Journal of Clinical Medicine

Research

13 pages, 1770 KiB

Open AccessArticle

Electroencephalogram-Based Evaluation of Impaired Sedation in Patients with Moderate to Severe COVID-19 ARDS

by Armin Niklas Flinspach, Sebastian Zinn, Kai Zacharowski, Ümniye Balaban, Eva Herrmann and Elisabeth Hannah Adam

J. Clin. Med. 2022, 11(12), 3494; https://doi.org/10.3390/jcm11123494 - 17 Jun 2022

Cited by 2 | Viewed by 1918

Abstract

The sedation management of patients with severe COVID-19 is challenging. Processed electroencephalography (pEEG) has already been used for sedation management before COVID-19 in critical care, but its applicability in COVID-19 has not yet been investigated. We performed this prospective observational study to evaluate [...] Read more.

The sedation management of patients with severe COVID-19 is challenging. Processed electroencephalography (pEEG) has already been used for sedation management before COVID-19 in critical care, but its applicability in COVID-19 has not yet been investigated. We performed this prospective observational study to evaluate whether the patient sedation index (PSI) obtained via pEEG may adequately reflect sedation in ventilated COVID-19 patients. Statistical analysis was performed by linear regression analysis with mixed effects. We included data from 49 consecutive patients. None of the patients received neuromuscular blocking agents by the time of the measurement. The mean value of the PSI was 20 (±23). The suppression rate was determined to be 14% (±24%). A deep sedation equivalent to the Richmond Agitation and Sedation Scale of −3 to −4 (correlation expected PSI 25–50) in bedside examination was noted in 79.4% of the recordings. Linear regression analysis revealed a significant correlation between the sedative dosages of propofol, midazolam, clonidine, and sufentanil (p < 0.01) and the sedation index. Our results showed a distinct discrepancy between the RASS and the determined PSI. However, it remains unclear to what extent any discrepancy is due to the electrophysiological effects of neuroinflammation in terms of pEEG alteration, to the misinterpretation of spinal or vegetative reflexes during bedside evaluation, or to other causes. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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14 pages, 522 KiB

Open AccessArticle

Outcomes of COVID-19 Critically Ill Extremely Elderly Patients: Analysis of a Large, National, Observational Cohort

by Stefan Andrei, Liana Valeanu, Mihai Gabriel Stefan, Dan Longrois, Mihai Popescu, Gabriel Stefan, Cosmin Balan, Raed Arafat, Dan Corneci, Gabriela Droc, Serban-Ion Bubenek-Turconi and on behalf of the COVATI-RO Collaborative

J. Clin. Med. 2022, 11(6), 1544; https://doi.org/10.3390/jcm11061544 - 11 Mar 2022

Cited by 7 | Viewed by 2439

Abstract

Background. During the COVID-19 pandemic, resource allocation became a major problem in globally overwhelmed ICUs. The main goal of this study was to describe the clinical characteristics of the very elderly patients (aged ≥ 80 years) with COVID-19 admitted in Romanian ICUs. The [...] Read more.

Background. During the COVID-19 pandemic, resource allocation became a major problem in globally overwhelmed ICUs. The main goal of this study was to describe the clinical characteristics of the very elderly patients (aged ≥ 80 years) with COVID-19 admitted in Romanian ICUs. The study objectives were to evaluate and determine the factors associated with ICU mortality. Methods. We designed a national, multicentric, observational platform with prospective enrolment. This study included patients aged ≥ 80 years admitted in Romanian ICUs with SARS-CoV-2 infection from March 2020 to December 2021. Results. We included 1666 patients with a median age of 83 years and 78% ICU mortality. Male sex, dyspnoea, lower Glasgow Coma Scale and lower SpO2 at ICU admission, the need for mechanical ventilation (MV), and corticosteroid use were independently associated with mortality. A total of 886/1666 (53%) elderly patients underwent invasive mechanical ventilation, with a mortality of 97%. The age impact on mortality was confirmed by a 1:1 propensity matching with less elderly ICU patients. Conclusion. In extremely elderly patients with COVID-19 admitted in the ICU, mortality is high, particularly when requiring MV. Therapy should be directed towards the optimization of less invasive ventilatory methods and the use of MV and corticosteroids only in highly selected patients. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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14 pages, 1038 KiB

Open AccessArticle

Comparing the Occurrence of Healthcare-Associated Infections in Patients with and without COVID-19 Hospitalized during the Pandemic: A 16-Month Retrospective Cohort Study in a Hospital Intensive Care Unit

by Claudia Isonne, Valentina Baccolini, Giuseppe Migliara, Mariateresa Ceparano, Francesco Alessandri, Giancarlo Ceccarelli, Guglielmo Tellan, Francesco Pugliese, Maria De Giusti, Corrado De Vito, Carolina Marzuillo, Paolo Villari, Lavinia Camilla Barone, Dara Giannini, Daniela Marotta, Mattia Marte, Elena Mazzalai, Irma Germani, Arianna Bellini, Andrea Bongiovanni, Marta Castellani, Ludovica D’Agostino, Andrea De Giorgi, Chiara De Marchi, Elisa Mazzeo, Shadi Orlandi, Matteo Piattoli, Eleonora Ricci, Leonardo Maria Siena, Alessandro Territo and Stefano Zanni Show full author list Hide full author list

J. Clin. Med. 2022, 11(5), 1446; https://doi.org/10.3390/jcm11051446 - 7 Mar 2022

Cited by 9 | Viewed by 2437

Abstract

The COVID-19 pandemic has increased the healthcare-associated infection (HAI) risk in intensive care unit (ICU) patients. However, a comparison between patients with and without COVID-19 in terms of HAI incidence has been rarely explored. In this study, we characterized the occurrence of HAI [...] Read more.

The COVID-19 pandemic has increased the healthcare-associated infection (HAI) risk in intensive care unit (ICU) patients. However, a comparison between patients with and without COVID-19 in terms of HAI incidence has been rarely explored. In this study, we characterized the occurrence of HAI among patients with and without COVID-19 admitted to the ICU of the Umberto I hospital of Rome during the first 16 months of the pandemic and also identified risk factors for HAI acquisition. Patients were divided into four groups according to their ICU admission date. A multivariable conditional risk set regression model for multiple events was constructed for each admission period. Adjusted hazard ratios and 95% confidence intervals were calculated. Overall, 352 COVID-19 and 130 non-COVID-19 patients were included, and a total of 361 HAIs were recorded. We found small differences between patients with and without COVID-19 in the occurrence and type of HAI, but the infections in the two cohorts mostly involved different microorganisms. The results indicate that patient management was likely an important factor influencing the HAI occurrence during the pandemic. Effective prevention and control strategies to reduce HAI rates should be implemented. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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14 pages, 1209 KiB

Open AccessArticle

Routine and Advanced Laboratory Tests for Hemostasis Disorders in COVID-19 Patients: A Prospective Cohort Study

by Paul Billoir, Perrine Leprêtre, Caroline Thill, Jeremy Bellien, Veronique Le Cam Duchez, Jean Selim, Fabienne Tamion, Thomas Clavier and Emmanuel Besnier

J. Clin. Med. 2022, 11(5), 1383; https://doi.org/10.3390/jcm11051383 - 3 Mar 2022

Cited by 5 | Viewed by 1824

Abstract

Background: Thrombosis is frequent during COVID-19 disease, and thus, identifying predictive factors of hemostasis associated with a poor prognosis is of interest. The objective was to explore coagulation disorders as early predictors of worsening critical conditions in the intensive care unit (ICU) using [...] Read more.

Background: Thrombosis is frequent during COVID-19 disease, and thus, identifying predictive factors of hemostasis associated with a poor prognosis is of interest. The objective was to explore coagulation disorders as early predictors of worsening critical conditions in the intensive care unit (ICU) using routine and more advanced explorations. Materials: Blood samples within 24 h of ICU admission for viscoelastic point-of-care testing, (VET), advanced laboratory tests: absolute immature platelet count (A-IPC), von Willebrand-GPIb activity (vWF-GpIb), prothrombin fragments 1 + 2 (F1 + 2), and the thrombin generation assay (TGA) were used. An association with worse outcomes was explored using univariable and multivariable analyses. Worsening was defined as death or the need for organ support. Results: An amount of 85 patients with 33 in critical condition were included. A-IPC were lower in worsening patients (9.6 [6.4–12.5] vs. 12.3 [8.3–20.7], p = 0.02) while fibrinogen (6.9 [6.1–7.7] vs. 6.2 [5.4–6.9], p = 0.03), vWF-GpIb (286 [265–389] vs. 268 [216–326], p = 0.03) and F1 + 2 (226 [151–578] vs. 155 [129–248], p = 0.01) were higher. There was no difference observed for D-dimer, TGA or VET. SAPS-II and A-IPC were independently associated with worsening (OR = 1.11 [1.06–1.17] and OR = 0.47 [0.25–0.76] respectively). The association of a SAPS-II ≥ 33 and an A-IPC ≤ 12.6 G/L predicted the worsening of patients (sensitivity 58%, specificity 89%). Conclusions: Immature platelets are early predictors of worsening in severe COVID-19 patients, suggesting a key role of thrombopoiesis in the adaption of an organism to SARS-CoV-2 infection. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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9 pages, 901 KiB

Open AccessArticle

Early Measurement of ROX Index in Intermediary Care Unit Is Associated with Mortality in Intubated COVID-19 Patients: A Retrospective Study

by Alexandre Leszek, Hannah Wozniak, Amélie Giudicelli-Bailly, Noémie Suh, Filippo Boroli, Jérôme Pugin, Olivier Grosgurin, Christophe Marti, Christophe Le Terrier and Hervé Quintard

J. Clin. Med. 2022, 11(2), 365; https://doi.org/10.3390/jcm11020365 - 12 Jan 2022

Cited by 9 | Viewed by 1766

Abstract

COVID-19 patients often present with rapidly progressing acute hypoxemic respiratory failure, requiring orotracheal intubation with different prognostic issues. However, ICU specialists lack predictive tools to stratify these patients. We conducted a single-center cross-sectional retrospective study to evaluate if the ROX index, measured under [...] Read more.

COVID-19 patients often present with rapidly progressing acute hypoxemic respiratory failure, requiring orotracheal intubation with different prognostic issues. However, ICU specialists lack predictive tools to stratify these patients. We conducted a single-center cross-sectional retrospective study to evaluate if the ROX index, measured under non-invasive oxygenation support, can predict ICU mortality in a COVID-19 intubated patient cohort. This study took place in the division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). We included all consecutive adult patients treated by non-invasive oxygenation support and requiring intubation for acute respiratory failure due to COVID-19 between 9 September 2020 and 30 March 2021, corresponding to the second local surge of COVID-19 cases. Baseline demographic data, comorbidities, median ROX between H0 and H8, and clinical outcomes were collected. Overall, 82 patients were intubated after failing a non-invasive oxygenation procedure. Women represented 25.6% of the whole cohort. Median age and median BMI were 70 (60–75) years and 28 (25–33), respectively. Before intubation, the median ROX between H0 and H8 was 6.3 (5.0–8.2). In a multivariate analysis, the median ROX H0–H8 was associated with ICU mortality as a protective factor with an odds ratio (95% CI) = 0.77 (0.60–0.99); p < 0.05. In intubated COVID-19 patients treated initially by non-invasive oxygenation support for acute respiratory failure, the median ROX H0–H8 could be an interesting predictive factor associated with ICU mortality. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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17 pages, 643 KiB

Open AccessArticle

Effect of Different Corticosteroid Regimens on the Outcome of Severe COVID-19-Related Acute Respiratory Failure. A Retrospective Analysis

by Michele Umbrello, Paolo Formenti, Stefano Nespoli, Eleonora Pisano, Cecilia Bonino and Stefano Muttini

J. Clin. Med. 2021, 10(21), 4847; https://doi.org/10.3390/jcm10214847 - 21 Oct 2021

Cited by 5 | Viewed by 1502

Abstract

Background: Systemic corticosteroids are associated with reduced mortality in COVID-19-related acute respiratory failure; however, the type and dose has not yet been established. Objectives: To compare the outcomes of dexamethasone vs. methylprednisolone, along with the effects of rescue, short-term, high-dose boluses of corticosteroids. [...] Read more.

Background: Systemic corticosteroids are associated with reduced mortality in COVID-19-related acute respiratory failure; however, the type and dose has not yet been established. Objectives: To compare the outcomes of dexamethasone vs. methylprednisolone, along with the effects of rescue, short-term, high-dose boluses of corticosteroids. Methods: Before/after and case/control retrospective analysis of consecutive critically ill COVID-19 subjects. Subjects were initially given dexamethasone; however, after review of the local protocol, methylprednisolone was suggested. A three-day course of 1000 mg/day of methylprednisolone was administered in the case of refractory hypoxemia within the first 10 days of treatment. Propensity score-adjusted comparisons were performed. Results: A total of 81 consecutive subjects were included (85% males, 60 ± 10 years, SAPS II 27 ± 7, SOFA 4 [IQR 3, 6] points) and 51 of these subjects (62.9%) received dexamethasone and 29 (35.8%) had methylprednisolone. The groups were well matched for age, comorbidities, and severity at admission. No differences were found in the duration of ICU stay, hospital mortality, or infectious complications between the groups. A total of 22 subjects (27.2%) received a rescue bolus; these subjects had a significantly lower oxygenation, a higher driving pressure, and an increased ventilatory ratio during the first ten days. Short-term/high-dose boluses were associated with higher hospital mortality, longer mechanical ventilation and ICU and hospital stay, and more infectious complications. A subgroup of subjects who received the boluses had significantly improved oxygenation and lower hospital mortality. Conclusions: We were unable to find any difference between dexamethasone or methylprednisolone on the explored outcomes; high-dose boluses of corticosteroids were associated with a worse outcome. However, a subgroup of subjects was identified in whom the high-dose boluses seemed beneficial. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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Review

Jump to: Research, Other

8 pages, 535 KiB

Open AccessReview

Ethical Lessons from an Intensivist’s Perspective

by Jean-Louis Vincent

J. Clin. Med. 2022, 11(6), 1613; https://doi.org/10.3390/jcm11061613 - 15 Mar 2022

Cited by 1 | Viewed by 1844

Abstract

Intensive care units (ICUs) around the world have been hugely impacted by the SARS-CoV-2 pandemic and the vast numbers of patients admitted with COVID-19, requiring respiratory support and prolonged stays. This pressure, with resulting shortages of ICU beds, equipment, and staff has raised [...] Read more.

Intensive care units (ICUs) around the world have been hugely impacted by the SARS-CoV-2 pandemic and the vast numbers of patients admitted with COVID-19, requiring respiratory support and prolonged stays. This pressure, with resulting shortages of ICU beds, equipment, and staff has raised ethical dilemmas as physicians have had to determine how best to allocate the sparse resources. Here, we reflect on some of the major ethical aspects of the COVID-19 pandemic, including resource allocation and rationing, end-of-life decision-making, and communication and staff support. Importantly, these issues are regularly faced in non-pandemic ICU patient management and useful lessons can be learned from the discussions that have occurred as a result of the COVID-19 situation. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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Other

Jump to: Research, Review

9 pages, 767 KiB

Open AccessBrief Report

The Effects of Early Rehabilitation in the Intensive Care Unit for Patients with Severe COVID-19 Pneumonia: A Retrospective Cohort Study

by Tokio Kinoshita, Yukihide Nishimura, Yasunori Umemoto, Yasuhisa Fujita, Ken Kouda, Yoshinori Yasuoka, Kyohei Miyamoto, Seiya Kato and Fumihiro Tajima

J. Clin. Med. 2022, 11(2), 357; https://doi.org/10.3390/jcm11020357 - 12 Jan 2022

Cited by 4 | Viewed by 2457

Abstract

This retrospective cohort study aimed to examine the rehabilitation effect of patients with coronavirus disease 2019 (COVID-19) in the intensive care unit (ICU) under mechanical ventilation and included ICU patients from a university hospital who received rehabilitation under ventilator control until 31 May [...] Read more.

This retrospective cohort study aimed to examine the rehabilitation effect of patients with coronavirus disease 2019 (COVID-19) in the intensive care unit (ICU) under mechanical ventilation and included ICU patients from a university hospital who received rehabilitation under ventilator control until 31 May 2021. Seven patients were included, and three of them died; thus, the results of the four survivors were examined. The rehabilitation program comprised the extremity range-of-motion training and sitting on the bed’s edge. The Sequential Organ Failure Assessment score (median (25–75th percentiles)) at admission was 7.5 (5.75–8.5), and the activities of daily living (ADLs) were bedridden, the lowest in the Functional Independence Measure (FIM) and Barthel Index (BI) surveys. Data on the mean time to extubation, ICU length of stay, and ADLs improvement (FIM and BI) during ICU admission were obtained. Inferential analyses were not performed considering the small sample size. The mean time to extubation was 4.9 ± 1.1 days, and the ICU length of stay was 11.8 ± 5.0 days. ΔFIM was 36.5 (28.0–40.5), and the ΔBI was 22.5 (3.75–40.0). Moreover, no serious adverse events occurred in the patients during rehabilitation. Early mobilization of patients with COVID-19 may be useful in ADLs improvement during ICU stay. Full article

(This article belongs to the Special Issue COVID-19 in the Intensive Care Unit)

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