Use Of Invasive Mechanical Ventilation Research Articles

Intracranial compliance in patients with COVID-19: a multicenter observational study.

Patients with severe coronavirus disease-19 (COVID-19) may require the use of invasive mechanical ventilation (MV) for prolonged periods. Aggressive MV parameters have been associated with changes in intracranial pressure (ICP) in patients with acute intracranial disorders. Significant ICP elevation could compromise intracranial compliance (ICC) and cerebrovascular hemodynamics (CVH). However, the effects of these parameters in individuals without neurological disorders have not yet been evaluated. To evaluate ICC in patients on MV with COVID-19 infection compared to other diagnoses, to better characterize the effects of MV and COVID-19 upon ICC. We also compared between the ICC in patients with COVID-19 who did not require MV and healthy volunteers, to assess the isolated effect of COVID-19 upon ICC. This was an exploratory, observational study with a convenience sample. The ICC was evaluated with a noninvasive ICP monitoring device. The P2/P1 ratio was calculated by dividing the amplitude of these two points, being defined as "abnormal" when P2 > P1. The statistical analysis was performed using a mixed linear model with random effects to compare the P2/P1 ratio in all four groups on the first monitoring day. A convenience sample of 78 subjects (15 MV-COVID-19, 15 MV non-COVID-19, 24 non-MV-COVID-19, and 24 healthy participants) was prospectively enrolled. There was no difference in P2/P1 ratios between MV patients with and without COVID-19, nor between non-MV patients with COVID-19 and healthy volunteers. However, the P2/P1 ratio was higher in COVID-19 patients with MV use than in those without it. This exploratory analysis suggests that COVID-19 does not impair ICC.

Acute kidney injury in hospitalized children in 20 hospitals of China’s Hunan Province: a cross-sectional survey

ABSTRACT: Objective The incidence of acute kidney injury (AKI) in pediatric patients has been increasing over the years, and AKI significantly impacts children’s health and quality of life. This article reviews the current epidemiological research on pediatric AKI. Methods The clinical data of hospitalized children aged 0 to 14 years from 20 different hospitals in Hunan Province, China, collected from December 2017 to February 2018, were analyzed. The incidence rate, misdiagnosis rate, main causes, and medical costs of AKI in hospitalized children were examined. Results A total of 29,639 patients were included, with an AKI incidence rate of 4.34% (1286/29,639). Among the 1286 AKI patients, 863 (67.11%) were classified as AKI stage 1324 (25.19%) as AKI stage 2, and 99 (7.7%) as AKI stage 3. AKI patients had significantly longer hospital stays [6.0 (4.0, 10) days vs. 6.0 (4.0, 8.0) days, p < 0.001] and higher hospitalization costs [3375.22 (1600, 6083.83) yuan vs. 2729.4 (1659.45, 8216.65) yuan, p = 0.003] than non-AKI patients. The mortality rate (1.2% vs. 0.1%, p < 0.001), intensive care unit (ICU) transfer rate (8.7% vs. 5.97%, p < 0.001), and use of invasive mechanical ventilation (3.6% vs. 1%, p < 0.001) were significantly greater in patients with AKI than in those without AKI patients. The etiology of AKI varied among different age groups, and dehydration, diarrhea, and shock were the main causes of pre-renal AKI. Conclusion The incidence and missed diagnosis rates of AKI in hospitalized children were high. AKI prolongs hospital stays, increases hospitalization costs, and increases the risk of mortality in children.

Sotrovimab in the treatment of coronavirus disease-2019 (COVID-19): a systematic review and meta-analysis of randomized clinical trials.

This study was carried out to verify the evidence regarding the effectiveness and safety of sotrovimab in patients with COVID-19. This is a systematic review of randomized clinical trials retrieved from the PubMed, Embase, Scopus, Lilacs, and Cochrane Library databases. The risk of bias was measured using the Cochrane Risk and Bias Checklist (RoB 2). For the meta-analysis, RStudio Version 2024.04.2 software was used. The certainty of evidence was assessed using GRADE. The study protocol was registered in PROSPERO (CRD42022355786). A total of 1893 studies were identified and four were included in the study. The total population consisted of 5470 patients with COVID-19, 1921 (35%) in the sotrovimab group and 3549 (65%) in the control group (placebo or BRII-196 + BRII-198 or casirivimab + imdevimab or bamlanivimab + etesevimab, administered in a similar way to sotrovimab, in a single dose with a 60-min intravenous infusion). For the effectiveness outcome, three studies presented low risk and one high risk of bias, while for safety all presented high risk of bias. The meta-analysis showed no significant difference between the sotrovimab and control groups in terms of hospitalization rates (95% confidence interval (CI) - 2.10-0.51; p = 0 > 0.05), use of invasive mechanical ventilation (95% CI - 2.78-0.65; p = 0.35) and mortality (95% CI - 0.92-0.59; p = 0.39). However, sensitivity analysis showed that sotrovimab may be effective in reducing hospitalization rates compared to the control (IV = - 1.57; 95% CI - 2.41-0.73; p = 0.99). The use of sotrovimab in the treatment of patients with COVID-19 had no significant impact on mortality and need for mechanical ventilation and did not appear to be safer compared to controls. However, there was evidence of effectiveness in reducing the rate of hospitalization, although the certainty of the evidence is moderate and the risk of bias is high.

Epidemiology, Outcomes, and Trend Analysis of Hospitalized Infants With Respiratory Syncytial Virus (RSV) Bronchiolitis From 1997 to 2019.

Background Most children with respiratory syncytial virus (RSV) infection have a self-limiting course that can be managed with supportive care, and hospitalization is uncommon. The objectives of this study were to evaluate the epidemiology, outcomes, associated comorbidities, and temporal trends in the prevalence of infants one to 24 months of age who required hospitalization for RSV infection in the United States of America from 1997 to 2019. Methods In this retrospective cross-sectional study, we utilized the Kids' Inpatient Database (KID) to investigate the prevalence and outcomes of RSV bronchiolitis within a large cohort of discharged patients from 1997 to 2019. We included children one to 24 months of age admitted with a diagnosis of RSV bronchiolitis. Neonates were excluded from the analysis. A chi-square for linear trend was used to analyze trends in the prevalence of RSV bronchiolitis hospitalization, the presence of complex chronic conditions (CCC), congenital heart disease (CHD), the use of non-invasive and invasive mechanical ventilation (NIV and IMV), and hospital mortality. Results There were a total of 566,786 infants aged one to 24 months hospitalized with RSV infection out of a total of 9,309,597 discharges during the eight-year cohort, with a hospital prevalence of 60.9 per 1000 discharges and a hospital mortality rate of 0.09% (95% confidence interval (CI): 0.08%-0.1%). There was no trend in hospitalization rates of RSV infections per 100,000 U.S. population during the study period, with a decrease in hospital mortality trend. Children with RSV bronchiolitis were more likely to have government insurance and reside in zip codes with the lowest income quartile. There was a significant seasonal and regional variation in RSV-related hospitalizations. The presence of CCC was identified in 2.4% of the RSV group compared to 5.1% of non-RSV discharges (odds ratio (OR): 0.46, 95% CI: 0.45-0.47; p<0.001). The prevalence of RSV among all discharges has significantly increased over the study period, rising from 51.6 cases per 1000 discharges in 1997 to 180.1 cases per 1000 discharges in 2019 (p<0.001). The prevalence of CCC and CHD among RSV patients has also shown an upward trend, with CCC cases increasing from 1,411 in 1997 to 2,795 in 2019 and CHD cases rising from 1,795 to 3,622 during the same period. The use of invasive mechanical ventilation, non-invasive ventilation, and extracorporeal membrane oxygenation has consistently increased over time. Additionally, complications such as the need for cardiopulmonary resuscitation have demonstrated a similar increasing trend, although they have remained overall low. However, population-based hospitalization rates showed no significant trend. Conclusions The hospitalization rates at a population level in the United States for RSV infection in children aged one to 24 months remained steady from 1997 to 2019, while hospital mortality rates showed a declining trend. There is an increased proportion of comorbid conditions and increased resource utilization in children with RSV. These findings are important for monitoring the effectiveness of preventive strategies for severe RSV infections.

Increasing plasma calprotectin (S100A8/A9) is associated with 12-month mortality and unfavourable functional outcome in critically ill COVID-19 patients

BackgroundCalprotectin (S100A8/A9) is a pro-inflammatory mediator primarily released from neutrophils. Previous studies have revealed associations between plasma calprotectin, disease severity and in-hospital mortality in unselected COVID-19 patients.ObjectiveWe aimed to assess whether plasma calprotectin dynamics during the first week of intensive care are associated with mortality and functional outcome in critically ill COVID-19 patients.MethodsThis prospective study included 498 COVID-19 patients admitted to six intensive care units (ICUs) in Sweden between May 2020 and May 2021. Blood samples were collected on ICU admission and on day 7. The primary outcome was 12-month mortality. Secondary outcomes were functional outcome of survivors at 3 and 12 months, and the need for invasive mechanical ventilation (IMV) or continuous renal replacement therapy (CRRT) during the ICU stay. Functional outcome was assessed by the Glasgow Outcome Scale Extended (GOSE, range 1–8, with < 5 representing an unfavourable outcome). Associations between plasma calprotectin and outcomes were examined in binary logistic regression analyses adjusted for age, sex, BMI, hypertension, smoking, and creatinine.ResultsHigh plasma calprotectin on admission and day 7 was independently associated with increased 12-month mortality. Increasing calprotectin from admission to day 7 was independently associated with higher mortality at 12 months [OR 2.10 (95% CI 1.18–3.74), p = 0.012], unfavourable functional outcome at 3 months [OR 2.53 (95% CI 1.07–6.10), p = 0.036], and the use of IMV [OR 2.23 (95% CI 1.10–4.53), p = 0.027)] and CRRT [OR 2.07 (95% CI 1.07–4.00), p = 0.031)]. A receiver operator characteristic (ROC) model including day 7 calprotectin and age was a good predictor of 12-month mortality [AUC 0.79 (95% CI 0.74–0.84), p < 0.001]. Day 7 calprotectin alone predicted an unfavourable functional outcome at 3 months [AUC 0.67 (95% CI 0.58–0.76), p < 0.001].ConclusionIn critically ill COVID-19 patients, increasing calprotectin levels after admission to the ICU are associated with 12-month mortality and unfavourable functional outcome in survivors. Monitoring plasma calprotectin dynamics in the ICU may be considered to evaluate prognosis in critical COVID-19.Study registration: ClinicalTrials.gov Identifier: NCT04974775, registered April 28, 2020.

A retrospective validation of the effective and safe treatment of patients on general care wards with high velocity nasal insufflation therapy utilizing prognostic risk scores during COVID-19

Background Non-invasive positive pressure ventilation (NIPPV) has been a traditional therapy for acute respiratory failure (ARF). However, the use of NIPPV during the COVID-19 pandemic was challenging, while the use of invasive mechanical ventilation produced poor outcomes. An alternative to NIPPV, high velocity nasal insufflation (HVNI) has shown promise in treating ARF effectively. Objective This study evaluated whether HVNI can be used to treat ARF safely on the general care ward (GCW) during COVID-19 pandemic surges. Methods After introducing HVNI therapy to the facility, an evidence-based scoring system, Modified Early Warning Score (MEWS), was used to risk stratify patients and assist in assigning care level. Initial settings, demographic data, patient outcomes, and health care worker (HCW) virus conversion were measured throughout the study. Treatment failure was defined as the need for invasive mechanical ventilation (IMV) or NIPPV after HVNI therapy. MEWS and ROX index were compared retrospectively using the Pearson product-moment correlation coefficient to identify trends. The Welch two sample t-test (desired power of 90% with alpha=0.05) was used for demographic and outcome analysis. Results Two hundred thirty-four patients were treated with HVNI. The GCW failure rate of 18.56% (n=31/167) was lower than the ICU failure rate of 37.31% (n=25/67) but not statistically significant (P 0.175). No elevated risk to patients or HCW was observed. Respiratory rate (GCW 24.85 vs. ICU 30.14; P &lt;0.001), MEWS (GCW 2.34 vs. ICU 3.09; p=0.002), and ROX index (GCW 5.49 vs. ICU 4.68; P 0.002) assessments appear to be adequate predictors of HVNI failure. The Pearson product-moment coefficient comparing MEWS and ROX index identified a moderate negative correlation (-0.434; P &lt;0.001). Discussion HVNI therapy is an effective alternative to NIPPV for treating patients with COVID-19 associated ARF. Using measures such as MEWS and/or ROX, strict patient monitoring, and HCW surveillance, HVNI can be safely utilized on the GCW. This has a direct impact when dealing with patient surges where ICU beds and resources are limited. Additional studies are needed to further delineate these concepts. Keywords: COVID-19, Non-invasive Positive Pressure Ventilation, Acute Respiratory Failure, High Flow Nasal Oxygen, High Velocity Nasal Insufflation, ICU Admission, General Care Ward, MEWS, ROX

Exploring intensivist involvement: Patient characteristics, interventions and outcomes.

Intensivists play a critical role in the management of intensive care units (ICUs) and in providing high quality care. While international guidelines recommend intensivist staffing for improved patient outcomes, there is a shortage of qualified intensivists in many regions, including Türkiye. This study aimed to assess the impact of introducing a full-time intensivist to a medical ICU on patient characteristics, outcomes, and ICU interventions. This retrospective study analyzed data from the Internal Medicine ICU at Van Yüzüncü Yıl University Dursun Odabaş Medical Center over two periods: Pre- and post-intensivist recruitment. The study included adult patients admitted to the ICU from February 2018 to January 2020. Patient demographics, reasons for ICU admission, APACHE-II and SOFA scores, ICU interventions, and outcomes were recorded and compared between the two periods. Of the 868 patients admitted during the study period, 820 were included in the analysis. There were no significant differences in demographic characteristics between the pre- and post-intensivist periods. However, patients in the post-intensivist period had higher APACHE-II and SOFA scores. Intensive care units mortality rates were comparable between the two periods. The post-intensivist period saw increased use of invasive mechanical ventilation and non-invasive ventilation compared to the pre-intensivist period. Renal replacement therapy usage and enteral nutrition provision also increased in the post-intensivist period. ICU and hospital lengths of stay remained similar between the two periods. The introduction of a full-time intensivist to the medical ICU led to changes in ICU interventions, including increased use of mechanical ventilation and renal replacement therapy. Despite these changes, ICU mortality rates remained unchanged. Further research is needed to explore the longterm impact of intensivist staffing on patient outcomes in Türkiye.

Sex disparities in short-term outcomes among patients with diffuse large B cell lymphoma undergoing chimeric antigen receptor T-cell therapy in the United States.

e19062 Background: Chimeric Antigen Receptor (CAR) T-cell therapy, a promising immunotherapy used in various cancers, including Diffuse large B cell lymphoma (DLBCL), can involve multiple complications and the need for medical interventions. Our retrospective study strives to gain up-to-date insight into sex-based differences among DLBCL patients undergoing CAR T-cell therapy. Methods: We focussed on DLBCL patients undergoing CAR T-cell therapy via the 2017-2020 National Inpatient Sample(NIS). The events of complications between males and females were examined via multivariate regression models. Since the ICD-10 code for cytokine release syndrome (CRS) involved cases between October and December 2020, we used samples for that timeline while evaluating that particular complication. Results: Our study involved 3280 adult cases of DLBCL undergoing CAR T-cell therapy, with 1930 (58.8%) males and 1350(41.2%) females. Age differences were seen as females were older(mean age 61.93 vs. 60.40 years, p&lt;0.01). Females also had lower odds of atrial fibrillation (6.7% vs. 14.2%, aOR 0.440, p&lt;0.01) and acute kidney injury (AKI) (10.0% vs. 18.4%, aOR 0.458, p&lt;0.01), while having higher odds of use of invasive mechanical ventilation (5.6% vs. 5.2%, aOR 2.179, p&lt;0.01), events of sepsis (9.6% vs. 7.8%, aOR 1.575, p&lt;0.01), pancytopenia (69.6% vs. 64.0%, aOR 1.454, p&lt;0.01), and cryoprecipitate transfusion (2.2% vs. 1.8%, aOR 2.325, p=0.041) than males. We did not find any statistically significant differences for events of gastrointestinal bleeding (GIB)(aOR 0.866, p=0.636), tumor lysis syndrome(aOR 0.980, p=0.890), acute pulmonary embolism(aOR 1.133, p=0.719), toxic encephalopathy(aOR 1.009, p=0.935), platelet transfusion(aOR 0.994, p=0.976), RBC transfusion(aOR 0.828, p=0.192), or all-cause mortality(aOR 1.829, p=0.064). In addition, while 51.6% of males and 51.7% of females reported CRS, it was not statistically valid (aOR 0.923, p=0.850). Conclusions: The sex of DLBCL patients undergoing CAR T-cell therapy can influence multiple complications, as described in our study. Further research and endeavors aimed to deepen our understanding of our findings will help bring changes in protocols by physicians to improve the quality of care and outcomes of these patients.

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

Serial invasive hemodynamics and clinical characteristics of patients with shock with and without invasive mechanical ventilation

Abstract Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p &amp;lt;0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p &amp;lt;0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Recurrent Intensive Care Episodes and Mortality Among Children With Severe Neurologic Impairment

Children requiring care in a pediatric intensive care unit (PICU) are known to have increased risk of subsequent mortality. Children with severe neurologic impairment (SNI)-who carry neurologic or genetic diagnoses with functional impairments and medical complexity-are frequently admitted to PICUs. Although recurrent PICU critical illness episodes (PICU-CIEs) are assumed to indicate a poor prognosis, the association between recurrent PICU-CIEs and mortality in this patient population is poorly understood. To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment. This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023. Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions). One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year. In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE. This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.

Impact of COVID-19 on posttraumatic stress disorder in ICU survivors: a prospective observational comparative cohort study

BackgroundPosttraumatic stress disorder (PTSD) after a stay in the intensive care unit (ICU) can affect one in five ICU survivors. At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, admission to the ICU for COVID-19 was stressful due to the severity of this disease. This study assessed whether admission to the ICU for COVID-19 was associated with a higher prevalence of PTSD compared with other causes of ICU admission after adjustment for pre-ICU psychological factors.MethodsThis prospective observational comparative cohort study included 31 ICUs. Eligible patients were adult ICU survivors hospitalized during the first wave of COVID-19 pandemic in France, regardless of the reason for admission. The prevalence of presumptive diagnosis of PTSD at 6 months was assessed using the PTSD Checklist for DSM-5 (PCL-5). Sociodemographics, clinical data, history of childhood trauma (Childhood Trauma Questionnaire [CTQ]), and exposure to potentially traumatic events (Life Events Checklist for DSM-5 [LEC-5]) were assessed.ResultsOf the 778 ICU survivors included during the first wave of COVID-19 pandemic in France, 417 and 361 were assigned to the COVID-19 and non-COVID-19 cohorts, respectively. Fourteen (4.9%) and 11 (4.9%), respectively, presented with presumptive diagnosis of PTSD at 6 months (p = 0.976). After adjusting for age, sex, severity score at admission, use of invasive mechanical ventilation, ICU duration, CTQ and LEC-5, COVID-19 status was not associated with presumptive diagnosis of PTSD using the PCL-5. Only female sex was associated with presumptive diagnosis of PTSD. However, COVID-19 patients reported significantly more intrusion and avoidance symptoms than non-COVID patients (39% vs. 29%, p = 0.015 and 27% vs. 19%, p = 0.030), respectively. The median PCL-5 score was higher in the COVID-19 than non-COVID-19 cohort (9 [3, 20] vs. 4 [2, 16], p = 0.034).ConclusionAdmission to the ICU for COVID-19 was not associated with a higher prevalence of PTSD compared with admission for another cause during the first wave of the COVID-19 pandemic in France. However, intrusion and avoidance symptoms were more frequent in COVID-19 patients than in non-COVID-19 patients.Trial Registration: Clinicaltrials.gov Identifier NCT03991611, registered on June 19, 2019.

Epidemiology and Clinical Characteristics of Pediatric Sepsis in PICUs in Southwest China: A Prospective Multicenter Study.

To describe the epidemiological characteristics of pediatric sepsis in Southwest China PICUs. A prospective, multicenter, and observational study. Twelve PICUs in Southwest China. The patients admitted to the PICU from April 1, 2022, to March 31, 2023. The age ranged from 28 days to 18 years. All patients met the criteria of severe sepsis or septic shock. None. Of the 31 PICUs invited to participate, 12 PICUs (capacity of 292 beds) enrolled patients in the study. During the study period, 11,238 children were admitted to the participating PICUs, 367 (3.3%) of whom met the diagnosis of severe sepsis or septic shock. The most prevalent sites of infection were the respiratory system (55%) and the digestive system (15%). The primary treatments administered to these patients included antibiotics (100%), albumin (61.3%), invasive mechanical ventilation (58.7%), glucocorticoids (55.6%), blood products (51%), gammaglobulin (51%), and vasoactive medications (46.6%). Sepsis-related mortality in the PICU was 11.2% (41/367). Nearly half of the sepsis deaths occurred within the first 3 days of PICU admission (22/41, 53.7%). The mortality rate of septic shock (32/167, 19.2%) was significantly higher than that of severe sepsis (9/200, 4.5%; p < 0.001). The outcomes of a multivariate logistic regression analysis suggested that a higher pediatric Sequential Organ Failure Assessment score, and the use of invasive mechanical ventilation and vasoactive medications were independently associated with PICU mortality in children with sepsis. This report updates the epidemiological data of pediatric sepsis in PICUs in Southwest China. Sepsis is still a life-threatening disease in children.

Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.

Evaluation of the last 2 decades in the characteristics of presentation, management and prognosis of serious spontaneous intracerebral hemorrhage in a third level hospital

ObjectiveTo analyze the change in the characteristics of presentation, evolution and treatment in the ICU, as well as the functional evolution at 12 months of spontaneous intracranial hemorrhages (ICHs) treated in an ICU reference center. Patient and methodsDescriptive, retrospective study in a Neurocritical Reference Hospital. All admissions of patients with HICE during three periods are studied: 1999–2001 (I), 2015–2016 (II) and 2020–2021 (III). Evolution in the three periods of demographic variables, baseline characteristics of the patients, clinical variables and characteristics of bleeding, evolutionary data in the ICU are studied. At one year we assessed the GOS scale (Glasgow Outcome Score) according to whether they had a poor (GOS 1−3) or good (GOS 4−5) prognosis. Results300 admitted patients, distributed in periods: I: 28.7%, II: 36.3% and III: 35%. 56.7% were males aged 66 (55.5–74) years; ICH score 2 (1−3). The ICU stay was 5 (2–14) days with a mortality of 36.8%. GOS 1−3 a year in 67.3% and GOS 4−5 in 32.7%. Comparing the three periods, we observed a higher prevalence in women, and the presence of cardiovascular factors; no changes in etiology; in relation to the location, it increases cerebellar hemorrhage and in the brainstem. Although the severity was greater, the stay in the ICU, the use of invasive mechanical ventilation and tracheostomy were lower. Open surgery has decreased its use by 50%. Mortality continues to be high, stagnating in the ICU at 35% and entails a high degree of disability one year after assessment. ConclusionsSevere ICH is a complex pathology that has changed some characteristics in the last two decades, with more severe patients, with more cardiovascular history and a greater predominance of brainstem and cerebellar hemorrhage. Despite the increase in severity, better parameters during the ICU stay, with open surgery used 50% less. Mortality remains stagnant at 35% with high disability per year.

Clinical characteristics and mortality prediction of patients admitted to the Hong Kong East Cluster intensive care units in the COVID‐19 fifth wave

AbstractIntroductionCOVID‐19 has been threatening global public health since 2019. To address the overwhelming caseload, several tools were developed to predict prognosis and aid triage of critically ill patients for intensive care. Currently, there is a lack of local data on the validity of such tools.ObjectiveThe objective of this study is to identify the predictors of intensive care unit (ICU) mortality in COVID‐19 patients in Hong Kong and externally validate the different scoring systems.MethodsA retrospective cohort analysis of patients admitted to the HKEC ICUs from 1 January 2022 to 30 April 2022 was performed. We collected data on patient demographics, vaccination status, laboratory parameters, and clinical outcomes including need for organ support and mortality. Clinical severities were estimated by Sequential Organ Failure Score, 4C Mortality Score, COVID‐Gram score, and Acute Physiology and Chronic Health Evaluation (APACHE) IV score based on the original studies. Comparison between individual scoring systems' performance on hospital mortality was conducted and summarized.ResultsIn these four months, 137 patients with COVID‐19 admitted to ICUs of Ruttonjee Hospital and Pamela Youde Nethersole Eastern Hospital were recruited. 64 patients (46.7%) were admitted for COVID‐19 related respiratory failure, among which mortality was 66.7%. The overall hospital and ICU mortality were 21.9% and 13.1%, respectively. Invasive mechanical ventilation (IMV) (OR 3.221, p 0.034), high flow nasal cannula (HFNC) oxygen therapy (OR 3.107, p 0.039), and higher APACHE IV score (OR 1.043, p &lt; 0.001) were independent predictors of hospital mortality using multivariate analysis. The scoring systems had good performance in mortality prediction in our population. The APACHE IV score (AUROC 0.79, 95% CI 0.698–0.894) and 4C Mortality Score (AUROC 0.751, 95% CI 0.657–0.844) outperformed other scoring systems in predicting hospital mortality.ConclusionIn patients with COVID‐19, the use of IMV or HFNC and APACHE IV score were independent risk factors for hospital mortality. The APACHE IV and the 4C Mortality Score were most useful in our population for predicting ICU and hospital mortality.

Risk factors for COVID-19-associated pulmonary aspergillosis: a systematic review and meta-analysis

COVID-19-associated pulmonary aspergillosis (CAPA) has been reported to be an emerging and potentially fatal complication of severe COVID-19. However, risk factors for CAPA have not been systematically addressed to date. In this systematic review and meta-analysis to identify factors associated with CAPA, we comprehensively searched five medical databases: Ovid MEDLINE; Ovid Embase; the Cochrane Database of Systematic Reviews; the Cochrane Central Register of Controlled Trials; and the WHO COVID-19 Database. All case-control and cohort studies in adults (aged >18 years) that described at least six cases of CAPA and evaluated any risk factors for CAPA, published from Dec 1, 2019, to July 27, 2023, were screened and assessed for inclusion. Only studies with a control population of COVID-19-positive individuals without aspergillosis were included. Two reviewers independently screened search results and extracted outcome data as summary estimates from eligible studies. The primary outcome was to identify the factors associated with CAPA. Meta-analysis was done with random-effects models, with use of the Mantel-Haenszel method to assess dichotomous outcomes as potential risk factors, or the inverse variance method to assess continuous variables for potential association with CAPA. Publication bias was assessed with funnel plots for factors associated with CAPA. The study is registered with PROSPERO, CRD42022334405. Of 3561 records identified, 27 articles were included in the meta-analysis. 6848 patients with COVID-19 were included, of whom 1324 (19·3%) were diagnosed with CAPA. Diagnosis rates of CAPA ranged from 2·5% (14 of 566 patients) to 47·2% (58 of 123). We identified eight risk factors for CAPA. These factors included pre-existing comorbidities of chronic liver disease (odds ratio [OR] 2·70 [95% CI 1·21-6·04], p=0·02; I2=53%), haematological malignancies (OR 2·47 [1·27-4·83], p=0·008; I2=50%), chronic obstructive pulmonary disease (OR 2·00 [1·42-2·83], p<0·0001; I2=26%), and cerebrovascular disease (OR 1·31 [1·01-1·71], p=0·05; I2=46%). Use of invasive mechanical ventilation (OR 2·83; 95% CI 1·88-4·24; p<0·0001; I2=69%), use of renal replacement therapy (OR 2·26 [1·76-2·90], p<0·0001; I2=14%), treatment of COVID-19 with interleukin-6 inhibitors (OR 2·88 [1·52-5·43], p=0·001; I2=89%), and treatment of COVID-19 with corticosteroids (OR 1·88 [1·28-2·77], p=0·001; I2=66%) were also associated with CAPA. Patients with CAPA were typically older than those without CAPA (mean age 66·6 years [SD 3·6] vs 63·5 years [5·3]; mean difference 2·90 [1·48-4·33], p<0·0001; I2=86%). The duration of mechanical ventilation in patients with CAPA was longer than in those without CAPA (n=7 studies; mean duration 19·3 days [8·9] vs 13·5 days [6·8]; mean difference 5·53 days [1·30-9·77], p=0·01; I2=88%). In post-hoc analysis, patients with CAPA had higher all-cause mortality than those without CAPA (n=20 studies; OR 2·65 [2·04-3·45], p<0·0001; I2=51%). The identified risk factors for CAPA could eventually be addressed with targeted antifungal prophylaxis in patients with severe COVID-19. None.

Pneumomediastinum as a primary manifestation of COVID-19: A case report

Introduction: Pneumomediastinum is a rare complication that occurs in patients with Pneumonia caused by COVID-19 and is more frequent in patients with ARDS that may or may not be related to the use of invasive mechanical ventilation. Pneumomediastinum is an indicator of clinical deterioration with potentially threatening consequences for the patient. Method: We described a case report of a 23-year-old man with Pneumomediastinum, infected with COVID-19 in conditions of respiratory failure due to interstitial pneumonia. Case presentation: A 23-year-old man, who had no pre-existing health conditions presented to the Infectious Diseases service with complaints of difficulty in breathing, dry cough, chest pain, muscle pain, joint pain, loss of taste, sore throat, pronounced body weakness, diarrhea. Symptoms started 11 days ago. On admission the patient refers that he doesn’t suffer from any other disease. The patient was not vaccinated against COVID-19. At the time of admission to the hospital, the objective examination revealed cervical subcutaneous emphysema and harsh respiration in both lungs. The nasopharyngeal swab test (RT-PCR) for Covid-19 was positive from the Institute of Public Health. The CT scan of the chest confirmed the presence of pneumomediastinum major, subcutaneous emphysema and bilateral ground glass opacities. Conclusion: Pneumomediastinum is a rare complication of pneumonia caused by Covid-19 in which the etiopathogenesis consists of severe pulmonary involvement that may or may not be affected using invasive mechanical ventilation. Timely diagnosis of pneumomediastinum in patients with Covid-19 would prevent the occurrence of life-threatening complications. Keywords: Covid-19, pneumomediastinum, ARDS, Macklin effect, vaccine.

Incidence and inhospital outcomes of coronavirus disease 2019-associated pulmonary aspergillosis in the United States.

The aim of this study was to estimate the predictors, associations, and outcomes of COVID-19-associated pulmonary disease (CAPA) in the United States. This retrospective cohort study was performed by using the National Inpatient Sample Database 2020 to identify coronavirus disease 2019 (COVID-19) and CAPA hospitalizations. Baseline variables and outcomes were compared between COVID-19 hospitalizations without aspergillosis and those with aspergillosis. These variables were then used to perform an adjusted analysis for obtaining predictors and factors associated with CAPA and its inhospital mortality. Of the 1,020,880 hospitalizations identified with the principal diagnosis of COVID-19, CAPA was identified in 1510 (0.1%) hospitalizations. The CAPA cohort consisted of a higher proportion of males (58%) as well as racial and ethnic minorities (Hispanics, Blacks, and others [including Asian or Pacific islanders, native Americans]). Inhospital mortality was significantly higher (47.35% vs. 10.87%, P < 0.001), the average length of stay was longer (27.61 vs. 7.29 days, P < 0.001), and the mean cost per hospitalization was higher ($121,560 vs. $18,423, P < 0.001) in the CAPA group compared to COVID-19 without aspergillosis. History of solid organ transplant, chronic obstructive pulmonary disease, and venous thromboembolism were associated with higher odds of CAPA among other factors. The use of invasive mechanical ventilation (adjusted odds ratio [aOR] 6.24, P < 0.001), acute kidney injury (aOR 2.02, P = 0.028), and septic shock (aOR 2.07, P = 0.018) were associated with higher inhospital mortality in the CAPA cohort. While CAPA is an infrequent complication during hospitalizations for COVID-19, it significantly increases all-cause mortality, prolongs hospital stays, and leads to higher hospital expenses compared to COVID-19 cases without aspergillosis.

Trends and sex differences in atrial fibrillation among patients hospitalized due to asthma: Insights from a nationwide population-based discharge database in Spain, 2016–2021

AimsTo analyze changes in the prevalence of atrial fibrillation (AF) in patients hospitalized due to asthma; to compare hospital outcomes in asthma patients with and without AF, assessing sex differences; to identify variables associated with the presence of AF; and to analyze the factors associated with in-hospital mortality (IHM) among asthma patients with AF. MethodsWe used data from the Registry of Specialized Care Activity-Basic Minimum Data Set to select all patients aged ≥40 years with an asthma diagnosis in Spain, from 2016 to 2021. We stratified the study population according to the presence of AF and sex. ResultsWe identified 65,233 hospitalizations that met the inclusion criteria (14.85 % with AF). The prevalence of AF significantly increased over time, with the male sex being a protective factor for its presentation. IHM were significantly higher in patients with AF. Older age, being a woman, congestive heart failure, renal disease, obstructive sleep apnea, hypertension, and hyperthyroidism were associated with the presence of AF. Advanced age and the presence of cancer and COVID-19 were factors associated with a higher IHM, as well as admission to an intensive care unit and the use of invasive mechanical ventilation. There were no association of sex with the IHM. ConclusionsAF is highly prevalent among subjects hospitalized due to asthma, with this prevalence having increased significantly in Spain over time. The presence of AF in patients with asthma was associated significantly with a higher LOHS and IHM. Sex was not associated with IHM in these patients.