Intensive care units Archives - Critical Care Science (CCS)

  • Review

    Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

    Crit Care Sci. 2024;36:e20240265en

    Abstract

    Review

    Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

    Crit Care Sci. 2024;36:e20240265en

    DOI 10.62675/2965-2774.20240265-en

    Views1

    ABSTRACT

    A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

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    Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up
  • Original Article

    Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

    Crit Care Sci. 2024;36:e20240196en

    Abstract

    Original Article

    Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

    Crit Care Sci. 2024;36:e20240196en

    DOI 10.62675/2965-2774.20240196-en

    Views114

    ABSTRACT

    Objective

    To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes.

    Methods

    We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE.

    Results

    We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%).

    Conclusion

    Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.

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  • Original Article

    Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients

    Crit Care Sci. 2024;36:e20240208en

    Abstract

    Original Article

    Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients

    Crit Care Sci. 2024;36:e20240208en

    DOI 10.62675/2965-2774.20240208-en

    Views163

    ABSTRACT

    Objective:

    To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19.

    Methods:

    This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality.

    Results:

    We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure.

    Conclusion:

    In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.

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    Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients
  • Original Article

    Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial

    Crit Care Sci. 2024;36:e20240144en

    Abstract

    Original Article

    Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial

    Crit Care Sci. 2024;36:e20240144en

    DOI 10.62675/2965-2774.20240144-pt

    Views1,043

    ABSTRACT

    Objective:

    To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults.

    Methods:

    In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge).

    Results:

    We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference.

    Conclusion:

    Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

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    Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial
  • Original Article

    Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

    Crit Care Sci. 2024;36:e20240158en

    Abstract

    Original Article

    Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

    Crit Care Sci. 2024;36:e20240158en

    DOI 10.62675/2965-2774.20240158-en

    Views74

    ABSTRACT

    Objective:

    To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients.

    Methods:

    An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression.

    Results:

    Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were −62.4% for C-reactive protein, +45.7% for total lymphocytes, and −32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 – 4.5; p < 0.001).

    Conclusion:

    In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.

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    Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study
  • Original Article

    Delirium severity and outcomes of critically ill COVID-19 patients

    Crit Care Sci. 2023;35(4):394-401

    Abstract

    Original Article

    Delirium severity and outcomes of critically ill COVID-19 patients

    Crit Care Sci. 2023;35(4):394-401

    DOI 10.5935/2965-2774.20230170-pt

    Views14

    ABSTRACT

    Objective:

    To investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes.

    Methods:

    This prospective cohort study was performed in two tertiary intensive care units in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of intensive care unit stay using the Richmond Agitation Sedation Scale, Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Confusion Method Assessment for Intensive Care Unit-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality.

    Results:

    Among the 277 COVID-19 patients included, delirium occurred in 101 (36.5%) during the first 7 days of intensive care unit stay, and it was associated with a higher length of intensive care unit stay in days (IQR 13 [7 - 25] versus 6 [4 - 12]; p < 0.001), higher hospital mortality (25.74% versus 5.11%; p < 0.001) and additional higher one-year mortality (5.3% versus 0.6%, p < 0.001). Delirium was classified by CAM-ICU-7 in terms of severity, and higher scores were associated with higher in-hospital mortality (17.86% versus 34.38% versus 38.46%, 95%CI, p value < 0.001). Severe delirium was associated with a higher risk of progression to coma (OR 7.1; 95%CI 1.9 - 31.0; p = 0.005) and to mechanical ventilation (OR 11.09; 95%CI 2.8 - 58.5; p = 0.002) in the multivariate analysis, adjusted by severity and frailty.

    Conclusion:

    In patients admitted with COVID-19 in the intensive care unit, delirium was an independent risk factor for the worst prognosis, including mortality. The delirium severity assessed by the CAM-ICU-7 during the first week in the intensive care unit was associated with poor outcomes, including progression to coma and to mechanical ventilation.

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    Delirium severity and outcomes of critically ill
					COVID-19 patients
  • Original Article

    Typical phenotypes of patients with acute respiratory failure with and without COVID-19 and their relationship with outcomes: a cohort study

    Crit Care Sci. 2023;35(4):355-366

    Abstract

    Original Article

    Typical phenotypes of patients with acute respiratory failure with and without COVID-19 and their relationship with outcomes: a cohort study

    Crit Care Sci. 2023;35(4):355-366

    DOI 10.5935/2965-2774.20230015-pt

    Views16

    ABSTRACT

    Objective:

    To compare, within a cohort of patients with acute respiratory failure, the phenotypes of patients with and without COVID-19 in the context of the pandemic and evaluate whether COVID-19 is an independent predictor of intensive care unit mortality.

    Methods:

    This historical cohort study evaluated 1001 acute respiratory failure patients with suspected COVID-19 admitted to the intensive care unit of 8 hospitals. Patients were classified as COVID-19 cases and non-COVID-19 cases according to real-time polymerase chain reaction results. Data on clinical and demographic characteristics were collected on intensive care unit admission, as well as daily clinical and laboratory data and intensive care unit outcomes.

    Results:

    Although the groups did not differ in terms of APACHE II or SOFA scores at admission, the COVID-19 group had more initial symptoms of fever, myalgia and diarrhea, had a longer duration of symptoms, and had a higher prevalence of obesity. They also had a lower PaO2/FiO2 ratio, lower platelet levels than non-COVID-19 patients, and more metabolic changes, such as higher levels of blood glucose, C-reactive protein, and lactic dehydrogenase. Patients with non-COVID-19 acute respiratory failure had a higher prevalence of chronic obstructive pulmonary disease/asthma and cardiopathy. Patients with COVID-19 stayed in the hospital longer and had more complications, such as acute kidney failure, severe acute respiratory distress syndrome and severe infection. The all-cause mortality rate was also higher in this group (43.7% in the COVID-19 group versus 27.4% in the non-COVID-19 group). The diagnosis of COVID-19 was a predictor of intensive care unit mortality (odds ratio, 2.77; 95%CI, 1.89 - 4.07; p < 0.001), regardless of age or Charlson Comorbidity Index score.

    Conclusion:

    In a prospective cohort of patients admitted with acute respiratory failure, patients with COVID-19 had a clearly different phenotype and a higher mortality than non-COVID-19 patients. This may help to outline more accurate screening and appropriate and timely treatment for these patients.

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    Typical phenotypes of patients with acute respiratory failure with
					and without COVID-19 and their relationship with outcomes: a cohort
					study
  • Original Article

    Impact of vertical positioning on lung aeration among mechanically ventilated intensive care unit patients: a randomized crossover clinical trial

    Crit Care Sci. 2023;35(4):367-376

    Abstract

    Original Article

    Impact of vertical positioning on lung aeration among mechanically ventilated intensive care unit patients: a randomized crossover clinical trial

    Crit Care Sci. 2023;35(4):367-376

    DOI 10.5935/2965-2774.20230069-pt

    Views15

    ABSTRACT

    Objective:

    To assess the impact of different vertical positions on lung aeration in patients receiving invasive mechanical ventilation.

    Methods:

    An open-label randomized crossover clinical trial was conducted between January and July 2020. Adults receiving invasive mechanical ventilation for > 24 hours and < 7 days with hemodynamic, respiratory and neurological stability were randomly assigned at a 1:1 ratio to the sitting position followed by passive orthostasis condition or the passive orthostasis followed by the sitting position condition. The primary outcome was lung aeration assessed using the lung ultrasound score (score ranges from 0 [better] to 36 [worse]).

    Results:

    A total of 186 subjects were screened; of these subjects, 19 were enrolled (57.8% male; mean age, 73.2 years). All participants were assigned to receive at least one verticalization protocol. Passive orthostasis resulted in mean lung ultrasound scores that did not differ significantly from the sitting position (11.0 versus 13.7; mean difference, -2.7; [95%CI -6.1 to 0.71; p = 0.11). Adverse events occurred in three subjects in the passive orthostasis group and in one in the sitting position group (p = 0.99).

    Conclusion:

    This analysis did not find significant differences in lung aeration between the sitting and passive orthostasis groups. A randomized crossover clinical trial assessing the impact of vertical positioning on lung aeration in patients receiving invasive mechanical ventilation is feasible. Unfortunately, the study was interrupted due to the need to treat COVID-19 patients.

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    Impact of vertical positioning on lung aeration among mechanically
					ventilated intensive care unit patients: a randomized crossover clinical
					trial

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