Clinical characteristics, respiratory management, and determinants of oxygenation in COVID-19 ARDS: A prospective cohort study.

PURPOSE: To identify determinants of oxygenation over time in patients with COVID-19 acute respiratory distress syndrome (ARDS); and to analyze their characteristics according to Berlin definition categories. MATERIALS AND METHODS: Prospective cohort study including consecutive mechanically ventilated patients admitted between 3/20/2020-10/31/2020 with ARDS. Epidemiological and clinical data on admission; outcomes; ventilation, respiratory mechanics and oxygenation variables were registered on days 1, 3 and 7 for the entire population and for ARDS categories. RESULTS: 1525 patients aged 61 ± 13, 69% male, met ARDS criteria; most frequent comorbidities were obesity, hypertension, diabetes and respiratory disease. On admission, 331(21%), 849(56%) and 345(23%) patients had mild, moderate and severe ARDS; all received lung-protective ventilation (mean tidal volumes between 6.3 and 6.7 mL/kg PBW) and intermediate PEEP levels (10-11 cmH2O). PaO2/FiO2, plateau pressure, static compliance, driving pressure, ventilation ratio, pH and D-dimer >2 mg/L remained significantly different among the ARDS categories over time. In-hospital mortality was, respectively, 55%, 58% and 70% (p < 0.000). Independent predictors of changes of PaO2/FiO2 over time were BMI; preexistent respiratory disease; D-dimer >2 mg/L; day 1-PEEP, and day 1-ventilatory ratio. CONCLUSION: Hypoxemia in patients with COVID-19-related ARDS is associated with comorbidities, deadspace and activated coagulation markers, and disease severity-reflected by the PEEP level required.

Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multicentre cohort study.

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.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission.

OBJECTIVES: To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death. DESIGN: Retrospective cohort. SETTING: Medical-surgical ICU in a university-affiliated hospital. PATIENTS: Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014). CONCLUSIONS: Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

Impacto de la internación en terapia intensiva en la calidad de vida después de 1, 3, 6 y 12 meses / The impact of hospitalization in intensive care units on quality of life after 1, 3, 6 and 12 months

INTRODUCCION: A medida que más pacientes sobreviven a una internación en Unidades de Terapia Intensiva (UTI), se hace necesario conocer las secuelas a largo plazo. La calidad de vida relacionada a la salud tras la enfermedad crítica se mantiene por debajo de la media de la población general aún cinco años después del alta.OBJETIVO: Evaluar la calidad de vida de los pacientes a egreso de UTI mediante el cuestionario EuroQol 5D y predictores de mala evolución. Evaluar secuelas psíquicas y físicas una vez transcurridos 1, 3, 6 y 12 meses después del alta de UTI.METODOS: Se realizó un estudio descriptivo en un Hospital Interzonal de la Provincia de Buenos Aires (estudio prospectivo de serie de casos). Fueron incluidos aquellos pacientes sometidos a asistencia respiratoria mecánica invasiva por un período ≥ 48 horas que egresaron de UTI entre el 01/04/2010 y el 01/04/2011.RESULTADOS: Los criterios de inclusión fueron cumplidos por 51 pacientes. Se entrevistó a 36/46 pacientes (tras un mes), 25/34 pacientes (a los 3 meses), 12/15 pacientes (a los 6 meses) y 5/7 pacientes (a los 12 meses). Los datos demográficos reflejaron edad 33 [25-50] años, 71% de los pacientes de sexo masculino, 57% sin comorbilidades y con un puntaje APACHE II de 14,6 ± 6. El principal motivo de ingreso fue el trauma (50%). La dimensión más afectada fue la realización de actividades cotidianas, seguida de dolor/malestar y movilidad. La incidencia de ansiedad/depresión y estrés postraumático fue la reportada en otros estudios. La anemia, la traqueostomía y la alimentación enteral al alta fueron predictores de mala evolución según el índice EuroQol.CONCLUSIONES: La calidad de vida al alta de UTI se encontró muy deteriorada en la mayoría de las dimensiones. Las secuelas psíquicas se presentaron dentro del rango esperado. El índice EuroQol fue bajo en el primer mes, pero evolucionó favorablemente junto a la percepción de la propia calidad de vida medida por Escala Visual Análoga EuroQol.

INTRODUCTION: As more and more patients survive their hospitalization in Intensive Care Units (ICU), it is of utmost importance to find out and understand the long-term outcomes. Health-related quality of life after a critical illness is still below the average, even five years after discharge.OBJECTIVE: To assess patients quality of life after ICU discharge using the EuroQol-5D score and predictors of unfavorable prognosis. To assess psychological after-effects like anxiety, depression and post-traumatic stress disorder (PTSD), along with physical morbodity at 1, 3, 6 and 12 months after ICU discharge.METHODS: A descriptive study was conducted in a public hospital located in the province of Buenos Aires (prospective case study). It included all patients treated with invasive mechanical ventilation for at least 48 hours that survived ICU from April 1, 2010 through April 1, 2011.RESULTS: 51 patients qualified for inclusion in this study. Interviews were made to 36/46 patients after 1 month; 25/34 patients after 3 months; 12/15 patients after 6 months and 5/7 patients after 12 months. The demographic data showed age 33 [25-50], 71% male, 57% with no comorbidities and 14,6 ± 6,4 points in APACHE II score. The main reason for ICU admission was trauma (50%). The most affected dimension, as measured by EQ-5D, was usual activities, followed by pain/discomfort and self-care or morbility. The incidence of PTSD and anxiety/depression was similar was to what was reported in other studies. Anemia, tracheostomy and enteral feeding at discharge were predictors of unfavorable prognosis as indicated by the EuroQol index.CONCLUSIONS: The quality of life after ICU discharge was severely deteriorated in most dimensions. Psychological after-effects were within the expected values. The EuroQol index was low in the first month, but then it improved along with the quality of life as measured by the EuroQol Visual Analogue Scale.

Impacto de la internación en terapia intensiva en la calidad de vida después de 1, 3, 6 y 12 meses / The impact of hospitalization in intensive care units on quality of life after 1, 3, 6 and 12 months

INTRODUCCION: A medida que más pacientes sobreviven a una internación en Unidades de Terapia Intensiva (UTI), se hace necesario conocer las secuelas a largo plazo. La calidad de vida relacionada a la salud tras la enfermedad crítica se mantiene por debajo de la media de la población general aún cinco años después del alta.OBJETIVO: Evaluar la calidad de vida de los pacientes a egreso de UTI mediante el cuestionario EuroQol 5D y predictores de mala evolución. Evaluar secuelas psíquicas y físicas una vez transcurridos 1, 3, 6 y 12 meses después del alta de UTI.METODOS: Se realizó un estudio descriptivo en un Hospital Interzonal de la Provincia de Buenos Aires (estudio prospectivo de serie de casos). Fueron incluidos aquellos pacientes sometidos a asistencia respiratoria mecánica invasiva por un período ≥ 48 horas que egresaron de UTI entre el 01/04/2010 y el 01/04/2011.RESULTADOS: Los criterios de inclusión fueron cumplidos por 51 pacientes. Se entrevistó a 36/46 pacientes (tras un mes), 25/34 pacientes (a los 3 meses), 12/15 pacientes (a los 6 meses) y 5/7 pacientes (a los 12 meses). Los datos demográficos reflejaron edad 33 [25-50] años, 71% de los pacientes de sexo masculino, 57% sin comorbilidades y con un puntaje APACHE II de 14,6 ± 6. El principal motivo de ingreso fue el trauma (50%). La dimensión más afectada fue la realización de actividades cotidianas, seguida de dolor/malestar y movilidad. La incidencia de ansiedad/depresión y estrés postraumático fue la reportada en otros estudios. La anemia, la traqueostomía y la alimentación enteral al alta fueron predictores de mala evolución según el índice EuroQol.CONCLUSIONES: La calidad de vida al alta de UTI se encontró muy deteriorada en la mayoría de las dimensiones. Las secuelas psíquicas se presentaron dentro del rango esperado. El índice EuroQol fue bajo en el primer mes, pero evolucionó favorablemente junto a la percepción de la propia calidad de vida medida por Escala Visual Análoga EuroQol.

INTRODUCTION: As more and more patients survive their hospitalization in Intensive Care Units (ICU), it is of utmost importance to find out and understand the long-term outcomes. Health-related quality of life after a critical illness is still below the average, even five years after discharge.OBJECTIVE: To assess patients quality of life after ICU discharge using the EuroQol-5D score and predictors of unfavorable prognosis. To assess psychological after-effects like anxiety, depression and post-traumatic stress disorder (PTSD), along with physical morbodity at 1, 3, 6 and 12 months after ICU discharge.METHODS: A descriptive study was conducted in a public hospital located in the province of Buenos Aires (prospective case study). It included all patients treated with invasive mechanical ventilation for at least 48 hours that survived ICU from April 1, 2010 through April 1, 2011.RESULTS: 51 patients qualified for inclusion in this study. Interviews were made to 36/46 patients after 1 month; 25/34 patients after 3 months; 12/15 patients after 6 months and 5/7 patients after 12 months. The demographic data showed age 33 [25-50], 71% male, 57% with no comorbidities and 14,6 ± 6,4 points in APACHE II score. The main reason for ICU admission was trauma (50%). The most affected dimension, as measured by EQ-5D, was usual activities, followed by pain/discomfort and self-care or morbility. The incidence of PTSD and anxiety/depression was similar was to what was reported in other studies. Anemia, tracheostomy and enteral feeding at discharge were predictors of unfavorable prognosis as indicated by the EuroQol index.CONCLUSIONS: The quality of life after ICU discharge was severely deteriorated in most dimensions. Psychological after-effects were within the expected values. The EuroQol index was low in the first month, but then it improved along with the quality of life as measured by the EuroQol Visual Analogue Scale.