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1.
Crit Care ; 24(1): 610, 2020 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-33066801

RESUMO

BACKGROUND: Data on SARS-CoV-2 load in lower respiratory tract (LRT) are scarce. Our objectives were to describe the viral shedding and the viral load in LRT and to determine their association with mortality in critically ill COVID-19 patients. METHODS: We conducted a binational study merging prospectively collected data from two COVID-19 reference centers in France and Switzerland. First, we described the viral shedding duration (i.e., time to negativity) in LRT samples. Second, we analyzed viral load in LRT samples. Third, we assessed the association between viral presence in LRT and mortality using mixed-effect logistic models for clustered data adjusting for the time between symptoms' onset and date of sampling. RESULTS: From March to May 2020, 267 LRT samples were performed in 90 patients from both centers. The median time to negativity was 29 (IQR 23; 34) days. Prolonged viral shedding was not associated with age, gender, cardiac comorbidities, diabetes, immunosuppression, corticosteroids use, or antiviral therapy. The LRT viral load tended to be higher in non-survivors. This difference was statistically significant after adjusting for the time interval between onset of symptoms and date of sampling (OR 3.78, 95% CI 1.13-12.64, p = 0.03). CONCLUSIONS: The viral shedding in LRT lasted almost 30 days in median in critically ill patients, and the viral load in the LRT was associated with the 6-week mortality.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/diagnóstico , Pneumonia Viral/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/terapia , Síndrome do Desconforto Respiratório do Adulto/virologia , Sistema Respiratório/virologia , Idoso , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/mortalidade , Estudos Prospectivos , Respiração Artificial , Suíça/epidemiologia , Carga Viral , Eliminação de Partículas Virais
2.
Crit Care Med ; 48(11): e1097-e1101, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33045152

RESUMO

OBJECTIVES: To characterize the impact of obesity on disease severity in patients with coronavirus disease 2019. DESIGN: This was a retrospective cohort study designed to evaluate the association between body mass index and risk of severe disease in patients with coronavirus disease 2019. Data were abstracted from the electronic health record. The primary endpoint was a composite of intubation or death. SETTING: Two hospitals in Massachusetts (one quaternary referral center and one affiliated community hospital). PATIENTS: Consecutive patients hospitalized with confirmed coronavirus disease 2019 admitted between March 13, 2020, and April 3, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 305 patients were included in this study. We stratified patients by body mass index category: < 25 kg/m (54 patients, 18%), ≥ 25 kg/m to < 30 kg/m (124 patients, 41%), ≥ 30 kg/m to < 35 kg/m (58 patients, 19%), and ≥ 35 kg/m (69 patients, 23%). In total, 128 patients (42%) had a primary endpoint (119 patients [39%] were intubated and nine died [3%] without intubation). Sixty-five patients (51%) with body mass index greater than or equal to 30 kg/m were intubated or died. Adjusted Cox models demonstrated that body mass index greater than or equal to 30 kg/m was associated with a 2.3-fold increased risk of intubation or death (95% CI, 1.2-4.3) compared with individuals with body mass index less than 25 kg/m. Diabetes was also independently associated with risk of intubation or death (hazard ratio, 1.8; 95% CI, 1.2-2.7). Fifty-six out of 127 patients (44%) with body mass index greater than or equal to 30 kg/m had diabetes, and the combination of both diabetes and body mass index greater than or equal to 30 kg/m was associated with a 4.5-fold increased risk of intubation or death (95% CI, 2.0-10.2) compared with patients without diabetes and body mass index less than 25 kg/m. CONCLUSIONS: Among consecutive patients hospitalized with coronavirus disease 2019, obesity was an independent risk factor for intubation or death.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Intubação Intratraqueal/mortalidade , Obesidade/mortalidade , Pneumonia Viral/mortalidade , Adulto , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Infecções por Coronavirus/terapia , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Pandemias , Pneumonia Viral/terapia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença
3.
Tohoku J Exp Med ; 252(2): 103-107, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32938838

RESUMO

Coronavirus disease 2019 (COVID-19) is a global public health concern that can be classified as mild, moderate, severe, or critical, based on disease severity. Since the identification of critical patients is crucial for developing effective management strategies, we evaluated clinical characteristics, laboratory data, treatment provided, and oxygenation to identify potential predictors of mortality among critical COVID-19 pneumonia patients. We retrospectively utilized data from seven critical patients who were admitted to our hospital during April 2020 and required mechanical ventilation. The primary endpoint was to clarify potential predictor of mortality. All patients were older than 70 years, five were men, six had hypertension, and three ultimately died. Compared with survivors, non-survivors tended to be never smokers (0 pack-years vs. 30 pack-years, p = 0.08), to have higher body mass index (31.3 kg/m2 vs. 25.3 kg/m2, p = 0.06), to require earlier tracheal intubation after symptom onset (2.7 days vs. 5.5 days, p = 0.07), and had fewer lymphocytes on admission (339 /µL vs. 518 /µL, p = 0.05). During the first week after tracheal intubation, non-survivors displayed lower values for minimum ratio of the partial pressure of oxygen to fractional inspiratory oxygen concentration (P/F ratio) (44 mmHg vs. 122 mmHg, p < 0.01) and poor response to intensive therapy compared with survivors. In summary, we show that obesity and lymphopenia could predict the severity of COVID-19 pneumonia and that the trend of lower P/F ratio during the first week of mechanical ventilation could provide useful prognostic information.


Assuntos
Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Estado Terminal/terapia , Intubação Intratraqueal , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Fumar , Idoso , Betacoronavirus/fisiologia , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Estado Terminal/epidemiologia , Estado Terminal/mortalidade , Feminino , Hospitalização , Humanos , Intubação Intratraqueal/mortalidade , Masculino , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Prognóstico , Radiografia Torácica , Estudos Retrospectivos , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Fumar/mortalidade , Fumar/terapia , Tomografia Computadorizada por Raios X
4.
S Afr Med J ; 110(7): 629-634, 2020 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-32880337

RESUMO

Pandemics challenge clinicians and scientists in many ways, especially when the virus is novel and disease expression becomes variable or unpredictable. Under such circumstances, research becomes critical to inform clinical care and protect future patients. Given that severely ill patients admitted to intensive care units are at high risk of mortality, establishing the cause of death at a histopathological level could prove invaluable in contributing to the understanding of COVID-19. Postmortem examination including autopsies would be optimal. However, in the context of high contagion and limited personal protective equipment, full autopsies are not being conducted in South Africa (SA). A compromise would require tissue biopsies and samples to be taken immediately after death to obtain diagnostic information, which could potentially guide care of future patients, or generate hypotheses for finding needed solutions. In the absence of an advance written directive (including a will or medical record) providing consent for postmortem research, proxy consent is the next best option. However, obtaining consent from distraught family members, under circumstances of legally mandated lockdown when strict infection control measures limit visitors in hospitals, is challenging. Their extreme vulnerability and emotional distress make full understanding of the rationale and consent process difficult either before or upon death of a family member. While it is morally distressing to convey a message of death telephonically, it is inhumane to request consent for urgent research in the same conversation. Careful balancing of the principles of autonomy, non-maleficence and justice becomes an ethical imperative. Under such circumstances, a waiver of consent, preferably followed by deferred proxy consent, granted by a research ethics committee in keeping with national ethics guidance and legislation, would fulfil the basic premise of care and research: first do no harm. This article examines the SA research ethics framework, guidance and legislation to justify support for a waiver of consent followed by deferred proxy consent, when possible, in urgent research after death to inform current and future care to contain the pandemic in the public interest.


Assuntos
Infecções por Coronavirus/epidemiologia , Cuidados Críticos/ética , Estado Terminal/terapia , Mortalidade Hospitalar , Consentimento Livre e Esclarecido/ética , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Causas de Morte , Infecções por Coronavirus/prevenção & controle , Cuidados Críticos/legislação & jurisprudência , Estado Terminal/mortalidade , Países em Desenvolvimento , Feminino , Humanos , Controle de Infecções/organização & administração , Unidades de Terapia Intensiva/ética , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Projetos de Pesquisa , Medição de Risco , África do Sul , Populações Vulneráveis/estatística & dados numéricos
5.
Int J Med Sci ; 17(14): 2225-2231, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32922185

RESUMO

Background: Lactate dehydrogenase (LDH) has been proved to be a prognostic factor for the severity and poor outcomes of coronavirus disease 2019 (COVID-19). In most studies, patients with various levels of COVID-19 severity were pooled and analyzed which may prevent accurate evaluation of the relationship between LDH and disease progression and in-hospital death. In this study, we aimed to evaluate the association of LDH with in-hospital mortality in severe and critically ill patients with COVID-19. Methods: This single-center retrospective study enrolled 119 patients. Survival curves were plotted using Kaplan-Meier method and compared by log-rank test. Multivariate Cox regression models were used to determine the independent risk factors for in-hospital mortality. Receiver-operator curves (ROCs) were constructed to evaluate the predictive accuracy of LDH and other prognostic biomarkers. Results: Compared to the survival group, LDH levels in the dead group were significantly higher [559.5 (172, 7575) U/L vs 228 (117, 490) U/L, (P < 0.001)]. In Multivariate Cox regression, it remained an independent risk factor for in-hospital mortality (Hazard ratio 5.985, 95.0%CI: 1.498-23.905; P=0.011). A cutoff value of 353.5 U/L predicted the in-hospital mortality with a sensitivity of 94.4% and a specificity of 89.2% respectively. Conclusion: LDH is a favorable prognostic biomarker with high accuracy for predicting in-hospital mortality in severe and critically ill patients with COVID-19. This may direct physicians worldwide to effectively prioritize resources for patients at high risk of death and to implement more aggressive treatments at an earlier phase to save patients' lives.


Assuntos
Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Mortalidade Hospitalar , L-Lactato Desidrogenase/sangue , Pneumonia Viral/mortalidade , Índice de Gravidade de Doença , Adulto , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus/isolamento & purificação , Betacoronavirus/patogenicidade , Biomarcadores/sangue , China/epidemiologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Estudos Retrospectivos , Fatores de Risco
6.
Int J Med Sci ; 17(15): 2257-2263, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32922189

RESUMO

Background: Corona Virus Disease 2019 (COVID-19) has become a global pandemic. This study established prognostic scoring models based on comorbidities and other clinical information for severe and critical patients with COVID-19. Material and Methods: We retrospectively collected data from 51 patients diagnosed as severe or critical COVID-19 who were admitted between January 29, 2020, and February 18, 2020. The Charlson (CCI), Elixhauser (ECI), and age- and smoking-adjusted Charlson (ASCCI) and Elixhauser (ASECI) comorbidity indices were used to evaluate the patient outcomes. Results: The mean hospital length of stay (LOS) of the COVID-19 patients was 22.82 ± 12.32 days; 19 patients (37.3%) were hospitalized for more than 24 days. Multivariate analysis identified older age (OR 1.064, P = 0.018, 95%CI 1.011-1.121) and smoking (OR 3.696, P = 0.080, 95%CI 0.856-15.955) as positive predictors of a long LOS. There were significant trends for increasing hospital LOS with increasing CCI, ASCCI, and ASECI scores (OR 57.500, P = 0.001, 95%CI 5.687-581.399; OR 71.500, P = 0.001, 95%CI 5.689-898.642; and OR 19.556, P = 0.001, 95%CI 3.315-115.372, respectively). The result was similar for the outcome of critical illness (OR 21.333, P = 0.001, 95%CI 3.565-127.672; OR 13.000, P = 0.009, 95%CI 1.921-87.990; OR 11.333, P = 0.008, 95%CI 1.859-69.080, respectively). Conclusions: This study established prognostic scoring models based on comorbidities and clinical information, which may help with the graded management of patients according to prognosis score and remind physicians to pay more attention to patients with high scores.


Assuntos
Comorbidade , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Modelos Estatísticos , Pneumonia Viral/mortalidade , Índice de Gravidade de Doença , Adulto , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus/isolamento & purificação , Betacoronavirus/patogenicidade , Tomada de Decisão Clínica , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos
7.
Medicine (Baltimore) ; 99(36): e21596, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32898996

RESUMO

INTRODUCTION: Globally, the coronavirus disease 2019 (COVID-19) is still spreading rapidly. At present, there are no specifically approved therapeutic agents or vaccines for its treatment. Previous studies have shown that the convalescent plasma therapy (CPT) is effective in patients with COVID-19. However, its efficacy in patients with persistently positive nucleic acid test is unknown. PATIENT CONCERNS: In this report, we present the clinical data of 5 critically ill COVID-19 patients admitted, between January 16 and February 26, 2020, in intensive care unit of Xiaogan Central Hospital. DIAGNOSIS AND INTERVENTIONS: All these patients had a persistently positive nucleic acid test and received CPT. All 5 patients had severe respiratory failure, and thus, required invasive mechanical ventilation. The median time from the onset of symptoms to initiating the CPT was 37 (Interquartile range, 34-44) days. OUTCOMES: Only 2 patients were cured and subsequently discharged, while 3 patients succumbed due to multiple organ failure. CONCLUSION: The time of initiating the CPT may be an important factor affecting its efficacy, and its therapeutic effect in the treatment of COVID-19, in the late stage, is limited.


Assuntos
Infecções por Coronavirus/terapia , Estado Terminal/terapia , Pneumonia Viral/terapia , APACHE , Idoso , Betacoronavirus , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Feminino , Humanos , Imunização Passiva , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/mortalidade , Técnicas de Amplificação de Ácido Nucleico , Pandemias , Pneumonia Viral/mortalidade , Respiração Artificial
8.
Medicine (Baltimore) ; 99(36): e22075, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899077

RESUMO

Red blood cell distribution width (RDW) is a component of routine complete blood count, which reflects variability in the size of circulating erythrocytes. Recently, there have been many reports about RDW as a strong prognostic marker in various disease conditions in the adult population. However, only a few studies have been performed in children. This study aimed to investigate the association between RDW and pediatric intensive care unit (PICU) mortality in critically ill children. This study includes 960 patients admitted to the PICU from November 2012 to May 2018. We evaluated the associations between RDW and clinical parameters including PICU mortality outcomes. The median age of the study population was 15.5 (interquartile range, 4.8-54.5) months. The mean RDW was 15.6% ±â€Š3.3%. The overall PICU mortality was 8.8%. As we categorized patients into 3 groups with respect to RDW values (Group 1: ≤14.5%; Group 2: 14.5%-16.5%; and Group 3: >16.5%) and compared clinical parameters, the higher RDW groups (Groups 2 and 3) showed more use of vasoactive-inotropic drugs, mechanical ventilator support, higher severity scores, including pediatric risk of mortality III, pediatric sequential organ failure assessment, pediatric logistic organ dysfunction-2 (PELOD-2), and pediatric multiple organ dysfunction syndrome scores, and higher PICU mortality than the lower RDW group (Group 1) (P < .05). Based on multivariate logistic regression analysis adjusted for age and sex, higher RDW value (≥14.5%) was an independent risk factor of PICU mortality. Moreover, adding RDW improved the performance of the PELOD-2 score in predicting PICU mortality (category-free net reclassification index 0.357, 95% confidence interval 0.153-0.562, P = .001). In conclusion, higher RDW value was significantly associated with worse clinical parameters including PICU mortality. RDW was an independent risk factor of PICU mortality and the addition of RDW significantly improved the performance of PELOD-2 score in predicting PICU mortality. Thus, RDW could be a promising prognostic factor with advantages of simple and easy measurement in critically ill pediatric patients.


Assuntos
Estado Terminal/mortalidade , Mortalidade Hospitalar/tendências , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Fatores Etários , Biomarcadores , Pré-Escolar , Índices de Eritrócitos , Feminino , Humanos , Lactente , Masculino , Insuficiência de Múltiplos Órgãos/mortalidade , Escores de Disfunção Orgânica , Prognóstico , Estudos Prospectivos , Curva ROC , República da Coreia/epidemiologia , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais
9.
R I Med J (2013) ; 103(8): 24-28, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32900008

RESUMO

BACKGROUND: Acute kidney injury (AKI) has been reported as a complication of COVID-19. However, the epidemiology, management, and associated outcomes have varied greatly between studies. The pathophysiology remains unclear.  Summary: The etiology of AKI in the setting of COVID-19 appears multifactorial. Systemic effects of sepsis, inflammation, and vascular injury likely play some role. Furthermore, SARS-CoV-2 binds to the angiotensin-converting enzyme 2 receptor, highly expressed in the kidney, providing a route for direct infection. Older age, baseline comorbidities, and respiratory failure are strong risk factors for the development of AKI. Regardless of etiology, AKI carries a significantly increased risk for in-hospital mortality, especially in those with critical illness. Currently, management of AKI in patients with COVID-19 remains supportive. Key Messages: AKI is common in patients with COVID-19. Future studies are needed to examine the response to anti-viral treatment as well as long-term renal outcomes in patients with AKI.


Assuntos
Lesão Renal Aguda , Betacoronavirus , Infecções por Coronavirus , Estado Terminal , Rim , Pandemias , Administração dos Cuidados ao Paciente/métodos , Pneumonia Viral , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Lesão Renal Aguda/virologia , Betacoronavirus/isolamento & purificação , Betacoronavirus/fisiologia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Estado Terminal/mortalidade , Estado Terminal/terapia , Mortalidade Hospitalar , Humanos , Rim/metabolismo , Rim/virologia , Peptidil Dipeptidase A/metabolismo , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Prognóstico , Medição de Risco , Fatores de Risco , Internalização do Vírus
10.
J Clin Pharmacol ; 60(11): 1411-1415, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32885463

RESUMO

The pathophysiology of respiratory failure associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains under investigation. One hypothesis is that progressive endothelial damage from the virus leads to microvascular thrombosis. It is uncertain if empiric therapeutic anticoagulation provides benefit over standard deep vein thrombosis (DVT) prophylaxis in critically ill patients with SARS-CoV-2. A retrospective cohort study was performed to evaluate adult patients admitted to the intensive care unit at 3 hospitals with polymerase chain reaction-confirmed SARS-CoV-2-associated respiratory failure requiring invasive mechanical ventilation. A Kaplan-Meier survival analysis was used to compare patients who were initiated on therapeutic anticoagulation prior to the time of intubation and those receiving standard DVT prophylaxis doses. The primary outcome was the difference in the 28-day mortality of patients between the 2 groups. Twenty-eight-day mortality did not differ between groups, occurring in 26.1% of patients who received therapeutic anticoagulation and 29.5% of those who received a prophylactic dose only (hazard ratio, 0.52; P = .055). There was no difference in 28-day mortality between groups in patients who were admitted with a serum D-dimer ≥ 2 µg/mL (hazard ratio, 0.67; P = .41). Empiric therapeutic anticoagulation in patients who require invasive mechanical ventilation for confirmed SARS-CoV-2 infection does not improve 28-day mortality compared with standard DVT prophylaxis, even among those with elevated D-dimer levels.


Assuntos
Anticoagulantes/uso terapêutico , Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Idoso , Anticoagulantes/efeitos adversos , Estudos de Coortes , Infecções por Coronavirus/tratamento farmacológico , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/tratamento farmacológico , Respiração Artificial , Insuficiência Respiratória/tratamento farmacológico , Estudos Retrospectivos , Análise de Sobrevida
11.
PLoS One ; 15(9): e0238352, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32881921

RESUMO

The dose of progressive active mobilization is still uncertain. The purpose of this study is to identify if the addition of a protocol of progressive active mobilization with dose and training load control to usual care is effective in reducing the length of stay in intensive care unit (ICU) and the improvement of the functioning, incidence of ICU-acquired weakness (ICUAW), mechanical ventilation duration and mortality rate in patients hospitalized in ICU. It is Double-blind randomised clinical trial. The setting for this trial will be medical and surgical ICU of a university hospital. The study participants will be 118 patients aged> 18 years admitted to ICU for less than 72 hours. Participants will be randomized to either an experimental or control group. The experimental group will undertake addition of a protocol of progressive active mobilization with dose and training load control to usual care, while the control group will undertake only usual care. The primary outcome will be length of ICU stay. The secondary outcomes will be Cross-sectional area and muscle thickness of the rectus femoris and biceps brachii, Change in muscle strength from the baseline, Functional Status, incidence of ICUAW, Days with mechanical ventilation and Mortality. All statistical analyses will be conducted following intention-to-treat principles. It has a detailed description of the dose of exercise, was designed with the strictest methodological criteria. These characteristics allow to investigate with greater certainty the results progressive active mobilization in critical patients, allowing replication and future combinations in meta-analyzes.


Assuntos
Estado Terminal/terapia , Adulto , Protocolos Clínicos , Estado Terminal/mortalidade , Método Duplo-Cego , Exercício Físico , Músculos Isquiossurais/fisiologia , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Tempo de Internação , Força Muscular , Músculo Quadríceps/fisiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Adulto Jovem
12.
Crit Care Med ; 48(11): e1004-e1011, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32897668

RESUMO

OBJECTIVES: To evaluate and compare the efficacy of National Early Warning Score, National Early Warning Score 2, Rapid Emergency Medicine Score, Confusion, Respiratory rate, Blood pressure, Age 65 score, and quick Sepsis-related Organ Failure Assessment on predicting in-hospital death in patients with coronavirus disease 2019. DESIGN: A retrospective, observational study. SETTING: Single center, West Campus of Wuhan Union hospital-a temporary center to manage critically ill patients with coronavirus disease 2019. PATIENTS: A total of 673 consecutive adult patients with coronavirus disease 2019 between January 30, 2020, and March 14, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data on demography, comorbidities, vital signs, mental status, oxygen saturation, and use of supplemental oxygen at admission to the ward were collected from medical records and used to score National Early Warning Score, National Early Warning Score 2, Rapid Emergency Medicine Score, Confusion, Respiratory rate, Blood pressure, Age 65 score, and quick Sepsis-related Organ Failure Assessment. Total number of patients was 673 (51% male) and median (interquartile range) age was 61 years (50-69 yr). One-hundred twenty-one patients died (18%). For predicting in-hospital death, the area under the receiver operating characteristics (95% CI) for National Early Warning Score, National Early Warning Score 2, Rapid Emergency Medicine Score, Confusion, Respiratory rate, Blood pressure, Age 65 score, and quick Sepsis-related Organ Failure Assessment were 0.882 (0.847-0.916), 0.880 (0.845-0.914), 0.839 (0.800-0.879), 0.766 (0.718-0.814), and 0.694 (0.641-0.746), respectively. Among the parameters of National Early Warning Score, the oxygen saturation score was found to be the most significant predictor of in-hospital death. The area under the receiver operating characteristic (95% CI) for oxygen saturation score was 0.875 (0.834-0.916). CONCLUSIONS: In this single-center study, the discrimination of National Early Warning Score/National Early Warning Score 2 for predicting mortality in patients with coronavirus disease 2019 admitted to the ward was found to be superior to Rapid Emergency Medicine Score, Confusion, Respiratory rate, Blood pressure, Age 65 score, and quick Sepsis-related Organ Failure Assessment. Peripheral oxygen saturation could independently predict in-hospital death in these patients. Further validation of our finding in multiple settings is needed to determine its applicability for coronavirus disease 2019.


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Escore de Alerta Precoce , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Idoso , Pressão Sanguínea , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Pandemias , Prognóstico , Estudos Retrospectivos , Medição de Risco
13.
Crit Care ; 24(1): 485, 2020 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-32758295

RESUMO

BACKGROUND: While obesity confers an increased risk of death in the general population, numerous studies have reported an association between obesity and improved survival among critically ill patients. This contrary finding has been referred to as the obesity paradox. In this retrospective study, two causal inference approaches were used to address whether the survival of non-obese critically ill patients would have been improved if they had been obese. METHODS: The study cohort comprised 6557 adult critically ill patients hospitalized at the Intensive Care Unit of the Ghent University Hospital between 2015 and 2017. Obesity was defined as a body mass index of ≥ 30 kg/m2. Two causal inference approaches were used to estimate the average effect of obesity in the non-obese (AON): a traditional approach that used regression adjustment for confounding and that assumed missingness completely at random and a robust approach that used machine learning within the targeted maximum likelihood estimation framework along with multiple imputation of missing values under the assumption of missingness at random. 1754 (26.8%) patients were discarded in the traditional approach because of at least one missing value for obesity status or confounders. RESULTS: Obesity was present in 18.9% of patients. The in-hospital mortality was 14.6% in non-obese patients and 13.5% in obese patients. The raw marginal risk difference for in-hospital mortality between obese and non-obese patients was - 1.06% (95% confidence interval (CI) - 3.23 to 1.11%, P = 0.337). The traditional approach resulted in an AON of - 2.48% (95% CI - 4.80 to - 0.15%, P = 0.037), whereas the robust approach yielded an AON of - 0.59% (95% CI - 2.77 to 1.60%, P = 0.599). CONCLUSIONS: A causal inference approach that is robust to residual confounding bias due to model misspecification and selection bias due to missing (at random) data mitigates the obesity paradox observed in critically ill patients, whereas a traditional approach results in even more paradoxical findings. The robust approach does not provide evidence that the survival of non-obese critically ill patients would have been improved if they had been obese.


Assuntos
Estado Terminal/mortalidade , Estado Terminal/terapia , Obesidade/epidemiologia , Idoso , Causalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
14.
J Intensive Care Med ; 35(10): 963-970, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32812834

RESUMO

BACKGROUND: The first confirmed case of novel coronavirus (2019-nCoV) infection in the United States was reported from the state of Washington in January, 2020. By March, 2020, New York City had become the epicenter of the outbreak in the United States. METHODS: We tracked all patients with confirmed coronavirus-19 (COVID-19) infection admitted to intensive care units (ICU) at Montefiore Medical Center (Bronx, NY). Data were obtained through manual review of electronic medical records. Patients had at least 30 days of follow-up. RESULTS: Our first 300 ICU patients were admitted March 10 through April 11, 2020. The majority (60.7%) of patients were men. Acute respiratory distress syndrome (ARDS) was documented in 91.7% of patients; 91.3% required mechanical ventilation. Prone positioning was employed in 58% of patients and neuromuscular blockade in 47.8% of mechanically-ventilated patients. Neither intervention was associated with decreased mortality. Vasopressors were required in 77.7% of patients. Acute kidney injury (AKI) was present on admission in 40.7% of patients, and developed subsequently in 36.0%; 50.9% of patients with AKI received renal replacement therapy (RRT). Overall 30-day mortality rate was 52.3%, and 55.8% among patients receiving mechanical ventilation. In univariate analysis, higher mortality rate was associated with increasing age, male sex, hypertension, obesity, smoking, number of comorbidities, AKI on presentation, and need for vasopressor support. A representative multivariable model for 30-day mortality is also presented, containing patient age, gender, body mass index, and AKI at admission. As of May 11, 2020, 2 patients (0.7%) remained hospitalized. CONCLUSIONS: Mortality in critical illness associated with COVID-19 is high. The majority of patients develop ARDS requiring mechanical ventilation, vasopressor-dependent shock, and AKI. The variation in mortality rates reported to date likely reflects differences in the severity of illness of the evaluated populations.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/mortalidade , Pneumonia Viral/mortalidade , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/virologia , Adulto , Idoso , Infecções por Coronavirus/complicações , Cuidados Críticos/métodos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Pneumonia Viral/complicações , Respiração Artificial/mortalidade , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Síndrome do Desconforto Respiratório do Adulto/virologia
15.
Malawi Med J ; 32(1): 19-23, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32733655

RESUMO

Background: Globally, critical illness causes up to 45 million deaths every year. The burden is highest in low-income countries such as Malawi. Critically ill patients require good quality, essential care in emergency departments and in hospital wards to avoid negative outcomes such as death. Little is known about the quality of care or the availability of necessary resources for emergency and critical care in Malawi. The aim of this study was to assess the availability of resources for emergency and critical care in Malawi using data from the Service Provision Assessment (SPA). Methods: We conducted a secondary data analysis of the SPA - a nationwide survey of all health facilities. We assessed the availability of resources for emergency and critical care using previously developed standards for hospitals in low-income countries. Each health facility received an availability score, calculated as the proportion of resources that were present. Resource availability was sub-divided into the seven a-priori defined categories of drugs, equipment, support services, emergency guidelines, infrastructure, training and routines. Results: Of the 254 indicators in the standards necessary for assessing the quality of emergency and critical care, SPA collected data for 102 (40.6%). Hospitals had a median resource availability score of 51.6% IQR (42.2-67.2) and smaller health facilities had a median of 37.5% (IQR 28.1-45.3). For the category of drugs, the hospitals' median score was 62.0% IQR (52.4-81.0), for equipment 51.9% IQR (40.7-66.7), support services 33.3% IQR (22.2-77.8) and emergency guidelines 33.3% IQR (0-66.7). SPA did not collect any data for resources in the categories of infrastructure, training or routines. Conclusion: Hospitals in Malawi lack resources for providing emergency and critical care. Increasing data about the availability of resources for emergency and critical care and improving the hospital systems for the care of critically ill patients in Malawi should be prioritized.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Serviço Hospitalar de Emergência/normas , Recursos em Saúde/provisão & distribução , Qualidade da Assistência à Saúde/normas , Estado Terminal/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Instalações de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde , Humanos , Malaui/epidemiologia , Inquéritos e Questionários
16.
Crit Care Med ; 48(10): 1403-1410, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32796181

RESUMO

OBJECTIVES: To describe the importance of critical care clinical research that is not pandemic-focused during pandemic times; outline principles to assist in the prioritization of nonpandemic research during pandemic times; and propose a guiding framework for decisions about whether, when and how to continue nonpandemic research while still honoring the moral and scientific imperative to launch research that is pandemic-focused. DESIGN/DATA SOURCES: Using in-person, email, and videoconference exchanges, we convened an interprofessional clinical research group, conducted a literature review of empirical studies, ethics documents and expert commentaries (2010 to present), and viewed traditional and social media posts (March 2020 to May 2020). Stakeholder consultation involved scientific, ethics, clinical, and administrative leaders. SETTING: Clinical research in the ICU. PATIENTS: Patients with and without coronavirus disease 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While clinical research should be prioritized to advantage patients with coronavirus disease 2019 in order to care for affected patients, it ideally would not unduly disadvantage patients without coronavirus disease 2019. Thus, timely, rigorous, relevant, and ethical clinical research is needed to improve the care and optimize outcomes for both patients with and without coronavirus disease 2019, acknowledging how many studies that are not exclusively focused on coronavirus disease 2019 remain relevant to patients with coronavirus disease 2019. Considerations to continue nonpandemic-focused research include the status of the pandemic, local jurisdictional guidance, capacity and safety of bedside and research personnel, disposition of patients already enrolled in nonpandemic studies, analyzing characteristics of each nonpandemic-focused study, research oversight, and final reporting requirements. CONCLUSIONS: Deliberation about continuing nonpandemic research should use objective, transparent criteria considering several aspects of the research process such as bedside and research staff safety, infection control, the informed consent model, protocol complexity, data collection, and implementation integrity. Decisions to pause or pursue nonpandemic research should be proportionate, transparent, and revisited as the pandemic abates.


Assuntos
Pesquisa Biomédica/organização & administração , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/normas , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Infecções por Coronavirus/prevenção & controle , Estado Terminal/mortalidade , Estado Terminal/terapia , Feminino , Saúde Global , Humanos , Controle de Infecções/normas , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Projetos de Pesquisa , Gestão da Segurança
17.
Resuscitation ; 155: 172-179, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32827587

RESUMO

BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR. METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019. RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001). CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.


Assuntos
Reanimação Cardiopulmonar/estatística & dados numéricos , Tomada de Decisão Clínica/ética , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Ordens quanto à Conduta (Ética Médica)/ética , Idoso , Reanimação Cardiopulmonar/métodos , Estudos de Coortes , Estado Terminal/mortalidade , Bases de Dados Factuais , Assistência à Saúde/tendências , Feminino , Mortalidade Hospitalar/tendências , Hospitais de Ensino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pandemias/prevenção & controle , Estudos Retrospectivos , Reino Unido
18.
PLoS One ; 15(8): e0238124, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32822433

RESUMO

BACKGROUND: Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs). METHODS: This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality. RESULTS: Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96). CONCLUSIONS: Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.


Assuntos
Estado Terminal/mortalidade , Mortalidade Hospitalar/tendências , Neoplasias/mortalidade , APACHE , Idoso de 80 Anos ou mais , Brasil , Estudos de Coortes , Feminino , Neoplasias Hematológicas/mortalidade , Neoplasias Hematológicas/patologia , Hospitalização , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Neoplasias/patologia , Estudos Retrospectivos , Fatores de Risco
20.
Respir Res ; 21(1): 194, 2020 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-32698822

RESUMO

RATIONALE: Oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) has been described as potential predictor of poor outcome for COVID-19, without considering its time-varying behavior though. METHODS: Prognostic value of SpO2/FiO2 was evaluated by jointly modeling the longitudinal responses of SpO2/FiO2 and time-to-event data retrieved from 280 severe and critically ill (intensive care) patients with COVID-19. RESULTS: A sharply decrease of SpO2/FiO2 from the first to second measurement for non-survivors was observed, and a strong association between square root SpO2/FiO2 and mortality risk was demonstrated, with a unit decrease in the marker corresponding to 1.82-fold increase in mortality risk (95% CI: 1.56-2.13). CONCLUSIONS: The current study suggested that SpO2/FiO2 could serve as a non-invasive prognostic marker to facilitate early adjustment for treatment, thus improving overall survival.


Assuntos
Infecções por Coronavirus/sangue , Infecções por Coronavirus/mortalidade , Cuidados Críticos/métodos , Estado Terminal/mortalidade , Mortalidade Hospitalar/tendências , Consumo de Oxigênio/fisiologia , Pneumonia Viral/sangue , Pneumonia Viral/mortalidade , Biomarcadores/sangue , China , Estudos de Coortes , Infecções por Coronavirus/diagnóstico , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Oximetria/métodos , Oxigênio/sangue , Pandemias , Pneumonia Viral/diagnóstico , Valor Preditivo dos Testes , Prognóstico
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