Factores de riesgo de reingreso en UCI y análisis de la mortalidad intrahospitalaria / Risk factors for readmission to ICU and analysis of intra-hospital mortality

IntroducciónLos pacientes críticos, a pesar de la recuperación inicial en la unidad de cuidados intensivos (UCI), pueden precisar reingreso en UCI o incluso fallecer en el mismo episodio hospitalario. Los objetivos son: conocer la incidencia e identificar factores de riesgo de reingreso en UCI, y determinar la mortalidad hospitalaria.MétodosEstudio de cohortes observacional de todos los pacientes ingresados consecutivamente más de 24h en la UCI del Hospital Universitario de Getafe entre el 1-04-2018 y el 30-09-2018 y dados de alta vivos de su primer ingreso en UCI.ResultadosDe los 164 pacientes vivos al alta de UCI, 14 (8,5%) fueron reingresados en UCI (2,4% en≤48h). El riesgo ajustado de reingreso en UCI fue mayor en los pacientes con déficit neurológico discapacitante previo al ingreso en UCI (odds ratio [OR]: 7,96; intervalo de confianza del 95% [IC 95%]: 1,55-40,92) o que recibieron fármacos vasoactivos (OR: 5,07; IC 95%: 1,41-18,29) durante su estancia en UCI. Los pacientes reingresados tuvieron mayor mortalidad hospitalaria (4 de 14 [29%] versus 5 de 150 [3%], p<0,001) y mayor estancia hospitalaria (74,5 [37,5-99,75] días versus 16 [9-34] días, mediana [rango intercuartílico], p=0,001).ConclusionesLos pacientes con déficit neurológico discapacitante previo al ingreso hospitalario o que recibieron fármacos vasoactivos durante la estancia en UCI tienen mayor riesgo de reingreso en UCI, lo que aumenta la estancia y la mortalidad hospitalaria.

Early Tracheostomy for Managing ICU Capacity During the COVID-19 Outbreak: A Propensity-Matched Cohort Study.

BACKGROUND: During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial. RESEARCH QUESTION: Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health care systems during viral epidemics? STUDY DESIGN AND METHODS: This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (≤ 7 days, 8-10 days, and 11-14 days after intubation). RESULTS: Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤ 7 days vs > 7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR, 0-7 days]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy. INTERPRETATION: Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability.

Risk factors for readmission to ICU and analysis of intra-hospital mortality. / Factores de riesgo de reingreso en UCI y análisis de la mortalidad intrahospitalaria.

INTRODUCTION: Critical patients, despite initial recovery in the intensive care unit (ICU), may require readmission to the ICU or even die in the same hospital episode. The objectives are to determine the incidence and to identify risk factors for ICU readmission, and to determine hospital mortality. METHODS: Observational cohort study of all patients admitted consecutively for more than 24hours to the ICU of the University Hospital of Getafe between April 1, 2018 and September 30, 2018 and discharged alive from their first ICU admission. RESULTS: Of the 164 patients alive at ICU discharge, 14 (8.5%) were readmitted to ICU (2.4% at≤48hours). The adjusted risk of ICU readmission was higher in patients with disabling neurological deficits prior to ICU admission [odds ratio (OR) 7.96, 95% confidence interval (CI) 1.55-40.92] or who received vasoactive drugs (OR 5.07, 95% CI 1.41-18.29) during their ICU stay. Readmitted patients had higher hospital mortality (4 of 14 [29%] versus 5 of 150 [3%], P<.001) and longer hospital stay (74.5 [37.5-99.75] days versus 16 [9-34] days, median [interquartile range], P=.001). CONCLUSIONS: Patients with disabling neurological deficits prior to hospital admission or who received vasoactive drugs during their ICU stay have a higher risk of readmission to the ICU, which increases hospital stay and mortality.

Long-term survival of mechanically ventilated patients with severe COVID-19: an observational cohort study.

BACKGROUND: Information is lacking regarding long-term survival and predictive factors for mortality in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) and undergoing invasive mechanical ventilation. We aimed to estimate 180-day mortality of patients with COVID-19 requiring invasive ventilation, and to develop a predictive model for long-term mortality. METHODS: Retrospective, multicentre, national cohort study between March 8 and April 30, 2020 in 16 intensive care units (ICU) in Spain. Participants were consecutive adults who received invasive mechanical ventilation for COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected in positive testing of a nasopharyngeal sample and confirmed by real time reverse-transcriptase polymerase chain reaction (rt-PCR). The primary outcomes was 180-day survival after hospital admission. Secondary outcomes were length of ICU and hospital stay, and ICU and in-hospital mortality. A predictive model was developed to estimate the probability of 180-day mortality. RESULTS: 868 patients were included (median age, 64 years [interquartile range [IQR], 56-71 years]; 72% male). Severity at ICU admission, estimated by SAPS3, was 56 points [IQR 50-63]. Prior to intubation, 26% received some type of noninvasive respiratory support. The unadjusted overall 180-day survival rates was 59% (95% CI 56-62%). The predictive factors measured during ICU stay, and associated with 180-day mortality were: age [Odds Ratio [OR] per 1-year increase 1.051, 95% CI 1.033-1.068)), SAPS3 (OR per 1-point increase 1.027, 95% CI 1.011-1.044), diabetes (OR 1.546, 95% CI 1.085-2.204), neutrophils to lymphocytes ratio (OR per 1-unit increase 1.008, 95% CI 1.001-1.016), failed attempt of noninvasive positive pressure ventilation prior to orotracheal intubation (OR 1.878 (95% CI 1.124-3.140), use of selective digestive decontamination strategy during ICU stay (OR 0.590 (95% CI 0.358-0.972) and administration of low dosage of corticosteroids (methylprednisolone 1 mg/kg) (OR 2.042 (95% CI 1.205-3.460). CONCLUSION: The long-term survival of mechanically ventilated patients with severe COVID-19 reaches more than 50% and may help to provide individualized risk stratification and potential treatments. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04379258. Registered 10 April 2020 (retrospectively registered).