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1.
JAMA Netw Open ; 4(8): e2120456, 2021 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-34379123

RESUMO

Importance: Prior studies on COVID-19 and pregnancy have reported higher rates of cesarean delivery and preterm birth and increased morbidity and mortality. Additional data encompassing a longer time period are needed. Objective: To examine characteristics and outcomes of a large US cohort of women who underwent childbirth with vs without COVID-19. Design, Setting, and Participants: This cohort study compared characteristics and outcomes of women (age ≥18 years) who underwent childbirth with vs without COVID-19 between March 1, 2020, and February 28, 2021, at 499 US academic medical centers or community affiliates. Follow-up was limited to in-hospital course and discharge destination. Childbirth was defined by clinical classification software procedural codes of 134-137. A diagnosis of COVID-19 was identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis of U07.1. Data were analyzed from April 1 to April 30, 2021. Exposures: The presence of a COVID-19 diagnosis using ICD-10. Main Outcomes and Measures: Analyses compared demographic characteristics, gestational age, and comorbidities. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, and discharge status. Continuous variables were analyzed using t test, and categorical variables were analyzed using χ2. Results: Among 869 079 women, 18 715 (2.2%) had COVID-19, and 850 364 (97.8%) did not. Most women were aged 18 to 30 years (11 550 women with COVID-19 [61.7%]; 447 534 women without COVID-19 [52.6%]) and were White (8060 White women [43.1%] in the COVID-19 cohort; 499 501 White women (58.7%) in the non-COVID-19 cohort). There was no significant increase in cesarean delivery among women with COVID-19 (6088 women [32.5%] vs 273 810 women [32.3%]; P = .57). Women with COVID-19 were more likely to have preterm birth (3072 women [16.4%] vs 97 967 women [11.5%]; P < .001). Women giving birth with COVID-19, compared with women without COVID-19, had significantly higher rates of ICU admission (977 women [5.2%] vs 7943 women [0.9%]; odds ratio [OR], 5.84 [95% CI, 5.46-6.25]; P < .001), respiratory intubation and mechanical ventilation (275 women [1.5%] vs 884 women [0.1%]; OR, 14.33 [95% CI, 12.50-16.42]; P < .001), and in-hospital mortality (24 women [0.1%] vs 71 [<0.01%]; OR, 15.38 [95% CI, 9.68-24.43]; P < .001). Conclusions and Relevance: This retrospective cohort study found that women with COVID-19 giving birth had higher rates of mortality, intubation, ICU admission, and preterm birth than women without COVID-19.


Assuntos
COVID-19/mortalidade , Unidades de Terapia Intensiva/estatística & dados numéricos , Nascimento Prematuro/epidemiologia , Centros Médicos Acadêmicos/estatística & dados numéricos , Adolescente , Adulto , COVID-19/terapia , Estudos de Casos e Controles , Cesárea/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Pandemias , Gravidez , Complicações Infecciosas na Gravidez/mortalidade , Complicações Infecciosas na Gravidez/terapia , Estudos Retrospectivos , SARS-CoV-2 , Estados Unidos/epidemiologia , Adulto Jovem
2.
Sci Rep ; 11(1): 14407, 2021 07 13.
Artigo em Inglês | MEDLINE | ID: mdl-34257366

RESUMO

Prone position (PP) is known to improve oxygenation and reduce mortality in COVID-19 patients. This systematic review and meta-analysis aimed to determine the effects of PP on respiratory parameters and outcomes. PubMed, EMBASE, ProQuest, SCOPUS, Web of Sciences, Cochrane library, and Google Scholar were searched up to 1st January 2021. Twenty-eight studies were included. The Cochran's Q-test and I2 statistic were assessed heterogeneity, the random-effects model was estimated the pooled mean difference (PMD), and a meta-regression method has utilized the factors affecting heterogeneity between studies. PMD with 95% confidence interval (CI) of PaO2/FIO2 Ratio in before-after design, quasi-experimental design and in overall was 55.74, 56.38, and 56.20 mmHg. These values for Spo2 (Sao2) were 3.38, 17.03, and 7.58. PP in COVID-19 patients lead to significantly decrease of the Paco2 (PMD: - 8.69; 95% CI - 14.69 to - 2.69 mmHg) but significantly increase the PaO2 (PMD: 37.74; 95% CI 7.16-68.33 mmHg). PP has no significant effect on the respiratory rate. Based on meta-regression, the study design has a significant effect on the heterogeneity of Spo2 (Sao2) (Coefficient: 12.80; p < 0.001). No significant associations were observed for other respiratory parameters with sample size and study design. The pooled estimate for death rate and intubation rates were 19.03 (8.19-32.61) and 30.68 (21.39-40.75). The prone positioning was associated with improved oxygenation parameters and reduced mortality and intubation rate in COVID-19 related respiratory failure.


Assuntos
COVID-19/mortalidade , COVID-19/fisiopatologia , Decúbito Ventral/fisiologia , COVID-19/terapia , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Modelos Teóricos , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia
3.
Lancet Respir Med ; 9(9): 989-998, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34224674

RESUMO

BACKGROUND: Although COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country. METHODS: In this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete. FINDINGS: Between March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52-70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7-22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0-7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H2O (8-12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO2) to fractional inspired oxygen (FiO2) was 160 (IQR 111-218), respiratory system compliance 36 mL/cm H2O (29-44), driving pressure 12 cm H2O (10-14), and FiO2 0·60 (0·45-0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01-1·03]), Charlson score (1·16 [1·11-1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10-1·71]), vasopressor use on day 1 (1·29 [1·07-1·55]), D-dimer concentration (1·02 [1·01-1·03]), PaO2/FiO2 on day 1 (0·998 [0·997-0·999]), arterial pH on day 1 (1·01 [1·00-1·01]), driving pressure on day 1 (1·05 [1·03-1·08]), acute kidney injury (1·66 [1·36-2·03]), and month of admission (1·10 [1·03-1·18]) as independent predictors of mortality. INTERPRETATION: In patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere. FUNDING: None. TRANSLATION: For the Spanish translation of the Summary see Supplementary Materials section.


Assuntos
COVID-19/terapia , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/terapia , Adulto , Idoso , Argentina/epidemiologia , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/mortalidade , Teste de Ácido Nucleico para COVID-19 , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/métodos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/virologia , Fatores de Risco , SARS-CoV-2/isolamento & purificação , Volume de Ventilação Pulmonar , Resultado do Tratamento , Adulto Jovem
4.
Scand J Trauma Resusc Emerg Med ; 29(1): 81, 2021 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-34154631

RESUMO

BACKGROUND: Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation. METHODS: Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma. RESULTS: One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma. CONCLUSION: We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.


Assuntos
Oxigenoterapia/métodos , Traumatismos Torácicos/terapia , Adulto , Idoso , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Oxigênio/metabolismo , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos , Resultado do Tratamento
5.
West J Emerg Med ; 22(3): 678-686, 2021 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-34125046

RESUMO

INTRODUCTION: The objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation. METHODS: We retrospectively collected data on non-operating room (OR) intubations from February 1-April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient's indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result. RESULTS: We obtained 406 independent procedure notes filed between February 1-April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success. DISCUSSION: An average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.


Assuntos
COVID-19/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , COVID-19/epidemiologia , Estudos de Casos e Controles , Feminino , Humanos , Intubação Intratraqueal/normas , Laringoscopia/efeitos adversos , Laringoscopia/métodos , Masculino , Melhoria de Qualidade , Estudos Retrospectivos , SARS-CoV-2
6.
J Surg Res ; 266: 361-365, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34087619

RESUMO

BACKGROUND: Tracheostomy improves outcomes for critically ill patients requiring prolonged mechanical ventilation. Data are limited on the use and benefit of tracheostomies for intubated, critically ill coronavirus disease 2019 (COVID-19) patients. During the surge in COVID 19 infections in metropolitan New York/New Jersey, our hospital cared for many COVID-19 patients who required prolonged intubation. This study describes the outcomes in COVID-19 patients who underwent tracheostomy. METHODS: We present a case series of patients with COVID-19 who underwent tracheostomy at a single institution. Tracheostomies were performed on patients with prolonged mechanical ventilation beyond 3 wk. Patient demographics, medical comorbidities, and ventilator settings prior to tracheostomy were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes included time on mechanical ventilation, length of ICU and hospital stay, and discharge disposition. RESULTS: Fifteen COVID-19 patients underwent tracheostomy at an average of 31 d post intubation. Two patients (13%) died. Half of our cohort was liberated from the ventilator (8 patients, 53%), with an average time to liberation of 14 ± 6 d after tracheostomy. Among patients off mechanical ventilation, 5 (63%) had their tracheostomies removed prior to discharge. The average intensive care length of stay was 47 ± 13 d (range 29-74 d) and the average hospital stay was 59 ± 16 d (range 34-103 d). CONCLUSIONS: This study reports promising outcomes in COVID-19 patients with acute respiratory failure and need for prolonged ventilation who undergo tracheostomy during their hospitalization. Further research is warranted to establish appropriate indications for tracheostomy in COVID-19 and confirm outcomes.


Assuntos
COVID-19/complicações , Intubação Intratraqueal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/terapia , Traqueostomia/estatística & dados numéricos , COVID-19/mortalidade , COVID-19/terapia , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Estado Terminal , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Traqueostomia/efeitos adversos , Resultado do Tratamento , Desmame do Respirador/estatística & dados numéricos
7.
Turk J Med Sci ; 51(3): 1675-1681, 2021 08 30.
Artigo em Inglês | MEDLINE | ID: mdl-34110723

RESUMO

Background and aim: The aim of this study is to evaluate whether the long-term (≥4 weeks) use of proton pump inhibitors (PPIs) is a risk factor for intubation requirement and mortality in patients hospitalized for COVID-19. Materials and methods: In this multicentric retrospective study, a total of 382 adult patients (≥18 years of age) with confirmed COVID-19 who were hospitalized for treatment were enrolled. The patients were divided into two groups according to the periods during which they used PPIs: the first group included patients who were not on PPI treatment, and the second group included those who have used PPIs for more than 4 weeks. Results: The study participants were grouped according to their PPI usage history over the last 6 months. In total, 291 patients did not use any type of PPI over the last 6 months, and 91 patients used PPIs for more than 4 weeks. Older age (HR: 1.047, 95% CI: 1.026­1.068), current smoking (HR: 2.590, 95% CI: 1.334­5.025), and PPI therapy for more than 4 weeks (HR: 1.83, 95% CI: 1.06­2.41) were found to be independent risk factors for mortality. Conclusion: The results obtained in this study show that using PPIs for more than 4 weeks is associated with negative outcomes for patients with COVID-19. Patients receiving PPI therapy should be evaluated more carefully if they are hospitalized for COVID-19 treatment.


Assuntos
COVID-19/mortalidade , Inibidores da Bomba de Prótons/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Tempo , Turquia/epidemiologia
8.
Arch Cardiovasc Dis ; 114(5): 415-425, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34099379

RESUMO

BACKGROUND: Although cardiovascular comorbidities seem to be strongly associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19), data regarding patients with preexisting heart failure are limited. AIMS: To investigate the incidence, characteristics and clinical outcomes of patients with COVID-19 with a history of heart failure with preserved or reduced ejection fraction. METHODS: We performed an observational multicentre study including all patients hospitalized for COVID-19 across 24 centres in France from 26 February to 20 April 2020. The primary endpoint was a composite of in-hospital death or need for orotracheal intubation. RESULTS: Overall, 2809 patients (mean age 66.4±16.9years) were included. Three hundred and seventeen patients (11.2%) had a history of heart failure; among them, 49.2% had heart failure with reduced ejection fraction and 50.8% had heart failure with preserved ejection fraction. COVID-19 severity at admission, defined by a quick sequential organ failure assessment score>1, was similar in patients with versus without a history of heart failure. Before and after adjustment for age, male sex, cardiovascular comorbidities and quick sequential organ failure assessment score, history of heart failure was associated with the primary endpoint (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.06-1.90; P=0.02). This result seemed to be mainly driven by a history of heart failure with preserved ejection fraction (HR: 1.61, 95% CI: 1.13-2.27; P=0.01) rather than heart failure with reduced ejection fraction (HR: 1.19, 95% CI: 0.79-1.81; P=0.41). CONCLUSIONS: History of heart failure in patients with COVID-19 was associated with a higher risk of in-hospital death or orotracheal intubation. These findings suggest that patients with a history of heart failure, particularly heart failure with preserved ejection fraction, should be considered at high risk of clinical deterioration.


Assuntos
COVID-19/epidemiologia , Insuficiência Cardíaca/epidemiologia , Sistema de Registros/estatística & dados numéricos , SARS-CoV-2 , Idoso , COVID-19/sangue , Comorbidade , Fatores de Confusão Epidemiológicos , Feminino , França/epidemiologia , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/fisiopatologia , Mortalidade Hospitalar , Humanos , Incidência , Intubação Intratraqueal/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Resultado do Tratamento
9.
Sci Rep ; 11(1): 11334, 2021 05 31.
Artigo em Inglês | MEDLINE | ID: mdl-34059708

RESUMO

Prophylactic low molecular weight heparin (pLMWH) is currently recommended in COVID-19 to reduce the risk of coagulopathy. The aim of this study was to evaluate whether the antinflammatory effects of pLMWH could translate in lower rate of clinical progression in patients with COVID-19 pneumonia. Patients admitted to a COVID-hospital in Rome with SARS-CoV-2 infection and mild/moderate pneumonia were retrospectively evaluated. The primary endpoint was the time from hospital admission to orotracheal intubation/death (OTI/death). A total of 449 patients were included: 39% female, median age 63 (IQR, 50-77) years. The estimated probability of OTI/death for patients receiving pLMWH was: 9.5% (95% CI 3.2-26.4) by day 20 in those not receiving pLMWH vs. 10.4% (6.7-15.9) in those exposed to pLMWH; p-value = 0.144. This risk associated with the use of pLMWH appeared to vary by PaO2/FiO2 ratio: aHR 1.40 (95% CI 0.51-3.79) for patients with an admission PaO2/FiO2 ≤ 300 mmHg and 0.27 (0.03-2.18) for those with PaO2/FiO2 > 300 mmHg; p-value at interaction test 0.16. pLMWH does not seem to reduce the risk of OTI/death mild/moderate COVID-19 pneumonia, especially when respiratory function had already significantly deteriorated. Data from clinical trials comparing the effect of prophylactic vs. therapeutic dosage of LMWH at various stages of COVID-19 disease are needed.


Assuntos
COVID-19/tratamento farmacológico , COVID-19/mortalidade , Heparina de Baixo Peso Molecular/uso terapêutico , Intubação Intratraqueal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Idoso , COVID-19/diagnóstico por imagem , COVID-19/fisiopatologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Cidade de Roma , Índice de Gravidade de Doença
10.
Turk J Med Sci ; 51(4): 1665-1674, 2021 08 30.
Artigo em Inglês | MEDLINE | ID: mdl-33957728

RESUMO

Background/aim: Coronavirus disease 2019 (COVID-19) is a disease with a high rate of progression to critical illness. However, the predictors of mortality in critically ill patients admitted to the intensive care unit (ICU) are not yet well understood. In this study, we aimed to investigate the risk factors associated with ICU mortality in our hospital. Materials and methods: In this single-centered retrospective study, we enrolled 86 critically ill adult patients with COVID-19 admitted to ICU of Dokuz Eylül University Hospital (Izmir, Turkey) between 18 March 2020 and 31 October 2020. Data on demographic information, preexisting comorbidities, treatments, the laboratory findings at ICU admission, and clinical outcomes were collected. The chest computerized tomography (CT) of the patients were evaluated specifically for COVID-19 and CT score was calculated. Data of the survivors and nonsurvivors were compared with survival analysis to identify risk factors of mortality in the ICU. Results: The mean age of the patients was 71.1 ± 14.1 years. The patients were predominantly male. The most common comorbidity in patients was hypertension. ICU mortality was 62.8%. Being over 60 years old, CT score > 15, acute physiology and chronic health evaluation (APACHE) II score ≥ 15, having dementia, treatment without favipiravir, base excess in blood gas analysis ≤ ­2.0, WBC > 10,000/mm3, D-dimer > 1.6 µg/mL, troponin > 24 ng/L, Na ≥ 145 mmol/L were considered to link with ICU mortality according to Kaplan­Meier curves (log-rank test, p < 0.05). The APACHE II score (HR: 1.055, 95% CI: 1.021­1.090) and chest CT score (HR: 2.411, 95% CI:1.193­4.875) were associated with ICU mortality in the cox proportional-hazard regression model adjusted for age, dementia, favipiravir treatment and troponin. Howewer, no difference was found between survivors and nonsurvivors in terms of intubation timing. Conclusions: COVID-19 patients have a high ICU admission and mortality rate. Studies in the ICU are also crucial in this respect. In our study, we investigated the ICU mortality risk factors of COVID-19 patients. We determined a predictive mortality model consisting of APACHE II score and chest CT score. It was thought that this feasible and practical model would assist in making clinical decisions.


Assuntos
COVID-19/diagnóstico por imagem , COVID-19/mortalidade , Cuidados Críticos/métodos , Mortalidade Hospitalar , Intubação Intratraqueal/métodos , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Análise de Sobrevida , Fatores de Tempo , Turquia/epidemiologia , Adulto Jovem
11.
West J Emerg Med ; 22(2): 360-368, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33856324

RESUMO

INTRODUCTION: The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). METHODS: We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014-June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. RESULTS: A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = -10.3%, 95% confidence interval (CI), -14.8% to -5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = -10.7%, 95% CI, -17.3% to -4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = -21.4%, 95% CI, -27.0% to -16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 - 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 - 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 - 0.33]. CONCLUSION: FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Intubação Intratraqueal , Sistema Respiratório , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/instrumentação , Manuseio das Vias Aéreas/métodos , Arizona/epidemiologia , Causalidade , Competência Clínica , Emergências/epidemiologia , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/normas , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Sistema Respiratório/anatomia & histologia , Sistema Respiratório/patologia , Sistema Respiratório/fisiopatologia , Risco Ajustado , Fatores de Risco , Falha de Tratamento
13.
Rev Bras Ter Intensiva ; 33(1): 68-74, 2021.
Artigo em Português, Inglês | MEDLINE | ID: mdl-33886854

RESUMO

OBJECTIVE: To analyze whether changes in medical care due to the application of COVID-19 protocols affected clinical outcomes in patients without COVID-19 during the pandemic. METHODS: This was a retrospective, observational cohort study carried out in a thirty-eight-bed surgical and medical intensive care unit of a high complexity private hospital. Patients with respiratory failure admitted to the intensive care unit during March and April 2020 and the same months in 2019 were selected. We compared interventions and outcomes of patients without COVID-19 during the pandemic with patients admitted in 2019. The main variables analyzed were intensive care unit respiratory management, number of chest tomography scans and bronchoalveolar lavages, intensive care unit complications, and status at hospital discharge. RESULTS: In 2020, a significant reduction in the use of a high-flow nasal cannula was observed: 14 (42%) in 2019 compared to 1 (3%) in 2020. Additionally, in 2020, a significant increase was observed in the number of patients under mechanical ventilation admitted to the intensive care unit from the emergency department, 23 (69%) compared to 11 (31%) in 2019. Nevertheless, the number of patients with mechanical ventilation after 5 days of admission was similar in both years: 24 (69%) in 2019 and 26 (79%) in 2020. CONCLUSION: Intensive care unit protocols based on international recommendations for the COVID-19 pandemic have produced a change in non-COVID-19 patient management. We observed a reduction in the use of a high-flow nasal cannula and an increased number of tracheal intubations in the emergency department. However, no changes in the percentage of intubated patients in the intensive care unit, the number of mechanical ventilation days or the length of stay in intensive care unit.


Assuntos
COVID-19/epidemiologia , Estado Terminal/terapia , Gerenciamento Clínico , Pandemias , Idoso , Argentina/epidemiologia , Lavagem Broncoalveolar/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
15.
Scand J Trauma Resusc Emerg Med ; 29(1): 49, 2021 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-33731197

RESUMO

BACKGROUND: Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative. METHODS: We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider's level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy. RESULTS: FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers' expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified. CONCLUSION: Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.


Assuntos
Resgate Aéreo , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Gravação de Videoteipe , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Serviços Médicos de Emergência , Feminino , Humanos , Lactente , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
16.
JAMA ; 325(17): 1731-1743, 2021 05 04.
Artigo em Inglês | MEDLINE | ID: mdl-33764378

RESUMO

Importance: High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19. Objective: To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone. Design, Setting, and Participants: Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200). Interventions: Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55). Main Outcomes and Measures: The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay. Results: Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, -2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, -21% [95% CI, -38% to -3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, -1% [95% CI, -17% to 15%]; P > .99). Conclusions and Relevance: Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation. Trial Registration: ClinicalTrials.gov Identifier: NCT04502576.


Assuntos
COVID-19/complicações , Intubação Intratraqueal/estatística & dados numéricos , Ventilação não Invasiva/instrumentação , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Idoso , COVID-19/mortalidade , COVID-19/terapia , Feminino , Mortalidade Hospitalar , Humanos , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/métodos , Insuficiência Respiratória/etiologia , Falha de Tratamento
17.
Crit Care ; 25(1): 121, 2021 03 25.
Artigo em Inglês | MEDLINE | ID: mdl-33766109

RESUMO

BACKGROUND: Although several international guidelines recommend early over late intubation of patients with severe coronavirus disease 2019 (COVID-19), this issue is still controversial. We aimed to investigate the effect (if any) of timing of intubation on clinical outcomes of critically ill patients with COVID-19 by carrying out a systematic review and meta-analysis. METHODS: PubMed and Scopus were systematically searched, while references and preprint servers were explored, for relevant articles up to December 26, 2020, to identify studies which reported on mortality and/or morbidity of patients with COVID-19 undergoing early versus late intubation. "Early" was defined as intubation within 24 h from intensive care unit (ICU) admission, while "late" as intubation at any time after 24 h of ICU admission. All-cause mortality and duration of mechanical ventilation (MV) were the primary outcomes of the meta-analysis. Pooled risk ratio (RR), pooled mean difference (MD) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42020222147). RESULTS: A total of 12 studies, involving 8944 critically ill patients with COVID-19, were included. There was no statistically detectable difference on all-cause mortality between patients undergoing early versus late intubation (3981 deaths; 45.4% versus 39.1%; RR 1.07, 95% CI 0.99-1.15, p = 0.08). This was also the case for duration of MV (1892 patients; MD - 0.58 days, 95% CI - 3.06 to 1.89 days, p = 0.65). In a sensitivity analysis using an alternate definition of early/late intubation, intubation without versus with a prior trial of high-flow nasal cannula or noninvasive mechanical ventilation was still not associated with a statistically detectable difference on all-cause mortality (1128 deaths; 48.9% versus 42.5%; RR 1.11, 95% CI 0.99-1.25, p = 0.08). CONCLUSIONS: The synthesized evidence suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19. These results might justify a wait-and-see approach, which may lead to fewer intubations. Relevant guidelines may therefore need to be updated.


Assuntos
COVID-19/terapia , Intubação Intratraqueal/estatística & dados numéricos , COVID-19/mortalidade , Estudos de Coortes , Estado Terminal , Humanos , Fatores de Tempo , Resultado do Tratamento
18.
Int J Lab Hematol ; 43 Suppl 1: 142-151, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33554466

RESUMO

INTRODUCTION: Studies have shown that iron metabolism is affected by coronavirus disease 19 (COVID-19), which has spread worldwide and has become a global health problem. Our study aimed to evaluate the relationship between COVID-19 and serum erythropoietin (EPO), hepcidin, and haptoglobin (Hpt) levels with disease severity, and other biochemical values. METHODS: Fifty nine COVID-19 patients hospitalized in the intensive care unit (ICU) and wards in our hospital between March and June 2020 and 19 healthy volunteers were included in the study. Participants were divided into mild, severe, and critical disease severity groups. Group mean values were analyzed with SPSS according to disease severity, mortality, and intubation status. RESULTS: Hemoglobin (Hb) levels were significantly lower in the critical patient group (P < .0001) and deceased group (P < .0001). The red blood cell distribution width-coefficient of variation (RDW-CV) and ferritin values were significantly higher in the intubated (P = .001, P = .005) and deceased (P = .014, P = .003) groups. Ferritin values were positively correlated with disease severity (P < .0001). Serum iron levels were lower in the patient group compared with the reference range. (P < .0001). It was found that the transferrin saturation (TfSat) was lower in the patient group compared with the control group (P < .0001). It was found that the mean EPO of the deceased was lower than the control group and the survived patient group (P = .035). Hepcidin levels were found to be significantly lower in the patient group (P < .0001). Hpt values were found to be significantly lower in the intubated group (P = .004) and the deceased group (P = .042). CONCLUSION: In our study, while serum iron and hepcidin levels decreased in patients diagnosed with COVID-19, we found that EPO and Hpt levels were significantly lower in critical and deceased patient groups. Our study is the first study examining EPO and Hpt levels in patients diagnosed with COVID-19.


Assuntos
COVID-19/sangue , Eritropoetina/sangue , Haptoglobinas/análise , Hepcidinas/sangue , SARS-CoV-2 , Idoso , Biomarcadores , Estudos Transversais , Feminino , Ferritinas/sangue , Hemoglobinas/análise , Homeostase , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Ferro/sangue , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Transferrina/análise
19.
Pediatrics ; 147(3)2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33602798

RESUMO

BACKGROUND: For novice providers, achieving competency in neonatal intubation is becoming increasingly difficult, possibly because of fewer intubation opportunities. In the present study, we compared intubation outcomes on manikins using direct laryngoscopy (DL), indirect video laryngoscopy (IVL) using a modified disposable blade, and augmented reality-assisted video laryngoscopy (ARVL), a novel technique using smart glasses to project a magnified video of the airway into the intubator's visual field. METHODS: Neonatal intensive care nurses (n = 45) with minimal simulated intubation experience were randomly assigned (n = 15) to the following 3 groups: DL, IVL, and ARVL. All participants completed 5 intubation attempts on a manikin using their assigned modalities and received verbal coaching by a supervisor, who viewed the video while assisting the IVL and ARVL groups. The outcome and time of each attempt were recorded. RESULTS: The DL group successfully intubated on 32% of attempts compared to 72% in the IVL group and 71% in the ARVL group (P < .001). The DL group intubated the esophagus on 27% of attempts, whereas there were no esophageal intubations in either the IVL or ARVL groups (P < .001). The median (interquartile range) time to intubate in the DL group was 35.6 (22.9-58.0) seconds, compared to 21.6 (13.9-31.9) seconds in the IVL group and 20.7 (13.2-36.5) seconds in the ARVL group (P < .001). CONCLUSIONS: Simulated intubation success of neonatal intensive care nurses was significantly improved by using either IVL or ARVL compared to DL. Future prospective studies are needed to explore the potential benefits of this technology when used in real patients.


Assuntos
Realidade Aumentada , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Manequins , Treinamento por Simulação/métodos , Óculos Inteligentes , Competência Clínica , Humanos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/estatística & dados numéricos , Laringoscopia/instrumentação , Laringoscopia/estatística & dados numéricos , Recursos Humanos de Enfermagem no Hospital/educação , Projetos Piloto , Fatores de Tempo
20.
Saudi Med J ; 42(3): 280-283, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33632906

RESUMO

OBJECTIVES: To review the patterns and outcomes of pediatric thoracic penetrating injuries in a level one trauma center. METHODS: Retrospective chart review of pediatric patients who presented to the King Abdulaziz Medical City Emergency Department (KAMC-ED), Riyadh, Saudi Arabia with thoracic penetrating injury from 2001 to 2016. RESULTS: Eighty-nine patients had a penetrating injury to the thorax were identified. The mean age was 15.5 ± 3.6 years. The mean length of hospital stay was 3.87 ± 5 days. The most common cause was stabbing followed by gunshot. Isolated injury to the thorax was seen in 58 patients. The most common injuries sustained were pneumothorax and hemothorax. In the ED, tube thoracostomy was required in 65 patients, endotracheal intubation in 12, blood transfusion in 14, massive blood transfusion in one, pericardiocentesis in one, and ED thoracotomy in 2. Only 15 patients required surgical intervention. The overall mortality rate was 3.4%. Death was mainly caused by associated injuries to the heart, aorta and/or inferior vena cava. CONCLUSION: Thoracic injuries represent 25% of the overall penetrating traumas in pediatric age group. Most sustained injuries can be safely managed non-operatively, with a favorable outcome. Prompt resuscitation and intervention are required to identify and manage life-threatening injuries.


Assuntos
Traumatismos Torácicos/epidemiologia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos Penetrantes/epidemiologia , Adolescente , Fatores Etários , Transfusão de Sangue/estatística & dados numéricos , Criança , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação , Masculino , Estudos Retrospectivos , Arábia Saudita/epidemiologia , Traumatismos Torácicos/mortalidade , Traumatismos Torácicos/cirurgia , Toracostomia/estatística & dados numéricos , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia
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