A Comparison of Long-Term Outcomes in Patients Managed With Venovenous Extracorporeal Membrane Oxygenation in the First and Second Waves of the COVID-19 Pandemic in the United Kingdom.

OBJECTIVES: Early studies of venovenous extracorporeal membrane oxygenation (ECMO) in COVID-19 have revealed similar outcomes to historical cohorts. Changes in the disease and treatments have led to differences in the patients supported on venovenous ECMO in the first and second waves. We aimed to compare these two groups in both the acute and follow-up phase. DESIGN: Retrospective single-center cohort study comparing mortality at censoring date (November 30, 2021) and decannulation, patient characteristics, complications and lung function and quality of life (QOL-by European Quality of Life 5 Dimensions 3 Level Version) at first follow-up in patients supported on venovenous ECMO between wave 1 and wave 2 of the COVID-19 pandemic. SETTING: Critical care department of a severe acute respiratory failure service. PATIENTS: Patients supported on ECMO for COVID-19 between wave 1 (March 17, 2020, to August 31, 2020) and wave 2 (January 9, 2020, to May 25, 2021). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-three patients were included in our analysis. Survival at censoring date (χ 2 , 6.35; p = 0.012) and decannulation (90.4% vs 70.0%; p < 0.001) was significantly lower in the second wave, while duration of ECMO run was longer (12.0 d [18.0-30.0 d] vs 29.5 d [15.5-58.3 d]; p = 0.005). Wave 2 patients had longer application of noninvasive ventilation (NIV) prior to ECMO and a higher frequency of barotrauma. Patient age and NIV use were independently associated with increased mortality (odds ratio 1.07 [1.01-1.14]; p = 0.025 and 3.37 [1.12-12.60]; p = 0.043, respectively). QOL and lung function apart from transfer coefficient of carbon monoxide corrected for hemoglobin was similar at follow-up across the waves. CONCLUSIONS: Most patients with COVID-19 supported on ECMO in both waves survived in the short and longer term. At follow-up patients had similar lung function and QOL across the two waves. This suggests that ECMO has an ongoing role in the management of a carefully selected group of patients with COVID-19.

Impact on hospital mortality of catheter removal and adequate antifungal therapy in Candida spp. bloodstream infections.

OBJECTIVES: We set out to identify the prognostic factors in adult patients with Candida spp. bloodstream infection, assessing the impact on in-hospital mortality of catheter removal and adequacy of antifungal therapy. METHODS: Patients with positive blood culture for Candida spp. and a central venous catheter in place at the time of candidaemia were included. Data collected included demographics, underlying diseases, severity of illness, clinical presentation, catheter withdrawal and adequacy of empirical therapy. RESULTS: We included 188 patients (mortality 36.7%). The mortality rate was 34.9% (23/66) in patients with early adequate antifungal treatment and 18.9% (7/37) in patients with early adequate antifungal therapy and catheter withdrawal in the first 48 h. The APACHE (Acute Physiology and Chronic Health Evaluation) II score on the day of candidaemia [adjusted hazard ratio (aHR) 1.12; 95% CI 1.06-1.17; P < 0.001] was associated with death whereas early adequate therapy (aHR 0.4; 95% CI 0.23-0.83; P = 0.012) and catheter withdrawal (aHR 0.34; 95% CI 0.16-0.70; P = 0.03) were protective factors. In primary candidaemia, mortality was 28% (14/50) in patients with adequate therapy and decreased to 17.7% (6/34) in patients with both interventions in the first 48 h. Catheter removal was a protective factor and adequacy of antifungal therapy in the first 48 h showed a strong tendency to protection against death (aHR 0.46; 95% CI 0.19-1.08; P = 0.07). In secondary non-catheter-related candidaemia, only early adequate therapy was a protective factor for mortality. CONCLUSIONS: Delay in catheter withdrawal and in administration of adequate antifungal therapy was associated with increased mortality in candidaemic patients. Catheter management did not influence the prognosis of secondary non-catheter-related candidaemia.

Risk factors for fluconazole-resistant candidemia.

Previous studies have sought to determine the risk factors associated with candidemia caused by non-albicans Candida spp. or with potentially fluconazole-resistant Candida spp. (C. glabrata and C. krusei). Non-albicans Candida strains are a heterogeneous group that includes species with different levels of virulence, and only a limited number of C. glabrata isolates are resistant to fluconazole. We set out to identify the risk factors associated with microbiologically proven fluconazole-resistant candidemia. A prospective study including adult patients with candidemia was performed. Data were collected on patient demographics; underlying diseases; exposure to corticosteroids, antibiotics, or fluconazole; and invasive procedures. Risk factors associated either with non-albicans Candida spp. or potentially fluconazole-resistant Candida spp. (C. glabrata or C. krusei) or with Candida spp. with microbiologically confirmed fluconazole resistance were assessed using logistic regressions. We included 226 candidemia episodes. Non-albicans Candida isolates accounted for 53.1% of the fungal isolates, but only 18.2% of the cases were caused by potentially fluconazole-resistant organisms. Thirty isolates exhibited microbiologically confirmed fluconazole resistance. The multivariate analysis revealed that independent predictors associated with fluconazole-resistant Candida spp. were neutropenia (odds ratio [OR]=4.94; 95% confidence interval [CI]=1.50 to 16.20; P=0.008), chronic renal disease (OR=4.82; 95% CI=1.47 to 15.88; P=0.01), and previous fluconazole exposure (OR=5.09; 95% CI=1.66 to 15.6; P=0.004). Independently significant variables associated with non-albicans Candida bloodstream infection or with potentially fluconazole-resistant Candida spp. did not include previous fluconazole exposure. We concluded that prior fluconazole treatment is an independent risk factor only for candidemia caused by microbiologically confirmed fluconazole resistant species. Our findings may be of value for selecting empirical antifungal therapy.

Stress echocardiography in patients who experienced mechanical ventilation weaning failure.

INTRODUCTION: Critically ill patients may suffer varying degrees of temporary myocardial dysfunction during respiratory weaning that could play an important role in weaning failure. OBJECTIVES: In this study, we tried to assess the existence of temporary diastolic dysfunction during respiratory weaning. METHODS: Inclusion period is from 2006 to 2015. In this study, we included 181 ventilated patients with cardiogenic shock that were being weaned from mechanical ventilation. Twenty of those patients were successfully weaned from mechanical ventilation, and the rest (161) experienced complications in their weaning process. All patients had a left ventricular ejection fraction >0.45 and E/E' ratio≤8, did not require vasoactive drugs at that time, and did not have remaining significant ischemic disease. We divided our patients into 3 groups, as follows: A, patients who could not tolerate a T-tube and required pressure-support ventilation (82); B, patients who successfully tolerated a T-tube period (20); and C, patients who could not tolerate spontaneous breathing modes of mechanical ventilation and remained on assisted mechanical ventilation. We performed stress echocardiography for the last two groups; using dobutamine to assess diastolic function and using ephedrine to evaluate functional mitral regurgitation (MR). We estimated pulmonary capillary wedge pressure through the E/E' ratio and the flow in the pulmonary veins. RESULTS: In group A (ie, those patients who could not tolerate a T-tube trial), we observed an increase in the E/E' ratio (6.32±0.77 vs 15.2±6.65; P=.0001) and a worsening of strain (S) and strain rate (SR) (-13.6±1.80 vs -11.88±5.6, P=.0001; and -1.3±1.28 vs -0.95±0.38, P=.0001; respectively). We did not observe a change in the E/E' ratio during stress echocardiogram on those patients with successful weaning from mechanical ventilation (7.41±0.43 vs 8.38±4.57, P=.001). However, we did see in this group an increased peak velocity of the S wave and of SR (-16.11±08.72 vs -19.89±5.62 and -1.48±0.23 vs -1.59±0.21, P=.001; respectively). In 42 weaning failure patients, the dobutamine echocardiography showed an increased E/E' ratio (7.41±0.43 vs 15.98±7.98; P=.0001) and deterioration of S (-15.41±09.56 vs -12.72±6.55; P=.0001) and SR (-1.41±0.78 vs -1.22±0.65; P=.0001). In 37 patients without systolic or diastolic impairment and functional MR grade >2, ephedrine echocardiography showed an increase of effective regurgitant volume (29.56±11.32 mL vs 46.56±0.13 mL, P=.0001) and effective regurgitant orifice area (0.19±0.09 cm2 vs 0.31±0.09 cm2, P=.0001). CONCLUSIONS: Stress echocardiography may be helpful in detecting silent diastolic and systolic dysfunction or severe MR that could have a major impact on respiratory weaning.