Timing of intubation and ICU mortality in COVID-19 patients: a retrospective analysis of 4198 critically ill patients during the first and second waves.

BACKGROUND: The optimal time to intubate patients with SARS-CoV-2 pneumonia has not been adequately determined. While the use of non-invasive respiratory support before invasive mechanical ventilation might cause patient-self-induced lung injury and worsen the prognosis, non-invasive ventilation (NIV) is frequently used to avoid intubation of patients with acute respiratory failure (ARF). We hypothesized that delayed intubation is associated with a high risk of mortality in COVID-19 patients. METHODS: This is a secondary analysis of prospectively collected data from adult patients with ARF due to COVID-19 admitted to 73 intensive care units (ICUs) between February 2020 and March 2021. Intubation was classified according to the timing of intubation. To assess the relationship between early versus late intubation and mortality, we excluded patients with ICU length of stay (LOS) < 7 days to avoid the immortal time bias and we did a propensity score and a cox regression analysis. RESULTS: We included 4,198 patients [median age, 63 (54‒71) years; 71% male; median SOFA (Sequential Organ Failure Assessment) score, 4 (3‒7); median APACHE (Acute Physiology and Chronic Health Evaluation) score, 13 (10‒18)], and median PaO2/FiO2 (arterial oxygen pressure/ inspired oxygen fraction), 131 (100‒190)]; intubation was considered very early in 2024 (48%) patients, early in 928 (22%), and late in 441 (10%). ICU mortality was 30% and median ICU stay was 14 (7‒28) days. Mortality was higher in the "late group" than in the "early group" (37 vs. 32%, p < 0.05). The implementation of an early intubation approach was found to be an independent protective risk factor for mortality (HR 0.6; 95%CI 0.5‒0.7). CONCLUSIONS: Early intubation within the first 24 h of ICU admission in patients with COVID-19 pneumonia was found to be an independent protective risk factor of mortality. TRIAL REGISTRATION: The study was registered at Clinical-Trials.gov (NCT04948242) (01/07/2021).

VLAD. Un sistema gráfico de expresión continua de efectividad asistencial aplicado en medicina intensiva / The variable life adjusted display (VLAD). A graphical technique of continuous expression of healthcare effectiveness applied to intensive care medicine

Introducción: Se describen distintos métodos para estimar y expresar la efectividad en la asistencia a pacientes críticos. De entre ellos, se hace especial hincapié en el método VLAD (Variable Life Adjusted Display), que permite una descripción secuencial y continua, con expresión gráfica, fácilmente comprensible y utilizable. El objetivo del trabajo no es hacer una descripción de un nuevo método, sino la difusión de uno poco conocido y su aplicación a pacientes críticos. Material y método: Se describe la metodología de cálculo del método VLAD como resultado de la resta acumulada entre supervivientes reales y predichos supervivientes, por cualquiera de los métodos al uso utilizados para predecir mortalidad en pacientes críticos. Los autores utilizan el Simplified Acute Physiology Score 2. Resultados: El método se aplica a 7.448 pacientes, ingresados consecutivamente en una unidad de cuidados intensivos polivalente desde 1999 a 2004, incluido. Se ofrecen distintos gráficos según que la expresión VLAD se realice sobre la totalidad de la muestra, o sobre submuestras homogéneas (tipo de ingreso, o determinadas causas de ingreso). Discusión: Se ofrece una visión crítica de los medios de expresión de efectividad, desde una perspectiva de gestión clínica, y de sus potenciales aplicaciones: instrumento de gestión, revisión de la asistencia prestada, docencia e investigación

Introduction: Different methods for estimating and expressing effectiveness of the care of critically ill patients are described. Among them, especial interest is placed on VLAD methodology, which allows continuous and sequential expression of the variable under study through a graphic display that is easy to use and understand. The aim of this article was not to describe a new methodology, but rather to present a little-known method not previously used in critically-ill patients in Spain. Material and method: We describe the procedure for calculating VLAD as the result of the cumulative subtraction of real mortality from predicted mortality, irrespective of the methodology used for prediction. In the present article, SAPS 2 was used. Results: The method was applied in 7,448 patients consecutively admitted to a medical­surgical ICU from 1999 to 2004 (inclusive). Graphs depicting the use of VLAD in the whole sample and in homogeneous subgroups (type of admission or certain admission diagnoses) were obtained. Discussion: We provide a critical view of techniques for expressing effectiveness, from the perspective of clinical management, as well as of the possible uses of these techniques in healthcare management, quality evaluation, teaching, and research