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1.
Front Endocrinol (Lausanne) ; 12: 649405, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34220705

RESUMO

The finding that high-dose dexamethasone improves survival in those requiring critical care due to COVID-19 will mean much greater usage of glucocorticoids in the subsequent waves of coronavirus infection. Furthermore, the consistent finding of adverse outcomes from COVID-19 in individuals with obesity, hypertension and diabetes has focussed attention on the metabolic dysfunction that may arise with critical illness. The SARS coronavirus itself may promote relative insulin deficiency, ketogenesis and hyperglycaemia in susceptible individuals. In conjunction with prolonged critical care, these components will promote a catabolic state. Insulin infusion is the mainstay of therapy for treatment of hyperglycaemia in acute illness but what is the effect of insulin on the admixture of glucocorticoids and COVID-19? This article reviews the evidence for the effect of insulin on clinical outcomes and intermediary metabolism in critical illness.


Assuntos
COVID-19/tratamento farmacológico , Glucocorticoides/efeitos adversos , Insulina/uso terapêutico , Doenças Metabólicas/induzido quimicamente , Doenças Metabólicas/prevenção & controle , COVID-19/complicações , Cuidados Críticos/métodos , Estado Terminal/terapia , Dexametasona/efeitos adversos , Dexametasona/uso terapêutico , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/tratamento farmacológico , Complicações do Diabetes/mortalidade , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/mortalidade , Diabetes Mellitus/virologia , Glucocorticoides/uso terapêutico , Humanos , Hiperglicemia/complicações , Hiperglicemia/tratamento farmacológico , Hiperglicemia/mortalidade , Doenças Metabólicas/etiologia , Obesidade/complicações , Obesidade/tratamento farmacológico , Obesidade/mortalidade , SARS-CoV-2/fisiologia , Resultado do Tratamento
2.
Medicine (Baltimore) ; 100(27): e26494, 2021 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-34232182

RESUMO

ABSTRACT: This retrospective study aimed to describe the association between the "ß-lactam allergy" labeling (BLAL) and the outcomes of a cohort of intensive care unit (ICU) patients.Retrospective cohort study.Seven ICU of the Aix Marseille University Hospitals from Marseille in France.We collected the uses of the label "ß-lactam allergy" in the electronic medical files of patients aged 18 years or more who required more than 48 hours in the ICU with mechanical ventilation and/or vasopressors admitted to 7 ICUs of a single institution.We retrospectively compared the patients with this labeling (BLAL group) with those without this labeling (control group).The primary outcome was the duration of ICU stay. Among the 7146 patients included in the analysis, 440 and 6706 patients were classified in the BLAL group and the control group, respectively. The prevalence of BLAL was 6.2%. In univariate and multivariate analyses, BLAL was weakly or not associated with the duration of ICU and hospital stays (respectively, 6 [3-14] vs 6 [3-14] days, standardized beta -0.09, P = .046; and 18 [10-29] vs 15 [8-28] days, standardized beta -0.09, P = .344). In multivariate analysis, the ICU and 28-day mortality rates were both lower in the BLAL group than in the control group (aOR 0.79 95% CI [0.64-0.98] P = .032 and 0.79 [0.63-0.99] P = .042). Antibiotic use differed between the 2 groups, but the outcomes were similar in the subgroups of septic patients in the BLAL group and the control group.In our cohort, the labeling of a ß-lactam allergy was not associated with prolonged ICU and hospital stays. An association was found between the labeling of a ß-lactam allergy and lower ICU and 28-day mortality rates.Trial registration: Retrospectively registered.


Assuntos
Cuidados Críticos/métodos , Hipersensibilidade/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , beta-Lactamas/efeitos adversos , Feminino , Seguimentos , França/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Hipersensibilidade/epidemiologia , Hipersensibilidade/terapia , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências
3.
Rev Bras Ter Intensiva ; 33(2): 196-205, 2021.
Artigo em Português, Inglês | MEDLINE | ID: mdl-34231800

RESUMO

OBJECTIVE: To identify more severe COVID-19 presentations. METHODS: Consecutive intensive care unit-admitted patients were subjected to a stepwise clustering method. RESULTS: Data from 147 patients who were on average 56 ± 16 years old with a Simplified Acute Physiological Score 3 of 72 ± 18, of which 103 (70%) needed mechanical ventilation and 46 (31%) died in the intensive care unit, were analyzed. From the clustering algorithm, two well-defined groups were found based on maximal heart rate [Cluster A: 104 (95%CI 99 - 109) beats per minute versus Cluster B: 159 (95%CI 155 - 163) beats per minute], maximal respiratory rate [Cluster A: 33 (95%CI 31 - 35) breaths per minute versus Cluster B: 50 (95%CI 47 - 53) breaths per minute], and maximal body temperature [Cluster A: 37.4 (95%CI 37.1 - 37.7)°C versus Cluster B: 39.3 (95%CI 39.1 - 39.5)°C] during the intensive care unit stay, as well as the oxygen partial pressure in the blood over the oxygen inspiratory fraction at intensive care unit admission [Cluster A: 116 (95%CI 99 - 133) mmHg versus Cluster B: 78 (95%CI 63 - 93) mmHg]. Subphenotypes were distinct in inflammation profiles, organ dysfunction, organ support, intensive care unit length of stay, and intensive care unit mortality (with a ratio of 4.2 between the groups). CONCLUSION: Our findings, based on common clinical data, revealed two distinct subphenotypes with different disease courses. These results could help health professionals allocate resources and select patients for testing novel therapies.


Assuntos
COVID-19/fisiopatologia , Cuidados Críticos/métodos , Estado Terminal/terapia , Unidades de Terapia Intensiva , Respiração Artificial/estatística & dados numéricos , Adulto , Idoso , Algoritmos , COVID-19/mortalidade , COVID-19/terapia , Análise por Conglomerados , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Fenótipo , Taxa Respiratória/fisiologia , Estudos Retrospectivos , Índice de Gravidade de Doença
4.
Front Endocrinol (Lausanne) ; 12: 649405, 2021.
Artigo em Inglês | MEDLINE | ID: covidwho-1295631

RESUMO

The finding that high-dose dexamethasone improves survival in those requiring critical care due to COVID-19 will mean much greater usage of glucocorticoids in the subsequent waves of coronavirus infection. Furthermore, the consistent finding of adverse outcomes from COVID-19 in individuals with obesity, hypertension and diabetes has focussed attention on the metabolic dysfunction that may arise with critical illness. The SARS coronavirus itself may promote relative insulin deficiency, ketogenesis and hyperglycaemia in susceptible individuals. In conjunction with prolonged critical care, these components will promote a catabolic state. Insulin infusion is the mainstay of therapy for treatment of hyperglycaemia in acute illness but what is the effect of insulin on the admixture of glucocorticoids and COVID-19? This article reviews the evidence for the effect of insulin on clinical outcomes and intermediary metabolism in critical illness.


Assuntos
COVID-19/tratamento farmacológico , Glucocorticoides/efeitos adversos , Insulina/uso terapêutico , Doenças Metabólicas/induzido quimicamente , Doenças Metabólicas/prevenção & controle , COVID-19/complicações , Cuidados Críticos/métodos , Estado Terminal/terapia , Dexametasona/efeitos adversos , Dexametasona/uso terapêutico , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/tratamento farmacológico , Complicações do Diabetes/mortalidade , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/mortalidade , Diabetes Mellitus/virologia , Glucocorticoides/uso terapêutico , Humanos , Hiperglicemia/complicações , Hiperglicemia/tratamento farmacológico , Hiperglicemia/mortalidade , Doenças Metabólicas/etiologia , Obesidade/complicações , Obesidade/tratamento farmacológico , Obesidade/mortalidade , SARS-CoV-2/fisiologia , Resultado do Tratamento
5.
Crit Care ; 25(1): 199, 2021 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-34108029

RESUMO

BACKGROUND: Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous small-case series or studies conducted at a national level. METHODS: We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe CRS-calculated as: tidal volume/[airway plateau pressure-positive end-expiratory pressure (PEEP)]-and its association with ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide. RESULTS: We studied 745 patients from 22 countries, who required admission to the ICU and MV from January 14 to December 31, 2020, and presented at least one value of CRS within the first seven days of MV. Median (IQR) age was 62 (52-71), patients were predominantly males (68%) and from Europe/North and South America (88%). CRS, within 48 h from endotracheal intubation, was available in 649 patients and was neither associated with the duration from onset of symptoms to commencement of MV (p = 0.417) nor with PaO2/FiO2 (p = 0.100). Females presented lower CRS than males (95% CI of CRS difference between females-males: - 11.8 to - 7.4 mL/cmH2O p < 0.001), and although females presented higher body mass index (BMI), association of BMI with CRS was marginal (p = 0.139). Ventilatory management varied across CRS range, resulting in a significant association between CRS and driving pressure (estimated decrease - 0.31 cmH2O/L per mL/cmH20 of CRS, 95% CI - 0.48 to - 0.14, p < 0.001). Overall, 28-day ICU mortality, accounting for the competing risk of being discharged within the period, was 35.6% (SE 1.7). Cox proportional hazard analysis demonstrated that CRS (+ 10 mL/cm H2O) was only associated with being discharge from the ICU within 28 days (HR 1.14, 95% CI 1.02-1.28, p = 0.018). CONCLUSIONS: This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV. CRS measured within 48 h from commencement of MV has marginal predictive value for 28-day mortality, but was associated with being discharged from ICU within the same period. Trial documentation: Available at https://www.covid-critical.com/study . TRIAL REGISTRATION: ACTRN12620000421932.


Assuntos
COVID-19/complicações , COVID-19/terapia , Complacência Pulmonar/fisiologia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Adulto , Estudos de Coortes , Cuidados Críticos/métodos , Europa (Continente) , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença
6.
Sci Rep ; 11(1): 13001, 2021 06 21.
Artigo em Inglês | MEDLINE | ID: mdl-34155241

RESUMO

Although international airports served as main entry points for SARS-CoV-2, the factors driving the uneven geographic spread of COVID-19 cases and deaths in Brazil remain mostly unknown. Here we show that three major factors influenced the early macro-geographical dynamics of COVID-19 in Brazil. Mathematical modeling revealed that the "super-spreading city" of São Paulo initially accounted for more than 85% of the case spread in the entire country. By adding only 16 other spreading cities, we accounted for 98-99% of the cases reported during the first 3 months of the pandemic in Brazil. Moreover, 26 federal highways accounted for about 30% of SARS-CoV-2's case spread. As cases increased in the Brazilian interior, the distribution of COVID-19 deaths began to correlate with the allocation of the country's intensive care units (ICUs), which is heavily weighted towards state capitals. Thus, severely ill patients living in the countryside had to be transported to state capitals to access ICU beds, creating a "boomerang effect" that contributed to skew the distribution of COVID-19 deaths. Therefore, if (i) a lockdown had been imposed earlier on in spreader-capitals, (ii) mandatory road traffic restrictions had been enforced, and (iii) a more equitable geographic distribution of ICU beds existed, the impact of COVID-19 in Brazil would be significantly lower.


Assuntos
COVID-19/prevenção & controle , COVID-19/transmissão , Portador Sadio/transmissão , Cuidados Críticos/métodos , Pandemias/prevenção & controle , Quarentena/métodos , SARS-CoV-2 , Doença Relacionada a Viagens , Automóveis , Brasil/epidemiologia , COVID-19/epidemiologia , COVID-19/virologia , Cidades/epidemiologia , Humanos , Unidades de Terapia Intensiva , Modelos Teóricos
7.
BMC Anesthesiol ; 21(1): 178, 2021 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-34182946

RESUMO

BACKGROUND: Point-of-care lung ultrasound (LU) is an established tool in the first assessment of patients with coronavirus disease (COVID-19). Purpose of this study was to evaluate the value of lung ultrasound in COVID-19 intensive care unit (ICU) patients in predicting clinical course and outcome. METHODS: We analyzed lung ultrasound score (LUS) of all COVID-19 patients admitted from March 2020 to December 2020 to the Internal Intensive Care Unit, Ludwig-Maximilians-University (LMU) of Munich. LU was performed according to a standardized protocol at ICU admission and in case of clinical deterioration with the need for intubation. A normal lung scores 0 points, the worst LUS has 24 points. Patients were stratified in a low (0-12 points) and a high (13-24 points) lung ultrasound score group. RESULTS: The study included 42 patients, 69% of them male. The most common comorbidities were hypertension (81%) and obesity (57%). The values of pH (7.42 ± 0.09 vs 7.35 ± 0.1; p = 0.047) and paO2 (107 [80-130] vs 80 [66-93] mmHg; p = 0.034) were significantly reduced in patients of the high LUS group. Furthermore, the duration of ventilation (12.5 [8.3-25] vs 36.5 [9.8-70] days; p = 0.029) was significantly prolonged in this group. Patchy subpleural thickening (n = 38; 90.5%) and subpleural consolidations (n = 23; 54.8%) were present in most patients. Pleural effusion was rare (n = 4; 9.5%). The median total LUS was 11.9 ± 3.9 points. In case of clinical deterioration with the need for intubation, LUS worsened significantly compared to baseline LU. Twelve patients died during the ICU stay (29%). There was no difference in survival in both LUS groups (75% vs 66.7%, p = 0.559). CONCLUSIONS: LU can be a useful monitoring tool to predict clinical course but not outcome of COVID-19 ICU patients and can early recognize possible deteriorations.


Assuntos
COVID-19/diagnóstico , COVID-19/epidemiologia , Cuidados Críticos/métodos , Pulmão/diagnóstico por imagem , SARS-CoV-2 , Ultrassonografia/métodos , Idoso , COVID-19/patologia , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Testes Imediatos , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos
8.
BMC Infect Dis ; 21(1): 616, 2021 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-34187382

RESUMO

BACKGROUND: Critically ill patients frequently suffer from vitamin C deficiency. Previous studies showed that high doses of vitamin C administration had conflicting results on clinical outcomes in patients with severe sepsis, burns, and trauma. Because of the high incidence and morbidity/mortality with severe pneumonia, we aimed to investigate the effect of administration of high dose vitamin C in critically ill patients with severe pneumonia. METHODS: Eighty critically ill patients with pneumonia were enrolled in this randomized double-blinded clinical trial. Patients with a CURB-65 score > 3, one major criterion, or ≥ 3 minor criteria were considered as severe pneumonia. Patients were randomly assigned to intervention or placebo groups receiving standard treatment plus 60 mg/kg/day vitamin C as a continuous infusion or normal saline in the same volume correspondingly for 96 h. Serum levels of vitamin C were noted at baseline and 48 h after vitamin C administration. Duration of mechanical ventilation, ICU length of stay, PaO2/FiO2, and mortality rate were noted for all patients till the 28th day. Any complications related to the vitamin C administration were recorded. RESULTS: Duration of mechanical ventilation and vasopressor use were significantly lower in the intervention group (p: < 0.001 and 0.003, respectively). Baseline levels of vitamin C in both groups did not have a significant difference but its levels increased in the intervention group and decreased in the control group during the study period. Mortality rate insignificantly decreased in the intervention group (p = 0.17). Three patients showed hypotension and tachycardia during the administration of vitamin C which was self-limited with decreasing the dose of vitamin C. Our results showed that the intravenous administration of a relatively high dose of vitamin C to critically ill patients with severe pneumonia was safe and could decrease the inflammation, duration of mechanical ventilation, and vasopressor use without any significant effect on mortality. TRIAL REGISTRATION: IRCT registration number: IRCT20190312043030N1, Registration date: 2019-08-26, Seied Hadi Saghaleini.


Assuntos
Ácido Ascórbico/administração & dosagem , Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Pneumonia/tratamento farmacológico , Pneumonia/mortalidade , Índice de Gravidade de Doença , Vitaminas/administração & dosagem , Administração Intravenosa , Adulto , Idoso , Ácido Ascórbico/sangue , Estado Terminal , Método Duplo-Cego , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia/sangue , Respiração Artificial/efeitos adversos , Resultado do Tratamento
9.
Air Med J ; 40(4): 211-215, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34172226

RESUMO

OBJECTIVE: As part of the humanitarian response to the coronavirus disease 2019 (COVID-19) pandemic, the German and French Armed Forces provided air transport for patients from overwhelmed regional hospitals in Italy and France. The objective of this study was to analyze the characteristics of the missions and the medical conditions of COVID-19 patients transported during an air medical evacuation on fixed wing aircraft in March and April 2020. METHOD: This was a retrospective analysis of transport records as well as other documents for 58 COVID-19 patients requiring artificial ventilation. RESULTS: The median age of the transported patients was 61.5 years, and 61% of them had preexisting medical conditions. They had been ventilated for a median of 5 days and experienced the first symptoms 18 days before transport. The patients flown out of France had less days of ventilation before flight, a lower end-tidal carbon dioxide level at the beginning of the flight, and a lower Charlson Comorbidity Index. There were also some differences between the ventilation and the flight level flown by the 2 air forces. CONCLUSION: The intensive care transport of ventilated COVID-19 patients requires highly qualified personnel and appropriate equipment and should be planned appropriately.


Assuntos
Resgate Aéreo , COVID-19/diagnóstico , COVID-19/terapia , Cuidados Críticos , Transferência de Pacientes , Idoso , Resgate Aéreo/organização & administração , Resgate Aéreo/estatística & dados numéricos , COVID-19/epidemiologia , Comorbidade , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Cuidados Críticos/estatística & dados numéricos , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Transferência de Pacientes/métodos , Transferência de Pacientes/organização & administração , Transferência de Pacientes/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença
10.
Air Med J ; 40(4): 220-224, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34172228

RESUMO

OBJECTIVE: There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients. METHODS: A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis. RESULTS: Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport. CONCLUSION: The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making.


Assuntos
COVID-19/terapia , Competência Clínica , Tomada de Decisão Clínica/métodos , Cuidados Críticos/métodos , Transporte de Pacientes/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/diagnóstico , Terapia Combinada , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Estado Terminal , Feminino , Humanos , Masculino , Maryland , Pessoa de Meia-Idade , Gravidade do Paciente , Transferência de Pacientes/métodos , Transferência de Pacientes/normas , Transferência de Pacientes/estatística & dados numéricos , Estudos Retrospectivos , Transporte de Pacientes/normas , Transporte de Pacientes/estatística & dados numéricos
11.
Sci Rep ; 11(1): 13001, 2021 06 21.
Artigo em Inglês | MEDLINE | ID: covidwho-1279897

RESUMO

Although international airports served as main entry points for SARS-CoV-2, the factors driving the uneven geographic spread of COVID-19 cases and deaths in Brazil remain mostly unknown. Here we show that three major factors influenced the early macro-geographical dynamics of COVID-19 in Brazil. Mathematical modeling revealed that the "super-spreading city" of São Paulo initially accounted for more than 85% of the case spread in the entire country. By adding only 16 other spreading cities, we accounted for 98-99% of the cases reported during the first 3 months of the pandemic in Brazil. Moreover, 26 federal highways accounted for about 30% of SARS-CoV-2's case spread. As cases increased in the Brazilian interior, the distribution of COVID-19 deaths began to correlate with the allocation of the country's intensive care units (ICUs), which is heavily weighted towards state capitals. Thus, severely ill patients living in the countryside had to be transported to state capitals to access ICU beds, creating a "boomerang effect" that contributed to skew the distribution of COVID-19 deaths. Therefore, if (i) a lockdown had been imposed earlier on in spreader-capitals, (ii) mandatory road traffic restrictions had been enforced, and (iii) a more equitable geographic distribution of ICU beds existed, the impact of COVID-19 in Brazil would be significantly lower.


Assuntos
COVID-19/prevenção & controle , COVID-19/transmissão , Portador Sadio/transmissão , Cuidados Críticos/métodos , Pandemias/prevenção & controle , Quarentena/métodos , SARS-CoV-2 , Doença Relacionada a Viagens , Automóveis , Brasil/epidemiologia , COVID-19/epidemiologia , COVID-19/virologia , Cidades/epidemiologia , Humanos , Unidades de Terapia Intensiva , Modelos Teóricos
12.
BMJ ; 373: n1007, 2021 06 08.
Artigo em Inglês | MEDLINE | ID: covidwho-1263910

RESUMO

Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.


Assuntos
Disfunção Cognitiva , Estado Terminal/psicologia , Delírio , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Cuidados Críticos/métodos , Estado Terminal/terapia , Delírio/complicações , Delírio/diagnóstico , Humanos , Efeitos Adversos de Longa Duração , Prognóstico
13.
Crit Care ; 25(1): 199, 2021 06 09.
Artigo em Inglês | MEDLINE | ID: covidwho-1262513

RESUMO

BACKGROUND: Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous small-case series or studies conducted at a national level. METHODS: We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe CRS-calculated as: tidal volume/[airway plateau pressure-positive end-expiratory pressure (PEEP)]-and its association with ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide. RESULTS: We studied 745 patients from 22 countries, who required admission to the ICU and MV from January 14 to December 31, 2020, and presented at least one value of CRS within the first seven days of MV. Median (IQR) age was 62 (52-71), patients were predominantly males (68%) and from Europe/North and South America (88%). CRS, within 48 h from endotracheal intubation, was available in 649 patients and was neither associated with the duration from onset of symptoms to commencement of MV (p = 0.417) nor with PaO2/FiO2 (p = 0.100). Females presented lower CRS than males (95% CI of CRS difference between females-males: - 11.8 to - 7.4 mL/cmH2O p < 0.001), and although females presented higher body mass index (BMI), association of BMI with CRS was marginal (p = 0.139). Ventilatory management varied across CRS range, resulting in a significant association between CRS and driving pressure (estimated decrease - 0.31 cmH2O/L per mL/cmH20 of CRS, 95% CI - 0.48 to - 0.14, p < 0.001). Overall, 28-day ICU mortality, accounting for the competing risk of being discharged within the period, was 35.6% (SE 1.7). Cox proportional hazard analysis demonstrated that CRS (+ 10 mL/cm H2O) was only associated with being discharge from the ICU within 28 days (HR 1.14, 95% CI 1.02-1.28, p = 0.018). CONCLUSIONS: This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV. CRS measured within 48 h from commencement of MV has marginal predictive value for 28-day mortality, but was associated with being discharged from ICU within the same period. Trial documentation: Available at https://www.covid-critical.com/study . TRIAL REGISTRATION: ACTRN12620000421932.


Assuntos
COVID-19/complicações , COVID-19/terapia , Complacência Pulmonar/fisiologia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Adulto , Estudos de Coortes , Cuidados Críticos/métodos , Europa (Continente) , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença
14.
PLoS One ; 16(6): e0252763, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34138871

RESUMO

BACKGROUND: Data on the post-acute and post-infectious complications of patients who have recovered from severe coronavirus disease 2019 (COVID-19) are limited. While studies report that approximately 5-15% of COVID-19 hospitalized patients require intensive care and mechanical ventilation, a substantially higher number need non-invasive ventilation and are subject to prolonged hospitalizations, with long periods of immobility and isolation. The purpose of this study is to describe the post-infectious sequelae of severe viral illness and the post-acute complications of intensive care treatments in critically ill patients who have recovered from severe COVID-19 infection. METHODS: We performed a retrospective chart review of adult patients initially hospitalized with confirmed COVID-19 infection, who recovered and were transferred to a general medical ward or discharged home between March 15, 2020 and May 15, 2020, dates inclusive, after an intensive care unit (ICU) or high dependency unit (HDU) admission in a designated COVID-19 hospital in the United Arab Emirates. Demographic data, underlying comorbidities, treatment, complications, and outcomes were collected. Descriptive statistical analyses were performed. RESULTS: Of 71 patients transferred out of ICU (n = 38, 54%) and HDU (n = 33, 46%), mean age was 48 years (SD, 9.95); 96% men; 54% under age 50. Mean ICU stay was 12.4 days (SD, 5.29), HDU stay was 13.4 days (SD, 4.53). Pre-existing conditions were not significantly associated with developing post-acute complications (Odds Ratio [OR] 1.1, 95% confidence interval [CI] 0.41, 2.93, p = 1.00). Fifty nine percent of patients had complications; myopathy, swallowing impairments, and pressure ulcers were most common. Delirium and confusion were diagnosed in 18% (n = 13); all were admitted to the ICU and required mechanical ventilation. Of note, of all patients studied, 59.2% (n = 42/71) had at least 1 complication, 32.4% (n = 23) had at least 2 complications, and 19.7% (n = 14) suffered 3 or more sequelae. Complications were significantly more common in ICU patients (n = 33/38, 87%), compared to HDU patients (n = 9/33, 27%) (OR 17.6, 95% CI 5.23, 59.21, p <0.05). CONCLUSION: In a subset of critically ill patients who recovered from severe COVID-19 infection, there was considerable short-term post-infectious and post-acute disability. Long-term follow-up of COVID-19 survivors is warranted.


Assuntos
COVID-19/prevenção & controle , Cuidados Críticos/métodos , Estado Terminal/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , SARS-CoV-2/isolamento & purificação , Adulto , COVID-19/virologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SARS-CoV-2/fisiologia , Emirados Árabes Unidos
15.
BMC Infect Dis ; 21(1): 616, 2021 Jun 29.
Artigo em Inglês | MEDLINE | ID: covidwho-1285992

RESUMO

BACKGROUND: Critically ill patients frequently suffer from vitamin C deficiency. Previous studies showed that high doses of vitamin C administration had conflicting results on clinical outcomes in patients with severe sepsis, burns, and trauma. Because of the high incidence and morbidity/mortality with severe pneumonia, we aimed to investigate the effect of administration of high dose vitamin C in critically ill patients with severe pneumonia. METHODS: Eighty critically ill patients with pneumonia were enrolled in this randomized double-blinded clinical trial. Patients with a CURB-65 score > 3, one major criterion, or ≥ 3 minor criteria were considered as severe pneumonia. Patients were randomly assigned to intervention or placebo groups receiving standard treatment plus 60 mg/kg/day vitamin C as a continuous infusion or normal saline in the same volume correspondingly for 96 h. Serum levels of vitamin C were noted at baseline and 48 h after vitamin C administration. Duration of mechanical ventilation, ICU length of stay, PaO2/FiO2, and mortality rate were noted for all patients till the 28th day. Any complications related to the vitamin C administration were recorded. RESULTS: Duration of mechanical ventilation and vasopressor use were significantly lower in the intervention group (p: < 0.001 and 0.003, respectively). Baseline levels of vitamin C in both groups did not have a significant difference but its levels increased in the intervention group and decreased in the control group during the study period. Mortality rate insignificantly decreased in the intervention group (p = 0.17). Three patients showed hypotension and tachycardia during the administration of vitamin C which was self-limited with decreasing the dose of vitamin C. Our results showed that the intravenous administration of a relatively high dose of vitamin C to critically ill patients with severe pneumonia was safe and could decrease the inflammation, duration of mechanical ventilation, and vasopressor use without any significant effect on mortality. TRIAL REGISTRATION: IRCT registration number: IRCT20190312043030N1, Registration date: 2019-08-26, Seied Hadi Saghaleini.


Assuntos
Ácido Ascórbico/administração & dosagem , Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Pneumonia/tratamento farmacológico , Pneumonia/mortalidade , Índice de Gravidade de Doença , Vitaminas/administração & dosagem , Administração Intravenosa , Adulto , Idoso , Ácido Ascórbico/sangue , Estado Terminal , Método Duplo-Cego , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia/sangue , Respiração Artificial/efeitos adversos , Resultado do Tratamento
16.
BMC Anesthesiol ; 21(1): 178, 2021 06 28.
Artigo em Inglês | MEDLINE | ID: covidwho-1286811

RESUMO

BACKGROUND: Point-of-care lung ultrasound (LU) is an established tool in the first assessment of patients with coronavirus disease (COVID-19). Purpose of this study was to evaluate the value of lung ultrasound in COVID-19 intensive care unit (ICU) patients in predicting clinical course and outcome. METHODS: We analyzed lung ultrasound score (LUS) of all COVID-19 patients admitted from March 2020 to December 2020 to the Internal Intensive Care Unit, Ludwig-Maximilians-University (LMU) of Munich. LU was performed according to a standardized protocol at ICU admission and in case of clinical deterioration with the need for intubation. A normal lung scores 0 points, the worst LUS has 24 points. Patients were stratified in a low (0-12 points) and a high (13-24 points) lung ultrasound score group. RESULTS: The study included 42 patients, 69% of them male. The most common comorbidities were hypertension (81%) and obesity (57%). The values of pH (7.42 ± 0.09 vs 7.35 ± 0.1; p = 0.047) and paO2 (107 [80-130] vs 80 [66-93] mmHg; p = 0.034) were significantly reduced in patients of the high LUS group. Furthermore, the duration of ventilation (12.5 [8.3-25] vs 36.5 [9.8-70] days; p = 0.029) was significantly prolonged in this group. Patchy subpleural thickening (n = 38; 90.5%) and subpleural consolidations (n = 23; 54.8%) were present in most patients. Pleural effusion was rare (n = 4; 9.5%). The median total LUS was 11.9 ± 3.9 points. In case of clinical deterioration with the need for intubation, LUS worsened significantly compared to baseline LU. Twelve patients died during the ICU stay (29%). There was no difference in survival in both LUS groups (75% vs 66.7%, p = 0.559). CONCLUSIONS: LU can be a useful monitoring tool to predict clinical course but not outcome of COVID-19 ICU patients and can early recognize possible deteriorations.


Assuntos
COVID-19/diagnóstico , COVID-19/epidemiologia , Cuidados Críticos/métodos , Pulmão/diagnóstico por imagem , SARS-CoV-2 , Ultrassonografia/métodos , Idoso , COVID-19/patologia , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Testes Imediatos , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos
17.
BMJ ; 373: n1007, 2021 06 08.
Artigo em Inglês | MEDLINE | ID: mdl-34103334

RESUMO

Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.


Assuntos
Disfunção Cognitiva , Estado Terminal/psicologia , Delírio , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Cuidados Críticos/métodos , Estado Terminal/terapia , Delírio/complicações , Delírio/diagnóstico , Humanos , Efeitos Adversos de Longa Duração , Prognóstico
18.
Medicine (Baltimore) ; 100(23): e26288, 2021 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-34115032

RESUMO

ABSTRACT: The leukocytes play an important role in immune function during sepsis. We performed a retrospective study to investigate if leukocytes kinetics was associated with survival in critically ill patients with septic shock in intensive care unit (ICU).Patients with septic shock from January 1, 2014 to June 30, 2018 in our ICU were included. We extracted the demographic, clinical and laboratory data, comorbidities from our clinical database. The number of white blood cell, neutrophil and lymphocyte on day 1 and day 3 after diagnosis were collected and neutrophil to lymphocyte ratios (NLR) were calculated. Our primary outcome was 28-day mortality. Univariate and multivariate logistic regression models and cox proportional risk model were used to analyze the association between the leukocytes kinetics during first 3 days after ICU admission and the day-28 mortality.A total of 1245 septic shock patients with a 28-day mortality of 35.02% were included into analysis. There were no significant difference of lymphocyte number (0.83 ±â€Š0.02 vs 0.80 ±â€Š0.04, P = .552) between survival and non-survivals on day 1. However, the lymphocyte counts was significantly lower (0.95 ±â€Š0.03 vs 0.85 ±â€Š0.04, P = .024) on the third day. Both multivariate logistic and Cox regression analysis showed that lymphocyte counts on day 3 were associated with day-28 mortality. Moreover, Kaplan-Meier survival analysis revealed that increasing in lymphocyte counts and decreasing WBC, neutrophils and NLR during the first 3 days after diagnosis were associated with longer survival.Leukocytes kinetics during the first 3 days is a valuable prognostic marker in patients with septic shock in the ICU.


Assuntos
Ensaios de Migração Celular/métodos , Contagem de Leucócitos , Linfócitos/imunologia , Neutrófilos/imunologia , Choque Séptico , China , Cuidados Críticos/métodos , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Estimativa de Kaplan-Meier , Contagem de Leucócitos/métodos , Contagem de Leucócitos/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Choque Séptico/diagnóstico , Choque Séptico/imunologia , Choque Séptico/mortalidade
19.
Best Pract Res Clin Anaesthesiol ; 35(2): 207-220, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34030805

RESUMO

Neuropatients often require invasive mechanical ventilation (MV). Ideal ventilator settings and respiratory targets in neuro patients are unclear. Current knowledge suggests maintaining protective tidal volumes of 6-8 ml/kg of predicted body weight in neuropatients. This approach may reduce the rate of pulmonary complications, although it cannot be easily applied in a neuro setting due to the need for special care to minimize the risk of secondary brain damage. Additionally, the weaning process from MV is particularly challenging in these patients who cannot control the brain respiratory patterns and protect airways from aspiration. Indeed, extubation failure in neuropatients is very high, while tracheostomy is needed in one-third of the patients. The aim of this manuscript is to review and describe the current management of invasive MV, weaning, and tracheostomy for the main four subpopulations of neuro patients: traumatic brain injury, acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage.


Assuntos
Manuseio das Vias Aéreas/métodos , Cuidados Críticos/métodos , Intubação Intratraqueal/métodos , Doenças do Sistema Nervoso/terapia , Respiração Artificial/métodos , Humanos , Doenças do Sistema Nervoso/fisiopatologia , Volume de Ventilação Pulmonar/fisiologia
20.
Crit Care ; 25(1): 178, 2021 05 25.
Artigo em Inglês | MEDLINE | ID: mdl-34034789

RESUMO

A growing consensus seems to be emerging that dexamethasone is a crucial component in the treatment of COVID-19-associated oxygen-dependent respiratory failure. Although dexamethasone has an undeniably beneficial effect on the inflammatory response in a subgroup of patients, the potential negative effects of corticosteroids must also be considered. In view of these negative effects, we argue that a one-size-fits-all dexamethasone approach may be potentially harmful in specific subsets of patients with COVID-19-associated ARDS. We propose a different individually tailored treatment strategy based on the patient's inflammatory response.


Assuntos
COVID-19/tratamento farmacológico , Cuidados Críticos/métodos , Dexametasona/uso terapêutico , Inflamação/prevenção & controle , Insuficiência Respiratória/tratamento farmacológico , COVID-19/complicações , Dexametasona/efeitos adversos , Humanos , Unidades de Terapia Intensiva , Insuficiência Respiratória/virologia , Resultado do Tratamento
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