Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study

Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study

 

by David Sanchez, Kathleen Brennan, Masar Al Sayfe, Sharon-Ann Shunker, Tony Bogdanoski, Sonja Hedges, Yu Chin Hou, Joan Lynch, Leanne Hunt, Evan Alexandrou, Manoj Saxena, Simon Abel, Ramanathan Lakshmanan, Deepak Bhonagiri, Michael J. Parr, Anders Aneman…

 

Critical Care volume 24, Article number: 609 (2020)  Published: 15 October 2020

 

 

Background

Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care.

Methods

This study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored.

Results

During the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63–79); 55% were male (n = 537). Among these patients, 39.2% (95% CI 36.1–42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n = 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (adjRR) = 1.71, 95% confidence interval (CI) 1.20–2.43, p = 0.003), had a longer hospital stay (2.6 days, 95% CI 1–7 days, p = 0.009) and had a higher risk of hospital mortality (19% versus 7%, adjRR = 2.54, 95% CI 1.72–3.75, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU.

Conclusion

Frailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

 

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

 

by Carlos Ferrando, Ricard Mellado-Artigas, Alfredo Gea, Egoitz Arruti, César Aldecoa, Ramón Adalia, Fernando Ramasco, Pablo Monedero, Emilio Maseda, Gonzalo Tamayo, María L. Hernández-Sanz, Jordi Mercadal, Ascensión Martín-Grande, Robert M. Kacmarek, Jesús Villar and Fernando Suárez-Sipmann

 

Critical Care volume 24, Article number: 597 (2020) Published: 06 October 2020

Background

Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.

Methods

Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.

Results

A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92].

Conclusion

In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Effect of PEEP decremental on respiratory mechanics, gasses exchanges, pulmonary regional ventilation, and hemodynamics in patients with SARS-Cov-2-associated acute respiratory distress syndrome

 

Effect of PEEP decremental on respiratory mechanics, gasses exchanges, pulmonary regional ventilation, and hemodynamics in patients with SARS-Cov-2-associated acute respiratory distress syndrome

 

by Vincent Bonny, Vincent Janiak, Savino Spadaro, Andrea Pinna, Alexandre Demoule and Martin Dres 

 

Critical Care volume 24, Article number: 596 (2020) Published: 06 October 2020

 

Previous reports of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2)-related acute respiratory distress syndrome (ARDS) have been highlighting a profound hypoxemia and it is not yet well defined how to set positive end-expiratory pressure (PEEP) in this context [1]. In this report, we describe the effects of two levels of PEEP on lung mechanics using a multimodal approach.

Patients with confirmed laboratory SARS-Cov-2 infection and meeting criteria for ARDS according to the Berlin definition [2] were eligible within the 48 h after intubation. Written informed consent was waived due to the observational nature of the study. The local ethic approved the study (N° CER-2020-16).

Patients were paralyzed and received lung protective ventilation on volume-controlled ventilation. Effects of PEEP decremental were evaluated at two levels of PEEP, arbitrarily 16 cm H2O and 8 cm H2O. These levels were decided based on previous reports [3, 4]. Measurements were performed after 20 min after changing the level of PEEP. Lung mechanics were assessed using an esophageal catheter (NutriVentTM, Italy) [5]. Hemodynamics, indexed extravascular lung water (EVLWi), pulmonary vascular permeability index (PVPI), and cardiac function index (CFI) were monitored by transpulmonary thermodilution (TPTD) device (PiCCO2, Pulsion Medical Systems, Germany). Pulmonary regional ventilation was monitored by the use of an EIT belt placed around the patient’s chest (PulmoVista500; Dräger Medical GmbH Lübeck, Germany) [6]…

Intra-abdominal hypertension and abdominal compartment syndrome in patients admitted to the ICU

 

Intra-abdominal hypertension and abdominal compartment syndrome in patients admitted to the ICU

 

by Marije Smit, Bart Koopman, Willem Dieperink, Jan B. F. Hulscher, H. Sijbrand Hofker, Matijs van Meurs and Jan G. Zijlstra

 

Annals of Intensive Care volume 10, Article number: 130 (2020) Published: 01 October 2020

 

 

Background

Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome have been widely investigated. However, data are lacking on prevalence and outcome in high-risk patients. Our objectives in this study were to investigate prevalence and outcome of intra-abdominal hypertension and abdominal compartment syndrome in high-risk patients in a prospective, observational, single-center cohort study.

Results

Between March 2014 and March 2016, we included 503 patients, 307 males (61%) and 196 females (39%). Patients admitted to the intensive care unit with a diagnosis of pancreatitis, elective or emergency open abdominal aorta surgery, orthotopic liver transplantation, other elective or emergency major abdominal surgery and trauma were enrolled. One hundred and sixty four (33%) patients developed intra-abdominal hypertension and 18 (3.6%) patients developed abdominal compartment syndrome. Highest prevalence of abdominal compartment syndrome occurred in pancreatitis (57%) followed by orthotopic liver transplantation (7%) and abdominal aorta surgery (5%). Length of intensive care stay increased by a factor 4 in patients with intra-abdominal hypertension and a factor 9 in abdominal compartment syndrome, compared to patients with normal intra-abdominal pressure. Rate of renal replacement therapy was higher in abdominal compartment syndrome (38.9%) and intra-abdominal hypertension (8.2%) compared to patients with normal intra-abdominal pressure (1.2%). Both intensive care mortality and 90-day mortality were significantly higher in intra-abdominal hypertension (4.8% and 15.2%) and abdominal compartment syndrome (16.7% and 38.9%) compared to normal intra-abdominal pressure (1.2% and 7.1%). Body mass index (odds ratio 1.08, 95% confidence interval 1.03–1.13), mechanical ventilation at admission (OR 3.52, 95% CI 2.08–5.96) and Apache IV score (OR 1.03, 95% CI 1.02–1.04) were independent risk factors for the development of intra-abdominal hypertension or abdominal compartment syndrome.

Conclusions

The prevalence of abdominal compartment syndrome was 3.6% and the prevalence of intra-abdominal hypertension was 33% in this cohort of high-risk patients. Morbidity and mortality increased when intra-abdominal hypertension or abdominal compartment syndrome was present. The patient most at risk of IAH or ACS in this high-risk cohort has a BMI > 30 kg/m2 and was admitted to the ICU after emergency abdominal surgery or with a diagnosis of pancreatitis.

Transpulmonary pressures in obese and non-obese COVID-19 ARDS

 

Transpulmonary pressures in obese and non-obese COVID-19 ARDS

by Mehdi Mezidi, Florence Daviet, Paul Chabert, Sami Hraiech, Laurent Bitker, Jean-Marie Forel, Hodane Yonis, Ines Gragueb, Francois Dhelft, Laurent Papazian, Jean-Christophe Richard and Christophe Guervilly

Annals of Intensive Care volume 10, Article number: 129 (2020) Published: 01 October 2020

Background

Data on respiratory mechanics of COVID-19 ARDS patients are scarce. Respiratory mechanics and response to positive expiratory pressure (PEEP) may be different in obese and non-obese patients.

Methods

We investigated esophageal pressure allowing determination of transpulmonary pressures (PL ) and elastances (EL) during a decremental PEEP trial from 20 to 6 cm H2O in a cohort of COVID-19 ARDS patients.

Results

Fifteen patients were investigated, 8 obese and 7 non-obese patients. PEEP ≥ 16 cm H2O for obese patients and PEEP ≥10 cm H2O for non-obese patients were necessary to obtain positive expiratory PL. Change of PEEP did not alter significantly ΔPL or elastances in obese patients. However, in non-obese patients lung EL  and ΔPL increased significantly with PEEP increase. Chest wall EL was not affected by PEEP variations in both groups.

Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure

 

Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure

 

by Virginie Montiel, Arnaud Robert, Annie Robert, Anas Nabaoui, Tourneux Marie, Natalia Morales Mestre, Maerckx Guillaume, Pierre-François Laterre and Xavier Wittebole

 

Annals of Intensive Care volume 10, Article number: 125 (2020) Published: 29 September 2020

 

Objective

Critically ill patients admitted in ICU because of COVID-19 infection display severe hypoxemic respiratory failure. The Surviving Sepsis Campaign recommends oxygenation through high-flow nasal cannula over non-invasive ventilation. The primary outcome of our study was to evaluate the effect of the addition of a surgical mask on a high-flow nasal cannula system on oxygenation parameters in hypoxemic COVID-19 patients admitted in ICU who do not require urgent intubation. The secondary outcomes were relevant changes in PaCO2 associated with clinical modifications and patient’s feelings.

Design

We prospectively assessed 21 patients admitted in our mixed Intensive Care Unit of the Cliniques Universitaires Saint Luc.

Main results

While FiO2 was unchanged, we demonstrate a significant increase of PaO2 (from 59 (± 6), to 79 mmHg (± 16), p < 0.001), PaO2/FiO2 from 83 (± 22), to 111 (± 38), p < 0.001) and SaO2 (from 91% (± 1.5), to 94% (± 1.6), p < 0.001), while the patients were under the surgical mask. The SpO2 returned to pre-treatment values when the surgical mask was removed confirming the effect of the device rather than a spontaneous positive evolution.

Conclusion

A surgical mask placed on patient’s face already treated by a High-flow nasal cannula device improves COVID-19 patient’s oxygenation admitted in Intensive Care Unit for severe hypoxemic respiratory failure without any clinically relevant side.

Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19

 

Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19

 

by John Whittle, Jeroen Molinger, David MacLeod, Krista Haines and Paul E. Wischmeyer 

 

Critical Care volume 24, Article number: 581 (2020) Published: 28 September 2020

 

 COVID-19 infection results in respiratory failure requiring ICU care in a small, yet significant, number of patients [1]. The longitudinal metabolic phenotype and energy expenditure of this novel pandemic disease has yet to be described. As a marked and often prolonged, systemic inflammatory response (SIRS) has been suggested to be a hallmark of severe COVID-19 infection [1], we hypothesized a prolonged hypermetabolic state would evolve over ICU stay that would persist beyond the 7–10 day hypermetabolic phase described previously in other ICU conditions [2].

Further, understanding the energy expenditure of COVID-19 ICU patients is essential to help determine safe, optimal nutrition needs for the ICU provider [3], as both over-/underfeeding is associated with increased ICU mortality [3, 4]. Prediction of resting energy expenditure (pREE) using standardized formulas or bodyweight calculations often correlates poorly with measured REE (mREE) [3]. Thus, our aim was to assess longitudinal mREE via indirect calorimetry (IC) in intubated COVID-19 patients.

COVID-19: instruments for the allocation of mechanical ventilators—a narrative review

 

COVID-19: instruments for the allocation of mechanical ventilators—a narrative review

 

by Marcelo José dos Santos, Maristela Santini Martins, Fabiana Lopes Pereira Santana, Maria Carolina Silvano Pacheco Corrêa Furtado, Fabiana Cristina Bazana Remédio Miname, Rafael Rodrigo da Silva Pimentel, Ágata Nunes Brito, Patrick Schneider, Edson Silva dos Santos and Luciane Hupalo da Silva

 

Critical Care volume 24, Article number: 582 (2020) Published: 29 September 2020

 

After the World Health Organization declared COVID-19 to be a pandemic, the elaboration of comprehensive and preventive public policies became important in order to stop the spread of the disease. However, insufficient or ineffective measures may have placed health professionals and services in the position of having to allocate mechanical ventilators. This study aimed to identify instruments, analyze their structures, and present the main criteria used in the screening protocols, in order to help the development of guidelines and policies for the allocation of mechanical ventilators in the COVID-19 pandemic. The instruments have a low level of scientific evidence, and, in general, are structured by various clinical, non-clinical, and tiebreaker criteria that contain ethical aspects. Few instruments included public participation in their construction or validation. We believe that the elaboration of these guidelines cannot be restricted to specialists as this question involves ethical considerations which make the participation of the population necessary. Finally, we propose seventeen elements that can support the construction of screening protocols in the COVID-19 pandemic.

Fibrin-derived peptide Bβ15-42 (FX06) as salvage treatment in critically ill patients with COVID-19-associated acute respiratory distress syndrome

 

Fibrin-derived peptide Bβ15-42 (FX06) as salvage treatment in critically ill patients with COVID-19-associated acute respiratory distress syndrome

 

by Elisabeth H. Adam, Benedikt Schmid, Michael Sonntagbauer, Peter Kranke, Kai Zacharowski and Patrick Meybohm

 

 Critical Care volume 24, Article number: 574 (2020) 

 

Practical strategies to reduce nosocomial transmission to healthcare professionals providing respiratory care to patients with COVID-19

 

Practical strategies to reduce nosocomial transmission to healthcare professionals providing respiratory care to patients with COVID-19

 

by Ramandeep Kaur, Tyler T. Weiss, Andrew Perez, James B. Fink, Rongchang Chen, Fengming Luo, Zongan Liang, Sara Mirza and Jie Li

Critical Care volume 24, Article number: 571 (2020) Published: 23 September 2020

 Coronavirus disease (COVID-19) is an emerging viral infection that is rapidly spreading across the globe. SARS-CoV-2 belongs to the same coronavirus class that caused respiratory illnesses such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). During the SARS and MERS outbreaks, many frontline healthcare workers were infected when performing high-risk aerosol-generating medical procedures as well as when providing basic patient care. Similarly, COVID-19 disease has been reported to infect healthcare workers at a rate of ~ 3% of cases treated in the USA. In this review, we conducted an extensive literature search to develop practical strategies that can be implemented when providing respiratory treatments to COVID-19 patients, with the aim to help prevent nosocomial transmission to the frontline workers.