Abstract
Rev Bras Ter Intensiva. 2022;34(3):342-350
DOI 10.5935/0103-507X.20220229-en
To evaluate whether critical SARS-CoV-2 infection is more frequently associated with signs of corticospinal tract dysfunction and other neurological signs, symptoms, and syndromes, than other infectious pathogens.
This was a prospective cohort study with consecutive inclusion of patients admitted to intensive care units due to primary infectious acute respiratory distress syndrome requiring invasive mechanical ventilation > 48 hours. Eligible patients were randomly assigned to three investigators for clinical evaluation, which encompassed the examination of signs of corticospinal tract dysfunction. Clinical data, including other neurological complications and possible predictors, were independently obtained from clinical records.
We consecutively included 54 patients with acute respiratory distress syndrome, 27 due to SARS-CoV-2 and 27 due to other infectious pathogens. The groups were comparable in most characteristics. COVID-19 patients presented a significantly higher risk of neurological complications (RR = 1.98; 95%CI 1.23 - 3.26). Signs of corticospinal tract dysfunction tended to be more prevalent in COVID-19 patients (RR = 1.62; 95%CI 0.72 - 3.44).
Our study is the first comparative analysis between SARS-CoV-2 and other infectious pathogens, in an intensive care unit setting, assessing neurological dysfunction. We report a significantly higher risk of neurological dysfunction among COVID-19 patients. As such, we suggest systematic screening for neurological complications in severe COVID-19 patients.
Abstract
Rev Bras Ter Intensiva. 2022;34(2):295-299
DOI 10.5935/0103-507X.20220028-en
Posterior reversible encephalopathy syndrome is a rare clinical and radiological syndrome characterized by vasogenic edema of the white matter of the occipital and parietal lobes, which are usually symmetrical, resulting from a secondary manifestation of acute dysfunction of the posterior cerebrovascular system. We describe a case of posterior reversible encephalopathy syndrome secondary to SARS-CoV-2 infection in a 9-year-old boy who developed acute hypoxemic respiratory failure and required assisted mechanical ventilation. The child developed multisystem inflammatory syndrome, and he was monitored in the pediatric intensive care unit and was provided mechanical ventilation and vasoactive agents for hemodynamic support. Additionally, he developed pulmonary and extrapulmonary clinical manifestations along with neuropsychiatric manifestations that required close follow-up and were verified using brain magnetic resonance imaging for timely intervention. Currently, there are few reports of children with posterior reversible encephalopathy syndrome associated with multisystem inflammatory syndrome.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):107-115
DOI 10.5935/0103-507X.20220005-en
To evaluate clinical practices and hospital resource organization during the early COVID-19 pandemic in Brazil.
This was a multicenter, cross-sectional survey. An electronic questionnaire was provided to emergency department and intensive care unit physicians attending COVID-19 patients. The survey comprised four domains: characteristics of the participants, clinical practices, COVID-19 treatment protocols and hospital resource organization.
Between May and June 2020, 284 participants [median (interquartile ranges) age 39 (33 - 47) years, 56.3% men] responded to the survey; 33% were intensivists, and 9% were emergency medicine specialists. Half of the respondents worked in public hospitals. Noninvasive ventilation (89% versus 73%; p = 0.001) and highflow nasal cannula (49% versus 32%; p = 0.005) were reported to be more commonly available in private hospitals than in public hospitals. Mechanical ventilation was more commonly used in public hospitals than private hospitals (70% versus 50%; p = 0,024). In the Emergency Departments, positive endexpiratory pressure was most commonly adjusted according to SpO2, while in the intensive care units, positive end-expiratory pressure was adjusted according to the best lung compliance. In the Emergency Departments, 25% of the respondents did not know how to set positive end-expiratory pressure. Compared to private hospitals, public hospitals had a lower availability of protocols for personal protection equipment during tracheal intubation (82% versus 94%; p = 0.005), managing mechanical ventilation [64% versus 75%; p = 0.006] and weaning patients from mechanical ventilation [34% versus 54%; p = 0.002]. Finally, patients spent less time in the emergency department before being transferred to the intensive care unit in private hospitals than in public hospitals [2 (1 - 3) versus 5 (2 - 24) hours; p < 0.001].
This survey revealed significant heterogeneity in the organization of hospital resources, clinical practices and treatments among physicians during the early COVID-19 pandemic in Brazil.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):124-130
DOI 10.5935/0103-507X.20220006-en
The current study assessed the prevalence of troponin elevation and its capacity to predict 60day mortality in COVID-19 patients in intensive care.
A longitudinal prospective single-center study was performed on a cohort of patients in intensive care due to a COVID-19 diagnosis confirmed using real-time test polymerase chain reaction from May to December 2020. A Receiver Operating Characteristic curve was constructed to predict death according to troponin level by calculating the area under the curve and its confidence intervals. A Cox proportional hazards model was generated to report the hazard ratios with confidence intervals of 95% and the p value for its association with 60day mortality.
A total of 296 patients were included with a 51% 60-day mortality rate. Troponin was positive in 39.9% (29.6% versus 49.7% in survivors and non-survivors, respectively). An area under the curve of 0.65 was found (95%CI: 0.59 - 0.71) to predict mortality. The Cox univariate model demonstrated a hazard ratio of 1.94 (95%CI: 1.41 - 2.67) and p < 0.001, but this relationship did not remain in the multivariate model, in which the hazard ratio was 1.387 (95%CI: 0.21 - 1.56) and the p value was 0.12.
Troponin elevation is frequently found in patients in intensive care for COVID-19. Although its levels are higher in patients who die, no relationship was found in a multivariate model, which indicates that troponin should not be used as an only prognostic marker for mortality in this population.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):131-140
DOI 10.5935/0103-507X.20220007-en
To evaluate the incidence of risk factors for postintubation hypotension in critically ill patients with COVID-19.
We conducted a retrospective study of 141 patients with COVID-19 who were intubated in the intensive care unit. Postintubation hypotension was defined as the need for any vasopressor dose at any time within the 60 minutes following intubation. Patients with intubation-related cardiac arrest and hypotension before intubation were excluded from the study.
Of the 141 included patients, 53 patients (37.5%) had postintubation hypotension, and 43.6% of the patients (n = 17) were female. The median age of the postintubation hypotension group was 75.0 (interquartile range: 67.0 - 84.0). In the multivariate analysis, shock index ≥ 0.90 (OR = 7.76; 95%CI 3.14 - 19.21; p < 0.001), albumin levels < 2.92g/dL (OR = 3.65; 95%CI 1.49 - 8.96; p = 0.005), and procalcitonin levels (OR = 1.07, 95%CI 1.01 - 1.15; p = 0.045) were independent risk factors for postintubation hypotension. Hospital mortality was similar in patients with postintubation hypotension and patients without postintubation hypotension (92.5% versus 85.2%; p = 0.29).
The incidence of postintubation hypotension was 37.5% in critically ill COVID-19 patients. A shock index ≥ 0.90 and albumin levels < 2.92g/dL were independently associated with postintubation hypotension. Furthermore, a shock index ≥ 0.90 may be a practical tool to predict the increased risk of postintubation hypotension in bedside scenarios before endotracheal intubation. In this study, postintubation hypotension was not associated with increased hospital mortality in COVID-19 patients.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):141-146
DOI 10.5935/0103-507X.20220008-en
To assess early postdischarge health-related quality of life and disability of all survivors of critical COVID-19 admitted for more than 24 hours to na intensive care unit..
Study carried out at the Intensive Care Medicine Department of Centro Hospitalar Universitário São João from 8th October 2020 to 16th February 2021. Approximately 1 month after hospital discharge, an intensive care-trained nurse performed a telephone consultation with 99 survivors already at home applying the EuroQol Five-Dimensional Five-Level questionnaire and the 12-item World Health Organization Disability Assessment Schedule 2.0.
The mean age of the population studied was 63 ± 12 years, and 32.5% were submitted to invasive mechanical ventilation. Their mean Simplified Acute Physiologic Score was 35 ± 14, and the Charlson Comorbidity Index was 3 ± 2. Intensive care medicine and hospital lengths of stay were 13 ± 22 and 22 ± 25 days, respectively. The mean EuroQol Visual Analog Scale was 65% (± 21), and only 35.3% had no or slight problems performing their usual activities, most having some degree of pain/discomfort and anxiety/depression. The 12-item World Health Organization Disability Assessment Schedule 2.0 showed marked impairments in terms of reassuring usual work or community activities and mobility. The use of both tools suggested that their health status was worse than their perception of it.
This early identification of sequelae may help define flows and priorities for rehabilitation and reinsertion after critical COVID-19.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):1-12
DOI 10.5935/0103-507X.20220001-en
Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil.
A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method.
Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made.
To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.
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