Critical Care Bulletin - March 2022

 

Use of Airway Pressure Release Ventilation in Patients With Acute Respiratory Failure Due to COVID-19: Results of a Single-Center Randomized Controlled Trial*

 

by Ibarra-Estrada, Miguel Á.; García-Salas, Yessica; Mireles-Cabodevila, Eduardo; López-Pulgarín, José A.; Chávez-Peña, Quetzalcóatl; García-Salcido, Roxana; Mijangos-Méndez, Julio C.; Aguirre-Avalos, Guadalupe 

 

Critical Care Medicine: April 2022 - Volume 50 - Issue 4 - p 586-594

 

OBJECTIVES: 

Airway pressure release ventilation is a ventilatory mode characterized by a mandatory inverse inspiratory:expiratory ratio with a very short expiratory phase, aimed to avoid derecruitment and allow spontaneous breathing. Recent basic and clinical evidence suggests that this mode could be associated with improved outcomes in patients with acute respiratory distress syndrome. The aim of this study was to compare the outcomes between airway pressure release ventilation and traditional ventilation targeting low tidal volume, in patients with severe coronavirus disease 2019.

DESIGN: 

Single-center randomized controlled trial.

SETTING: 

ICU of a Mexican referral center dedicated to care of patients with confirmed diagnosis of coronavirus disease 2019.

PATIENTS: 

Ninety adult intubated patients with acute respiratory distress syndrome associated with severe coronavirus disease 2019.

INTERVENTIONS: 

Within 48 hours after intubation, patients were randomized to either receive ventilatory management with airway pressure release ventilation or continue low tidal volume ventilation.

MEASUREMENTS AND MAIN RESULTS: 

Forty-five patients in airway pressure release ventilation group and 45 in the low tidal volume group were included. Ventilator-free days were 3.7 (0–15) and 5.2 (0–19) in the airway pressure release ventilation and low tidal volume groups, respectively (p = 0.28). During the first 7 days, patients in airway pressure release ventilation had a higher Pao2/Fio2 (mean difference, 26 [95%CI, 13–38]; p < 0.001) and static compliance (mean difference, 3.7 mL/cm H2O [95% CI, 0.2–7.2]; p = 0.03), higher mean airway pressure (mean difference, 3.1 cm H2O [95% CI, 2.1–4.1]; p < 0.001), and higher tidal volume (mean difference, 0.76 mL/kg/predicted body weight [95% CI, 0.5–1.0]; p < 0.001). More patients in airway pressure release ventilation had transient severe hypercapnia, defined as an elevation of Pco2 at greater than or equal to 55 along with a pH less than 7.15 (42% vs 15%; p = 0.009); other outcomes were similar. Overall mortality was 69%, with no difference between the groups (78% in airway pressure release ventilation vs 60% in low tidal volume; p = 0.07).

CONCLUSIONS: 

In conclusion, when compared with low tidal volume, airway pressure release ventilation was not associated with more ventilator-free days or improvement in other relevant outcomes in patients with severe coronavirus disease 2019.

 

Nasal pressure swings as the measure of inspiratory effort in spontaneously breathing patients with de novo acute respiratory failure

by Roberto Tonelli, Andrea Cortegiani, Alessandro Marchioni, Riccardo Fantini, Luca Tabbì, Ivana Castaniere, Emanuela Biagioni, Stefano Busani, Chiara Nani, Caterina Cerbone, Morgana Vermi, Filippo Gozzi, Giulia Bruzzi, Linda Manicardi, Maria Rosaria Pellegrino, Bianca Beghè… 

Critical Care volume 26, Article number: 70 (2022) Published: 24 March 2022

Background

Excessive inspiratory effort could translate into self-inflicted lung injury, thus worsening clinical outcomes of spontaneously breathing patients with acute respiratory failure (ARF). Although esophageal manometry is a reliable method to estimate the magnitude of inspiratory effort, procedural issues significantly limit its use in daily clinical practice. The aim of this study is to describe the correlation between esophageal pressure swings (ΔPes) and nasal (ΔPnos) as a potential measure of inspiratory effort in spontaneously breathing patients with de novo ARF.

Methods

From January 1, 2021, to September 1, 2021, 61 consecutive patients with ARF (83.6% related to COVID-19) admitted to the Respiratory Intensive Care Unit (RICU) of the University Hospital of Modena (Italy) and candidate to escalation of non-invasive respiratory support (NRS) were enrolled. Clinical features and tidal changes in esophageal and nasal pressure were recorded on admission and 24 h after starting NRS. Correlation between ΔPes and ΔPnos served as primary outcome. The effect of ΔPnos measurements on respiratory rate and ΔPes was also assessed.

Results

ΔPes and ΔPnos were strongly correlated at admission (R2 = 0.88, p < 0.001) and 24 h apart (R2 = 0.94, p < 0.001). The nasal plug insertion and the mouth closure required for ΔPnos measurement did not result in significant change of respiratory rate and ΔPes. The correlation between measures at 24 h remained significant even after splitting the study population according to the type of NRS (high-flow nasal cannulas [R2 = 0.79, p < 0.001] or non-invasive ventilation [R2 = 0.95, p < 0.001]).

Conclusions

In a cohort of patients with ARF, nasal pressure swings did not alter respiratory mechanics in the short term and were highly correlated with esophageal pressure swings during spontaneous tidal breathing. ΔPnos might warrant further investigation as a measure of inspiratory effort in patients with ARF.

 

 

 

Drug dosing in hospitalized obese patients with COVID-19

 

By Jeffrey F. Barletta and Brian L. Erstad 

 

Critical Care volume 26, Article number: 60 (2022) Published: 14 March 2022

 

 

Obesity is highly prevalent in hospitalized patients admitted with COVID-19. Evidence based guidelines are available for COVID-19-related therapies but dosing information specific to patients with obesity is lacking. Failure to account for the pharmacokinetic alterations that exist in this population can lead to underdosing, and treatment failure, or overdosing, resulting in an adverse effect. The objective of this manuscript is to provide clinicians with guidance for making dosing decisions for medications used in the treatment of patients with COVID-19. A detailed literature search was conducted for medications listed in evidence-based guidelines from the National Institutes of Health with an emphasis on pharmacokinetics, dosing and obesity. Retrieved manuscripts were evaluated and the following prioritization strategy was used to form the decision framework for recommendations: clinical outcome data > pharmacokinetic studies > adverse effects > physicochemical properties. Most randomized controlled studies included a substantial number of patients who were obese but few had large numbers of patients more extreme forms of obesity. Pharmacokinetic data have described alterations with volume of distribution and clearance but this variability does not appear to warrant dosing modifications. Future studies should provide more information on size descriptors and stratification of data according to obesity and body habitus.

 

Target temperature management following cardiac arrest: a systematic review and Bayesian meta-analysis

by Anders Aneman, Steven Frost, Michael Parr and Markus B. Skrifvars 

Critical Care volume 26, Article number: 58 (2022) Published: 12 March 2022

Background

Temperature control with target temperature management (TTM) after cardiac arrest has been endorsed by expert societies and adopted in international clinical practice guidelines but recent evidence challenges the use of hypothermic TTM.

Methods

Systematic review and Bayesian meta-analysis of clinical trials on adult survivors from cardiac arrest undergoing TTM for at least 12 h comparing TTM versus no TTM or with a separation > 2 °C between intervention and control groups using the PubMed/MEDLINE, EMBASE, CENTRAL databases from inception to 1 September 2021 (PROSPERO CRD42021248140). All randomised and quasi-randomised controlled trials were considered. The risk ratio and 95% confidence interval for death (primary outcome) and unfavourable neurological recovery (secondary outcome) were captured using the original study definitions censored up to 180 days after cardiac arrest. Bias was assessed using the updated Cochrane risk-of-bias for randomised trials tool and certainty of evidence assessed using the Grading of Recommendation Assessment, Development and Evaluation methodology. A hierarchical robust Bayesian model-averaged meta-analysis was performed using both minimally informative and data-driven priors and reported by mean risk ratio (RR) and its 95% credible interval (95% CrI).

Results

In seven studies (three low bias, three intermediate bias, one high bias, very low to low certainty) recruiting 3792 patients the RR by TTM 32–34 °C was 0.95 [95% CrI 0.78—1.09] for death and RR 0.93 [95% CrI 0.84—1.02] for unfavourable neurological outcome. The posterior probability for no benefit (RR ≥ 1) by TTM 32–34 °C was 24% for death and 12% for unfavourable neurological outcome. The posterior probabilities for favourable treatment effects of TTM 32–34 °C were the highest for an absolute risk reduction of 2–4% for death (28–53% chance) and unfavourable neurological outcome (63–78% chance). Excluding four studies without active avoidance of fever in the control arm reduced the probability to achieve an absolute risk reduction > 2% for death or unfavourable neurological outcome to ≤ 50%.

Conclusions

The posterior probability distributions did not support the use of TTM at 32–34 °C compared to 36 °C also including active control of fever to reduce the risk of death and unfavourable neurological outcome at 90–180 days. Any likely benefit of hypothermic TTM is smaller than targeted in RCTs to date.

 

IV Vitamin C in Critically Ill Patients: A Systematic Review and Meta-Analysis

by Patel, Jayshil J.; Ortiz-Reyes, Alfonso; Dhaliwal, Rupinder; Clarke, John; Hill, Aileen; Stoppe, Christian; Lee, Zheng-Yii; Heyland, Daren K. 

 

Critical Care Medicine: March 2022 - Volume 50 - Issue 3 - p e304-e312

OBJECTIVES: 

To conduct a systematic review and meta-analysis to evaluate the impact of IV vitamin C on outcomes in critically ill patients.

DATA SOURCES: 

Systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Register of Controlled Trials.

STUDY SELECTION: 

Randomized controlled trials testing IV vitamin C in critically ill patients.

Two independent reviewers abstracted patient characteristics, treatment details, and clinical outcomes.

DATA SYNTHESIS: 

Fifteen studies involving 2,490 patients were identified. Compared with placebo, IV vitamin C administration is associated with a trend toward reduced overall mortality (relative risk, 0.87; 95% CI, 0.75–1.00; p = 0.06; test for heterogeneity I2 = 6%). High-dose IV vitamin C was associated with a significant reduction in overall mortality (relative risk, 0.70; 95% CI, 0.52–0.96; p = 0.03), whereas low-dose IV vitamin C had no effect (relative risk, 0.94; 95% CI, 0.79–1.07; p = 0.46; test for subgroup differences, p = 0.14). IV vitamin C monotherapy was associated with a significant reduction in overall mortality (relative risk, 0.64; 95% CI, 0.49–0.83; p = 0.006), whereas there was no effect with IV vitamin C combined therapy. No trial reported an increase in adverse events related to IV vitamin C.

CONCLUSIONS: 

IV vitamin C administration appears safe and may be associated with a trend toward reduction in overall mortality. High-dose IV vitamin C monotherapy may be associated with improved overall mortality, and further randomized controlled trials are warranted.

 

Limitations of the ARDS criteria during high-flow oxygen or non-invasive ventilation: evidence from critically ill COVID-19 patients

 

By Michael Hultström, Ola Hellkvist, Lucian Covaciu, Filip Fredén, Robert Frithiof, Miklós Lipcsey, Gaetano Perchiazzi and Mariangela Pellegrini 

 

Critical Care volume 26, Article number: 55 (2022) Published: 07 March 2022

 

Background

The ratio of partial pressure of arterial oxygen to inspired oxygen fraction (PaO2/FIO2) during invasive mechanical ventilation (MV) is used as criteria to grade the severity of respiratory failure in acute respiratory distress syndrome (ARDS). During the SARS-CoV2 pandemic, the use of PaO2/FIO2 ratio has been increasingly used in non-invasive respiratory support such as high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV). The grading of hypoxemia in non-invasively ventilated patients is uncertain. The main hypothesis, investigated in this study, was that the PaO2/FIO2 ratio does not change when switching between MV, NIV and HFNC.

Methods

We investigated respiratory function in critically ill patients with COVID-19 included in a single-center prospective observational study of patients admitted to the intensive care unit (ICU) at Uppsala University Hospital in Sweden. In a steady state condition, the PaO2/FIO2 ratio was recorded before and after any change between two of the studied respiratory support techniques (i.e., HFNC, NIV and MV).

Results

A total of 148 patients were included in the present analysis. We find that any change in respiratory support from or to HFNC caused a significant change in PaO2/FIO2 ratio. Changes in respiratory support between NIV and MV did not show consistent change in PaO2/FIO2 ratio. In patients classified as mild to moderate ARDS during MV, the change from HFNC to MV showed a variable increase in PaO2/FIO2 ratio ranging between 52 and 140 mmHg (median of 127 mmHg). This made prediction of ARDS severity during MV from the apparent ARDS grade during HFNC impossible.

Conclusions

HFNC is associated with lower PaO2/FIO2 ratio than either NIV or MV in the same patient, while NIV and MV provided similar PaO2/FIO2 and thus ARDS grade by Berlin definition. The large variation of PaO2/FIO2 ratio indicates that great caution should be used when estimating ARDS grade as a measure of pulmonary damage during HFNC.

 

 

Prevalence and prognosis of respiratory pendelluft phenomenon in mechanically ventilated ICU patients with acute respiratory failure: a retrospective cohort study

 

by Yi Chi, Zhanqi Zhao, Inéz Frerichs, Yun Long and Huaiwu He 

 

Annals of Intensive Care volume 12, Article number: 22 (2022) Published: 05 March 2022

 

Background

Respiratory pendelluft phenomenon, defined as intrapulmonary gas redistribution caused by asynchronous alveolar ventilation, could be potentially harmful by inducing lung injury. The aim of the present study was to investigate its prevalence and prognosis in intensive care unit (ICU) patients with acute respiratory failure (ARF).

Methods

This was a retrospective observational study on 200 mechanically ventilated ARF patients treated in a tertiary ICU. The presence of pendelluft was determined using electrical impedance tomography (EIT) within 48 h after admission. Its amplitude was defined as the impedance difference between the sum of all regional tidal impedance variation and the global tidal impedance variation. A value above 2.5% (the 95th percentile from 30 healthy volunteers) was considered confirmative for its occurrence.

Results

Pendelluft was found in 61 patients (39 in 94 patients with spontaneous breathing, 22 in 106 receiving controlled ventilation), with an overall prevalence of 31%. Existence of spontaneous breathing and higher global inhomogeneity index were associated with pendelluft. Patients with pendelluft had a longer ICU length of stay [10 (6, 14) vs. 7 (4, 11) days; median (lower, upper quartile); p = 0.022] and shorter 14-day ventilator-free days [8 (1, 10) vs. 10 (6, 12) days; p = 0.015]. Subgroup survival analysis suggested the association between pendelluft and longer ventilation duration, which was significant only in patients with PaO2/FiO2 ratio below 200 mmHg (log-rank p = 0.042). ICU mortality did not differ between the patients with and without pendelluft.

Conclusions

Respiratory pendelluft occurred often in our study group and it was associated with longer ventilation duration. Early recognition of this phenomenon should trigger interventions aimed at alleviating pendelluft.

 

 

Prognostic and Predictive Biomarkers in Patients With Coronavirus Disease 2019 Treated With Tocilizumab in a Randomized Controlled Trial*

 

by Tom, Jennifer; Bao, Min; Tsai, Larry; Qamra, Aditi; Summers, David; Carrasco-Triguero, Montserrat; McBride, Jacqueline; Rosenberger, Carrie M.; Lin, Celia J. F.; Stubbings, William; Blyth, Kevin G.; Carratalà, Jordi; François, Bruno; Benfield, Thomas; Haslem, Derrick; Bonfanti, Paolo; van der Leest, Cor H.; Rohatgi, Nidhi; Wiese, Lothar; Luyt, Charles Edouard; Kheradmand, Farrah; Rosas, Ivan O.; Cai, Fang 

 

Critical Care Medicine: March 2022 - Volume 50 - Issue 3 - p 398-409

 

OBJECTIVES: 

To explore candidate prognostic and predictive biomarkers identified in retrospective observational studies (interleukin-6, C-reactive protein, lactate dehydrogenase, ferritin, lymphocytes, monocytes, neutrophils, d-dimer, and platelets) in patients with coronavirus disease 2019 pneumonia after treatment with tocilizumab, an anti–interleukin-6 receptor antibody, using data from the COVACTA trial in patients hospitalized with severe coronavirus disease 2019 pneumonia.

DESIGN: 

Exploratory analysis from a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial.

SETTING: 

Hospitals in North America and Europe.

PATIENTS: 

Adults hospitalized with severe coronavirus disease 2019 pneumonia receiving standard care.

INTERVENTION: 

Randomly assigned 2:1 to IV tocilizumab 8 mg/kg or placebo.

MEASUREMENTS AND MAIN RESULTS: 

Candidate biomarkers were measured in 295 patients in the tocilizumab arm and 142 patients in the placebo arm. Efficacy outcomes assessed were clinical status on a seven-category ordinal scale (1, discharge; 7, death), mortality, time to hospital discharge, and mechanical ventilation (if not receiving it at randomization) through day 28. Prognostic and predictive biomarkers were evaluated continuously with proportional odds, binomial or Fine-Gray models, and additional sensitivity analyses. Modeling in the placebo arm showed all candidate biomarkers except lactate dehydrogenase and d-dimer were strongly prognostic for day 28 clinical outcomes of mortality, mechanical ventilation, clinical status, and time to hospital discharge. Modeling in the tocilizumab arm showed a predictive value of ferritin for day 28 clinical outcomes of mortality (predictive interaction, p = 0.03), mechanical ventilation (predictive interaction, p = 0.01), and clinical status (predictive interaction, p = 0.02) compared with placebo.

CONCLUSIONS: 

Multiple biomarkers prognostic for clinical outcomes were confirmed in COVACTA. Ferritin was identified as a predictive biomarker for the effects of tocilizumab in the COVACTA patient population; high ferritin levels were associated with better clinical outcomes for tocilizumab compared with placebo at day 28.

 

Intensive care unit capacity and mortality in older adults: a three nations retrospective observational cohort study

 

by Ran Abuhasira, Matthew Anstey, Victor Novack, Somnath Bose, Daniel Talmor and Lior Fuchs 

 

Annals of Intensive Care volume 12, Article number: 20 (2022) Published: 04 March 2022

Background

Intensive care unit (ICU) admissions among older adults are expected to increase, while the benefit remains uncertain. The availability of ICU beds varies between hospitals and between countries and is an important factor in the decision to admit older adults in the ICU. We aimed to assess if a non-restrictive approach to ICU older adults admission is associated with a corresponding change in survival.

Methods

Retrospective cohort study that included patients ≥ 80 years who were admitted to each of the three participating hospitals in Australia, Israel, and the United States (USA), between the years 2006–2015, each with distinct ICU capacities and admission criteria. The primary outcomes were in-hospital mortality and all-cause mortality at 6, 12, 18, and 24 months following index hospitalization.

Results

The cohort included 62,866 patients with a mean age of 85.9 ± 4.6 years and 58.8% were women. The ICU admission rates were 22.5%, 2.6% and 2.3% in USA, Australia, and Israel, respectively. We constructed a model for ICU admissions based on the USA cohort (highest availability of ICU beds) and then calculated the expected probabilities for the Israeli and Australian cohorts. For the patients in the highest quintile of the admission model, actual ICU admission rates were 67.6% in USA, 22.1% in Australia and 6.0% in Israel. Of these, in-hospital death rates were 52.3% in Israel, 29.8% in Australia, and 22.1% in USA. Two years after hospital discharge, the survival rates in the USA and Australia were 53%, while in Israel 48%.

Conclusion

ICU admission of adults ≥ 80 years is associated with increased in-hospital survival compared to ward admission, but survival rates 2 years later are similar.

 

Distribution of delirium motor subtypes in the intensive care unit: a systematic scoping review

 

by Kirstine N. la Cour, Nina C. Andersen-Ranberg, Sarah Weihe, Lone M. Poulsen, Camilla B. Mortensen, Cilia K. W. Kjer, Marie O. Collet, Stine Estrup and Ole Mathiesen 

 

Critical Care volume 26, Article number: 53 (2022) Published: 03 March 2022

 

Background

Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on the clinical manifestation. The aim of this review was to describe the distribution, pharmacological interventions, and outcomes of delirium motor subtypes in ICU patients.

Methods

This systematic scoping review was performed according to the PRISMA-ScR and Cochrane guidelines. We performed a systematic search in six major databases to identify relevant studies. A meta-regression analysis was performed where pooled estimates with 95% confidence intervals were computed by a random effect model.

Results

We included 131 studies comprising 13,902 delirious patients. There was a large between-study heterogeneity among studies, including differences in study design, setting, population, and outcome reporting. Hypoactive delirium was the most prevalent delirium motor subtype (50.3% [95% CI 46.0–54.7]), followed by mixed delirium (27.7% [95% CI 24.1–31.3]) and hyperactive delirium (22.7% [95% CI 19.0–26.5]). When comparing the delirium motor subtypes, patients with mixed delirium experienced the longest delirium duration, ICU and hospital length of stay, the highest ICU and hospital mortality, and more frequently received administration of specific agents (antipsychotics, α2-agonists, benzodiazepines, and propofol) during ICU stay. In studies with high average age for delirious patients (> 65 years), patients were more likely to experience hypoactive delirium.

Conclusions

Hypoactive delirium was the most prevalent motor subtype in critically ill patients. Mixed delirium had the worst outcomes in terms of delirium duration, length of stay, and mortality, and received more pharmacological interventions compared to other delirium motor subtypes. Few studies contributed to secondary outcomes; hence, these results should be interpreted with care. The large between-study heterogeneity suggests that a more standardized methodology in delirium research is warranted.

 

 

Randomized controlled trial: neostigmine for intra-abdominal hypertension in acute pancreatitis

 

by Wenhua He, Peng Chen, Yupeng Lei, Liang Xia, Pi Liu, Yong Zhu, Hao Zeng, Yao Wu, Huajing Ke, Xin Huang, Wenhao Cai, Xin Sun, Wei Huang, Robert Sutton, Yin Zhu and Nonghua Lu 

 

Critical Care volume 26, Article number: 52 (2022) Published: 03 March 2022

 

 

Background

Intra-abdominal hypertension (IAH) in acute pancreatitis (AP) is associated with deterioration in organ function. This trial aimed to assess the efficacy of neostigmine for IAH in patients with AP.

Methods

In this single-center, randomized trial, consenting patients with IAH within 2 weeks of AP onset received conventional treatment for 24 h. Patients with sustained intra-abdominal pressure (IAP) ≥ 12 mmHg were randomized to receive intramuscular neostigmine (1 mg every 12 h increased to every 8 h or every 6 h, depending on response) or continue conventional treatment for 7 days. The primary outcome was the percent change of IAP at 24 h after randomization.

Results

A total of 80 patients were recruited to neostigmine (n = 40) or conventional treatment (n = 40). There was no significant difference in baseline parameters. The rate of decrease in IAP was significantly faster in the neostigmine group compared to the conventional group by 24 h (median with 25th–75th percentile: −18.7% [− 28.4 to − 4.7%] vs. − 5.4% [− 18.0% to 0], P = 0.017). This effect was more pronounced in patients with baseline IAP ≥ 15 mmHg (P = 0.018). Per-protocol analysis confirmed these results (P = 0.03). Stool volume was consistently higher in the neostigmine group during the 7-day observational period (all P < 0.05). Other secondary outcomes were not significantly different between neostigmine and conventional treatment groups.

Conclusion

Neostigmine reduced IAP and promoted defecation in patients with AP and IAH. These results warrant a larger, placebo-controlled, double-blind phase III trial.

Trial registration Clinical Trial No: NCT02543658 (registered August /27, 2015).

 

Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review

 

Intensive Care Medicine volume 48, pages 389–413 (2022) Published: 04 March 2022

 

 

Purpose

To assess the ability of clinical examination, blood biomarkers, electrophysiology or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict good neurological outcome, defined as no, mild, or moderate disability (CPC 1–2 or mRS 0–3) at discharge from intensive care unit or later, in comatose adult survivors from cardiac arrest (CA).

Methods

PubMed, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were searched. Sensitivity and specificity for good outcome were calculated for each predictor. The risk of bias was assessed using the QUIPS tool.

Results

A total of 37 studies were included. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. A withdrawal or localisation motor response to pain immediately or at 72–96 h after ROSC, normal blood values of neuron-specific enolase (NSE) at 24 h-72 h after ROSC, a short-latency somatosensory evoked potentials (SSEPs) N20 wave amplitude > 4 µV or a continuous background without discharges on electroencephalogram (EEG) within 72 h from ROSC, and absent diffusion restriction in the cortex or deep grey matter on MRI on days 2–7 after ROSC predicted good neurological outcome with more than 80% specificity and a sensitivity above 40% in most studies. Most studies had moderate or high risk of bias.

Conclusions

In comatose cardiac arrest survivors, clinical, biomarker, electrophysiology, and imaging studies identified patients destined to a good neurological outcome with high specificity within the first week after cardiac arrest (CA).

 

Survival benefit of extracorporeal membrane oxygenation in severe COVID-19: a multi-centre-matched cohort study

 

Intensive Care Medicine volume 48, pages 467–478 (2022) Published: 03 March 2022

 

Purpose

Extracorporeal membrane oxygenation (ECMO) has become an established therapy for severe respiratory failure in coronavirus disease 2019 (COVID-19). The added benefit of receiving ECMO in COVID-19 remains uncertain. The aim of this study is to analyse the impact of receiving ECMO at specialist centres on hospital mortality.

Methods

A multi-centre retrospective study was conducted in COVID-19 patients from 111 hospitals, referred to two specialist ECMO centres in the United Kingdom (UK) (March 2020 to February 2021). Detailed covariate data were contemporaneously curated from electronic referral systems. We analysed added benefit of ECMO treatment in specialist centres using propensity score matching techniques.

Results

1363 patients, 243 receiving ECMO, were analysed. The best matching technique generated 209 matches, with a marginal odds ratio (OR) for mortality of 0.44 (95% CI 0.29–0.68, p < 0.001) and absolute mortality reduction of 18.2% (44% vs 25.8%, p < 0.001) for treatment with ECMO in a specialist centre.

Conclusion

We found ECMO provided at specialist centres conferred significant survival benefit. Where resources and specialism allow, ECMO should be widely offered.