents.


Asunto(s)
/terapia , Unidades de Cuidados Intensivos , Farmacéuticos/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Adulto , Anciano , Anciano de 80 o más Años , Antivirales/administración & dosificación , Antivirales/efectos adversos , China , Enfermedad Crítica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/organización & administración , Rol Profesional , Estudios Retrospectivos
2.
J Trauma Acute Care Surg ; 90(1): e7-e12, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33009340

RESUMEN

BACKGROUND: Critically ill coronavirus disease 2019 (COVID-19) patients have frequent thrombotic complications and laboratory evidence of hypercoagulability. The relationship of coagulation tests and thrombosis requires investigation to identify best diagnostic and treatment approaches. We assessed for hypercoagulable characteristics in critically ill COVID-19 patients using rotational thromboelastometry (ROTEM) and explored relationships of D-dimer and ROTEM measurements with thrombotic complications. METHODS: Critically ill adult COVID-19 patients receiving ROTEM testing between March and April 2020 were analyzed. Patients receiving therapeutic anticoagulation before ROTEM were excluded. Rotational thromboelastometry measurements from COVID-19 patients were compared with non-COVID-19 patients matched by age, sex, and body mass index. Intergroup differences in ROTEM measurements were assessed using t tests. Correlations of D-dimer levels to ROTEM measurements were assessed in COVID-19 patients who had available concurrent testing. Intergroup differences of D-dimer and ROTEM measurements were explored in COVID-19 patients with and without thrombosis. RESULTS: Of 30 COVID-19 patients receiving ROTEM, we identified hypercoagulability from elevated fibrinogen compared with non-COVID-19 patients (fibrinogen assay maximum clot firmness [MCF], 47 ± 13 mm vs. 20 ± 7 mm; mean intergroup difference, 27.4 mm; 95% confidence interval [CI], 22.1-32.7 mm; p < 0.0001). In our COVID-19 cohort, thrombotic complications were identified in 33%. In COVID-19 patients developing thrombotic complications, we identified higher D-dimer levels (17.5 ± 4.3 µg/mL vs. 8.0 ± 6.3 µg/mL; mean difference, 9.5 µg/mL; 95% CI, 13.9-5.1; p < 0.0001) but lower fibrinogen assay MCF (39.7 ± 10.8 mm vs. 50.1 ± 12.0 mm; mean difference, -11.2 mm; 95% CI, -2.1 to -20.2; p = 0.02) compared with patients without thrombosis. We identified negative correlations of D-dimer levels and ROTEM MCF in these patients (r = -0.61; p = 0.001). CONCLUSION: We identified elevated D-dimer levels and hypercoagulable blood clot characteristics from increased fibrinogen on ROTEM testing in critically ill COVID-19 patients. However, we identified lower, albeit still hypercoagulable, ROTEM measurements of fibrinogen in COVID-19 patients with thrombotic complications compared with those without. Further work is required to externally validate these findings and to investigate the mechanistic drivers for these relationships to identify best diagnostic and treatment approaches for these patients. LEVEL OF EVIDENCE: Epidemiologic, level IV.


Asunto(s)
/fisiopatología , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Tromboelastografía/métodos , Trombofilia/sangre , Trombosis/etiología , Anciano , Estudios de Casos y Controles , Enfermedad Crítica , Femenino , Hemostasis , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York , Tiempo de Tromboplastina Parcial , Trombosis/diagnóstico
3.
Clin Microbiol Infect ; 27(1): 105-111, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32971254

RESUMEN

OBJECTIVE: To assess the efficacy of corticosteroids in patients with coronavirus disease 2019 (COVID-19). METHODS: A multicentre observational study was performed from 22 February through 30 June 2020. We included consecutive adult patients with severe COVID-19, defined as respiratory rate ≥30 breath per minute, oxygen saturation ≤93% on ambient air or arterial partial pressure of oxygen to fraction of inspired oxygen ≤300 mm Hg. We excluded patients being treated with other immunomodulant drugs, receiving low-dose corticosteroids and receiving corticosteroids 72 hours after admission. The primary endpoint was 30-day mortality from hospital admission. The main exposure variable was corticosteroid therapy at a dose of ≥0.5 mg/kg of prednisone equivalents. It was introduced as binomial covariate in a logistic regression model for the primary endpoint and inverse probability of treatment weighting using the propensity score. RESULTS: Of 1717 patients with COVID-19 evaluated, 513 were included in the study, and of these, 170 (33%) were treated with corticosteroids. During hospitalization, 166 patients (34%) met the criteria of the primary outcome (60/170, 35% in the corticosteroid group and 106/343, 31% in the noncorticosteroid group). At multivariable analysis corticosteroid treatment was not associated with lower 30-day mortality rate (adjusted odds ratio, 0.59; 95% confidence interval (CI), 0.20-1.74; p 0.33). After inverse probability of treatment weighting, corticosteroids were not associated with lower 30-day mortality (average treatment effect, 0.05; 95% CI, -0.02 to 0.09; p 0.12). However, subgroup analysis revealed that in patients with PO2/FiO2 < 200 mm Hg at admission (135 patients, 52 (38%) treated with corticosteroids), corticosteroid treatment was associated with a lower risk of 30-day mortality (23/52, 44% vs. 45/83, 54%; adjusted odds ratio, 0.20; 95% CI, 0.04-0.90; p 0.036). CONCLUSIONS: The effect of corticosteroid treatment on mortality might be limited to critically ill COVID-19 patients.


Asunto(s)
Corticoesteroides/uso terapéutico , /mortalidad , /mortalidad , /patogenicidad , Adulto , Anciano , Antivirales/uso terapéutico , Enfermedad Crítica , Femenino , Heparina de Bajo-Peso-Molecular/uso terapéutico , Mortalidad Hospitalaria , Hospitales , Humanos , Hidroxicloroquina/uso terapéutico , Italia , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento
4.
Clin Microbiol Infect ; 27(1): 112-117, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33007478

RESUMEN

OBJECTIVES: Use of corticosteroids is common in the treatment of coronavirus disease 2019, but clinical effectiveness is controversial. We aimed to investigate the association of corticosteroids therapy with clinical outcomes of hospitalized COVID-19 patients. METHODS: In this single-centre, retrospective cohort study, adult patients with confirmed coronavirus disease 2019 and dead or discharged between 29 December 2019 and 15 February 2020 were studied; 1:1 propensity score matchings were performed between patients with or without corticosteroid treatment. A multivariable COX proportional hazards model was used to estimate the association between corticosteroid treatment and in-hospital mortality by taking corticosteroids as a time-varying covariate. RESULTS: Among 646 patients, the in-hospital death rate was higher in 158 patients with corticosteroid administration (72/158, 45.6% vs. 56/488, 11.5%, p < 0.0001). After propensity score matching analysis, no significant differences were observed in in-hospital death between patients with and without corticosteroid treatment (47/124, 37.9% vs. 47/124, 37.9%, p 1.000). When patients received corticosteroids before they required nasal high-flow oxygen therapy or mechanical ventilation, the in-hospital death rate was lower than that in patients who were not administered corticosteroids (17/86, 19.8% vs. 26/86, 30.2%, log rank p 0.0102), whereas the time from admission to clinical improvement was longer (13 (IQR 10-17) days vs. 10 (IQR 8-13) days; p < 0.001). Using the Cox proportional hazards regression model accounting for time varying exposures in matched pairs, corticosteroid therapy was not associated with mortality difference (HR 0.98, 95% CI 0.93-1.03, p 0.4694). DISCUSSION: Corticosteroids use in COVID-19 patients may not be associated with in-hospital mortality.


Asunto(s)
Corticoesteroides/uso terapéutico , /mortalidad , /patogenicidad , Anciano , Antivirales/uso terapéutico , China , Enfermedad Crítica , Esquema de Medicación , Femenino , Mortalidad Hospitalaria/tendencias , Hospitales , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Respiración Artificial , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento
5.
Am J Hosp Palliat Care ; 38(2): 191-198, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33021094

RESUMEN

Advance care directives (ACDs) are instructions regarding what types of medical treatments a patient desires and/or who they would like to designate as a healthcare surrogate to make important healthcare decisions when the patient is mentally incapacitated. At end-of-life, when faced with poor prognosis for a meaningful health-related quality of life, most patients indicate their preference to abstain from aggressive, life-sustaining treatments. Patients whose wishes are left unsaid often receive burdensome life sustain therapy by default, prolonging patient suffering. The CoVID pandemic has strained our healthcare resources and raised the need for prioritization of life-sustaining therapy. This highlights the urgency of ACDs more than ever. Despite ACDs' potential to provide patients with care that aligns with their values and preferences and reduce resource competition, there has been relatively little conversation regarding the overlap of ACDs and CoVID-19. There is low uptake among patients, lack of training for healthcare professionals, and inequitable adoption in vulnerable populations. However, solutions are forthcoming and may include electronic medical record completion, patient outreach efforts, healthcare worker programs to increase awareness of at-risk minority patients, and restructuring of incentives and reimbursement policies. This review carefully describes the above challenges and unique opportunities to address them in the CoVID-19 era. If solutions are leveraged appropriately, ACDs have the potential to address the described challenges and ethically resolve resource conflicts during the current crisis and beyond.


Asunto(s)
Planificación Anticipada de Atención/organización & administración , Directivas Anticipadas/psicología , Enfermedad Crítica/psicología , Toma de Decisiones , Humanos , Pandemias/estadística & datos numéricos , Relaciones Profesional-Paciente , Calidad de Vida/psicología
6.
Clin Microbiol Infect ; 27(1): 47-54, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33190794

RESUMEN

OBJECTIVES: Coronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients. METHODS: We performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection. RESULTS: From 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5-59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5-11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6-13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors. CONCLUSIONS: This systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay.


Asunto(s)
/epidemiología , Cuidados Críticos/métodos , /patogenicidad , /mortalidad , Enfermedad Crítica , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Terapia de Reemplazo Renal/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento , Vasoconstrictores/uso terapéutico
7.
Nursing ; 51(1): 46-51, 2021 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-33346618

RESUMEN

ABSTRACT: In Europe, the novel coronavirus outbreak started in the northern regions of Italy at the end of February 2020. Initially, resources were insufficient to deal with the abrupt influx of critically ill patients requiring respiratory support. This article recounts the authors' experiences caring for patients with COVID-19 in an Italian ICU during this period in order to help colleagues in the international critical care nursing community successfully manage similar circumstances in the ongoing pandemic.


Asunto(s)
/enfermería , Enfermedad Crítica/enfermería , Rol de la Enfermera , Respiración Artificial/enfermería , Cuidados Críticos/métodos , Humanos , Unidades de Cuidados Intensivos , Italia , Respiración con Presión Positiva/enfermería
8.
Ann Med ; 53(1): 197-207, 2021 12.
Artículo en Inglés | MEDLINE | ID: mdl-33345622

RESUMEN

BACKGROUND: COVID-19 counts 46 million people infected and killed more than 1.2 million. Hypoxaemia is one of the main clinical manifestations, especially in severe cases. HIF1α is a master transcription factor involved in the cellular response to oxygen levels. The immunopathogenesis of this severe form of COVID-19 is poorly understood. METHODS: We performed scRNAseq from leukocytes from five critically ill COVID-19 patients and characterized the expression of hypoxia-inducible factor1α and its transcriptionally regulated genes. Also performed metanalysis from the publicly available RNAseq data from COVID-19 bronchoalveolar cells. RESULTS: Critically-ill COVID-19 patients show a shift towards an immature myeloid profile in peripheral blood cells, including band neutrophils, immature monocytes, metamyelocytes, monocyte-macrophages, monocytoid precursors, and promyelocytes-myelocytes, together with mature monocytes and segmented neutrophils. May be the result of a physiological response known as emergency myelopoiesis. These cellular subsets and bronchoalveolar cells express HIF1α and their transcriptional targets related to inflammation (CXCL8, CXCR1, CXCR2, and CXCR4); virus sensing, (TLR2 and TLR4); and metabolism (SLC2A3, PFKFB3, PGK1, GAPDH and SOD2). CONCLUSIONS: The up-regulation and participation of HIF1α in events such as inflammation, immunometabolism, and TLR make it a potential molecular marker for COVID-19 severity and, interestingly, could represent a potential target for molecular therapy. Key messages Critically ill COVID-19 patients show emergency myelopoiesis. HIF1α and its transcriptionally regulated genes are expressed in immature myeloid cells which could serve as molecular targets. HIF1α and its transcriptionally regulated genes is also expressed in lung cells from critically ill COVID-19 patients which may partially explain the hypoxia related events.


Asunto(s)
/genética , Enfermedad Crítica , Subunidad alfa del Factor 1 Inducible por Hipoxia/genética , Células Mieloides/metabolismo , Análisis de Secuencia de ARN/métodos , Femenino , Humanos , Masculino , ARN Mensajero/genética , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Regulación hacia Arriba
9.
J Intensive Care Med ; 36(2): 233-240, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33380235

RESUMEN

PURPOSE: Montefiore Medical Center (MMC) in the Bronx, New York, was subjected to an unprecedented surge of critically ill patients with COVID-19 disease during the initial outbreak of the pandemic in New York State in the spring of 2020. It is important to describe our experience in order to assist hospitals in other areas of the country that may soon be subjected to similar surges. MATERIALS AND METHODS: We retrospectively reviewed the expansion of critical care medicine services at Montefiore during the COVID-19 surge in terms of space, staff, stuff, and systems. In addition, we report on a debriefing session held with a multidisciplinary group of frontline CCM providers at Montefiore. FINDINGS: The surge of critically ill patients from COVID-19 disease necessitated a tripling of critical care bed capacity at (MMC), with attendant increased needs for staffing, equipment, and systematic innovations to increase efficiency and effectiveness. Feedback from a multidisciplinary group of frontline providers revealed multiple opportunities for improvement for the next potential surge at MMC as well as guidance for other hospitals. CONCLUSIONS: Given increasing cases and burden of critical illness from COVID-19 across the US, engineering safe and effective expansions of critical care capacity will be crucial. We hope that our description of what worked and what did not at MMC will help guide other hospitals in their pandemic preparedness.


Asunto(s)
/epidemiología , Cuidados Críticos , Enfermedad Crítica/epidemiología , Enfermedad Crítica/terapia , Unidades de Cuidados Intensivos/organización & administración , Femenino , Humanos , Masculino , Ciudad de Nueva York/epidemiología , Pandemias , Estudios Retrospectivos
10.
Yonsei Med J ; 62(1): 50-58, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33381934

RESUMEN

PURPOSE: Critical care medicine continues to evolve. However, critical care cases require increasing amount of medical resources. Intensive care unit (ICU) mortality significantly impacts the overall efficiency of healthcare resources within a system of limited medical resources. This study investigated the factors related to ICU mortality using long-term nationwide cohort data in South Korea. MATERIALS AND METHODS: This retrospective cohort study used data of 14905721 patients who submitted reimbursement claims to the Korean Health Insurance Service between January 1, 2011 and December 31, 2015. A total of 1498102 patients who were admitted to all ICU types, except neonatal and long-term acute care hospitals, were enrolled. RESULTS: Of the total 1498102 participants, 861397 (57.5%) were male and 636705 (42.5%) were female. The mean age at admission was 63.4±18.2 years; most of the subjects were aged over 60 years. During the 5-year period, in-hospital mortality rate was 12.9%. In Cox analysis, both in-hospital and 28-day mortality rates were significantly higher in male patients and those of lower socioeconomic status. As age increased and the number of nursing staff decreased, the mortality risk increased significantly by two or three times. The mortality risk was lower in patients admitted to an ICU of a tertiary university hospital and an ICU where intensivists worked. CONCLUSION: The number of nursing staff and the presence of an intensivist in ICU were associated with the ICU mortality rate. Also, increasing the number of nursing staff and the presence of intensivist might reduce the mortality rate among ICU patients.


Asunto(s)
Enfermedad Crítica/mortalidad , Enfermedad Crítica/enfermería , Unidades de Cuidados Intensivos/estadística & datos numéricos , Personal de Enfermería/estadística & datos numéricos , Médicos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , República de Corea , Estudios Retrospectivos , Centros de Atención Terciaria
11.
Heart Lung ; 50(1): 28-32, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33138974

RESUMEN

BACKGROUND: As of June 15, 2020, a cumulative total of 7,823,289 confirmed cases of COVID-19 have been reported across 216 countries and territories worldwide. However, there is little information on the clinical characteristics and outcomes of critically ill patients with severe COVID-19 who were admitted to intensive care units (ICUs) in Latin America. The present study evaluated the clinical characteristics and outcomes of critically ill patients with severe COVID-19 who were admitted to ICUs in Mexico. METHODS: This was a multicenter observational study that included 164 critically ill patients with laboratory-confirmed COVID-19 who were admitted to 10 ICUs in Mexico, from April 1 to April 30, 2020. Demographic data, comorbid conditions, clinical presentation, treatment, and outcomes were collected and analyzed. The date of final follow-up was June 4, 2020. RESULTS: A total of 164 patients with severe COVID-19 were included in this study. The mean age of patients was 57.3 years (SD 13.7), 114 (69.5%) were men, and 6.0% were healthcare workers. Comorbid conditions were common in patients with critical COVID-19: 38.4% of patients had hypertension and 32.3% had diabetes. Compared to survivors, nonsurvivors were older and more likely to have diabetes, hypertension or other conditions. Patients presented to the hospital a median of 7 days (IQR 4.5-9) after symptom onset. The most common presenting symptoms were shortness of breath, fever, dry cough, and myalgias. One hundred percent of patients received invasive mechanical ventilation for a median time of 11 days (IQR 6-14). A total of 139 of 164 patients (89.4%) received vasopressors, and 24 patients (14.6%) received renal replacement therapy during hospitalization. Eighty-five (51.8%) patients died at or before 30 days, with a median survival of 25 days. Age (OR, 1.05; 95% CI, 1.02-1.08; p<0.001) and C-reactive protein levels upon ICU admission (1.008; 95% CI, 1.003-1.012; p<0.001) were associated with a higher risk of in-hospital death. ICU length of stay was associated with reduced in-hospital mortality risk (OR, 0.89; 95% CI, 0.84-0.94; p<0.001). CONCLUSIONS: This observational study of critically ill patients with laboratory-confirmed COVID-19 who were admitted to the ICU in Mexico demonstrated that age and C-reactive protein level upon ICU admission were associated with in-hospital mortality, and the overall hospital mortality rate was high. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04336345.


Asunto(s)
Enfermedad Crítica , Humanos , Unidades de Cuidados Intensivos , Masculino , México/epidemiología , Persona de Mediana Edad
12.
Heart Lung ; 50(1): 37-43, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33138976

RESUMEN

BACKGROUND: The clinical characteristics of the patients with COVID-19 complicated by pneumothorax have not been clarified. OBJECTIVES: To determine the epidemiology and risks of pneumothorax in the critically ill patients with COVID-19. METHODS: Retrospectively collecting and analysing medical records, laboratory findings, chest X-ray and CT images of 5 patients complicated by pneumothorax. RESULTS: The incidence of pneumothorax was 10% (5/49) in patients with ARDS, 24% (5/21) in patients receiving mechanical ventilation, and 56% (5/9) in patients requiring invasive mechanical ventilation, with 80% (4/5) patients died. All the 5 patients were male and aged ranging from 54 to 79 years old. Pneumothorax was most likely to occur 2 weeks after the beginning of dyspnea and associated with reduction of neuromuscular blockers, recruitment maneuver, severe cough, changes of lung structure and function. CONCLUSIONS: Pneumothorax is a frequent and fatal complication of critically ill patients with COVID-19.


Asunto(s)
Neumotórax , Anciano , Enfermedad Crítica , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neumotórax/epidemiología , Neumotórax/etiología , Estudios Retrospectivos
13.
Am J Emerg Med ; 39: 143-145, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33039212

RESUMEN

Facing the novel coronavirus disease (COVID-19) pandemic, evidence to inform decision-making at all care levels is essential. Based on the results of a study by Petrilli et al., we have developed a calculator using patient data at admission to predict critical illness (intensive care, mechanical ventilation, hospice care, or death). We report a retrospective validation of the calculator on 145 consecutive patients admitted with COVID-19 to a single hospital in Israel. Despite considerable differences between the original and validation study populations, of 18 patients with critical illness, 17 were correctly identified (sensitivity: 94.4%, 95% CI, 72.7%-99.9%; specificity: 81.9%, 95% CI, 74.1%-88.2%). Of 127 patients with non-critical illness, 104 were correctly identified. Our results indicate that published knowledge can be reliably applied to assess patient risk, potentially reducing the cognitive burden on physicians, and helping policymakers better prepare for future needs.


Asunto(s)
/fisiopatología , Técnicas de Laboratorio Clínico/normas , Cuidados Críticos/organización & administración , Enfermedad Crítica/terapia , Anciano , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Israel , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo/normas , Factores de Riesgo
14.
Nutrition ; 81: 110989, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33049573

RESUMEN

Coronavirus disease 2019 (COVID-19) is a global pandemic causing one of the biggest challenges for critical care medicine. Mortality from COVID-19 is much greater in elderly men, many of whom succumb to acute respiratory distress syndrome (ARDS) triggered by the viral infection. Because there is no specific antiviral treatment against COVID-19, new strategies are urgently needed. Selenium is an essential trace element with antioxidant and immunomodulatory effects. Poor nutritional status increases the pathogenicity of viruses and low selenium in particular can be a determinant of viral virulence. In the past decade, selenium pharmaconutrition studies have demonstrated some reduction in overall mortality, including how reduced incidence of ventilator-associated pneumonia and infectious complications such as ARDS in the critically ill. Consequently, we postulate that intravenous selenium therapy, could be part of the therapeutic fight against COVID-19 in intensive care unit patients with ARDS and that outcomes could be affected by age, sex, and body weight. Our working hypothesis addresses the question: Could high-dose selenite pharmaconutrition, as an early pharmacologic intervention, be effective at reducing the incidence and the progression from type 1 respiratory failure (non-ARDS) to severe ARDS, multiorgan failure, and new infectious complications in patients with COVID-19 patients?


Asunto(s)
/dietoterapia , Selenio/uso terapéutico , /complicaciones , Enfermedad Crítica , Femenino , Interacciones Microbiota-Huesped , Humanos , Inflamación/etiología , Masculino , Micronutrientes/administración & dosificación , Micronutrientes/farmacocinética , Micronutrientes/uso terapéutico , Modelos Biológicos , Fenómenos Fisiológicos de la Nutrición , Obesidad/complicaciones , Pandemias , Guías de Práctica Clínica como Asunto , Selenio/administración & dosificación , Selenio/farmacocinética
15.
J Pediatr ; 228: 94-100.e3, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32910943

RESUMEN

OBJECTIVE: To summarize and evaluate current reports on community-onset severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in young infants. STUDY DESIGN: We performed a systematic review to identify reports published from November 1, 2019, until June 15, 2020, on laboratory-confirmed community-onset SARS-CoV-2 infection in infants younger than 3 months of age. We excluded studies reporting neonates with perinatal coronavirus disease 2019 (COVID-19) exposure and diagnosis before hospital discharge and hospital-onset disease, as well as clinically diagnosed cases without confirmation. Two independent reviewers performed study screening, data abstraction, and risk of bias assessment. Variables of interest included patient age, exposure to COVID-19, medical history, clinical symptoms, SARS-CoV-2 testing, laboratory findings, clinical course, and disposition. RESULTS: In total, 38 publications met inclusion criteria, including 23 single case reports, 14 case series, and 1 cohort study, describing 63 infants younger than 3 months of age with laboratory-confirmed SARS-CoV-2 infection. Most cases were mild to moderate. Fever, respiratory, gastrointestinal, cardiac, and neurologic findings were reported. Laboratory abnormalities included neutropenia, lymphopenia, and elevated serum levels of inflammatory markers and aminotransferases. Fifty-eight (92%) infants were hospitalized, 13 (21%) were admitted to the intensive care unit, and 2 (3%) required mechanical ventilation. No death was reported. CONCLUSIONS: Among young infants with laboratory-confirmed SARS-CoV-2 infection, most cases were mild to moderate and improved with supportive care. Our results demonstrate a need for a high index of suspicion for SARS-CoV-2 infection in young infants presenting with generalized symptoms such as fever or decreased feeding, even in the absence of respiratory symptoms.


Asunto(s)
/diagnóstico , /epidemiología , Cuidados Críticos , Enfermedad Crítica , Femenino , Hospitalización , Humanos , Lactante , Recién Nacido , Inflamación , Masculino , Alta del Paciente , Atención Perinatal , Salud Pública , Respiración Artificial
16.
J Cardiovasc Pharmacol Ther ; 26(1): 12-24, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32924567

RESUMEN

Coronavirus-2019 (COVID-19) predisposes patients to arterial and venous thrombosis commonly complicating the clinical course of hospitalized patients and attributed to the inflammatory state, endothelial dysfunction, platelet activation and blood stasis. This viral coagulopathy may occur despite thromboprophylaxis and raises mortality; the risk appears highest among critically ill inpatients monitored in the intensive care unit. The prevalence of venous thromboembolism in COVID-19 patients has been reported to reach ∼10-35%, while autopsies raise it to nearly 60%. The most common thrombotic complication is pulmonary embolism, which though may occur in the absence of a recognizable deep venous thrombosis and may be due to pulmonary arterial thrombosis rather than embolism, resulting in thrombotic occlusion of small- to mid-sized pulmonary arteries and subsequent infarction of lung parenchyma. This micro-thrombotic pattern seems more specific for COVID-19 and is associated with an intense immuno-inflammatory reaction that results in diffuse occlusive thrombotic micro-angiopathy with alveolar damage and vascular angiogenesis. Furthermore, thrombosis has also been observed in various arterial sites, including coronary, cerebral and peripheral arteries. Biomarkers related to coagulation, platelet activation and inflammation have been suggested as useful diagnostic and prognostic tools for COVID-19-associated coagulopathy; among them, D-dimer remains a key biomarker employed in clinical practice. Various medical societies have issued guidelines or consensus statements regarding thromboprophylaxis and treatment of these thrombotic complications specifically adapted to COVID-19 patients. All these issues are detailed in this review, data from meta-analyses and current guidelines are tabulated, while the relevant mechanisms of this virus-associated coagulopathy are pictorially illustrated.


Asunto(s)
Anticoagulantes/administración & dosificación , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Alarminas/metabolismo , Biomarcadores , Proteínas del Sistema Complemento/biosíntesis , Enfermedad Crítica , Citocinas/biosíntesis , Productos de Degradación de Fibrina-Fibrinógeno/biosíntesis , Humanos , Unidades de Cuidados Intensivos , Pandemias , Activación Plaquetaria/fisiología , Embolia Pulmonar/mortalidad , Embolia Pulmonar/prevención & control , Tromboembolia Venosa/fisiopatología
17.
Diagn Microbiol Infect Dis ; 99(1): 115183, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33069002

RESUMEN

The FilmArray® Pneumonia Plus (FA-PP) panel can provide rapid identifications and semiquantitative results for many pathogens. We performed a prospective single-center study in 43 critically ill patients with coronavirus disease 2019 (COVID-19) in which we performed 96 FA-PP tests and cultures of blind bronchoalveolar lavage (BBAL). FA-PP detected 1 or more pathogens in 32% (31/96 of samples), whereas culture methods detected at least 1 pathogen in 35% (34/96 of samples). The most prevalent bacteria detected were Pseudomonas aeruginosa (n = 14) and Staphylococcus aureus (n = 11) on both FA-PP and culture. The FA-PP results from BBAL in critically ill patients with COVID-19 were consistent with bacterial culture findings for bacteria present in the FA-PP panel, showing sensitivity, specificity, and positive and negative predictive value of 95%, 99%, 82%, and 100%, respectively. Median turnaround time for FA-PP was 5.5 h, which was significantly shorter than for standard culture (26 h) and antimicrobial susceptibility testing results (57 h).


Asunto(s)
Bacterias/aislamiento & purificación , Técnicas Bacteriológicas/métodos , Reacción en Cadena de la Polimerasa Multiplex/métodos , Neumonía Bacteriana/diagnóstico , Anciano , Bacterias/clasificación , Bacterias/genética , Líquido del Lavado Bronquioalveolar/microbiología , Enfermedad Crítica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/microbiología , Sensibilidad y Especificidad , Factores de Tiempo
19.
Crit Care Med ; 49(1): 102-111, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33116052

RESUMEN

OBJECTIVES: To identify characteristics that predict 30-day mortality among patients critically ill with coronavirus disease 2019 in England, Wales, and Northern Ireland. DESIGN: Observational cohort study. SETTING: A total of 258 adult critical care units. PATIENTS: A total of 10,362 patients with confirmed coronavirus disease 2019 with a start of critical care between March 1, 2020, and June 22, 2020, of whom 9,990 were eligible (excluding patients with a duration of critical care less than 24 hr or missing core variables). MEASUREMENTS AND MAIN RESULTS: The main outcome measure was time to death within 30 days of the start of critical care. Of 9,990 eligible patients (median age 60 yr, 70% male), 3,933 died within 30 days of the start of critical care. As of July 22, 2020, 189 patients were still receiving critical care and a further 446 were still in acute hospital. Data were missing for between 0.1% and 7.2% of patients across prognostic factors. We imputed missing data ten-fold, using fully conditional specification and continuous variables were modeled using restricted cubic splines. Associations between the candidate prognostic factors and time to death within 30 days of the start of critical care were determined after adjustment for multiple variables with Cox proportional hazards modeling. Significant associations were identified for age, ethnicity, deprivation, body mass index, prior dependency, immunocompromise, lowest systolic blood pressure, highest heart rate, highest respiratory rate, Pao2/Fio2 ratio (and interaction with mechanical ventilation), highest blood lactate concentration, highest serum urea, and lowest platelet count over the first 24 hours of critical care. Nonsignificant associations were found for sex, sedation, highest temperature, and lowest hemoglobin concentration. CONCLUSIONS: We identified patient characteristics that predict an increased likelihood of death within 30 days of the start of critical care for patients with coronavirus disease 2019. These findings may support development of a prediction model for benchmarking critical care providers.


Asunto(s)
/mortalidad , Enfermedad Crítica/mortalidad , Índice de Severidad de la Enfermedad , Adulto , Estudios de Cohortes , Enfermedad Crítica/terapia , Inglaterra , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Irlanda del Norte , Pronóstico , Respiración Artificial/mortalidad , Gales
20.
Crit Care Med ; 49(1): e31-e40, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33122577

RESUMEN

OBJECTIVES: We aimed to assess the frequency of ICU-acquired bloodstream infections in coronavirus disease 2019 patients. DESIGN: Retrospective observational study. SETTING: The emergency expansion of an ICU from eight general beds to 30 coronavirus disease 2019 beds. PARTICIPANTS: Patients with coronavirus disease 2019 admitted to the ICU of Luigi Sacco Hospital (Milan, Italy) for greater than or equal to 48 hours between February 21, 2020, and April 30, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The frequency of bloodstream infections per 1,000 days of ICU stay was calculated in 89 coronavirus disease 2019 patients, and the cumulative probability of bloodstream infection was estimated using death and ICU discharge as competing events. Sixty patients (67.4%) experienced at least one of the 93 recorded episodes of bloodstream infection, a frequency of 87 per 1,000 days of ICU stay (95% CI, 67-112).The patients who experienced a bloodstream infection had a higher Sequential Organ Failure Assessment score upon ICU admission (9.5; interquartile range, 8-12 vs 8, interquartile range, 5-10; p = 0.042), a longer median ICU stay (15 d; interquartile range, 11-23 vs 8, interquartile range, 5-12; p < 0.001), and more frequently required invasive mechanical ventilation (98.3% vs 82.8%; p = 0.013) than those who did not. The median time from ICU admission to the first bloodstream infection episode was 10 days. Gram-positive bacteria accounted for 74 episodes (79.6%), with Enterococcus species being the most prevalent (53 episodes, 55.8%). Thirty-two isolates (27.3%) showed multidrug resistance. CONCLUSIONS: Coronavirus disease 2019 seemed to increase the frequency of bloodstream infections (particularly Enterococcus-related bloodstream infection) after ICU admission. This may have been due to enteric involvement in patients with severe coronavirus disease 2019 and/or limitations in controlling the patient-to-patient transmission of infectious agents in extremely challenging circumstances.


Asunto(s)
/microbiología , Enterococcus/aislamiento & purificación , Infecciones por Bacterias Grampositivas/microbiología , Tiempo de Internación/estadística & datos numéricos , Sepsis/microbiología , Adulto , Anciano , Enfermedad Crítica , Femenino , Infecciones por Bacterias Grampositivas/epidemiología , Humanos , Unidades de Cuidados Intensivos , Italia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sepsis/epidemiología , Resultado del Tratamiento
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