The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials

 

The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials

 

by Zheng-Yii Lee, Cindy Sing Ling Yap, M. Shahnaz Hasan, Julia Patrick Engkasan, Mohd Yusof Barakatun-Nisak, Andrew G. Day, Jayshil J. Patel and Daren K. Heyland 

 

Critical Care volume 25, Article number: 260, Published: 23 July 2021

Background

The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients.

Methods

We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes).

Results

Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75–1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD −3.44% per week, 95% CI −4.99 to −1.90; p < 0.0001).

Conclusion

In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery.

PROSPERO registration number: CRD42021237530

The Effect of Early Sedation With Dexmedetomidine on Body Temperature in Critically Ill Patients*

 

The Effect of Early Sedation With Dexmedetomidine on Body Temperature in Critically Ill Patients*

by Grayson, Kim E.; Bailey, Michael; Balachandran, Mayurathan; Banneheke, Piyusha P.; Belletti, Alessandro; Bellomo, Rinaldo; Naorungroj, Thummaporn; Serpa-Neto, Ary; Wright, Jason D.; Yanase, Fumitaka; Young, Paul J.; Shehabi, Yahya 

 

Critical Care Medicine: July 2021 - Volume 49 - Issue 7 - p 1118-1128

 

OBJECTIVES: Previous case series reported an association between dexmedetomidine use and hyperthermia. Temperature data have not been systematically reported in previous randomized controlled trials evaluating dexmedetomidine. A causal link between dexmedetomidine administration and elevated temperature has not been demonstrated.

DESIGN: Post hoc analysis.

SETTING: Four ICUs in Australia and New Zealand.

PATIENTS: About 703 mechanically ventilated ICU patients.

INTERVENTIONS: Early sedation with dexmedetomidine versus usual care.

MEASUREMENTS AND MAIN RESULTS: The primary outcome was mean daily body temperature. Secondary outcomes included the proportions of patients with body temperatures greater than or equal to 38.3°C and greater than or equal to 39°C, respectively. Outcomes were recorded for 5 days postrandomization in the ICU. The mean daily temperature was not different between the dexmedetomidine (n = 351) and usual care (n = 352) groups (36.84°C ± sd vs 36.78°C ± sd; p = 0.16). Over the first 5 ICU days, more dexmedetomidine group (vs usual care) patients had a temperature greater than or equal to 38.3°C (43.3% vs 32.7%, p = 0.004; absolute difference 10.6 percentage points) and greater than or equal to 39.0°C (19.4% vs 12.5%, p = 0.013; absolute difference 6.9 percentage points). Results were similar after adjusting for diagnosis, admitting temperature, age, weight, study site, sepsis occurrence, and the time from dexmedetomidine initiation to first hyperthermia recorded. There was a significant dose response relationship with temperature increasing by 0.30°C ±0.08 for every additional 1 μg/kg/hr of dexmedetomidine received p < 0.0002.

CONCLUSIONS: Our study suggests potentially important elevations in body temperature are associated with early dexmedetomidine sedation, in adults who are mechanically ventilated in the ICU.

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

 

by Maeva Rodriguez, Stéphanie Ragot, Rémi Coudroy, Jean-Pierre Quenot, Philippe Vignon, Jean-Marie Forel, Alexandre Demoule, Jean-Paul Mira, Jean-Damien Ricard, Saad Nseir, Gwenhael Colin, Bertrand Pons, Pierre-Eric Danin, Jérome Devaquet, Gwenael Prat, Hamid Merdji…

 

Annals of Intensive Care volume 11, Article number: 114, Published: 22 July 2021

 

Background

Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity.

Methods

Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure.

Results

Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m−2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77–93] with noninvasive ventilation and 86% [78–92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission.

Conclusions

Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen.

Trial registration Clinical trial number: NCT02668458 (http://www.clinicaltrials.gov)

 

 

Treatment of the lung injury of drowning: a systematic review

 

Treatment of the lung injury of drowning: a systematic review

 

by Ogilvie Thom, Kym Roberts, Susan Devine, Peter A. Leggat and Richard C. Franklin 

 

Critical Care volume 25, Article number: 253, Published: 19 July 2021

 

Background

Drowning is a cause of significant global mortality. The mechanism of injury involves inhalation of water, lung injury and hypoxia. This systematic review addressed the following question: In drowning patients with lung injury, what is the evidence from primary studies regarding treatment strategies and subsequent patient outcomes?

Methods

The search strategy utilised PRISMA guidelines. Databases searched were MEDLINE, EMBASE, CINAHL, Web of Science and SCOPUS. There were no restrictions on publication date or age of participants. Quality of evidence was evaluated using GRADE methodology.

Results

Forty-one papers were included. The quality of evidence was very low. Seventeen papers addressed the lung injury of drowning in their research question and 24 had less specific research questions, however included relevant outcome data. There were 21 studies regarding extra-corporeal life support, 14 papers covering the theme of ventilation strategies, 14 addressed antibiotic use, seven papers addressed steroid use and five studies investigating diuretic use. There were no clinical trials. One retrospective comparison of therapeutic strategies was found. There was insufficient evidence to make recommendations as to best practice when supplemental oxygen alone is insufficient. Mechanical ventilation is associated with barotrauma in drowning patients, but the evidence predates the practice of lung protective ventilation. There was insufficient evidence to make recommendations regarding adjuvant therapies.

Conclusions

Treating the lung injury of drowning has a limited evidentiary basis. There is an urgent need for comparative studies of therapeutic strategies in drowning.

Exhalation Spreading During Nasal High-Flow Therapy at Different Flow Rates

 

Exhalation Spreading During Nasal High-Flow Therapy at Different Flow Rates

by Dellweg, Dominic; Kerl, Jens; Gena, Amayu Wakoya; Alsaad, Hayder; Voelker, Conrad 

Critical Care Medicine: July 2021 - Volume 49 - Issue 7 - p e693-e700

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 is transmitted through aerosols and droplets. Nasal high-flow therapy could possibly increase the spreading of exhalates from patients. The aim of this study is to investigate whether nasal high-flow therapy affects the range of the expiratory plume compared with spontaneous breathing.

DESIGN: Interventional experiment on single breaths of a healthy volunteer. 

SETTING: Research laboratory at the Bauhaus-University Weimar. Subjects: A male subject. INTERVENTIONS: Videos and images from a schlieren optical system were analyzed during spontaneous breathing and different nasal high-flow rates.

MEASUREMENTS AND MAIN RESULTS: The maximal exhalation spread was 0.99, 2.18, 2.92, and 4.1 m during spontaneous breathing, nasal high-flow of 20 L/min, nasal high-flow of 40 L/min, and nasal high-flow of 60 L/min, respectively. Spreading of the expiratory plume in the sagittal plane can completely be blocked with a surgical mask.

CONCLUSIONS: Nasal high-flow therapy increases the range of the expiratory air up to more than 4 meters. The risk to pick up infectious particles could be increased within this range. Attachment of a surgical mask over the nasal high-flow cannula blocks the expiratory airstream.

Personalized mechanical ventilation in acute respiratory distress syndrome

 

Personalized mechanical ventilation in acute respiratory distress syndrome

 

by Paolo Pelosi, Lorenzo Ball, Carmen S. V. Barbas, Rinaldo Bellomo, Karen E. A. Burns, Sharon Einav, Luciano Gattinoni, John G. Laffey, John J. Marini, Sheila N. Myatra, Marcus J. Schultz, Jean Louis Teboul and Patricia R. M. Rocco 

 

Critical Care volume 25, Article number: 250, Published: 16 July 2021

 

Abstract

A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.

Higher versus lower positive end-expiratory pressure in patients without acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

 

Higher versus lower positive end-expiratory pressure in patients without acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

 

by Tommaso Pettenuzzo, Annalisa Boscolo, Alessandro De Cassai, Nicolò Sella, Francesco Zarantonello, Paolo Persona, Laura Pasin, Giovanni Landoni and Paolo Navalesi 

 

Critical Care volume 25, Article number: 247, Published: 15 July 2021

Background

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the association of higher positive end-expiratory pressure (PEEP), as opposed to lower PEEP, with hospital mortality in adult intensive care unit (ICU) patients undergoing invasive mechanical ventilation for reasons other than acute respiratory distress syndrome (ARDS).

Methods

We performed an electronic search of MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science from inception until June 16, 2021 with no language restrictions. In addition, a research-in-progress database and grey literature were searched.

Results

We identified 22 RCTs (2225 patients) comparing higher PEEP (1007 patients) with lower PEEP (991 patients). No statistically significant association between higher PEEP and hospital mortality was observed (risk ratio 1.02, 95% confidence interval 0.89–1.16; I2 = 0%, p = 0.62; low certainty of evidence). Among secondary outcomes, higher PEEP was associated with better oxygenation, higher respiratory system compliance, and lower risk of hypoxemia and ARDS occurrence. Furthermore, barotrauma, hypotension, duration of ventilation, lengths of stay, and ICU mortality were similar between the two groups.

Conclusions

In our meta-analysis of RCTs, higher PEEP, compared with lower PEEP, was not associated with mortality in patients without ARDS receiving invasive mechanical ventilation. Further large high-quality RCTs are required to confirm these findings.

Emerging SARS-CoV-2 variants of concern and potential intervention approaches

 

Emerging SARS-CoV-2 variants of concern and potential intervention approaches

by Jasmin Khateeb, Yuchong Li and Haibo Zhang 

Critical Care volume 25, Article number: 244, Published: 12 July 2021

The major variant of concerns (VOCs) have shared mutations in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike proteins, mostly on the S1 unit and resulted in higher transmissibility rate and affect viral virulence and clinical outcome. The spike protein mutations and other non-structural protein mutations in the VOCs may lead to escape approved vaccinations in certain extend. We will discuss these VOC mutations and discuss the need for combination therapeutic strategies targeting viral cycle and immune host responses.

Lopinavir-ritonavir and hydroxychloroquine for critically ill patients with COVID-19: REMAP-CAP randomized controlled trial

 

Lopinavir-ritonavir and hydroxychloroquine for critically ill patients with COVID-19: REMAP-CAP randomized controlled trial

By: Yaseen M. Arabi, Anthony C. Gordon, the REMAP-CAP Investigators

 

Intensive Care Medicine volume 47, pages867–886  Published: 12 July 2021

 

Purpose

To study the efficacy of lopinavir-ritonavir and hydroxychloroquine in critically ill patients with coronavirus disease 2019 (COVID-19).

Methods

Critically ill adults with COVID-19 were randomized to receive lopinavir-ritonavir, hydroxychloroquine, combination therapy of lopinavir-ritonavir and hydroxychloroquine or no antiviral therapy (control). The primary endpoint was an ordinal scale of organ support-free days. Analyses used a Bayesian cumulative logistic model and expressed treatment effects as an adjusted odds ratio (OR) where an OR > 1 is favorable.

Results

We randomized 694 patients to receive lopinavir-ritonavir (n = 255), hydroxychloroquine (n = 50), combination therapy (n = 27) or control (n = 362). The median organ support-free days among patients in lopinavir-ritonavir, hydroxychloroquine, and combination therapy groups was 4 (– 1 to 15), 0 (– 1 to 9) and—1 (– 1 to 7), respectively, compared to 6 (– 1 to 16) in the control group with in-hospital mortality of 88/249 (35%), 17/49 (35%), 13/26 (50%), respectively, compared to 106/353 (30%) in the control group. The three interventions decreased organ support-free days compared to control (OR [95% credible interval]: 0.73 [0.55, 0.99], 0.57 [0.35, 0.83] 0.41 [0.24, 0.72]), yielding posterior probabilities that reached the threshold futility (≥ 99.0%), and high probabilities of harm (98.0%, 99.9% and > 99.9%, respectively). The three interventions reduced hospital survival compared with control (OR [95% CrI]: 0.65 [0.45, 0.95], 0.56 [0.30, 0.89], and 0.36 [0.17, 0.73]), yielding high probabilities of harm (98.5% and 99.4% and 99.8%, respectively).

Conclusion

Among critically ill patients with COVID-19, lopinavir-ritonavir, hydroxychloroquine, or combination therapy worsened outcomes compared to no antiviral therapy.

 

 

 

 

 

Mental health outcomes of ICU and non-ICU healthcare workers during the COVID-19 outbreak: a cross-sectional study

 

Mental health outcomes of ICU and non-ICU healthcare workers during the COVID-19 outbreak: a cross-sectional study

by Hannah Wozniak, Lamyae Benzakour, Grégory Moullec, Niccolò Buetti, Alice Nguyen, Sandrine Corbaz, Pauline Roos, Laure Vieux, Jean-Claude Suard, Rafaël Weissbrodt, Jérôme Pugin, Jacques A. Pralong and Sara Cereghetti 

Annals of Intensive Care volume 11, Article number: 106, Published: 10 July 2021

Background

Intensive care workers are known for their stressful work environment and for a high prevalence of mental health outcomes. The aim of this study was to evaluate the mental health, well-being and changes in lifestyle among intensive care unit (ICU) healthcare workers (HCW) during the first wave of the COVID-19 pandemic and to compare these results with those of HCW in other hospital units. Another objective was to understand which associated factors aggravate their mental health during the COVID-19 outbreak.

Methods

This cross-sectional survey collected socio-demographic data, lifestyle changes and mental health evaluations as assessed by the Generalized Anxiety Disorder 7 items (GAD-7), the Patient Health Questionnaire 9 items (PHQ-9), the Peritraumatic Distress Inventory (PDI) and the World Health Organization Well-Being Index (WHO-5) from the 28th May to 7th July 2020. The study was carried out at Geneva University Hospitals, a group of eight public hospitals in Switzerland. ICU HCW were analyzed for mental health outcomes and lifestyles changes and then compared to non-ICU HCW. A series of linear regression analyses were performed to assess factors associated with mental health scores.

Results

A total of 3461 HCW were included in the study, with 352 ICU HCW. Among ICU HCW, 145 (41%) showed low well-being, 162 (46%) symptoms of anxiety, 163 (46%) symptoms of depression and 76 (22%) had peritraumatic distress. The mean scores of GAD-7, PHQ-9 and WHO-5 were worse in ICU HCW than in non-ICU HCW (p < 0.01). Working in the ICU rather than in other departments resulted in a change of eating habits, sleeping patterns and alcohol consumption (p < 0.01). Being a woman, the fear of catching and transmitting COVID-19, anxiety of working with COVID-19 patients, work overload, eating and sleeping disorders as well as increased alcohol consumption were associated with worse mental health outcomes.

Conclusion

This study confirms the suspicion of a high prevalence of anxiety, depression, peritraumatic distress and low well-being during the first COVID-19 wave among HCW, especially among ICU HCW. This allows for the identification of associated risk factors. Long-term psychological follow-up should be considered for HCW.

Transmission of Severe Acute Respiratory Syndrome Coronavirus 1 and Severe Acute Respiratory Syndrome Coronavirus 2 During Aerosol-Generating Procedures in Critical Care: A Systematic Review and Meta-Analysis of Observational Studies*

 

Transmission of Severe Acute Respiratory Syndrome Coronavirus 1 and Severe Acute Respiratory Syndrome Coronavirus 2 During Aerosol-Generating Procedures in Critical Care: A Systematic Review and Meta-Analysis of Observational Studies*

 

by Chan, Vinson Wai-Shun; Ng, Helen Hoi-Lam; Rahman, Laiba; Tang, Audrey; Tang, Kwan Pui; Mok, Alex; Liu, Jeremy Ho Pak; Ho, Kenny Shiu Cheong; Chan, Shannon Melissa; Wong, Sunny; Teoh, Anthony Yuen-Bun; Chan, Albert; Wong, Martin; Yuan, Yuhong; Teoh, Jeremy Yuen-Chun 

 

Critical Care Medicine: July 2021 - Volume 49 - Issue 7 - p 1159-1168

 

OBJECTIVES: 

To assess the risk of coronavirus transmission to healthcare workers performing aerosol-generating procedures and the potential benefits of personal protective equipment during these procedures.

DATA SOURCES: 

MEDLINE, EMBASE, and Cochrane CENTRAL were searched using a combination of related MeSH terms and keywords.

STUDY SELECTION: 

Cohort studies and case controls investigating common anesthetic and critical care aerosol-generating procedures and transmission of severe acute respiratory syndrome coronavirus 1, Middle East respiratory syndrome coronavirus, and severe acute respiratory syndrome coronavirus 2 to healthcare workers were included for quantitative analysis.

DATA EXTRACTION: 

Qualitative and quantitative data on the transmission of severe acute respiratory syndrome coronavirus 1, severe acute respiratory syndrome coronavirus 2, and Middle East respiratory syndrome coronavirus to healthcare workers via aerosol-generating procedures in anesthesia and critical care were collected independently. The Risk Of Bias In Non-randomized Studies - of Interventions tool was used to assess the risk of bias of included studies.

DATA SYNTHESIS: 

Seventeen studies out of 2,676 yielded records were included for meta-analyses. Endotracheal intubation (odds ratio, 6.69, 95% CI, 3.81–11.72; p < 0.001), noninvasive ventilation (odds ratio, 3.65; 95% CI, 1.86–7.19; p < 0.001), and administration of nebulized medications (odds ratio, 10.03; 95% CI, 1.98–50.69; p = 0.005) were found to increase the odds of healthcare workers contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. The use of N95 masks (odds ratio, 0.11; 95% CI, 0.03–0.39; p < 0.001), gowns (odds ratio, 0.59; 95% CI, 0.48–0.73; p < 0.001), and gloves (odds ratio, 0.39; 95% CI, 0.29–0.53; p < 0.001) were found to be significantly protective of healthcare workers from contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2.

CONCLUSIONS: 

Specific aerosol-generating procedures are high risk for the transmission of severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2 from patients to healthcare workers. Personal protective equipment reduce the odds of contracting severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2.

Prone Positioning in Coronavirus Disease 2019: Just Do It!*

 

Prone Positioning in Coronavirus Disease 2019: Just Do It!*

by Dembinski, Rolf 

 

Critical Care Medicine: July 2021 - Volume 49 - Issue 7 - p 1186-1188

 

Acute respiratory failure is the most common cause of death in patients with coronavirus disease 2019 (COVID-19) (1). Comparable with non-COVID-19–related acute respiratory distress syndrome (ARDS) formation of consolidated atelectasis with concomitant hypoxemia refractory to conventional mechanical ventilation with high Fio2 has been considered as the most decisive pathophysiologic mechanism (2). Accordingly, widely accepted recommendations for the treatment of ARDS such as prone positioning have been applied for the treatment of COVID-19–related respiratory failure in the absence of specific therapeutic options despite a lack of evidence (3).

In ARDS, prone positioning has been shown to improve gas exchange in several studies (4). The most important underlying mechanism is probably a homogenization of transpulmonary pressures resulting in a recruitment of dorsal atelectatic areas thereby reducing ventilation-perfusion mismatch and intrapulmonary right-to-left shunt. In a landmark study by Guérin et al (5), prone positioning within 36 hours after the onset of mechanical ventilation reduced mortality from 33% to 16% in severe ARDS with a Pao2/Fio2 less than 150 mm Hg. Notably, prone positioning in this so-called Proning Severe ARDS Patients (PROSEVA) trial was conducted in well experienced ARDS centers and performed for at least 16 hours. Since then, early prone positioning for at least 16 hours is regularly recommended as an important therapeutic measure in severe ARDS. Unfortunately, prone positioning is still underused in clinical practice, possibly due to limited expertise and the fear of hemodynamic instability (6). Indeed, only a few contraindications such as cardiogenic shock or unstable spine fractures should be accepted.

The gut in COVID-19

 The gut in COVID-19

By: Annika Reintam Blaser, Jan Gunst & Yaseen M. Arabi 

Intensive Care Medicine Published: 08 July 2021

In the last year, a growing number of articles addressed coronavirus disease 2019 (COVID-19), including its link with gastrointestinal (GI) (dys)function. We here highlight the most important findings regarding the role of the gut in this disease, with a focus on critically ill patients…

Why and how do we need comprehensive international clinical epidemiology of ARDS?

 

Why and how do we need comprehensive international clinical epidemiology of ARDS?

By: Gianni Tognoni, Luigi Vivona & Antonio Pesenti 

Intensive Care Medicine Published: 03 July 2021

One of the most evident weaknesses of scientific and public health strategies in the management of the coronavirus disease 2019 (COVID-19) pandemic is certainly the scarcity of robust epidemiological data, not limited to the quali-quantitative descriptions of patient populations and their outcomes, specifically in the hardly comparable ICU settings of care, but aimed at what has become the core and the vocation of a clinically oriented epidemiological investigation. Clinical data collected and analysed with sound methodological criteria are the essential source of information, closely complementary to physio-pathological data for a better understanding of the causes of the outcomes of critical and still uncertain clinical conditions.

The substantial absence of this type of epidemiology has suggested a broader question: whether and how far the failure documented in publications relating to the ICU phases of Covid-19 coincides with the state of the art also for the acute respiratory distress syndrome (ARDS), closely overlapping the severe pulmonary involvement seen in a small but dramatic fraction of the Covid-19-infected population.

We felt that a targeted survey of the clinical epidemiological literature could provide an overview of the methodological strengths and weaknesses of recent research, and serve as an informed suggestion as to most practicable strategies…

Acute kidney injury in the critically ill: an updated review on pathophysiology and management

 

Acute kidney injury in the critically ill: an updated review on pathophysiology and management

By: Peter Pickkers, Michael Darmon, Eric Hoste, Michael Joannidis, Matthieu Legrand, Marlies Ostermann, John R. Prowle, Antoine Schneider & Miet Schetz 

Intensive Care Medicine volume 47, pages 835–850 Published: 02 July 2021

Abstract: Acute kidney injury (AKI) is now recognized as a heterogeneous syndrome that not only affects acute morbidity and mortality, but also a patient’s long-term prognosis. In this narrative review, an update on various aspects of AKI in critically ill patients will be provided. Focus will be on prediction and early detection of AKI (e.g., the role of biomarkers to identify high-risk patients and the use of machine learning to predict AKI), aspects of pathophysiology and progress in the recognition of different phenotypes of AKI, as well as an update on nephrotoxicity and organ cross-talk. In addition, prevention of AKI (focusing on fluid management, kidney perfusion pressure, and the choice of vasopressor) and supportive treatment of AKI is discussed. Finally, post-AKI risk of long-term sequelae including incident or progression of chronic kidney disease, cardiovascular events and mortality, will be addressed.

Take home message: Acute kidney injury (AKI) is recognized as an heterogeneous syndrome affecting short- and long-term morbidity and mortality. Progress on prediction and early detection, clinical phenotypes, pathophysiology, nephrotoxicity, organ cross-talk, prevention and supportive treatment of AKI as well as long-term sequelae are addressed in this review paper

Delirium in COVID-19: can we make the unknowns knowns?

 

Delirium in COVID-19: can we make the unknowns knowns?

By: M. Elizabeth Wilcox, Manu Shankar-Hari & Daniel F. McAuley 

Intensive Care Medicine (2021) Published: 30 June 2021

Delirium is an important public health problem. It is independently associated with worse clinical outcomes, including persistent cognitive impairment, increased mortality, and greater risk of institutionalization. The prevalence of delirium is high in the intensive care unit (ICU), occurring in up to 70% of the sickest patients requiring mechanical ventilation. Early studies in hospitalized patients with coronavirus disease 2019 (COVID-19) report delirium rates of 20–30%, which increase to 60–70% in severe illness. An international multicenter cohort study that included 69 adult ICUs across 14 countries of 2088 COVID-19 patients reported that over a 21-day period, delirium had a prevalence of 55% and lasted a median of 3 days (IQR, 2–6 days), which is more common and prolonged than that in non-COVID cohorts…