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1.
Medicine (Baltimore) ; 100(40): e27325, 2021 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-34622831

RESUMO

ABSTRACT: The National Early Warning Score (NEWS)-2 is an early warning scale that is used in emergency departments to identify patients at risk of clinical deterioration and to help establish rapid and timely management. The objective of this study was to determine the validity and prediction of mortality using the NEWS2 scale for adults in the emergency department of a tertiary clinic in Colombia.A prospective observational study was conducted between August 2018 and June 2019 at the Universidad de La Sabana Clinic.The nursing staff in the triage classified the patients admitted to the emergency room according to Emergency Severity Index and NEWS2. Demographic data, physiological variables, admission diagnosis, mortality outcome, and comorbidities were extracted.Three thousand nine hundred eighty-six patients were included in the study. Ninety-two (2%) patients required intensive care unit management, with a mean NEWS2 score of 7. A total of 158 patients died in hospital, of which 63 were women (40%). Of these 65 patients required intensive care unit management. The receiver operating characteristic curve for NEWS2 had an area of 0.90 (CI 95%: 0.87-0.92). A classification and score equivalency analysis was performed between triage and the NEWS2 scale in terms of mortality. Of the patients classified as triage I, 32.3% died, and those who obtained a NEWS2 score greater than or equal to 10 had a mortality of 38.6%.Among our population, NEWS2 was not inferior in its area under the receiver operating characteristic curve when predicting mortality than triage, and the cutoff point for NEWS2 to predict in-hospital mortality was higher.


Assuntos
Escore de Alerta Precoce , Serviço Hospitalar de Emergência/organização & administração , Adulto , Idoso , Deterioração Clínica , Colômbia/epidemiologia , Estado Terminal/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Centros de Atenção Terciária/estatística & dados numéricos , Triagem/métodos
2.
Crit Care ; 25(1): 344, 2021 09 23.
Artigo em Inglês | MEDLINE | ID: mdl-34556171

RESUMO

BACKGROUND: The primary aim of this study was to assess the outcome of elderly intensive care unit (ICU) patients treated during the spring and autumn COVID-19 surges in Europe. METHODS: This was a prospective European observational study (the COVIP study) in ICU patients aged 70 years and older admitted with COVID-19 disease from March to December 2020 to 159 ICUs in 14 European countries. An electronic database was used to register a number of parameters including: SOFA score, Clinical Frailty Scale, co-morbidities, usual ICU procedures and survival at 90 days. The study was registered at ClinicalTrials.gov (NCT04321265). RESULTS: In total, 2625 patients were included, 1327 from the first and 1298 from the second surge. Median age was 74 and 75 years in surge 1 and 2, respectively. SOFA score was higher in the first surge (median 6 versus 5, p < 0.0001). The PaO2/FiO2 ratio at admission was higher during surge 1, and more patients received invasive mechanical ventilation (78% versus 68%, p < 0.0001). During the first 15 days of treatment, survival was similar during the first and the second surge. Survival was lower in the second surge after day 15 and differed after 30 days (57% vs 50%) as well as after 90 days (51% vs 40%). CONCLUSION: An unexpected, but significant, decrease in 30-day and 90-day survival was observed during the second surge in our cohort of elderly ICU patients. The reason for this is unclear. Our main concern is whether the widespread changes in practice and treatment of COVID-19 between the two surges have contributed to this increased mortality in elderly patients. Further studies are urgently warranted to provide more evidence for current practice in elderly patients. TRIAL REGISTRATION NUMBER: NCT04321265 , registered March 19th, 2020.


Assuntos
COVID-19/mortalidade , Estado Terminal/mortalidade , Pneumonia Viral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Europa (Continente)/epidemiologia , Feminino , Idoso Fragilizado , Humanos , Unidades de Terapia Intensiva , Masculino , Escores de Disfunção Orgânica , Pandemias , Pneumonia Viral/virologia , Estudos Prospectivos , SARS-CoV-2 , Análise de Sobrevida
3.
JAMA ; 326(9): 830-838, 2021 09 07.
Artigo em Inglês | MEDLINE | ID: mdl-34547081

RESUMO

Importance: Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality. Objective: To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU). Design, Setting, and Participants: Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately). Interventions: Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design. Main Outcomes and Measures: The primary end point was 90-day survival. Results: Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98). Conclusions and Relevance: Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate. Trial Registration: ClinicalTrials.gov Identifier: NCT02875873.


Assuntos
Estado Terminal/mortalidade , Estado Terminal/terapia , Hidratação/métodos , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais
4.
PLoS One ; 16(9): e0256203, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34555027

RESUMO

OBJECTIVES: We conducted the present multicenter, retrospective study to assess the epidemiological, clinical, laboratory, and radiological characteristics associated with critical illness among patients with COVID-19 from Egypt. METHODS: The present study was a multicenter, retrospective study that retrieved the data of all Egyptian cases with confirmed COVID-19 admitted to hospitals affiliated to the General Organization for Teaching Hospitals and Institutes (GOTHI) through the period from March to July 2020. The diagnosis of COVID-19 was based on a positive reverse transcription-polymerase chain reaction (RT-PCR) laboratory test. RESULTS: This retrospective study included 2724 COVID-19 patients, of whom 423 (15.52%) were critically ill. Approximately 45.86% of the critical group aged above 60 years, compared to 39.59% in the non-critical group (p = 0.016). Multivariate analysis showed that many factors were predictors of critically illness, including age >60 years (OR = 1.30, 95% CI [1.05, 1.61], p = 0.014), low oxygen saturation (OR = 0.93, 95% CI [0.91, 0.95], p<0.001), low Glasgow coma scale (OR = 0.75, 95% CI [0.67, 0.84], p<0.001), diabetes (OR = 1.62, 95% CI [1.26, 2.08], p<0.001), cancer (OR = 2.47, 95% CI [1.41, 4.35], p = 0.002), and serum ferritin (OR = 1.004, 95% CI [1.0003, 1.008], p = 0.031). CONCLUSION: In the present report, we demonstrated that many factors are associated with COVID-19 critical illness, including older age groups, fatigue, elevated temperature, increased pulse, lower oxygen saturation, the preexistence of diabetes, malignancies, cardiovascular disease, renal diseases, and pulmonary disease. Moreover, elevated serum levels of ALT, AST, and ferritin are associated with worse outcomes. Further studies are required to identify independent predictors of mortality for patients with COVID-19.


Assuntos
COVID-19/complicações , COVID-19/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estado Terminal/mortalidade , Egito , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Fatores de Risco , SARS-CoV-2/patogenicidade , Adulto Jovem
5.
PLoS One ; 16(9): e0258018, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34587211

RESUMO

BACKGROUND: Data of critically ill COVID-19 patients are being evaluated worldwide, not only to understand the various aspects of the disease and to refine treatment strategies but also to improve clinical decision-making. For clinical decision-making in particular, prognostic factors of a lethal course of the disease would be highly relevant. METHODS: In this retrospective cohort study, we analyzed the first 59 adult critically ill Covid-19 patients treated in one of the intensive care units of the University Medical Center Regensburg, Germany. Using uni- and multivariable regression models, we extracted a set of parameters that allowed for prognosing in-hospital mortality. RESULTS: Within the cohort, 19 patients died (mortality 32.2%). Blood pH value, mean arterial pressure, base excess, troponin, and procalcitonin were identified as highly significant prognostic factors of in-hospital mortality. However, no significant differences were found for other parameters expected to be relevant prognostic factors, like low arterial partial pressure of oxygen or high lactate levels. In the multivariable logistic regression analysis, the pH value and the mean arterial pressure turned out to be the most influential prognostic factors for a lethal course.


Assuntos
COVID-19/sangue , COVID-19/mortalidade , Adulto , Idoso , Pressão Arterial/fisiologia , Fenômenos Fisiológicos Sanguíneos , Pressão Sanguínea/fisiologia , Estudos de Coortes , Estado Terminal/mortalidade , Feminino , Alemanha/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Concentração de Íons de Hidrogênio , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Prognóstico , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2/patogenicidade
6.
Medicine (Baltimore) ; 100(35): e26164, 2021 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-34477112

RESUMO

ABSTRACT: Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.


Assuntos
Prognóstico , Doenças Reumáticas/complicações , Idoso , Idoso de 80 Anos ou mais , Estado Terminal/epidemiologia , Estado Terminal/mortalidade , Feminino , França , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doenças Reumáticas/epidemiologia , Doenças Reumáticas/mortalidade
7.
Sci Rep ; 11(1): 17476, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34471146

RESUMO

Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory biomarker and risk factor for kidney diseases, with a potential prognostic value in critically ill patients. In this monocentric prospective study, we measured plasma suPAR levels immediately after ICU admission in unselected 237 consecutive patients using a turbidimetric assay. Primary objective was the prognostic value for ICU- and 28-day mortality. Secondary objectives were association with sequential organ failure assessment (SOFA) score, coagulation and inflammation markers, AKI-3 and differences in prespecified subgroups. Median suPAR levels were 8.0 ng/mL [25th-75th percentile 4.3-14.4], with lower levels in ICU survivors than non-survivors (6.7 vs. 11.6 ng/mL, p < 0.001). SuPAR levels were higher in COVID-19, kidney disease, moderate-to-severe liver disease, and sepsis. ICU mortality increased by an odds ratio (OR) of 4.7 in patients with the highest compared to lowest quartile suPAR. Kaplan-Meier overall survival estimates at 3 months were 63% and 49%, in patients with suPAR below/above 12 ng/mL (log-rank p = 0.027). Due to an observed interaction between SOFA score and suPAR, we performed a random forest method identifying cutoffs. ICU mortality was 53%, 17% and 2% in patients with a SOFA score > 7, SOFA ≤ 7 & suPAR > 8 ng/mL, and SOFA score ≤ 7 & suPAR ≤ 8 ng/mL, respectively. suPAR was a significant predictor for AKI-3 occurrence (OR per doubling 1.89, 95% CI: 1.20-2.98; p = 0.006). suPAR levels at ICU admission may offer additional value for risk stratification especially in ICU patients with moderate organ dysfunction as reflected by a SOFA score ≤ 7.


Assuntos
COVID-19/sangue , Estado Terminal/mortalidade , Nefropatias/sangue , Receptores de Ativador de Plasminogênio Tipo Uroquinase/sangue , Insuficiência Renal/mortalidade , Idoso , Feminino , Humanos , Imunoturbidimetria , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Mortalidade , Razão de Chances , Escores de Disfunção Orgânica , Prognóstico , Estudos Prospectivos , Insuficiência Renal/sangue , Análise de Sobrevida
8.
PLoS Pathog ; 17(9): e1009804, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34529726

RESUMO

Prior studies have demonstrated that immunologic dysfunction underpins severe illness in COVID-19 patients, but have lacked an in-depth analysis of the immunologic drivers of death in the most critically ill patients. We performed immunophenotyping of viral antigen-specific and unconventional T cell responses, neutralizing antibodies, and serum proteins in critically ill patients with SARS-CoV-2 infection, using influenza infection, SARS-CoV-2-convalescent health care workers, and healthy adults as controls. We identify mucosal-associated invariant T (MAIT) cell activation as an independent and significant predictor of death in COVID-19 (HR = 5.92, 95% CI = 2.49-14.1). MAIT cell activation correlates with several other mortality-associated immunologic measures including broad activation of CD8+ T cells and non-Vδ2 γδT cells, and elevated levels of cytokines and chemokines, including GM-CSF, CXCL10, CCL2, and IL-6. MAIT cell activation is also a predictor of disease severity in influenza (ECMO/death HR = 4.43, 95% CI = 1.08-18.2). Single-cell RNA-sequencing reveals a shift from focused IFNα-driven signals in COVID-19 ICU patients who survive to broad pro-inflammatory responses in fatal COVID-19 -a feature not observed in severe influenza. We conclude that fatal COVID-19 infection is driven by uncoordinated inflammatory responses that drive a hierarchy of T cell activation, elements of which can serve as prognostic indicators and potential targets for immune intervention.


Assuntos
COVID-19/imunologia , COVID-19/mortalidade , Anticorpos Neutralizantes/imunologia , Anticorpos Antivirais/imunologia , Antígenos CD/imunologia , Antígenos de Diferenciação de Linfócitos T/imunologia , Linfócitos B/imunologia , Biomarcadores/sangue , Proteínas Sanguíneas/metabolismo , Estudos de Coortes , Estado Terminal/mortalidade , Feminino , Humanos , Imunofenotipagem , Influenza Humana/imunologia , Lectinas Tipo C/imunologia , Ativação Linfocitária , Masculino , Pessoa de Meia-Idade , Células T Invariantes Associadas à Mucosa/imunologia , Gravidade do Paciente
9.
Nutrients ; 13(9)2021 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-34578888

RESUMO

We aimed to study the possible association of stress hyperglycemia in COVID-19 critically ill patients with prognosis, artificial nutrition, circulating osteocalcin, and other serum markers of inflammation and compare them with non-COVID-19 patients. Fifty-two critical patients at the intensive care unit (ICU), 26 with COVID-19 and 26 non-COVID-19, were included. Glycemic control, delivery of artificial nutrition, serum osteocalcin, total and ICU stays, and mortality were recorded. Patients with COVID-19 had higher ICU stays, were on artificial nutrition for longer (p = 0.004), and needed more frequently insulin infusion therapy (p = 0.022) to control stress hyperglycemia. The need for insulin infusion therapy was associated with higher energy (p = 0.001) and glucose delivered through artificial nutrition (p = 0.040). Those patients with stress hyperglycemia showed higher ICU stays (23 ± 17 vs. 11 ± 13 days, p = 0.007). Serum osteocalcin was a good marker for hyperglycemia, as it inversely correlated with glycemia at admission in the ICU (r = -0.476, p = 0.001) and at days 2 (r = -0.409, p = 0.007) and 3 (r = -0.351, p = 0.049). In conclusion, hyperglycemia in critically ill COVID-19 patients was associated with longer ICU stays. Low circulating osteocalcin was a good marker for stress hyperglycemia.


Assuntos
COVID-19/sangue , Hiperglicemia/sangue , Osteocalcina/sangue , Nutrição Parenteral/mortalidade , SARS-CoV-2 , Idoso , Biomarcadores/sangue , COVID-19/complicações , COVID-19/mortalidade , Resultados de Cuidados Críticos , Estado Terminal/mortalidade , Feminino , Humanos , Hiperglicemia/mortalidade , Hiperglicemia/virologia , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prognóstico
10.
Lancet Child Adolesc Health ; 5(10): 739-750, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34370979

RESUMO

In an era of tremendous medical advancements, it is important to characterise and address inequities in the provision of health care and in outcomes. There is a large body of evidence describing such disparities by race or ethnicity and socioeconomic position in critically ill adults; however, this important issue has received less attention in children and adolescents (aged ≤21 years). This Review presents a summary of the available evidence on disparities in outcomes in paediatric critical illness in the USA as a result of racism and socioeconomic privilege. The majority of evidence of racial and socioeconomic disparities in paediatric critical care originates from the USA and is retrospective, with only one prospective intervention-based study. Although there is mixed evidence of disparities by race or ethnicity and socioeconomic position in general paediatric intensive care unit admissions and outcomes in the USA, there are striking trends within some disease processes. Notably, there is evidence of disparities in management and outcomes for out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and oncology, and in families' perceptions of care. Furthermore, there is clear evidence that critical care research is limited by under-enrolment of participants from minority race or ethnicity groups. We advocate for rigorous research standards and increases in the recruitment and enrolment of a diverse range of participants in paediatric critical care research to better understand the disparities observed, including the effects of racism and poverty. A clearer understanding of when, where, and how such disparities affect patients will better enable the development of effective strategies to inform practice, interventions, and policy.


Assuntos
Cuidados Críticos/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde , Avaliação de Resultados em Cuidados de Saúde , Adolescente , Criança , Estado Terminal/mortalidade , Estado Terminal/terapia , Grupos Étnicos , Mortalidade Hospitalar/etnologia , Humanos , Grupos Minoritários , Características de Residência , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos/epidemiologia
11.
Crit Care ; 25(1): 283, 2021 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-34362415

RESUMO

BACKGROUND: The intensity of ventilation, reflected by driving pressure (ΔP) and mechanical power (MP), has an association with outcome in invasively ventilated patients with or without acute respiratory distress syndrome (ARDS). It is uncertain if a similar association exists in coronavirus disease 2019 (COVID-19) patients with acute respiratory failure. METHODS: We aimed to investigate the impact of intensity of ventilation on patient outcome. The PRoVENT-COVID study is a national multicenter observational study in COVID-19 patients receiving invasive ventilation. Ventilator parameters were collected a fixed time points on the first calendar day of invasive ventilation. Mean dynamic ΔP and MP were calculated for individual patients at time points without evidence of spontaneous breathing. A Cox proportional hazard model, and a double stratification analysis adjusted for confounders were used to estimate the independent associations of ΔP and MP with outcome. The primary endpoint was 28-day mortality. RESULTS: In 825 patients included in this analysis, 28-day mortality was 27.5%. ΔP was not independently associated with mortality (HR 1.02 [95% confidence interval 0.88-1.18]; P = 0.750). MP, however, was independently associated with 28-day mortality (HR 1.17 [95% CI 1.01-1.36]; P = 0.031), and increasing quartiles of MP, stratified on comparable levels of ΔP, had higher risks of 28-day mortality (HR 1.15 [95% CI 1.01-1.30]; P = 0.028). CONCLUSIONS: In this cohort of critically ill invasively ventilated COVID-19 patients with acute respiratory failure, we show an independent association of MP, but not ΔP with 28-day mortality. MP could serve as one prognostic biomarker in addition to ΔP in these patients. Efforts aiming at limiting both ΔP and MP could translate in a better outcome. Trial registration Clinicaltrials.gov (study identifier NCT04346342).


Assuntos
COVID-19/mortalidade , COVID-19/terapia , Respiração Artificial/mortalidade , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Idoso , Estudos de Coortes , Estado Terminal/mortalidade , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Respiração Artificial/tendências , Estudos Retrospectivos , Volume de Ventilação Pulmonar/fisiologia
12.
PLoS One ; 16(8): e0255644, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34347836

RESUMO

OBJECTIVES: In severe COVID-19 pneumonia, the appropriate timing and dosing of corticosteroids (CS) is not known. Patient subgroups for which CS could be more beneficial also need appraisal. The aim of this study was to assess the effect of early CS in COVID-19 pneumonia patients admitted to the ICU on the occurrence of 60-day mortality, ICU-acquired-bloodstream infections(ICU-BSI), and hospital-acquired pneumonia and ventilator-associated pneumonia(HAP-VAP). METHODS: We included patients with COVID-19 pneumonia admitted to 11 ICUs belonging to the French OutcomeReaTM network from January to May 2020. We used survival models with ponderation with inverse probability of treatment weighting (IPTW). RESULTS: The study population comprised 303 patients having a median age of 61.6 (53-70) years of whom 78.8% were male and 58.6% had at least one comorbidity. The median SAPS II was 33 (25-44). Invasive mechanical ventilation was required in 34.8% of the patients. Sixty-six (21.8%) patients were in the Early-C subgroup. Overall, 60-day mortality was 29.4%. The risks of 60-day mortality (IPTWHR = 0.86;95% CI 0.54 to 1.35, p = 0.51), ICU-BSI and HAP-VAP were similar in the two groups. Importantly, early CS treatment was associated with a lower mortality rate in patients aged 60 years or more (IPTWHR, 0.53;95% CI, 0.3-0.93; p = 0.03). In contrast, CS was associated with an increased risk of death in patients younger than 60 years without inflammation on admission (IPTWHR = 5.01;95% CI, 1.05, 23.88; p = 0.04). CONCLUSION: For patients with COVID-19 pneumonia, early CS treatment was not associated with patient survival. Interestingly, inflammation and age can significantly influence the effect of CS.


Assuntos
Corticosteroides/administração & dosagem , COVID-19/tratamento farmacológico , COVID-19/mortalidade , Adulto , Idoso , COVID-19/terapia , Estudos de Coortes , Redes Comunitárias , Estado Terminal/mortalidade , Estado Terminal/terapia , Esquema de Medicação , Intervenção Médica Precoce/métodos , Feminino , França/epidemiologia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
13.
Medicine (Baltimore) ; 100(32): e26856, 2021 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-34397894

RESUMO

ABSTRACT: Rapid response systems (RRS) have been introduced worldwide to reduce unpredicted in-hospital cardiac arrest (IHCA) and in-hospital mortality. The role of advance care planning (ACP) in the management of critical patients has not yet been fully determined in Japan.We retrospectively assessed the characteristics of all inpatients with unpredicted IHCA in our hospital between 2016 and 2018. Yearly changes in the number of RRS activations and the incidence of unpredicted IHCA with or without code status discussion were evaluated from 2014 to 2018. Hospital standardized mortality ratios were assessed from the data reported in the annual reports by the National Hospital Organization.A total of 81 patients (age: 70.9 ±â€Š13.3 years) suffered an unpredicted IHCA and had multiple background diseases, including heart disease (75.3%), chronic kidney disease (25.9%), and postoperative status (cardiovascular surgery, 18.5%). Most of the patients manifested non-shockable rhythms (69.1%); survival to hospital discharge rate was markedly lower than that with shockable rhythms (26.8% vs 72.0%, P < .001). The hospital standardized mortality ratios was maintained nearly constant at approximately 50.0% for 3 consecutive years. The number of cases of RRS activation markedly increased from 75 in 2014 to 274 patients in 2018; conversely, the number of unpredicted IHCA cases was reduced from 40 in 2014 to 18 in 2018 (P < .001). Considering the data obtained in 2014 and 2015 as references, the RRS led to a reduction in the relative risk of unpredicted IHCA from 2016 to 2018 (ie, 0.618, 95% confidence interval 0.453-0.843). The reduction in unpredicted IHCA was attributed partly to the increased number of patients who had discussed the code status, and a significant correlation was observed between these parameters (R2 = 0.992, P < .001). The reduction in the number of patients with end-stage disease, including congestive heart failure and chronic renal failure, paralleled the incidence of unpredicted IHCA.Both RRS and ACP reduced the incidence of unpredicted IHCA; RRS prevents progression to unpredicted IHCA, whereas ACP decreases the number of patients with no code status discussion and thus potentially reducing the patient subgroup progressing to an unpredicted IHCA.


Assuntos
Reanimação Cardiopulmonar , Estado Terminal , Parada Cardíaca , Equipe de Respostas Rápidas de Hospitais , Hospitais Urbanos , Planejamento Antecipado de Cuidados/organização & administração , Idoso , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/normas , Estado Terminal/mortalidade , Estado Terminal/terapia , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Equipe de Respostas Rápidas de Hospitais/organização & administração , Equipe de Respostas Rápidas de Hospitais/normas , Hospitais Urbanos/organização & administração , Hospitais Urbanos/normas , Humanos , Incidência , Japão/epidemiologia , Masculino , Determinação de Necessidades de Cuidados de Saúde , Prognóstico , Medição de Risco
14.
Nutrients ; 13(8)2021 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-34444886

RESUMO

Skeletal muscle wasting in the intensive care unit (ICU) has been associated with mortality, but it is unclear whether sarcopenia, defined by skeletal muscle mass and function, is useful for detailed risk stratification after ICU discharge. In this cohort study, 72 critically ill patients with an ICU stay of ≥48 h were identified. Skeletal muscle mass was assessed from the muscle thickness (MT) of the patients' quadriceps using ultrasound images before ICU discharge. Skeletal muscle function was assessed from the patients' muscle strength (MS) before ICU discharge according to the Medical Research Council sum score. A diagnosis of sarcopenia in the ICU was made in patients with low MT and low MS. The study endpoint was 1-year mortality. Sarcopenia in the ICU was diagnosed in 26/72 patients (36%). After adjusting for covariates in the Cox regression, sarcopenia in the ICU was significantly associated with 1-year mortality (hazard ratio 3.82; 95% confidence interval, 1.40-10.42). Sarcopenia in the ICU, defined by low skeletal muscle mass and function, was associated with 1-year mortality in survivors of critical illness. Skeletal muscle mass and function assessed at the bedside could be used to identify higher-risk patients in the ICU.


Assuntos
Estado Terminal/mortalidade , Avaliação Nutricional , Alta do Paciente/estatística & dados numéricos , Sarcopenia/mortalidade , Sobreviventes/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Força Muscular , Músculo Esquelético/fisiopatologia , Modelos de Riscos Proporcionais , Músculo Quadríceps/diagnóstico por imagem , Músculo Quadríceps/fisiopatologia , Medição de Risco , Sarcopenia/diagnóstico , Ultrassonografia
15.
Crit Care ; 25(1): 240, 2021 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-34233720

RESUMO

BACKGROUND: A plasma glutamine concentration outside the normal range at Intensive Care Unit (ICU) admission has been reported to be associated with an increased mortality rate. Whereas hypoglutaminemia has been frequently reported, the number of patients with hyperglutaminemia has so far been quite few. Therefore, the association between hyperglutaminemia and mortality outcomes was studied in a prospective, observational study. PATIENTS AND METHODS: Consecutive admissions to a mixed general ICU were eligible. Exclusion criteria were < 18 years of age, readmissions, no informed consent, or a 'do not resuscitate' order at admission. A blood sample was saved within one hour from admission to be analysed by high-pressure liquid chromatography for glutamine concentration. Conventional risk scoring (Simplified Acute Physiology Score and Sequential Organ Failure Assessment) at admission, and mortality outcomes were recorded for all included patients. RESULTS: Out of 269 included patients, 26 were hyperglutaminemic (≥ 930 µmol/L) at admission. The six-month mortality rate for this subgroup was 46%, compared to 18% for patients with a plasma glutamine concentration < 930 µmol/L (P = 0.002). A regression analysis showed that hyperglutaminemia was an independent mortality predictor that added prediction value to conventional admission risk scoring and age. CONCLUSION: Hyperglutaminemia in critical illness at ICU admission was an independent mortality predictor, often but not always, associated with an acute liver condition. The mechanism behind a plasma glutamine concentration outside normal range, as well as the prognostic value of repeated measurements of plasma glutamine during ICU stay, remains to be investigated.


Assuntos
Glutamina/análise , Idoso , Estado Terminal/mortalidade , Feminino , Glutamina/sangue , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Pessoa de Meia-Idade , Prognóstico , Curva ROC , Análise de Regressão , Fatores de Risco , Estatísticas não Paramétricas
16.
Biomed Res Int ; 2021: 6616120, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34258271

RESUMO

Background: Acute kidney injury (AKI) is a common clinical syndrome carrying high morbidity and mortality. Body mass index (BMI) is a common health indicator, and a high BMI value-obesity has been shown to be associated with the outcomes of several diseases. However, the relationship between different BMI categories and mortality in all critically ill patients with AKI is unclear and needs further investigation. Therefore, we evaluated the ability of BMI to predict the severity and all-cause mortality of AKI in critically ill patients. Methods: We extracted clinical data from the MIMIC-III v1.4 database. All adult patients with AKI were initially screened. The baseline data extracted within 24 hours after ICU admission were presented according to WHO BMI categories. Logistic regression models and the Cox proportional hazards models were, respectively, constructed to assess the relationship between BMI and the severity and all-cause mortality of AKI. The generalized additive model (GAM) was used to identify nonlinear relationships as BMI was a continuous variable. The subgroup analyses were performed to further analyze the stability of the association between BMI category and 365-day all-cause mortality of AKI. Result: A total of 15,174 patients were extracted and were divided into four groups according to BMI. Obese patients were more likely to be young and male. In the fully adjusted logistic regression model, we found that overweight and obesity were significant predictors of AKI stage III (OR, 95 CI: 1.17, 1.05-1.30; 1.32, 1.18-1.47). In the fully adjusted Cox proportional hazards model, overweight and obesity were associated with significantly lower 30-day, 90-day, and 365-day all-cause mortality. The corresponding adjusted HRs (95 CIs) for overweight patients were 0.87 (0.77, 0.99), 0.84 (0.76, 0.93), and 0.80 (0.74, 0.88), and for obese patients, they were 0.87 (0.77, 0.98), 0.79 (0.71, 0.88), and 0.73 (0.66, 0.80), respectively. The subgroup analyses further presented a stable relationship between BMI category and 365-day all-cause mortality. Conclusions: BMI was independently associated with the severity and all-cause mortality of AKI in critical illness. Overweight and obesity were associated with increased risk of AKI stage III; however, they were predictive of a relatively lower mortality risk in these patients.


Assuntos
Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/patologia , Índice de Massa Corporal , Cuidados Críticos , Estado Terminal/mortalidade , Bases de Dados Factuais , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Intervalos de Confiança , Feminino , Humanos , Masculino
17.
Med Intensiva (Engl Ed) ; 45(6): 325-331, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34294231

RESUMO

OBJECTIVE: To describe outcomes of critically ill patients with COVID-19, particularly the association of renal replacement therapy to mortality. DESIGN: A single-center prospective observational study was carried out. SETTING: ICU of a tertiary care center. PATIENTS: Consecutive adults with COVID-19 admitted to the ICU. INTERVENTION: Renal replacement therapy. MAIN VARIABLES OF INTEREST: Demographic data, medical history, illness severity, type of oxygen therapy, laboratory data and use of renal replacement therapy to generate a logistic regression model describing independent risk factors for mortality. RESULTS: Of the total of 166 patients, 51% were mechanically ventilated and 26% required renal replacement therapy. The overall hospital mortality rate was 36%, versus 56% for those requiring renal replacement therapy, and 68% for those with both mechanical ventilation and renal replacement therapy. The logistic regression model identified four independent risk factors for mortality: age (adjusted OR 2.8 [95% CI 1.8-4.4] for every 10-year increase), mechanical ventilation (4.2 [1.7-10.6]), need for continuous venovenous hemofiltration (2.3 [1.3-4.0]) and C-reactive protein (1.1 [1.0-1.2] for every 10mg/L increase). CONCLUSIONS: In our cohort, acute kidney injury requiring renal replacement therapy was associated to a high mortality rate similar to that associated to the need for mechanical ventilation, while multiorgan failure necessitating both techniques implied an extremely high mortality risk.


Assuntos
Injúria Renal Aguda/terapia , COVID-19/complicações , Estado Terminal/terapia , Terapia de Substituição Renal , SARS-CoV-2 , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/mortalidade , Corticosteroides/uso terapêutico , Adulto , Fatores Etários , Idoso , Proteína C-Reativa/análise , COVID-19/sangue , Comorbidade , Terapia de Substituição Renal Contínua , Estado Terminal/mortalidade , District of Columbia/epidemiologia , Feminino , Mortalidade Hospitalar , Hospitais Universitários/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Oxigenoterapia/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Estudos Prospectivos , Terapia de Substituição Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Fatores de Risco , Centros de Atenção Terciária/estatística & dados numéricos , Resultado do Tratamento
18.
Front Endocrinol (Lausanne) ; 12: 644055, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34220703

RESUMO

Objective: We aimed to measure insulin-like growth factor 1 (IGF1) and growth hormone (GH) in critically and non-critically ill patients with Covid-19 and assess them vis-a-vis clinical and laboratory parameters and prognostic tools. Subjects and Methods: We included patients who were admitted to the wards or the ICU of the largest Covid-19 referral hospital in Greece; patients with non-Covid-19 pneumonia served as controls. Apart from the routine laboratory work-up for Covid-19 we measured GH and IGF1 (and calculated normalized IGF-1 values as standard deviation scores; SDS), after blood sampling upon admission to the wards or the ICU. Results: We studied 209 critically and non-critically ill patients with Covid-19 and 39 control patients. Patients with Covid-19 who were ICU non-survivors were older and presented with a worse hematological/biochemical profile (including white blood cell count, troponin, glucose, aminotransferases and lactate dehydrogenase) compared to ICU survivors or Covid-19 survivors in the wards. Overall, IGF-1 SDS was higher in Covid-19 survivors compared to non-survivors (-0.96 ± 1.89 vs -2.05 ± 2.48, respectively, p=0.030). No significant differences were noted in GH between the groups. Nevertheless, in critically ill patients with Covid-19, the prognostic value of IGF-1 (raw data), IGF-1 (SDS) and GH for survival/non-survival was on a par with that of APACHE II and SOFA (with a marginal difference between GH and SOFA). Conclusion: In conclusion, our findings suggest that there might be an association between low IGF1 (and possibly GH) and poor outcome in patients with Covid-19.


Assuntos
COVID-19/metabolismo , COVID-19/patologia , Estado Terminal , Hormônio do Crescimento Humano/metabolismo , Fator de Crescimento Insulin-Like I/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/diagnóstico , COVID-19/mortalidade , Estudos de Casos e Controles , Estado Terminal/mortalidade , Feminino , Grécia/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prognóstico , SARS-CoV-2/fisiologia , Índice de Gravidade de Doença , Sobreviventes/estatística & dados numéricos
19.
Crit Care ; 25(1): 223, 2021 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-34193235

RESUMO

BACKGROUND: Thiamine is a precursor of the essential coenzyme thiamine pyrophosphate required for glucose metabolism; it improves the immune system function and has shown to reduce the risk of several diseases. The role of thiamine in critically ill septic patient has been addressed in multiple studies; however, it's role in COVID-19 patients is still unclear. The aim of this study was to evaluate the use of thiamine as an adjunctive therapy on mortality in COVID-19 critically ill patients. METHODS: This is a two-center, non-interventional, retrospective cohort study for critically ill patients admitted to intensive care units (ICUs) with a confirmed diagnosis of COVID19. All patients aged 18 years or older admitted to ICUs between March 1, 2020, and December 31, 2020, with positive PCR COVID-19 were eligible for inclusion. We investigated thiamine use as an adjunctive therapy on the clinical outcomes in critically ill COVID-19 patients after propensity score matching. RESULTS: A total of 738 critically ill patients with COVID-19 who had been admitted to ICUs were included in the study. Among 166 patients matched using the propensity score method, 83 had received thiamine as adjunctive therapy. There was significant association between thiamine use with in-hospital mortality (OR = 0.39; 95% CI 0.19-0.78; P value = 0.008) as well as the 30-day mortality (OR = 0.37; 95% CI 0.18-0.78; P value = 0.009). Moreover, patients who received thiamine as an adjunctive therapy were less likely to have thrombosis during ICU stay [OR (95% CI) 0.19 (0.04-0.88), P value = 0.03]. CONCLUSION: Thiamine use as adjunctive therapy may have potential survival benefits in critically ill patients with COVID-19. Additionally, it was associated with a lower incidence of thrombosis. Further interventional studies are required to confirm these findings.


Assuntos
COVID-19/tratamento farmacológico , COVID-19/mortalidade , Estado Terminal/mortalidade , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/mortalidade , Tiamina/uso terapêutico , Adulto , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Trombose/prevenção & controle
20.
Vet J ; 273: 105677, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34148600

RESUMO

Critical illness-related corticosteroid insufficiency (CIRCI) refers to a lack of adequate corticosteroid activity, which occurs in up to 48% of dogs with sepsis. However, data regarding the occurrence of CIRCI in critically-ill dogs are still scarce. This study aimed to assess: (1) the relationship between CIRCI and clinicopathological inflammatory markers, hypotension and mortality; and (2) the impact of low-dose hydrocortisone treatment on survival. Twenty-one dogs diagnosed with systemic inflammatory response syndrome (SIRS) were enrolled in a prospective case-control study. All dogs were initially evaluated for adrenal function with an ACTH stimulation test and dogs with Δcortisol ≤ 3 µg/dL were diagnosed with CIRCI. Mean arterial pressure (MAP), white blood cell (WBC), band neutrophils (bNs), c-reactive protein (CRP), and 28-day mortality rate were assessed. Fourteen dogs were treated with low-dose hydrocortisone. The relationships between CIRCI and MAP, WBC, bN, CRP, basal cortisol and mortality were investigated, as was the association between mortality and hydrocortisone treatment. Ten of 21 (48%) dogs were diagnosed with CIRCI. Increased bNs were associated with the presence of CIRCI (P = 0.0075). CRP was higher in dogs with CIRCI (P = 0.02). Fourteen of 21 (66%) dogs died during the study (6/14 had CIRCI). Basal hypercortisolemia (>5 µg/dL) was associated with increased risk of mortality (P = 0.025). Based on our diagnostic criteria, CIRCI occurs frequently in dogs with SIRS and was associated with increased bNs and increased CRP. In this study, CIRCI and low-dose hydrocortisone treatment were not significantly associated with mortality, but basal hypercortisolemia was associated with increased mortality.


Assuntos
Corticosteroides/deficiência , Hidrocortisona/uso terapêutico , Síndrome de Resposta Inflamatória Sistêmica/veterinária , Animais , Estudos de Casos e Controles , Estado Terminal/mortalidade , Doenças do Cão/tratamento farmacológico , Doenças do Cão/fisiopatologia , Cães , Feminino , Hidrocortisona/sangue , Hipotensão/veterinária , Masculino , Neutrófilos , Projetos Piloto , Estudos Prospectivos , Síndrome de Resposta Inflamatória Sistêmica/tratamento farmacológico , Síndrome de Resposta Inflamatória Sistêmica/mortalidade , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologia
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