RESUMO
BACKGROUND: Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was considered at the time of COVID-19 pandemic to avoid overloading the intensive care units. We aimed to determine whether prone position plus usual care could reduce the rate of non-invasive ventilation (NIV) or intubation or death as compared to usual care alone. METHODS: In this multicentre randomised clinical trial, 268 patients were randomly assigned to awake prone position plus usual care (N = 135) or usual care alone (N = 132). The primary outcome was the proportion of patients who underwent NIV or intubation or died within 28 days. Main secondary outcomes included the rates of NIV, of intubation or death, within 28 days. RESULTS: Median time spent each day in the prone position within 72 h of randomisation was 90 min (IQR 30-133). The proportion of NIV or intubation or death within 28 days was 14.1% (19/135) in the prone position group and 12.9% (17/132) in the usual care group [odds ratio adjusted for stratification (aOR) 0.43; 95% confidence interval (CI) 0.14-1.35]. The probability of intubation, or intubation or death (secondary outcomes) was lower in the prone position group than in the usual care group (aOR 0.11; 95% CI 0.01-0.89 and aOR 0.09; 95% CI 0.01-0.76, respectively) in the whole study population and in the prespecified subgroup of patients with SpO2 ≥ 95% on inclusion (aOR 0.11; 95% CI 0.01-0.90, and aOR 0.09; 95% CI 0.03-0.27, respectively). CONCLUSIONS: Awake prone position plus usual care in COVID-19 patients in medical wards did not decrease the composite outcome of need for NIV or intubation or death. Trial registration ClinicalTrials.gov Identifier: NCT04363463 . Registered 27 April 2020.
Assuntos
COVID-19 , Ventilação não Invasiva , Insuficiência Respiratória , Humanos , COVID-19/terapia , Decúbito Ventral , Pandemias , Respiração Artificial , Insuficiência Respiratória/terapiaRESUMO
In active cancers, venous thromboembolism is a poor prognosis factor and one of the main causes of death. Venous thromboembolism is 4 to 7 times more common in patients with active cancer compared with the general population. The risk of thrombosis depends on characteristics related to the patient, cancer, and current treatments. The management of these patients is essentially based on therapeutic anticoagulation, which prevents the progression of the thrombus and reduces the risk of recurrence. Risks of thromboembolism recurrence and bleeding are increased in oncologic context, despite therapeutic anticoagulation, which complicates the management of these patients. Low molecular weight heparins have been the treatment of choice in recent decades, because more effective than vitamin K antagonists with a similar tolerance profile. More recently, several studies have evaluated direct oral anticoagulants, which are easier to use, in cancer-associated thrombosis. Compared with low molecular weight heparins, direct oral anticoagulants have similar efficacity concerning thromboembolism recurrence, but an increased risk of bleeding observed mainly in gastrointestinal and urogenital cancers. This overview summarizes the epidemiology, pathophysiology, and therapeutic management of cancer-associated thrombosis.
