Purpose
To improve the outcome of the acute respiratory distress syndrome (ARDS), one needs to identify potentially modifiable factors associated with mortality.
Methods
The large observational study ...to understand the global impact of severe acute respiratory failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across five continents. A pre-specified secondary aim was to examine the factors associated with outcome. Analyses were restricted to patients (93.1 %) fulfilling ARDS criteria on day 1–2 who received invasive mechanical ventilation.
Results
2377 patients were included in the analysis. Potentially modifiable factors associated with increased hospital mortality in multivariable analyses include lower PEEP, higher peak inspiratory, plateau, and driving pressures, and increased respiratory rate. The impact of tidal volume on outcome was unclear. Having fewer ICU beds was also associated with higher hospital mortality. Non-modifiable factors associated with worsened outcome from ARDS included older age, active neoplasm, hematologic neoplasm, and chronic liver failure. Severity of illness indices including lower pH, lower PaO
2
/FiO
2
ratio, and higher non-pulmonary SOFA score were associated with poorer outcome. Of the 578 (24.3 %) patients with a limitation of life-sustaining therapies or measures decision, 498 (86.0 %) died in hospital. Factors associated with increased likelihood of limitation of life-sustaining therapies or measures decision included older age, immunosuppression, neoplasia, lower pH and increased non-pulmonary SOFA scores.
Conclusions
Higher PEEP, lower peak, plateau, and driving pressures, and lower respiratory rate are associated with improved survival from ARDS.
Trial Registration: ClinicalTrials.gov NCT02010073.
Intensive care unit (ICU) survivors can experience wide-ranging and long-lasting symptoms after hospital discharge. Cognitive impairment has received increased attention in relation to the COVID-19 ...pandemic and can affect patients’ long-term quality of life. This study aimed to investigate the prevalence of cognitive impairment using an objective neurocognitive test 6 and 12 months following ICU admission and possible predictive factors for scoring below the defined cut-off. We also explored the prevalence of subjective cognitive complaints at 12 months, including the associated factors.
This was a prospective observational study of a national cohort of COVID-19 ICU survivors during the three first pandemic waves in Norway. Data was collected by the Norwegian Intensive Care and Pandemic Registry and the study group.
At the six-month follow-up, 23.1% (95% CI 18.2─28.5) of the 273 respondents scored below the cut-off on the Mini-MoCA, indicating mild cognitive impairment. At the 12-month follow-up, the prevalence declined to 11.1% (95% CI 7.5─15.6) in 253 respondents. Older age (OR 1.06, 95% CI 1.02─1.12) and depression (OR 1.25, 95% CI 1.07─1.55) were associated with cognitive impairment at six months. At 12 months, almost half of the patients reported subjective cognitive complaints. Symptoms of mental health problems and fatigue were associated with subjective cognitive complaints in our exploratory analyses.
Cognitive impairment declined significantly from 6 to 12 months in this cohort of COVID-19 ICU patients, while subjective cognitive complaints remained high at 12 months, perhaps attributed to a high total symptom burden.
•Cognitive impairment was measured with the Mini-MoCA at 6 and 12 months after ICU admission in a cohort of Norwegian COVID-19 survivors.•Cognitive impairment was found to improve from 6 to 12 months after ICU admission when using a neurocognitive test.•Older age and having symptoms of depression were associated with cognitive impairment at 6 months following ICU admission.•Subjective cognitive complaints were measured at 12 months after ICU admission.•When measuring subjective cognitive complaints after 12 months, a high number of patients reported complaints, such as difficulty concentrating and poor memory.
Purpose
To identify key components and variations in family-centered care practices.
Methods
A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire ...covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate.
Results
The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6–8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness.
Conclusions
This study emphasizes the need to prioritize healthcare providers’ mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.
This is the fourteenth version (thirteenth update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this ...guideline.
What is the role of drugs in the treatment of patients with covid-19?
The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and underway. Emerging SARS-CoV-2 variants and subvariants are changing the role of therapeutics.
The guideline development group (GDG) defined 1.5% as a new threshold for an important reduction in risk of hospitalisation in patients with non-severe covid-19. Combined with updated baseline risk estimates, this resulted in stratification into patients at low, moderate, and high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New pharmacokinetic evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation for ivermectin in patients with non-severe illness was updated in light of additional trial evidence which reduced the high degree of uncertainty informing previous guidance. A new recommendation was made against the antiviral agent VV116 for patients with non-severe and with severe or critical illness outside of randomised clinical trials based on one RCT comparing the drug with nirmatrelvir/ritonavir. The structure of the guideline publication has also been changed; recommendations are now ordered by severity of covid-19.
This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF on the WHO website, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact.
Recommendations on anticoagulation are planned for the next update to this guideline. Updated data regarding systemic corticosteroids, azithromycin, favipiravir and umefenovir for non-severe illness, and convalescent plasma and statin therapy for severe or critical illness, are planned for review in upcoming guideline iterations.
Background
Norwegian hospitals have operated within capacity during the COVID‐19 pandemic. We present patient and management characteristics, and outcomes for the entire cohort of adult (>18 years) ...COVID‐19 patients admitted to Norwegian intensive care units (ICU) from 10 March to 19 June 2020.
Methods
Data were collected from The Norwegian intensive care and pandemic registry (NIPaR). Demographics, co‐morbidities, management characteristics and outcomes are described. ICU length of stay (LOS) was analysed with linear regression, and associations between risk factors and mortality were quantified using Cox regression.
Results
In total, 217 patients were included. The male to female ratio was 3:1 and the median age was 63 years. A majority (70%) had one or more co‐morbidities, most frequently cardiovascular disease (39%), chronic lung disease (22%), diabetes mellitus (20%), and obesity (17%). Most patients were admitted for acute hypoxaemic respiratory failure (AHRF) (91%) and invasive mechanical ventilation (MV) was used in 86%, prone ventilation in 38% and 25% of patients received a tracheostomy. Vasoactive drugs were used in 79% and renal replacement therapy in 15%. Median ICU LOS and time of MV was 14.0 and 12.0 days. At end of follow‐up 45 patients (21%) were dead. Age, co‐morbidities and severity of illness at admission were predictive of death. Severity of AHRF and male gender were associated with LOS.
Conclusions
In this national cohort of COVID‐19 patients, mortality was low and attributable to known risk factors. Importantly, prolonged length‐of‐stay must be taken into account when planning for resource allocation for any next surge.
A lingua franca for guidelines—or a Tower of Babel? Laake, Jon Henrik; Møller, Morten Hylander
Acta anaesthesiologica Scandinavica,
August 2023, 2023-08-00, 20230801, Letnik:
67, Številka:
7
Journal Article
PDF
