Clinical characteristics and outcomes of patients with COVID-19 admitted to the intensive care unit during the first and second waves of the pandemic in Brazil: a single-center retrospective cohort study.

OBJECTIVE: To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic. METHODS: In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic. RESULTS: In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves. CONCLUSION: In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.

Clinical characteristics and outcomes of patients with COVID-19 admitted to the intensive care unit during the first and second waves of the pandemic in Brazil: a single-center retrospective cohort study

ABSTRACT Objective To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic. Methods In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic. Results In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves. Conclusion In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.

Closed-loop oxygen control for patients with hypoxaemia during hospitalisation: a living systematic review and meta-analysis protocol.

INTRODUCTION: Oxygen is the most common drug used in critical care patients to correct episodes of hypoxaemia. The adoption of new technologies in clinical practice, such as closed-loop systems for an automatic oxygen titration, may improve outcomes and reduce the healthcare professionals' workload at the bedside; however, certainty of the evidence regarding the safety and benefits still remains low. We aim to evaluate the effectiveness, efficacy and safety of the closed-loop oxygen control for patients with hypoxaemia during the hospitalisation period by conducting a systematic review and meta-analysis. METHODS AND ANALYSIS: MEDLINE, CENTRAL, EMBASE, LILACS, CINAHL and LOVE evidence databases will be searched. Randomised controlled trials and cross-over studies investigating the PICO (Population, Intervention, Comparator and Outcome) framework will be included. The primary outcomes will be the time in the peripheral oxygen saturation target. Secondary outcomes will include time for oxygen weaning time; length of stay; costs; adverse events; mortality; healthcare professionals' workload, and percentage of time with hypoxia and hyperoxia. Two reviewers will independently screen and extract data and perform quality assessment of included studies. The Cochrane risk of bias tool will be used to assess risk of bias. The RevMan V.5.4 software will be used for statistical analysis. Heterogeneity will be analysed using I2 statistics. Mean difference or standardised mean difference with 95% CI and p value will be used to calculate treatment effect for outcome variables. ETHICS AND DISSEMINATION: Ethical approval is not required because this systematic review and meta-analysis is based on previously published data. Final results will be published in peer-reviewed journals and presented at relevant conferences and events. PROSPERO REGISTRATION NUMBER: CRD42022306033.

Analysis of mobility level of COVID-19 patients undergoing mechanical ventilation support: A single center, retrospective cohort study.

BACKGROUND: Severe coronavirus disease 2019 (COVID-19) patients frequently require mechanical ventilation (MV) and undergo prolonged periods of bed rest with restriction of activities during the intensive care unit (ICU) stay. Our aim was to address the degree of mobilization in critically ill patients with COVID-19 undergoing to MV support. METHODS: Retrospective single-center cohort study. We analyzed patients' mobility level, through the Perme ICU Mobility Score (Perme Score) of COVID-19 patients admitted to the ICU. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge-ICU admission)/ICU length of stay], and patients were categorized as "improved" (PMI > 0) or "not improved" (PMI ≤ 0). Comparisons were performed with stratification according to the use of MV support. RESULTS: From February 2020, to February 2021, 1,297 patients with COVID-19 were admitted to the ICU and assessed for eligibility. Out of those, 949 patients were included in the study [524 (55.2%) were classified as "improved" and 425 (44.8%) as "not improved"], and 396 (41.7%) received MV during ICU stay. The overall rate of patients out of bed and able to walk ≥ 30 meters at ICU discharge were, respectively, 526 (63.3%) and 170 (20.5%). After adjusting for confounders, independent predictors of improvement of mobility level were frailty (OR: 0.52; 95% CI: 0.29-0.94; p = 0.03); SAPS III Score (OR: 0.75; 95% CI: 0.57-0.99; p = 0.04); SOFA Score (OR: 0.58; 95% CI: 0.43-0.78; p < 0.001); use of MV after the first hour of ICU admission (OR: 0.41; 95% CI: 0.17-0.99; p = 0.04); tracheostomy (OR: 0.54; 95% CI: 0.30-0.95; p = 0.03); use of extracorporeal membrane oxygenation (OR: 0.21; 95% CI: 0.05-0.8; p = 0.03); neuromuscular blockade (OR: 0.53; 95% CI: 0.3-0.95; p = 0.03); a higher Perme Score at admission (OR: 0.35; 95% CI: 0.28-0.43; p < 0.001); palliative care (OR: 0.05; 95% CI: 0.01-0.16; p < 0.001); and a longer ICU stay (OR: 0.79; 95% CI: 0.61-0.97; p = 0.04) were associated with a lower chance of mobility improvement, while non-invasive ventilation within the first hour of ICU admission and after the first hour of ICU admission (OR: 2.45; 95% CI: 1.59-3.81; p < 0.001) and (OR: 2.25; 95% CI: 1.56-3.26; p < 0.001), respectively; and vasopressor use (OR: 2.39; 95% CI: 1.07-5.5; p = 0.03) were associated with a higher chance of mobility improvement. CONCLUSION: The use of MV reduced mobility status in less than half of critically ill COVID-19 patients.

Telerehabilitation improves physical function and reduces dyspnoea in people with COVID-19 and post-COVID-19 conditions: a systematic review.

QUESTION: How effective and safe is telerehabilitation for people with COVID-19 and post-COVID-19 conditions? DESIGN: Systematic review of randomised trials. PARTICIPANTS: People with COVID-19 and post-COVID-19 conditions. INTERVENTION: Any type of telerehabilitation. OUTCOME MEASURES: Satisfaction, quality of life, adverse events, adherence to telerehabilitation, dyspnoea, functional performance, readmissions, mortality, pulmonary function and level of independence. RESULTS: Database searches retrieved 2,962 records, of which six trials with 323 participants were included in the review. Breathing exercises delivered via telerehabilitation improved 6-minute walk distance (MD 101 m, 95% CI 61 to 141; two studies), 30-second sit-to-stand test performance (MD 2.2 repetitions, 95% CI 1.5 to 2.8; two studies), Multidimensional Dyspnoea-12 questionnaire scores (MD -6, 95% CI -7 to -5; two studies) and perceived effort on the 0-to-10 Borg scale (MD -2.8, 95% CI -3.3 to -2.3; two studies), with low certainty of evidence. Exercise delivered via telerehabilitation improved 6-minute walk distance (MD 62 m, 95% CI 42 to 82, four studies), 30-second sit-to-stand test performance (MD 2.0 repetitions, 95% CI 1.3 to 2.7; two studies) and Multidimensional Dyspnoea-12 scores (MD -1.8, 95% CI -2.5 to -1.1; one study), with low certainty of evidence. Adverse events were almost all mild or moderate and occurred with similar frequency in the telerehabilitation group (median 0 per participant, IQR 0 to 2.75) as in the control group (median 0 per participant, IQR 0 to 2); Hodges-Lehmann median difference 0 (95% CI 0 to 0), with low certainty of evidence. CONCLUSION: Telerehabilitation may improve functional capacity, dyspnoea, performance and physical components of quality of life and does not substantially increase adverse events. REGISTRATION: PROSPERO CRD42021271049.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study.

OBJECTIVE: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. METHODS: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. RESULTS: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. CONCLUSION: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

The Perme Mobility Index: A new concept to assess mobility level in patients with coronavirus (COVID-19) infection.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. Data on the mobility level of patients with COVID-19 in the intensive care unit (ICU) are needed. OBJECTIVE: To describe the mobility level of patients with COVID-19 admitted to the ICU and to address factors associated with mobility level at the time of ICU discharge. METHODS: Single center, retrospective cohort study. Consecutive patients admitted to the ICU with confirmed COVID-19 infection were analyzed. The mobility status was assessed by the Perme Score at admission and discharge from ICU with higher scores indicating higher mobility level. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge-ICU admission)/ICU length of stay]. Based on the PMI, patients were divided into two groups: "Improved" (PMI > 0) and "Not improved" (PMI ≤ 0). RESULTS: A total of 136 patients were included in this analysis. The hospital mortality rate was 16.2%. The Perme Score improved significantly when comparing ICU discharge with ICU admission [20.0 (7-28) points versus 7.0 (0-16) points; P < 0.001]. A total of 88 patients (64.7%) improved their mobility level during ICU stay, and the median PMI of these patients was 1.5 (0.6-3.4). Patients in the improved group had a lower duration of mechanical ventilation [10 (5-14) days versus 15 (8-24) days; P = 0.021], lower hospital length of stay [25 (12-37) days versus 30 (11-48) days; P < 0.001], and lower ICU and hospital mortality rate. Independent predictors for mobility level were lower age, lower Charlson Comorbidity Index, and not having received renal replacement therapy. CONCLUSION: Patients' mobility level was low at ICU admission; however, most patients improved their mobility level during ICU stay. Risk factors associated with the mobility level were age, comorbidities, and use of renal replacement therapy.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study / Características clínicas e desfechos de pacientes com COVID-19 admitidos em unidade de terapia intensiva durante o primeiro ano de pandemia no Brasil: um estudo de coorte retrospectivo em centro único

ABSTRACT Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. Conclusion: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

RESUMO Objetivo: Descrever características clínicas, uso de recursos e desfechos e identificar preditores de mortalidade intra-hospitalar de pacientes com COVID-19 admitidos na unidade de terapia intensiva. Métodos: Estudo de coorte retrospectivo, em centro único, realizado em um hospital privado localizado em São Paulo (SP). Pacientes adultos (≥18 anos) admitidos consecutivamente na unidade de terapia intensiva, entre 4 de março de 2020 a 28 de fevereiro de 2021, foram incluídos neste estudo. Os pacientes foram classificados como sobreviventes e não sobreviventes, de acordo com a alta hospitalar. Resultados: Durante o período do estudo, 1.296 pacientes [mediana (intervalo interquartil) de idade: 66 (53-77) anos] com COVID-19 foram admitidos na unidade de terapia intensiva. Destes, 170 (13,6%) pacientes morreram no hospital (não sobreviventes), e 1.078 (86,4%) receberam alta hospitalar (sobreviventes). Comparados aos sobreviventes, os não sobreviventes eram mais idosos [80 (70-88) versus 63 (50-74) anos; p<0,001], apresentavam pontuação mais alta no sistema prognóstico Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53); pontos p<0,001] e tinham mais comorbidades. Durante a internação na unidade de terapia intensiva, 56,6% dos pacientes usaram ventilação não invasiva, 32,9% usaram ventilação mecânica invasiva, 31,3% usaram cateter nasal de alto fluxo, 11,7% foram submetidos à terapia renal substitutiva, e 1,5% usou oxigenação por membrana extracorpórea. Os preditores independentes de mortalidade intra-hospitalar foram idade, Sequential Organ Failure Assessment, Índice de Comorbidade de Charlson, necessidade de ventilação mecânica, uso de cateter nasal de alto fluxo, uso de terapia renal substitutiva e suporte por oxigenação por membrana extracorpórea. Conclusão: Pacientes com quadros graves da COVID-19 admitidos na unidade de terapia intensiva apresentaram considerável mortalidade e morbidade, com alta demanda de terapia de suporte e internação prolongada em unidade de terapia intensiva e hospitalar.

Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection.

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection / Recomendações de suporte intensivo para pacientes graves com infecção suspeita ou confirmada pela COVID-19

ABSTRACT In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

RESUMO Em dezembro de 2019, uma série de pacientes com pneumonia grave foi identificada em Wuhan, província de Hubei, na China. Esses pacientes evoluíram para síndrome respiratória aguda grave e síndrome do desconforto respiratório agudo. Posteriormente, a COVID-19 foi atribuída a um novo betacoronavírus, o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2). Cerca de 20% dos pacientes com diagnóstico de COVID-19 desenvolvem formas graves da doença, incluindo insuficiência respiratória aguda hipoxêmica, síndrome respiratória aguda grave, síndrome do desconforto respiratório agudo e insuficiência renal aguda e requerem admissão em unidade de terapia intensiva. Não há nenhum ensaio clínico randomizado controlado que avalie potenciais tratamentos para pacientes com infecção confirmada pela COVID-19 no momento da publicação destas recomendações de tratamento. Dessa forma, essas recomendações são baseadas predominantemente na opinião de especialistas (grau de recomendação de nível C).

Perme Intensive Care Unit Mobility Score and ICU Mobility Scale: translation into Portuguese and cross-cultural adaptation for use in Brazil / Perme Intensive Care Unit Mobility Score e ICU Mobility Scale: tradução e adaptação cultural para a língua portuguesa falada no Brasil

ABSTRACT Objective: To translate the Perme Intensive Care Unit Mobility Score and the ICU Mobility Scale (IMS) into Portuguese, creating versions that are cross-culturally adapted for use in Brazil, and to determine the interobserver agreement and reliability for both versions. Methods: The processes of translation and cross-cultural validation consisted in the following: preparation, translation, reconciliation, synthesis, back-translation, review, approval, and pre-test. The Portuguese-language versions of both instruments were then used by two researchers to evaluate critically ill ICU patients. Weighted kappa statistics and Bland-Altman plots were used in order to verify interobserver agreement for the two instruments. In each of the domains of the instruments, interobserver reliability was evaluated with Cronbach's alpha coefficient. The correlation between the instruments was assessed by Spearman's correlation test. Results: The study sample comprised 103 patients-56 (54%) of whom were male-with a mean age of 52 ± 18 years. The main reason for ICU admission (in 44%) was respiratory failure. Both instruments showed excellent interobserver agreement ( > 0.90) and reliability ( > 0.90) in all domains. Interobserver bias was low for the IMS and the Perme Score (−0.048 ± 0.350 and −0.06 ± 0.73, respectively). The 95% CIs for the same instruments ranged from −0.73 to 0.64 and −1.50 to 1.36, respectively. There was also a strong positive correlation between the two instruments (r = 0.941; p < 0.001). Conclusions: In their versions adapted for use in Brazil, both instruments showed high interobserver agreement and reliability.

RESUMO Objetivo: Realizar a tradução e a validação cultural para a língua portuguesa falada no Brasil e determinar a concordância e a confiabilidade dos instrumentos Perme Intensive Care Unit Mobility Score (designado Perme Escore) e ICU Mobility Scale (designada Escala de Mobilidade em UTI, EMU). Métodos: Os processos de tradução e adaptação cultural seguiram as seguintes etapas: preparação, tradução, reconciliação, síntese, tradução reversa, revisão, aprovação e pré-teste. Após esses processos, as versões em português dos dois instrumentos foram utilizadas por dois pesquisadores na avaliação de pacientes críticos em UTI. O índice kappa ponderado e a disposição gráfica de Bland-Altman foram utilizados para verificar a concordância entre os instrumentos. O coeficiente alfa de Cronbach foi utilizado para verificar a confiabilidade entre as respostas dos avaliadores dentro de cada domínio dos instrumentos. A correlação entre os instrumentos foi verificada pelo teste de correlação de Spearman. Resultados: A amostra foi composta por 103 pacientes, sendo a maioria homens (n = 56; 54%), com média de idade = 52 ± 18 anos. O principal motivo de internação nas UTIs foi insuficiência respiratória (em 44%). Os dois instrumentos apresentaram excelente concordância interobservador (> 0,90) e confiabilidade ( > 0,90) em todos os domínios. Constatou-se um baixo viés interobservador na EMU e no Perme Escore (−0,048 ± 0,350 e −0,06 ± 0,73, respectivamente). Os IC95% para os mesmos instrumentos variaram, respectivamente, de −0,73 a 0,64 e de −1,50 a 1,36, respectivamente. Além disso, verificou-se alta correlação positiva entre os dois instrumentos (r = 0,941; p < 0,001). Conclusões: As versões dos dois instrumentos apresentaram alta concordância e confiabilidade interobservador.