Long-Term Mortality and Health-Related Quality of Life After Continuous Versus Intermittent Renal Replacement Therapy in ICU Survivors: A Secondary Analysis of the Quality of Life After ICU Study.

Purpose: We assessed long-term outcomes in intensive care unit (ICU) survivors with acute kidney injury (AKI) submitted to intermittent or continuous renal replacement therapy (RRT) for comparisons between groups. Methods: The multicenter prospective cohort study included 195 adult ICU survivors with an ICU stay >72 h in 10 ICUs that had at least one episode of AKI treated with intermittent RRT (IRRT) or continuous RRT (CRRT) during ICU stay. The main outcomes were mortality and health-related quality of life (HRQoL). Hospital readmissions and physical dependence were also assessed. Results: Regarding RRT, 83 (42.6%) patients received IRRT and 112 (57.4%) received CRRT. Despite the similarity regarding sociodemographic characteristics, pre-ICU state of health and type of admission between groups, the risk of death (23.5% vs 42.7%; P < .001), the prevalence of sepsis (60.7%) and acute respiratory distress syndrome (17%) were higher at ICU admission among CRRT patients. The severity of critical illness was higher among CRRT patients, regarding the need for mechanical ventilation (75.0% vs 50.6%, P = .002) and vasopressors (91.1% vs 63.9%, P < .001). One year after ICU discharge, 67 of 195 ICU survivors died (34.4%) and, after adjustment for confounders, there were no significant differences in mortality when comparing IRRT and CRTT patients (34.9% vs 33.9%; P = .590), on HRQoL in both physical (41.9% vs 42.2%; P = .926) and mental dimensions (57.6% vs 56.6%; P = .340), and on the number of hospital readmissions and physical dependence. Conclusions: Our study suggests that among ICU survivors RRT modality (IRRT vs CRRT) in the ICU does not impact long-term outcomes after ICU discharge.

Predictors of early and long-term mortality after ICU discharge in critically ill COVID-19 patients: A prospective cohort study.

BACKGROUND: To mitigate mortality among critically ill COVID-19 patients, both during their Intensive Care Unit (ICU) stay and following ICU discharge, it is crucial to measure its frequency, identify predictors and to establish an appropriate post-ICU follow-up strategy. METHODS: In this multicentre, prospective cohort study, we included 586 critically ill COVID-19 patients. RESULTS: We observed an overall ICU mortality of 20.1% [95%CI: 17.1% to 23.6%] (118/586) and an overall hospital mortality of 25.4% [95%CI: 22.1% to 29.1%] (149/586). For ICU survivors, 30 days (early) post-ICU mortality was 5.3% [95%CI: 3.6% to 7.8%] (25/468) and one-year (late) post-ICU mortality was 7.9% [95%CI: 5.8% to 10.8%] (37/468). Pre-existing conditions/comorbidities were identified as the main independent predictors of mortality after ICU discharge: hypertension and heart failure were independent predictors of early mortality; and hypertension, chronic kidney disease, chronic obstructive pulmonary disease and cancer were independent predictors of late mortality. CONCLUSION: Early and late post-ICU mortality exhibited an initial surge (in the first 30 days post-ICU) followed by a subsequent decline over time. Close monitoring of critically ill COVID-19 post-ICU survivors, especially those with pre-existing conditions, is crucial to prevent adverse outcomes, reduce mortality and to establish an appropriate follow-up strategy.

Modulating Influence of State Anxiety on the Effect of Midazolam on Postsurgical Pain.

Anxiety contributes to postsurgical pain, and midazolam is frequently prescribed preoperatively. Conflicting results have been described concerning the impact of midazolam on pain. This study aims to evaluate the effect of systemic midazolam on pain after open inguinal hernia repair, clarifying its relationship with preoperative anxiety. A prospective observational cohort study was conducted in three Portuguese ambulatory units between September 2018 and March 2020. Variable doses of midazolam were administered. Postsurgical pain was evaluated up to three months after surgery. We enrolled 306 patients and analyzed 281 patients. The mean preoperative anxiety Numeric Rating Scale score was 4 (3) and the mean Surgical Fear Questionnaire score was 22 (16); the mean midazolam dose was 1.7 (1.1) mg with no correlation to preoperative anxiety scores. Pain ≥4 was present in 67% of patients 24 h after surgery and in 54% at seven days; at three months, 27% were classified as having chronic postsurgical pain. Preoperative anxiety correlated to pain severity at all time points. In multivariable regression, higher midazolam doses were associated with less pain during the first week, with no apparent effect on chronic pain. However, subgroup analyses uncovered an effect modification according to preoperative anxiety: the decrease in acute pain occurred in the low-anxiety patients with no effect on the high-anxiety group. Inversely, there was an increase in chronic postsurgical pain in the very anxious patients, without any effect on the low-anxiety group. Midazolam, generally used as an anxiolytic, might impact distinctively on pain depending on anxiety.

Sedation, analgesia, and delirium management in Portugal: a survey and point prevalence study. / Abordagem da sedação, da analgesia e do delirium em Portugal: inquérito nacional e estudo de prevalência.

OBJECTIVE: To establish current Portuguese critical care practices regarding analgesia, sedation, and delirium based on a comparison between the activities reported and daily clinical practice. METHODS: A national survey was conducted among physicians invited to report their practice toward analgesia, sedation, and delirium in intensive care units. A point prevalence study was performed to analyze daily practices. RESULTS: A total of 117 physicians answered the survey, and 192 patients were included in the point prevalence study. Survey and point prevalence studies reflect a high sedation assessment (92%; 88.5%), with the Richmond Agitated Sedation Scale being the most reported and used scale (41.7%; 58.2%) and propofol being the most reported and used medication (91.4%; 58.6%). Midazolam prescribing was reported by 68.4% of responders, but a point prevalence study revealed a use of 27.6%.Although 46.4% of responders reported oversedation, this was actually documented in 32% of the patients. The survey reports the daily assessment of pain (92%) using standardized scales (71%). The same was identified in the point prevalence study, with 91.1% of analgesia assessment mainly with the Behavioral Pain Scale. In the survey, opioids were reported as the first analgesic. In clinical practice, acetaminophen was the first option (34.6%), followed by opioids. Delirium assessment was reported by 70% of physicians but was performed in less than 10% of the patients. CONCLUSION: The results from the survey did not accurately reflect the common practices in Portuguese intensive care units, as reported in the point prevalence study. Efforts should be made specifically to avoid oversedation and to promote delirium assessment.

OBJETIVO: Determinar as práticas atuais de cuidados intensivos em Portugal quanto à analgesia, à sedação e ao delirium, com base em uma comparação entre as atividades relatadas e a prática clínica diária. MÉTODOS: Inquérito nacional em que os médicos foram convidados a relatar sua prática em relação à analgesia, à sedação e ao delirium em unidades de terapia intensiva. Para analisar a prática diária, realizou-se um estudo de prevalência pontual. RESULTADOS: Responderam ao inquérito 117 médicos, e 192 pacientes foram incluídos no estudo de prevalência pontual. O inquérito e o estudo de prevalência mostraram uma avaliação generalizada do nível de sedação (92%; 88,5%). A Escala de Agitação e Sedação de Richmond foi a mais reportada e utilizada (41,7%; 58,2%), e o propofol foi o medicamento mais reportado e utilizado (91,4%; 58,6%). A prescrição de midazolam foi relatada por 68,4% dos respondentes, mas o estudo de prevalência pontual revelou a sua utilização em 27,6%.Embora 46,4% dos respondentes tenham relatado excesso de sedação, na realidade foi documentado em 32% dos pacientes. O inquérito relatou avaliação diária de dor (92%) com uso de escalas padronizadas (71%). Identificou-se resultado semelhante no estudo de prevalência pontual, com 91,1% de avaliação da analgesia feita principalmente com a Escala Comportamental de Dor. No inquérito, os opioides foram relatados como analgésicos de primeira linha. Na prática clínica, o paracetamol foi a primeira opção (34,6%), seguido de opioides. A avaliação do delirium foi relatada por 70% dos médicos, embora tenha sido realizada em menos de 10% dos pacientes. CONCLUSÃO: Os resultados do inquérito não refletiram com precisão as práticas habituais nas unidades de terapia intensiva portuguesas, tal como relatado no estudo de prevalência pontual. Devem ser feitos esforços principalmente para evitar o excesso de sedação e promover a avaliação do delirium.

Abordagem da sedação, da analgesia e do delirium em Portugal: inquérito nacional e estudo de prevalência / Sedation, analgesia, and delirium management in Portugal: a survey and point prevalence study

RESUMO Objetivo: Determinar as práticas atuais de cuidados intensivos em Portugal quanto à analgesia, à sedação e ao delirium, com base em uma comparação entre as atividades relatadas e a prática clínica diária. Métodos: Inquérito nacional em que os médicos foram convidados a relatar sua prática em relação à analgesia, à sedação e ao delirium em unidades de terapia intensiva. Para analisar a prática diária, realizou-se um estudo de prevalência pontual. Resultados: Responderam ao inquérito 117 médicos, e 192 pacientes foram incluídos no estudo de prevalência pontual. O inquérito e o estudo de prevalência mostraram uma avaliação generalizada do nível de sedação (92%; 88,5%). A Escala de Agitação e Sedação de Richmond foi a mais reportada e utilizada (41,7%; 58,2%), e o propofol foi o medicamento mais reportado e utilizado (91,4%; 58,6%). A prescrição de midazolam foi relatada por 68,4% dos respondentes, mas o estudo de prevalência pontual revelou a sua utilização em 27,6%. Embora 46,4% dos respondentes tenham relatado excesso de sedação, na realidade foi documentado em 32% dos pacientes. O inquérito relatou avaliação diária de dor (92%) com uso de escalas padronizadas (71%). Identificou-se resultado semelhante no estudo de prevalência pontual, com 91,1% de avaliação da analgesia feita principalmente com a Escala Comportamental de Dor. No inquérito, os opioides foram relatados como analgésicos de primeira linha. Na prática clínica, o paracetamol foi a primeira opção (34,6%), seguido de opioides. A avaliação do delirium foi relatada por 70% dos médicos, embora tenha sido realizada em menos de 10% dos pacientes. Conclusão: Os resultados do inquérito não refletiram com precisão as práticas habituais nas unidades de terapia intensiva portuguesas, tal como relatado no estudo de prevalência pontual. Devem ser feitos esforços principalmente para evitar o excesso de sedação e promover a avaliação do delirium.

ABSTRACT Objective: To establish current Portuguese critical care practices regarding analgesia, sedation, and delirium based on a comparison between the activities reported and daily clinical practice. Methods: A national survey was conducted among physicians invited to report their practice toward analgesia, sedation, and delirium in intensive care units. A point prevalence study was performed to analyze daily practices. Results: A total of 117 physicians answered the survey, and 192 patients were included in the point prevalence study. Survey and point prevalence studies reflect a high sedation assessment (92%; 88.5%), with the Richmond Agitated Sedation Scale being the most reported and used scale (41.7%; 58.2%) and propofol being the most reported and used medication (91.4%; 58.6%). Midazolam prescribing was reported by 68.4% of responders, but a point prevalence study revealed a use of 27.6%. Although 46.4% of responders reported oversedation, this was actually documented in 32% of the patients. The survey reports the daily assessment of pain (92%) using standardized scales (71%). The same was identified in the point prevalence study, with 91.1% of analgesia assessment mainly with the Behavioral Pain Scale. In the survey, opioids were reported as the first analgesic. In clinical practice, acetaminophen was the first option (34.6%), followed by opioids. Delirium assessment was reported by 70% of physicians but was performed in less than 10% of the patients. Conclusion: The results from the survey did not accurately reflect the common practices in Portuguese intensive care units, as reported in the point prevalence study. Efforts should be made specifically to avoid oversedation and to promote delirium assessment.

Gut Microbiota Diversity and C-Reactive Protein Are Predictors of Disease Severity in COVID-19 Patients.

The risk factors for coronavirus disease 2019 (COVID-19) severity are still poorly understood. Considering the pivotal role of the gut microbiota on host immune and inflammatory functions, we investigated the association between changes in the gut microbiota composition and the clinical severity of COVID-19. We conducted a multicenter cross-sectional study prospectively enrolling 115 COVID-19 patients categorized according to: (1) the WHO Clinical Progression Scale-mild, 19 (16.5%); moderate, 37 (32.2%); or severe, 59 (51.3%), and (2) the location of recovery from COVID-19-ambulatory, 14 (household isolation, 12.2%); hospitalized in ward, 40 (34.8%); or hospitalized in the intensive care unit, 61 (53.0%). Gut microbiota analysis was performed through 16S rRNA gene sequencing, and the data obtained were further related to the clinical parameters of COVID-19 patients. The risk factors for COVID-19 severity were identified by univariate and multivariable logistic regression models. In comparison to mild COVID-19 patients, the gut microbiota of moderate and severe patients have: (a) lower Firmicutes/Bacteroidetes ratio; (b) higher abundance of Proteobacteria; and (c) lower abundance of beneficial butyrate-producing bacteria such as the genera Roseburia and Lachnospira. Multivariable regression analysis showed that the Shannon diversity index [odds ratio (OR) = 2.85, 95% CI = 1.09-7.41, p = 0.032) and C-reactive protein (OR = 3.45, 95% CI = 1.33-8.91, p = 0.011) are risk factors for severe COVID-19 (a score of 6 or higher in the WHO Clinical Progression Scale). In conclusion, our results demonstrated that hospitalized patients with moderate and severe COVID-19 have microbial signatures of gut dysbiosis; for the first time, the gut microbiota diversity is pointed out as a prognostic biomarker of COVID-19 severity.

Children's Understanding of Informed Assents in Research Studies.

The assent procedure reflects an effort to enable the minor to understand, to the degree they are capable of, what their participation in the decision making process would involve. AIMS: To evaluate the minors' ability to understand the information provided to them when obtaining assent and to evaluate the opinion of the parents regarding the importance of asking the child's assent. METHODS: The sample included a total of 52 minors aged between 10 and 17 years who underwent exercise echocardiogram. The Quality of Informed Consent is divided into two parts: Part A was used to measure objective understanding and part B to measure subjective understanding. RESULTS: The results show that the minors have a high capacity to understand the information given to them when asking for assent. A positive relationship was found between the two parts of the questionnaire. No statistically significant relationship was found between age and sex and part A and part B or between both age groups (<14 years old and ≥14 years old) and the measure. In the case of the parents, 96.6% of parents consider assent as an advantage for the child's acceptance of health care. The opinion of the parents is not related to the age, sex or level of schooling. CONCLUSION: Minors showed a substantial level of understanding regarding the information provided to them. The parents considered the implementation of assent fundamental to the child's acceptance of health care.

Surviving cardiac arrest: What happens after admission to the intensive care unit?

INTRODUCTION: Patients successfully resuscitated from cardiac arrest (CA) are admitted to the intensive care unit (ICU) for post-resuscitation care. These patients' prognosis remains dismal, with only a minority surviving to hospital discharge. Understanding the clinical factors involved in the management of these patients is essential to improve their prognosis. OBJECTIVES: To characterize the population admitted after successful reanimation from CA, and to analyze the factors associated with their outcomes. METHODS: We performed a retrospective descriptive study of patients admitted to an ICU after CA over a five-year period from January 2014 to December 2018. Demographic factors, CA characteristics, early management, mortality and neurologic outcomes were analyzed. RESULTS: A total of 187 patients, median age 67 years, were admitted after CA, of whom 39% suffered out-of-hospital CA; 87% had an initial non-shockable rhythm and the most frequent presumed cause was cardiac (31%). In-hospital mortality was 63%. Significant neurologic dysfunction (cerebral performance category 3 or 4) was seen in 31% of survivors at hospital discharge. Non-immediate initiation of basic life support (BLS), higher Simplified Acute Physiology Score II score and longer relative duration of vasopressor support were independent predictors of in-hospital mortality, while shockable rhythms were associated with improved survival. Higher Glasgow coma scale at ICU discharge and shorter length of ICU stay were predictors of better neurologic outcome. CONCLUSION: This study highlights the positive prognostic impact of shockable rhythms, and confirms the importance of immediate initiation of BLS and prompt defibrillation, supporting the need for better training both outside and inside hospitals.

Surviving cardiac arrest: What happens after admission to the intensive care unit?

INTRODUCTION: Patients successfully resuscitated from cardiac arrest (CA) are admitted to the intensive care unit (ICU) for post-resuscitation care. These patients' prognosis remains dismal, with only a minority surviving to hospital discharge. Understanding the clinical factors involved in the management of these patients is essential to improve their prognosis. OBJECTIVES: To characterize the population admitted after successful reanimation from CA, and to analyze the factors associated with their outcomes. METHODS: We performed a retrospective descriptive study of patients admitted to an ICU after CA over a five-year period from January 2014 to December 2018. Demographic factors, CA characteristics, early management, mortality and neurologic outcomes were analyzed. RESULTS: A total of 187 patients, median age 67 years, were admitted after CA, of whom 39% suffered out-of-hospital CA; 87% had an initial non-shockable rhythm and the most frequent presumed cause was cardiac (31%). In-hospital mortality was 63%. Significant neurologic dysfunction (cerebral performance category 3 or 4) was seen in 31% of survivors at hospital discharge. Non-immediate initiation of basic life support (BLS), higher Simplified Acute Physiology Score II score and longer relative duration of vasopressor support were independent predictors of in-hospital mortality, while shockable rhythms were associated with improved survival. Higher Glasgow coma scale at ICU discharge and shorter length of ICU stay were predictors of better neurologic outcome. CONCLUSION: This study highlights the positive prognostic impact of shockable rhythms, and confirms the importance of immediate initiation of BLS and prompt defibrillation, supporting the need for better training both outside and inside hospitals.

Effectiveness of Delayed Intrapleural Alteplase Instillation for Infected Residual Traumatic Hemothorax. Case Report.

In thoracic trauma, many cases may present with hemothorax, and, of those, a portion can complicate in empyema. These cases can reveal themselves to be of difficult management, particularly in peripheral hospitals with complicated access to thoracic surgery. Intrapleural fibrinolytic instillation can be of use and has been widely reported, mostly in the case of empyema. In the literature, the use of fibrinolytics in hemothorax mostly pertained to the older fibrinolytics, such as streptokinase and urokinase. Recent studies describe the use of alteplase in these patients but mostly in the first days after the trauma, when it becomes clear that the first chest tube is not being effective. We report a case of residual traumatic hemothorax that could not be evacuated after multiple chest tubes placements and was finally cleared after instillation of alteplase late in the course of the disease.

Waiting for ICU admission may increase the risk of death-A plea for better resource organization.

BACKGROUND: Mortality is high in critically ill patients. In order to study the risk factors associated with mortality in these patients, we conducted an observational retrospective study in the general Intensive Care Unit (ICU) of Faro Hospital. METHODS: All patients discharged from the general ICU in the year 2015 were evaluated for inclusion. Mortality was characterized in the first 48 hours of ICU stay, at the time of discharge from ICU, and at discharge from hospital. Collected variables included demographic variables (age), and ICU variables: type of ICU admission (scheduled surgery, urgent surgery, medical and trauma), Simplified Acute Physiology Score (SAPS II), main diagnosis, hospital length of stay (HLS) before ICU (BICULS), in ICU (ICULS) and after ICU (AICULS). RESULTS: When comparing survivors with non-survivors, we found that age, disease severity expressed by SAPS II and BICULS were significantly higher in non-survivors. After multivariate regression analysis, BICULS was still significantly associated with mortality in the hospital. CONCLUSION: Further studies are needed to characterize whether this longer BICULS is related to non-modifiable prior conditions or whether it is related to delayed ICU admission, which is a modifiable factor.

A new global health outcome score after trauma (GHOST) for disability, cognitive impairment, and health-related quality of life: data from a prospective cross-sectional observational study.

Background:Trauma patients experience morbidity related to disability and cognitive impairment that negatively impact their health-related quality of life (HRQoL). We assessed the impact of trauma on disability, cognitive impairment and HRQoL after intensive care in patients with and without traumatic brain injury (TBI) and created a predictive score to identify patients with worse outcome. Methods:We identified 262 patients with severe trauma (ISS>15) admitted to the emergency room of a level 1 trauma center. Patients above 13 years were included. After 6 months, patients were assessed for disability, cognitive impairment, and HRQoL. A global health outcome score after trauma (GHOST) was obtained through the combination of these domains. Logistic regression analysis was considered for the effect of demographic, trauma and hospital factors on global outcome. p > 0.05. Statistics performed with SPSS 23.0. Results:Patients with the worst outcomes were older and had a longer length of Intensive Care Unit (ICU) stay. The effect of gender was found in all "GHOST dimensions". TBI was not significantly associated with worse outcome. Conclusions:No significant differences were seen on disability, cognitive impairment and decreased HRQoL in patients with or without TBI. Our GHOST score showed that female gender, older age, and longer ICU stay were significantly associated with the worst outcome. Abbreviations: AIS: Abbreviated Injury Scale; EQ-5D: EuroQol 5-dimensions; EQ-5D-3L: EuroQol 5-dimensions 3-levels; GCS: Glasgow Coma Scale; GOSE: Glasgow Outcome Scale Extended; HRQoL: Health-Related Quality of Life; ICU: Intensive Care Unit; ISS: Injury Severity Score; MMS: Mini Mental State; NICE: National Institute for Health and Care Excellence; RTS: Revised Trauma Score; TBI: Traumatic brain injury; TRISS: Trauma Injury Severity Score; VAS: Visual Analogue Scale.

The role of memories on health-related quality of life after intensive care unit care: an unforgettable controversy?

BACKGROUND: Decreased health-related quality of life (HRQoL) is a significant problem after an intensive care stay and is affected by several known factors such as age, sex, and previous health-state. The objective of this study was to assess the association between memory and self-reported perceived HRQoL of patients discharged from the intensive care unit (ICU). METHODS: A prospective, multicenter study involving nine general ICUs in Portugal. All adult patients with a length of stay >48 hours were invited to participate in a 6-month follow-up after ICU discharge by answering a set of structured questionnaires, including EuroQol 5-Dimensions and ICU memory tool. RESULTS: A total of 313 (52% of the eligible) patients agreed to enter the study. The median age of patients was 60 years old, 58% were males, the median Simplified Acute Physiology Score II (SAPS II) was 38, and the median length of stay was 8 days for ICU and 21 days for total hospital stay. Eighty-nine percent (n=276) of the admissions were emergencies. Seventy-eight percent (n=234) of the patients had memories associated with the ICU stay. Patients with no memories had 2.1 higher chances (P=0.011) of being in the bottom half of the HRQoL score (<0.5 Euro-Qol 5-Dimensions index score). Even after adjusting for pre-admission characteristics, having memories was associated with higher perceived HRQoL (adjusted odds ratio =2.1, P=0.022). CONCLUSION: This study suggests that most of the ICU survivors have memories of their ICU stay. For the ICU survivors, having memories of the ICU stay is associated with a higher perceived HRQoL 6 months after ICU discharge.