scholarly journals Timing of elective tracheotomy and duration of mechanical ventilation amongst patients admitted to intensive care with severe COVID-19: a multicentre prospective cohort study

2021 ◽  
Author(s):  
Albert Prats-Uribe ◽  
Marc Tobed ◽  
José Miguel Villacampa ◽  
Adriana Agüero ◽  
Clara García-Bastida ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cohort Study ◽  
Intensive Care ◽  
Postoperative Complications ◽  
Critically Ill ◽  
Prospective Cohort ◽  
Invasive Mechanical Ventilation ◽  
Optimal Timing ◽  
Early Tracheotomy

AbstractBackgroundThe COVID-19 pandemic has strained intensive care unit (ICU) resources. Tracheotomy is the most frequent surgery performed on ICU patients and can affect the duration of ICU care. We studied the association between when tracheotomy occurs and weaning from mechanical ventilation, mortality, and intraoperative and postoperative complications.MethodsMulticentre prospective cohort including all COVID-19 patients admitted to ICUs in 36 hospitals in Spain who received invasive mechanical ventilation and tracheotomy between 11 March and 20 July 2020. We used a target emulation trial framework to study the causal effects of early (7 to 10 days post-intubation) versus late (>10 days) tracheotomy on time from tracheotomy to weaning, postoperative mortality, and tracheotomy complications. Cause-specific Cox models were used for the first two outcomes and Poisson regression for the third, all adjusted for potential confounders.FindingsWe included 696 patients, of whom 142 (20·4%) received early tracheotomy. Using late tracheotomy as the reference group, multivariable cause-specific analysis showed that early tracheotomy was associated with faster post-tracheotomy weaning (fully adjusted hazard ratio (HR) [95% confidence interval (CI)]: 1·31 [1·02 to 1·81]) without differences in mortality (fully adjusted HR [95% CI]: 0·91 [0·56 to 1·47]) or intraoperative or postoperative complications (adjusted rate ratio [95% CI]: 0·21 [0·03 to 1·57] and 1·49 [0·99 to 2·24], respectively).InterpretationEarly tracheotomy reduced post-tracheotomy weaning time, resulting in fewer mechanical ventilation days and shorter ICU stays, without changing complication or mortality rates. These results support early tracheotomy for COVID-19 patients when clinically indicated.FundingSupported by the NIHR, FAME, and MRC.Research in contextEvidence before this studyThe optimal timing of tracheotomy for critically ill COVID-19 patients remains controversial. Existing guidelines and recommendations are based on limited experiences with SARS-CoV-1 and expert opinions derived from situations that differ from a pandemic outbreak. Most of the available guidance recommends late tracheotomy (>14 days), mainly due to the potential risk of infection for the surgical team and the high patient mortality rate observed early in the first wave of the COVID-19 pandemic.Recent publications have shown that surgical teams can safely perform tracheotomies for COVID-19 patients if they use adequate personal protective equipment. Early tracheotomy seems to reduce the length of invasive mechanical ventilation without increasing complications, which may release crucial intensive care unit (ICU) beds sooner.The current recommendations do not suggest an optimal time for tracheotomy for COVID-19 patients, and no study has provided conclusions based on objective clinical parameters.Added value of this studyThis is the first study aiming to establish the optimal timing for tracheotomy for critically ill COVID-19 patients requiring invasive mechanical ventilation (IMV). The study prospectively recruited a large multicentre cohort of 696 patients under IMV due to COVID-19 and collected data about the severity of respiratory failure, clinical and ventilatory parameters, and whether patients need to be laid flat during their ICU stay (proned). The analysis focused on the duration of IMV, mortality, and complication rates. We used a prospective cohort study design to compare the ‘exposures’ of early (performed at day 7 to 10 after starting IMV) versus late (performed after day 10) tracheotomy and set the treatment decision time on the 7th day after orotracheal intubation.Implications of all the available evidenceThe evidence suggests that tracheotomy within 10 days of starting COVID-19 patients on mechanical ventilation allows these patients to be removed from ventilation and discharged from ICU quicker than later tracheotomy, without added complications or increased mortality. This evidence may help to release ventilators and ICU beds more quickly during the pandemic.

scholarly journals Prediction of prolonged mechanical ventilation for intensive care unit patients: A cohort study

2013 ◽  
pp. 184-188 ◽  
Author(s):  
Alvaro Sanabria ◽  
Ximena Gomez ◽  
Valentin Vega ◽  
Luis Carlos Dominguez ◽  
Camilo Osorio
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cohort Study ◽  
Intensive Care ◽  
Critically Ill ◽  
Medical Condition ◽  
Prolonged Mechanical Ventilation ◽  
Invasive Mechanical Ventilation ◽  
Adult Patients ◽  
Saps Ii Score

Introduction: There are no established guidelines for selecting patients for early tracheostomy. The aim was to determine the factors that could predict the possibility of intubation longer than 7 days in critically ill adult patients. Methods: This is cohort study made at a general intensive care unit. Patients who required at least 48 hours of mechanical ventilation were included. Data on the clinical and physiologic features were collected for every intubated patient on the third day. Uni- and multivariate statistical analyses were conducted to determine the variables associated with extubation. Results: 163 (62%) were male, and the median age was 59±17 years. Almost one-third (36%) of patients required mechanical ventilation longer than 7 days. The variables strongly associated with prolonged mechanical ventilation were: age (HR 0.97 (95% CI 0.96-0.99); diagnosis of surgical emergency in a patient with a medical condition (HR 3.68 (95% CI 1.62-8.35), diagnosis of surgical condition-non emergency (HR 8.17 (95% CI 2.12-31.3); diagnosis of non-surgical-medical condition (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) and SAPS II score (HR 1.04 (95% CI 1.00-1.09) The area under ROC curve used for prediction was 0.52. 16% of patients were extubated after day 8 of intubation. Conclusions: It was not possible to predict early extubation in critically ill adult patients with invasive mechanical ventilation with common clinical scales used at the ICU. However, the probability of successfully weaning patients from mechanical ventilation without a tracheostomy is low after the eighth day of intubation.

scholarly journals Obesity May Not Be Associated with 28-Day Mortality, Duration of Invasive Mechanical Ventilation and Length of Intensive Care Unit and Hospital Stay in Critically Ill Patients with Severe Acute Respiratory Syndrome Coronavirus-2: A Retrospective Cohort Study

Medicina ◽  
2021 ◽  
Vol 57 (7) ◽  
pp. 674
Author(s):  
Sjaak Pouwels ◽  
Dharmanand Ramnarain ◽  
Emily Aupers ◽  
Laura Rutjes-Weurding ◽  
Jos van Oers
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cohort Study ◽  
Intensive Care ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Invasive Mechanical Ventilation ◽  
Significant Difference

Background and Objectives: The aim of this study was to investigate the association between obesity and 28-day mortality, duration of invasive mechanical ventilation and length of stay at the Intensive Care Unit (ICU) and hospital in patients admitted to the ICU for SARS-CoV-2 pneumonia. Materials and Methods: This was a retrospective observational cohort study in patients admitted to the ICU for SARS-CoV-2 pneumonia, in a single Dutch center. The association between obesity (body mass index > 30 kg/m2) and 28-day mortality, duration of invasive mechanical ventilation and length of ICU and hospital stay was investigated. Results: In 121 critically ill patients, pneumonia due to SARS-CoV-2 was confirmed by RT-PCR. Forty-eight patients had obesity (33.5%). The 28-day all-cause mortality was 28.1%. Patients with obesity had no significant difference in 28-day survival in Kaplan–Meier curves (log rank p 0.545) compared with patients without obesity. Obesity made no significant contribution in a multivariate Cox regression model for prediction of 28-day mortality (p = 0.124), but age and the Sequential Organ Failure Assessment (SOFA) score were significant independent factors (p < 0.001 and 0.002, respectively). No statistically significant correlation was observed between obesity and duration of invasive mechanical ventilation and length of ICU and hospital stay. Conclusion: One-third of the patients admitted to the ICU for SARS-CoV-2 pneumonia had obesity. The present study showed no relationship between obesity and 28-day mortality, duration of invasive mechanical ventilation, ICU and hospital length of stay. Further studies are needed to substantiate these findings.

scholarly journals Association between Malnutrition and Hospital Mortality and Duration of Intensive Care Unit Admission in the Critically Ill: A Prospective Cohort Study

2017 ◽  
Author(s):  
Charles Chin Han Lew ◽  
Gabriel Jun Yung Wong ◽  
Ka Po Cheung ◽  
Ai Ping Chua ◽  
Mary Foong Fong Chong ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cohort Study ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Prospective Cohort Study ◽  
Critically Ill Patients ◽  
Prospective Cohort ◽  
Unit Length ◽  
Increased Risk

There is limited evidence for the association between malnutrition and hospital mortality as well as Intensive Care Unit length-of-stay (ICU-LOS) in critically ill patients. We aimed to examine the aforementioned associations by conducting a prospective cohort study in an ICU of a Singapore tertiary hospital. Between August 2015 and October 2016, all adult patients with &ge;24 h of ICU-LOS were included. The 7-point Subjective Global Assessment (7-point SGA) was used to determine patients&rsquo; nutritional status within 48 hours of ICU admission. Multivariate analyses were conducted in two ways: 1) presence versus absence of malnutrition, and 2) dose-dependent association for each 1-point decrease in the 7-point SGA. There were 439 patients of which 28.0% were malnourished, and 29.6% died before hospital discharge. Malnutrition was associated with an increased risk of hospital mortality [adjusted-RR 1.39 (95%CI: 1.10&ndash;1.76)], and this risk increased with a greater degree of malnutrition [adjusted-RR 1.09 (95%CI: 1.01&ndash;1.18) for each 1-point decrease in the 7-point SGA]. No significant association was found between malnutrition and ICU-LOS. Conclusion: There was a clear association between malnutrition and higher hospital mortality in critically ill patients. The association between malnutrition and ICU-LOS could not be replicated and hence requires further evaluation.

scholarly journals Vitamin D levels and intensive care unit outcomes of a cohort of critically ill COVID-19 patients

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Laurence Orchard ◽  
Matthew Baldry ◽  
Myra Nasim-Mohi ◽  
Chantelle Monck ◽  
Kordo Saeed ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Vitamin D ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Clinical Outcomes ◽  
Critically Ill ◽  
Large Scale ◽  
Invasive Mechanical Ventilation ◽  
Plasma Vitamin ◽  
Vitamin D Levels

Abstract Objectives The pattern of global COVID-19 has caused many to propose a possible link between susceptibility, severity and vitamin-D levels. Vitamin-D has known immune modulatory effects and deficiency has been linked to increased severity of viral infections. Methods We evaluated patients admitted with confirmed SARS-COV-2 to our hospital between March-June 2020. Demographics and outcomes were assessed for those admitted to the intensive care unit (ICU) with normal (>50 nmol/L) and low (<50 nmol/L) vitamin-D. Results There were 646 SARS-COV-2 PCR positive hospitalisations and 165 (25.5%) had plasma vitamin-D levels. Fifty patients were admitted to ICU. There was no difference in vitamin-D levels of those hospitalised (34, IQR 18.5–66 nmol/L) and those admitted to the ICU (31.5, IQR 21–42 nmol/L). Higher proportion of vitamin-D deficiency (<50 nmol/L) noted in the ICU group (82.0 vs. 65.2%). Among the ICU patients, low vitamin D level (<50 nmol/L) was associated with younger age (57 vs. 67 years, p=0.04) and lower Cycle Threshold (CT) real time polymerase chain reaction values (RT-PCR) (26.96 vs. 33.6, p=0.02) analogous to higher viral loads. However, there were no significant differences in ICU clinical outcomes (invasive and non-invasive mechanical ventilation, acute kidney injury and mechanical ventilation and hospital days) between patients with low and normal vitamin-D levels. Conclusions Despite the association of low vitamin-D levels with low CT values, there is no difference in clinical outcomes in this small cohort of critically ill COVID-19 patients. The complex relationship between vitamin-D levels and COVID-19 infection needs further exploration with large scale randomized controlled trials.

scholarly journals Clinical Characteristics and Outcome of Critically Ill SARS-CoV-2 Patients Admitted to Intensive Care Unit of a Tertiary Care Hospital in North India: A Retrospective Study

2021 ◽  
Author(s):  
Reetu Verma ◽  
Rajeev Kumar Nishad ◽  
Rohit Patawa ◽  
Alok Kumar
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Retrospective Study ◽  
Critically Ill ◽  
Clinical Characteristics ◽  
Invasive Mechanical Ventilation ◽  
Age Groups ◽  
World Health ◽  
Comorbid Conditions

Introduction: World Health Organisation (WHO) declared the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outbreak a pandemic on 11 March 2020, due to the constantly increasing number of cases outside China. Previously, India had global record of highest single day spike of Corona Virus Disease-19 (COVID-19) cases, with 97,894 cases on 17thSeptember 2020. Aim: To find out the demographic and clinical characteristics of critically ill patients of SARS-CoV-2 and comparing the outcomes of patients admitted in COVID dedicated Intensive Care Unit (ICU) with and without co-morbidities and also in different age groups and sex. Material and Methods: This retrospective study from July 2020 to December 2020 was a single centre observational experience of management of COVID-19 patients at COVID dedicated ICU in Firozabad, India. The following data were recorded: age, sex, comorbidities and mode of oxygen delivery (invasive mechanical ventilation, non-invasive mechanical ventilation, high flow nasal canula). Chi-square test was used to compare the outcomes of patients admitted in COVID dedicated ICU with and without co-morbidities and also in different age groups and sex. Results: In this study, the data of 120 severely ill COVID-19 patients were reviewed. The mean age of patients were (58±15.29) years and male to female ratio was 3:1. At least one comorbid condition was reported in 53.3% of patients-most common being Hypertension (36.6%) followed by Diabetes mellitus 2 (20%), COPD (15%). Then Cardiovascular Diseases, Renal, Liver diseases and ailments followed. All patients admitted to COVID ICU had moderate to severe Acute Respiratory Distress Syndrome (ARDS). Older age (61 years and above, mortality 17%), male sex (16.7% deaths among 90 critically ill male COVID patients) and presence of comorbid conditions appear to have higher mortality in this study. However apart from comorbid conditions (p=0.001) none was statistically significant. The overall mortality in this study of 120 critically ill COVID patients was 14.16%. Conclusion: From this study, it can be suggested that survival of critically ill COVID patients can further be improved by better management of their comorbid conditions and avoiding complications of invasive ventilation. However, further multicentric studies with large sample size are needed to confirm these findings.

scholarly journals Corticosteroid Administration and Impaired Glycemic Control in Mechanically Ventilated COVID-19 Patients

2021 ◽  
pp. 108925322110433
Author(s):  
David J. Douin ◽  
Martin Krause ◽  
Cynthia Williams ◽  
Kenji Tanabe ◽  
Ana Fernandez-Bustamante ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cohort Study ◽  
Intensive Care ◽  
Glycemic Control ◽  
Extracorporeal Membrane Oxygenation ◽  
Invasive Mechanical Ventilation ◽  
Corticosteroid Administration ◽  
Mechanically Ventilated ◽  
Membrane Oxygenation

Objective Recent clinical trials confirmed the corticosteroid dexamethasone as an effective treatment for patients with COVID-19 requiring mechanical ventilation. However, limited attention has been given to potential adverse effects of corticosteroid therapy. The objective of this study was to determine the association between corticosteroid administration and impaired glycemic control among COVID-19 patients requiring mechanical ventilation and/or veno-venous extracorporeal membrane oxygenation. Design Multicenter retrospective cohort study between March 9 and May 17, 2020. The primary outcome was days spent with at least 1 episode of blood glucose either >180 mg/dL or <80 mg/dL within the first 28 days of admission. Setting Twelve hospitals in a United States health system. Patients Adults diagnosed with COVID-19 requiring invasive mechanical ventilation and/or veno-venous extracorporeal membrane oxygenation. Interventions None. Measurements and Main Results We included 292 mechanically ventilated patients. We fitted a quantile regression model to assess the association between steroid administration ≥320 mg methylprednisolone (equivalent to 60 mg dexamethasone) and impaired glycemic control. Sixty-six patients (22.6%) died within 28 days of intensive care unit admission. Seventy-one patients (24.3%) received a cumulative dose of least 320 mg methylprednisolone equivalents. After adjustment for gender, history of diabetes mellitus, chronic liver disease, sequential organ failure assessment score on intensive care unit day 1, and length of stay, administration of ≥320 mg methylprednisolone equivalent was associated with 4 additional days spent with glucose either <80 mg/dL or >180 mg/dL (B = 4.00, 95% CI = 2.15-5.85, P < .001). Conclusions In this cohort study of 292 mechanically ventilated COVID-19 patients, we found an association between corticosteroid administration and higher incidence of both hyperglycemia and hypoglycemia.

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