Abstract
Critical Care Science. 2024;36:e20240020en
DOI 10.62675/2965-2774.20240020-en
To analyze in-hospital and 1-year morbidity and mortality associated with acute gastrointestinal dysfunction in critically ill patients with COVID-19 via a prespecified scoring system.
Between March and July 2020, consecutive hospitalized patients with COVID-19 from a single institution were retrospectively analyzed by medical chart review. Only those who remained in the intensive care unit for more than 24 hours were included. Gastrointestinal dysfunction was assessed according to a predefined 5-point progressive gastrointestinal injury scoring system, considering the first 7 days of hospitalization. Laboratory data, comorbidities, the need for mechanical ventilation, the duration of intensive care unit stay, and subsequent in-hospital and 1-year mortality rates were also recorded.
Among 230 patients who were screened, 215 were included in the analysis. The median age was 68 years (54 - 82), and 57.7% were male. The total gastrointestinal dysfunction scores were 0 (79.1%), I (15.3%), II (4.7%), III (0.9%), and IV (0%). Any manifestation of gastrointestinal dysfunction was present in 20.9% of all patients and was associated with longer lengths of stay (20 days [11 - 33] versus 7 days [4 – 16]; p < 0.001] and higher C-reactive protein levels on admission (12.8mg/mL [6.4 - 18.4] versus 5.7mg/mL [3.2 - 13.4]; p < 0.001). The gastrointestinal dysfunction score was significantly associated with mortality (OR 2.8; 95%CI 1.7 - 4.8; p < 0.001) and the need for mechanical ventilation (OR 2.8; 95%CI 1.7 - 4.6; p < 0.001). Both in-hospital and 1-year death rates progressively increased as gastrointestinal dysfunction scores increased.
In the current series of intensive care unit patients with COVID-19, gastrointestinal dysfunction severity, as defined by a prespecified scoring system, was predictive of adverse in-hospital and 1-year outcomes.
Abstract
Critical Care Science. 2024;36:e20240065en
DOI 10.62675/2965-2774.20240065-en
To compare the effectiveness of the awake-prone position on relevant clinical outcomes in patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen between different waves in Argentina.
This multicenter, prospective cohort study included adult patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen. The main exposure position was the awake-prone position (≥ 6 hours/day) compared to the non-prone position. The primary outcome was endotracheal intubation, and the secondary outcome was in-hospital mortality. The inverse probability weighting–propensity score was used to adjust the conditional probability of treatment assignment. We then adjusted for contextual variables that varied over time and compared the effectiveness between the first and second waves.
A total of 728 patients were included: 360 during the first wave and 368 during the second wave, of whom 195 (54%) and 227 (62%) remained awake-prone for a median (p25 - 75) of 12 (10 - 16) and 14 (8 - 17) hours/day, respectively (Awake-Prone Position Group). The ORs (95%CIs) for endotracheal intubation in the Awake-Prone Position Group were 0.25 (0.13 - 0.46) and 0.19 (0.09 - 0.31) for the first and second waves, respectively (p = 0.41 for comparison between waves). The ORs for in-hospital mortality in the awake-prone position were 0.35 (0.17 - 0.65) and 0.22 (0.12 - 0.43), respectively (p = 0.44 for comparison between waves).
The awake-prone position was associated with a reduction in the risk of endotracheal intubation and in-hospital mortality. These effects were independent of the context in which the intervention was applied, and no differences were observed between the different waves.
Abstract
Critical Care Science. 2024;36:e20240236en
DOI 10.62675/2965-2774.20240236-en
To elucidate the impact of lymphopenia on critical COVID-19 patient outcomes.
We conducted a multicenter prospective cohort study across five hospitals in Portugal and Brazil from 2020 to 2021. The study included adult patients admitted to the intensive care unit with SARS-CoV-2 pneumonia. Patients were categorized into two groups based on their lymphocyte counts within 48 hours of intensive care unit admission: the Lymphopenia Group (lymphocyte serum count < 1 × 109/L) and the Nonlymphopenia Group. Multivariate logistic regression, propensity score matching, Kaplan‒Meier survival curve analysis and Cox proportional hazards regression analysis were used.
A total of 912 patients were enrolled, with 191 (20.9%) in the Nonlymphopenia Group and 721 (79.1%) in the Lymphopenia Group. Lymphopenia patients displayed significantly elevated disease severity indices, including Sequential Organ Failure Assessment and Simplified Acute Physiology Score 3 scores, at intensive care unit admission (p = 0.001 and p < 0.001, respectively). Additionally, they presented heightened requirements for vasopressor support (p = 0.045) and prolonged intensive care unit and in-hospital stays (both p < 0.001). Multivariate logistic regression analysis after propensity score matching revealed a significant contribution of lymphopenia to mortality, with an odds ratio of 1,621 (95%CI: 1,275 - 2,048; p < 0.001). Interaction models revealed an increase of 8% in mortality for each decade of longevity in patients with concomitant lymphopenia. In the subanalysis utilizing three-group stratification, the Severe Lymphopenia Group had the highest mortality rate, not only in direct comparisons but also in Kaplan‒Meier survival analysis (log-rank test p = 0.0048).
Lymphopenia in COVID-19 patients is associated with increased disease severity and an increased risk of mortality, underscoring the need for prompt support for critically ill high-risk patients. These findings offer important insights into improving patient care strategies for COVID-19 patients.
Abstract
Critical Care Science. 2024;36:e202400251en
DOI 10.62675/2965-2774.20240251-en
To describe the 12-month mortality of Dutch COVID-19 intensive care unit patients, the total COVID-19 population and various subgroups on the basis of the number of comorbidities, age, sex, mechanical ventilation, and vasoactive medication use.
We included all patients admitted with COVID-19 between March 1, 2020, and March 29, 2022, from the Dutch National Intensive Care (NICE) database. The crude 12-month mortality rate is presented via Kaplan-Meier survival curves for each patient subgroup. We used Cox regression models to analyze the effects of patient characteristics on 12-month mortality after hospital discharge.
We included 16,605 COVID-19 patients. The in-hospital mortality rate was 28.1%, and the 12-month mortality rate after intensive care unit admission was 29.8%. Among hospital survivors, 12-month mortality after hospital discharge was 2.5% (300/11,931). The hazard of death at 12 months after hospital discharge was greater in patients between 60 and 79 years (HR 4.74; 95%CI 2.23 - 10.06) and ≥ 80 years (HR 22.77; 95%CI 9.91 - 52.28) than in patients < 40 years of age; in male patients than in female patients (HR 1.38; 95%CI 1.07 - 1.78); and in patients with one (adjusted HR 1.95; 95%CI 1.5 - 2.53), two (adjusted HR 4.49; 95%CI 3.27 - 6.16) or more than two comorbidities (adjusted HR 4.99; 95%CI 2.62 - 9.5) than in patients with no comorbidities. Neither vasoactive medication use nor mechanical ventilation resulted in statistically significant results.
For Dutch COVID-19 intensive care unit patients, most deaths occurred during their hospital stay. For hospital survivors, the crude 12-month mortality rate was low. Patient age (older than 60), sex and the number of comorbidities were associated with a greater hazard of death at 12 months after hospital discharge, whereas mechanical ventilation and vasoactive medication were not.
Abstract
Critical Care Science. 2024;36:e20240253en
DOI 10.62675/2965-2774.20240253-en
To identify the influence of obesity on mortality, time to weaning from mechanical ventilation and mobility at intensive care unit discharge in patients with COVID-19.
This retrospective cohort study was carried out between March and August 2020. All adult patients admitted to the intensive care unit in need of ventilatory support and confirmed to have COVID-19 were included. The outcomes included mortality, time on mechanical ventilation, and mobility at intensive care unit discharge.
Four hundred and twenty-nine patients were included, 36.6% of whom were overweight and 43.8% of whom were obese. Compared with normal body mass index patients, overweight and obese patients had lower mortality (p = 0.002) and longer intensive care unit survival (log-rank p < 0.001). Compared with patients with a normal body mass index, overweight patients had a 36% lower risk of death (p = 0.04), while patients with obesity presented a 23% lower risk (p < 0.001). There was no association between obesity and time on mechanical ventilation. The level of mobility at intensive care unit discharge did not differ between groups and showed a moderate inverse correlation with length of stay in the intensive care unit (r = -0.461; p < 0.001).
Overweight and obese patients had lower mortality and higher intensive care unit survival rates. The duration of mechanical ventilation and mobility level at intensive care unit discharge did not differ between the groups.