Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with covid-19 admitted to hospital: RAPID randomised clinical trial

Abstract Objective To evaluate the effects of therapeutic heparin compared with prophylactic heparin among moderately ill patients with covid-19 admitted to hospital wards. Design Randomised controlled, adaptive, open label clinical trial. Setting 28 hospitals in Brazil, Canada, Ireland, Saudi Arabia, United Arab Emirates, and US. Participants 465 adults admitted to hospital wards with covid-19 and increased D-dimer levels were recruited between 29 May 2020 and 12 April 2021 and were randomly assigned to therapeutic dose heparin (n=228) or prophylactic dose heparin (n=237). Interventions Therapeutic dose or prophylactic dose heparin (low molecular weight or unfractionated heparin), to be continued until hospital discharge, day 28, or death. Main outcome measures The primary outcome was a composite of death, invasive mechanical ventilation, non-invasive mechanical ventilation, or admission to an intensive care unit, assessed up to 28 days. The secondary outcomes included all cause death, the composite of all cause death or any mechanical ventilation, and venous thromboembolism. Safety outcomes included major bleeding. Outcomes were blindly adjudicated. Results The mean age of participants was 60 years; 264 (56.8%) were men and the mean body mass index was 30.3 kg/m 2 . At 28 days, the primary composite outcome had occurred in 37/228 patients (16.2%) assigned to therapeutic heparin and 52/237 (21.9%) assigned to prophylactic heparin (odds ratio 0.69, 95% confidence interval 0.43 to 1.10; P=0.12). Deaths occurred in four patients (1.8%) assigned to therapeutic heparin and 18 patients (7.6%) assigned to prophylactic heparin (0.22, 0.07 to 0.65; P=0.006). The composite of all cause death or any mechanical ventilation occurred in 23 patients (10.1%) assigned to therapeutic heparin and 38 (16.0%) assigned to prophylactic heparin (0.59, 0.34 to 1.02; P=0.06). Venous thromboembolism occurred in two patients (0.9%) assigned to therapeutic heparin and six (2.5%) assigned to prophylactic heparin (0.34, 0.07 to 1.71; P=0.19). Major bleeding occurred in two patients (0.9%) assigned to therapeutic heparin and four (1.7%) assigned to prophylactic heparin (0.52, 0.09 to 2.85; P=0.69). Conclusions In moderately ill patients with covid-19 and increased D-dimer levels admitted to hospital wards, therapeutic heparin was not significantly associated with a reduction in the primary outcome but the odds of death at 28 days was decreased. The risk of major bleeding appeared low in this trial. Trial registration ClinicalTrials.gov NCT04362085 .

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Heparin for Moderately Ill Patients with Covid-19

10.1101/2021.07.08.21259351 ◽

2021 ◽

Author(s):

Michelle Sholzberg ◽

Grace H. Tang ◽

Hassan Rahhal ◽

Musaad AlHamzah ◽

Lisa Baumann Kreuziger ◽

...

Keyword(s):

Mechanical Ventilation ◽

Major Bleeding ◽

Odds Ratio ◽

Primary Outcome ◽

Invasive Mechanical Ventilation ◽

Heparin Group ◽

Intention To Treat ◽

Non Invasive ◽

Primary Composite Outcome ◽

D Dimer

Background Heparin, in addition to its anticoagulant properties, has anti-inflammatory and potential anti-viral effects, and may improve endothelial function in patients with Covid-19. Early initiation of therapeutic heparin could decrease the thrombo-inflammatory process, and reduce the risk of critical illness or death. Methods We randomly assigned moderately ill hospitalized ward patients admitted for Covid-19 with elevated D-dimer level to therapeutic or prophylactic heparin. The primary outcome was a composite of death, invasive mechanical ventilation, non-invasive mechanical ventilation or ICU admission. Safety outcomes included major bleeding. Analysis was by intention-to-treat. Results At 28 days, the primary composite outcome occurred in 37 of 228 patients (16.2%) assigned to therapeutic heparin, and 52 of 237 patients (21.9%) assigned to prophylactic heparin (odds ratio, 0.69; 95% confidence interval [CI], 0.43 to 1.10; p=0.12). Four patients (1.8%) assigned to therapeutic heparin died compared with 18 patients (7.6%) assigned to prophylactic heparin (odds ratio, 0.22; 95%-CI, 0.07 to 0.65). The composite of all-cause mortality or any mechanical ventilation occurred in 23 (10.1%) in the therapeutic heparin group and 38 (16.0%) in the prophylactic heparin group (odds ratio, 0.59; 95%-CI, 0.34 to 1.02). Major bleeding occurred in 2 patients (0.9%) with therapeutic heparin and 4 patients (1.7%) with prophylactic heparin (odds ratio, 0.52; 95%-CI, 0.09 to 2.85). Conclusions In moderately ill ward patients with Covid-19 and elevated D-dimer level, therapeutic heparin did not significantly reduce the primary outcome but decreased the odds of death at 28 days.

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Nasal High-Frequency Oscillatory Ventilation in Preterm Infants with Moderate Respiratory Distress Syndrome: A Multicenter Randomized Clinical Trial

Neonatology ◽

10.1159/000515226 ◽

2021 ◽

pp. 1-7

Author(s):

Xingwang Zhu ◽

Zhichun Feng ◽

Chengjun Liu ◽

Liping Shi ◽

Yuan Shi ◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Distress Syndrome ◽

Preterm Infants ◽

High Frequency ◽

Primary Outcome ◽

Distress Syndrome ◽

Invasive Mechanical Ventilation ◽

Risk Difference ◽

High Frequency Oscillatory Ventilation ◽

High Frequency Oscillatory

Objective: To determine whether nasal high-frequency oscillatory ventilation (NHFOV) as a primary mode of respiratory support as compared with nasal continuous airway pressure (NCPAP) will reduce the need for invasive mechanical ventilation in preterm infants (260/7–336/7 weeks of gestational age [GA]) with respiratory distress syndrome (RDS). Methods: This multicenter randomized controlled trial was conducted in 18 tertiary neonatal intensive care units in China. A total of 302 preterm infants born at a GA of 260/7–336/7 weeks with a diagnosis of RDS were randomly assigned to either the NCPAP (n = 150) or the NHFOV (n = 152) group. The primary outcome was the need for invasive mechanical ventilation during the first 7 days after birth. Results: Treatment failure occurred in 15 of 152 infants (9.9%) in the NHFOV group and in 26 of 150 infants (17.3%) in the NCPAP group (95% CI of risk difference: −15.2 to 0.4, p = 0.06). In the subgroup analysis, NHFOV resulted in a significantly lower rate of treatment failure than did NCPAP in the strata of 26+0/7–29+6/7weeks of GA (11.9 vs. 32.4%, 95% CI of risk difference: −39.3 to −1.7, p = 0.03) and birth weight <1,500 g (10.4 vs. 29.6%, 95% CI of risk difference: −33.8 to −4.6, p = 0.01). The rate of thick secretions causing an airway obstruction was higher in the NHFOV group than in the NCPAP group (13.8 vs. 5.3%, 95% CI of risk difference: 1.9–15.1, p = 0.01). No significant differences in other secondary outcomes were found between the NHFOV and NCPAP groups. Conclusions: NHFOV was not superior to NCPAP with regard to the primary outcome when applied as the primary respiratory support for RDS in infants between 26+0/7 and 33+6/7 weeks of GA. In the subgroup analysis, NHFOV seemed to improve effectiveness than NCPAP in preterm infants <30 weeks of GA.

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Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

Biomarker Research ◽

10.1186/s40364-021-00283-y ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Bo Yu ◽

Victor Perez Gutierrez ◽

Alex Carlos ◽

Gregory Hoge ◽

Anjana Pillai ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Propensity Score Matching ◽

Major Bleeding ◽

Risk Estimation ◽

Large Population ◽

Invasive Mechanical Ventilation ◽

Bleeding Risk ◽

Hospitalized Patients ◽

Significant Difference

Abstract Background Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016). Conclusion Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

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Early versus deferred anti-SARS-CoV-2 convalescent plasma in patients admitted for COVID-19: A randomized phase II clinical trial

PLoS Medicine ◽

10.1371/journal.pmed.1003415 ◽

2021 ◽

Vol 18 (3) ◽

pp. e1003415

Author(s):

María Elvira Balcells ◽

Luis Rojas ◽

Nicole Le Corre ◽

Constanza Martínez-Valdebenito ◽

María Elena Ceballos ◽

...

Keyword(s):

Clinical Trial ◽

Mechanical Ventilation ◽

Clearance Rate ◽

Neutralizing Antibodies ◽

Statistical Power ◽

Primary Outcome ◽

Medical Center ◽

Academic Medical Center ◽

Group Versus ◽

Hospital Length Of Stay

Background Convalescent plasma (CP), despite limited evidence on its efficacy, is being widely used as a compassionate therapy for hospitalized patients with COVID-19. We aimed to evaluate the efficacy and safety of early CP therapy in COVID-19 progression. Methods and findings The study was an open-label, single-center randomized clinical trial performed in an academic medical center in Santiago, Chile, from May 10, 2020, to July 18, 2020, with final follow-up until August 17, 2020. The trial included patients hospitalized within the first 7 days of COVID-19 symptom onset, presenting risk factors for illness progression and not on mechanical ventilation. The intervention consisted of immediate CP (early plasma group) versus no CP unless developing prespecified criteria of deterioration (deferred plasma group). Additional standard treatment was allowed in both arms. The primary outcome was a composite of mechanical ventilation, hospitalization for >14 days, or death. The key secondary outcomes included time to respiratory failure, days of mechanical ventilation, hospital length of stay, mortality at 30 days, and SARS-CoV-2 real-time PCR clearance rate. Of 58 randomized patients (mean age, 65.8 years; 50% male), 57 (98.3%) completed the trial. A total of 13 (43.3%) participants from the deferred group received plasma based on clinical aggravation. We failed to find benefit in the primary outcome (32.1% versus 33.3%, odds ratio [OR] 0.95, 95% CI 0.32–2.84, p > 0.999) in the early versus deferred CP group. The in-hospital mortality rate was 17.9% versus 6.7% (OR 3.04, 95% CI 0.54–17.17 p = 0.246), mechanical ventilation 17.9% versus 6.7% (OR 3.04, 95% CI 0.54–17.17, p = 0.246), and prolonged hospitalization 21.4% versus 30.0% (OR 0.64, 95% CI, 0.19–2.10, p = 0.554) in the early versus deferred CP group, respectively. The viral clearance rate on day 3 (26% versus 8%, p = 0.204) and day 7 (38% versus 19%, p = 0.374) did not differ between groups. Two patients experienced serious adverse events within 6 hours after plasma transfusion. The main limitation of this study is the lack of statistical power to detect a smaller but clinically relevant therapeutic effect of CP, as well as not having confirmed neutralizing antibodies in donor before plasma infusion. Conclusions In the present study, we failed to find evidence of benefit in mortality, length of hospitalization, or mechanical ventilation requirement by immediate addition of CP therapy in the early stages of COVID-19 compared to its use only in case of patient deterioration. Trial registration NCT04375098.

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Early Use of Sarilumab in Patients Hospitalised with COVID-19 Pneumonia and Features of Systemic Inflammation.

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.02107-21 ◽

2021 ◽

Author(s):

Nicolás Merchante ◽

Sheila Cárcel ◽

José Carlos Garrido-Gracia ◽

Marta Trigo-Rodríguez ◽

María Ángeles Esteban Moreno ◽

...

Keyword(s):

Mechanical Ventilation ◽

Systemic Inflammation ◽

Primary Outcome ◽

Invasive Mechanical Ventilation ◽

Control Group ◽

Controlled Clinical Trial ◽

Open Label ◽

Randomized Controlled ◽

Subcutaneous Dose ◽

Early Use

In this phase II, open-label, randomized, controlled clinical trial of 115 patients hospitalized with COVID-19 and systemic inflammation, early use of sarilumab was associated with a low risk of acute respiratory distress syndrome requiring high-flow devices or mechanical ventilation. Objective: To investigate the efficacy and safety of early treatment with sarilumab, added to standard of care (SOC), in hospitalised adults with COVID-19. Methods: Phase II, open-label, randomized, controlled clinical trial of hospitalised patients with COVID-19 pneumonia and interleukin (IL)-6 levels ≥ 40 pg/mL and/or D-dimer > 1500 ng/mL. Participants were randomized (1:1:1) to receive SOC (control group), SOC plus a single subcutaneous dose of sarilumab 200 mg (Sarilumab-200) or SOC plus a single subcutaneous dose of sarilumab 400 mg (Sarilumab-400). The primary outcome variable was the development of acute respiratory distress syndrome (ARDS) requiring high-flow nasal oxygenation (HFNO), non-invasive mechanical ventilation (NIMV) or invasive mechanical ventilation (IMV) at day 28. Results: One-hundred and fifteen participants (control group, n = 39; Sarilumab-200, n = 37; Sarilumab-400, n = 39) were included. At randomization, 104 (90%) patients had supplemental oxygen and 103 (90%) received corticosteroids. Eleven (28%) patients in the control group, ten (27%) in Sarilumab-200 and five (13%) in Sarilumab-400 developed the primary outcome (hazard ratio [95% CI] of Sarilumab-400 vs control group: 0.41 [0.14-1.18]; p=0.09). Seven (6%) patients died: three in the control group and four in Sarilumab-200. There were no deaths in Sarilumab-400 (p = 0.079, log-rank test for comparisons with the control group). Conclusion: In patients recently hospitalised with COVID-19 pneumonia and features of systemic inflammation, early IL-6 blockade with a single dose of sarilumab 400 mg was safe and associated with a trend for better outcomes.

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Abstract 17292: Does Morbid Obesity Worsens Outcomes in COVID-19?

Circulation ◽

10.1161/circ.142.suppl_3.17292 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sohaib Roomi ◽

Waqas Ullah ◽

Nayab Nadeem ◽

Rehan Saeed ◽

Donald Haas ◽

...

Keyword(s):

Morbid Obesity ◽

Mechanical Ventilation ◽

Hospital Mortality ◽

Invasive Mechanical Ventilation ◽

Multivariate Logistic Regression Analysis ◽

Odds Ratios ◽

Increased Risk ◽

Significant Difference ◽

The Mean ◽

Mean Differences

Introduction: Given the high prevalence of obesity around the globe, patients with coronavirus disease 2019 (COVID-19) are at an increased risk of devastating complications. Hypothesis: We hypothesize that morbid obesity is independently associated with increased risk of in-hospital mortality, upgrade to intensive care unit, invasive mechanical ventilation(IVM), and acute renal failure necessitating dialysis. Methods: A retrospective cohort study was performed to determine the association of basal metabolic index (BMI) with the above-mentioned outcomes. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI), respectively. Results: A total of 176 patients with confirmed COVID-19 diagnosis were included. The mean age was 62.2 years, with 51% of male patients. The mean BMI for non-surviving patients was significantly higher compared to patients surviving on the 7th day of hospitalization (35 vs. 30 kg/m2, p=0.022) and patients with a higher BMI had higher in-hospital mortality (21% vs. 9%, OR 3.2, 95% CI 1.3-8.2, p=0.01) compared to patients with a normal BMI. Similarly, patients requiring IMV had a higher BMI (33 vs. 29, p=0.002) compared to non-intubated patients. aOR of patients needing IMV (56% vs. 28%, OR 3.3, 95% CI 1.6-7.0, p=0.002) and upgrade to ICU (46% vs. 28%, OR 2.2, 1.07-4.6, p=0.04) were significantly higher compared to patients with a lower BMI. There was no significant difference between the two groups in terms of the need for dialysis (5% vs. 13%, OR 3.8, 13% vs. 4%, 1.1-14.1, p=0.07). Adjusted odds ratios controlled for baseline comorbidities and medications mirrored the overall results, except for the need to upgrade to ICU. Conclusions: In patients with confirmed COVID-19, morbid obesity serves as an independent risk factor of high in-hospital mortality and the need for invasive mechanical ventilation.

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Síndrome de Dificuldade Respiratória Aguda: Casuística de Dois Anos numa Unidade de Cuidados Intensivos

Acta Médica Portuguesa ◽

10.20344/amp.4266 ◽

2014 ◽

Vol 27 (2) ◽

pp. 211 ◽

Cited By ~ 1

Author(s):

Lúcia Taborda ◽

Filipa Barros ◽

Vitor Fonseca ◽

Manuel Irimia ◽

Ramiro Carvalho ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Intensive Care ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Invasive Mechanical Ventilation ◽

Interquartile Range ◽

The Mean

Introduction: Acute Respiratory Distress Syndrome has a significant incidence and mortality at Intensive Care Units. Therefore, more studies are necessary in order to develop new effective therapeutic strategies. The authors have proposed themselves to characterize Acute Respiratory Distress Syndrome patients admitted to an Intensive Care Unit for 2 years. Material and Methods: This was an observational retrospective study of the patients filling the Acute Respiratory Distress Syndrome criteria from the American-European Consensus Conference on ARDS, being excluded those non invasively ventilated. Demographic data, Acute Respiratory Distress Syndrome etiology, comorbidities, Gravity Indices, PaO2/FiO2, ventilator modalities and programmation, pulmonary compliance, days of invasive mechanical ventilation, corticosteroids use, rescue therapies, complications, days at Intensive Care Unit and obits were searched for and were submitted to statistic description and analysis. Results: A 40 patients sample was obtained, with a median age of 72.5 years (interquartile range = 22) and a female:male ratio of ≈1:1.86. Fifty five percent of the Acute Respiratory Distress Syndrome cases had pulmonary etiology. The mean minimal PaO2/FiO2 was 88mmHg (CI 95%: 78.5–97.6). The mean maximal applied PEEP was 12.4 cmH2O (Standard Deviation 4.12) and the mean maximal used tidal volume was 8.2 mL/ Kg ideal body weight (CI 95%: 7.7–8.6). The median invasive mechanical ventilation days was 10. Forty seven and one half percent of the patients had been administered corticosteroids and 52.5% had been submitted to recruitment maneuvers. The most frequent complication was Ventilator Associated Pneumonia (20%). The median Intensive Care Unit stay was 10.7 days (interquartile range 10.85). The fatality rate was 60%. The probability of the favorable outcome ‘non-death in Intensive Care Unit’ was 4.4x superior for patients who were administered corticosteroids and 11x superior for patients < 65 years old. Discussion and Conclusions: Acute Respiratory Distress Syndrome is associated with long hospitalization and significant mortality. New prospective studies will be necessary to endorse the potential benefit of steroid therapy and to identify the subgroups of patients that warrant its use.

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Effect of prophylactic non-invasive mechanical ventilation on functional capacity after heart valve replacement: a clinical trial

Clinics ◽

10.6061/clinics/2017(10)05 ◽

2017 ◽

Vol 72 (10) ◽

pp. 618-623 ◽

Cited By ~ 5

Author(s):

AA Araújo-Filho ◽

ML Cerqueira-Neto ◽

LA Cacau ◽

GU Oliveira ◽

TC Cerqueira ◽

...

Keyword(s):

Clinical Trial ◽

Mechanical Ventilation ◽

Valve Replacement ◽

Heart Valve ◽

Functional Capacity ◽

Invasive Mechanical Ventilation ◽

Heart Valve Replacement ◽

Non Invasive

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Effects of Methylprednisolone on Ventilator-Free Days in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome and COVID-19

10.20944/preprints202101.0177.v1 ◽

2021 ◽

Author(s):

Mohamed Badr ◽

Bruno De Oliveira ◽

Khaled Abdallah ◽

Ashraf Nadeem ◽

Yeldho Varghese ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Length Of Stay ◽

Competing Risks ◽

Primary Outcome ◽

Distress Syndrome ◽

Invasive Mechanical Ventilation ◽

Hospital Length ◽

Blood Cultures ◽

Hospital Length Of Stay

Objectives: There are limited data regarding the efficacy of methylprednisolone in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) requiring invasive mechanical ventilation. We aimed to determine whether methylprednisolone increases the number of ventilator-free days (VFDs) among these patients. Design: Retrospective single-center study Setting: Intensive care unit Patients: All patients with ARDS due to confirmed SARS-CoV-2 infection and requiring invasive mechanical ventilation between 1 March and 29 May 2020 were included Interventions: None Measurements and Main Results: The primary outcome was ventilator-free days (VFDs) during the first 28 days, defined as being alive and free from mechanical ventilation. The primary outcome was analyzed with competing-risks regression based on Fine and Gray’s proportional subhazards model. Death before day 28 was considered to be the competing event. A total of 77 patients met the inclusion criteria. Thirty-two patients (41.6%) received methylprednisolone. The median dose was 1 mg.kg-1 (IQR: 1-1.3 mg.kg-1) and median duration of 5 days (IQR:5-7 days). Patients who received methylprednisolone had a mean 18.8 VFDs (95% CI, 16.6-20.9) during the first 28 days vs. 14.2 VFDs (95% CI, 12.6-16.7) in patients who did not receive methylprednisolone (difference, 4.61; 95% CI, 1.10-8.12; P = 0.001). In the multivariable competing-risks regression analysis and after adjusting for potential confounders (ventilator settings, prone position, organ failure support, severity of the disease, tocilizumab, and inflammatory markers), methylprednisolone was independently associated with a higher number of VFDs (subhazards ratio: 0.10, 95%CI: 0.02-0.45; p=0.003). Hospital mortality did not differ between the two groups (31.2% vs. 28.9%, p=0.82). Hospital length of stay was significantly shorter in the methylprednisolone group (24 days [IQR:15-41 days] vs. 37 days [IQR:23-52 days], p=0.046). The incidence of positive blood cultures was higher in patients who received methylprednisolone (37.5% vs. 17.8%, p=0.052). However, 91% of patients who received methylprednisolone also received tocilizumab. The number of days with hyperglycemia was similar in the two groups. Conclusions: Methylprednisolone was independently associated with increased VFDs and shortened hospital length of stay. The combination of methylprednisolone and tocilizumab was associated with a higher rate of positive blood cultures. Further trials are needed to evaluate the benefits and safety of methylprednisolone in moderate or severe COVID-19 ARDS.

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Neurally adjusted ventilatory assist as a weaning mode for adults with invasive mechanical ventilation: a systematic review and meta-analysis

Critical Care ◽

10.1186/s13054-021-03644-z ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Xueyan Yuan ◽

Xinxing Lu ◽

Yali Chao ◽

Jennifer Beck ◽

Christer Sinderby ◽

...

Keyword(s):

Mechanical Ventilation ◽

Clinical Practice ◽

Primary Outcome ◽

Meta Analysis ◽

Invasive Mechanical Ventilation ◽

Ventilatory Support ◽

Cochrane Library ◽

Neurally Adjusted Ventilatory Assist ◽

Partial Support ◽

Ventilatory Assist

Abstract Background Prolonged ventilatory support is associated with poor clinical outcomes. Partial support modes, especially pressure support ventilation, are frequently used in clinical practice but are associated with patient–ventilation asynchrony and deliver fixed levels of assist. Neurally adjusted ventilatory assist (NAVA), a mode of partial ventilatory assist that reduces patient–ventilator asynchrony, may be an alternative for weaning. However, the effects of NAVA on weaning outcomes in clinical practice are unclear. Methods We searched PubMed, Embase, Medline, and Cochrane Library from 2007 to December 2020. Randomized controlled trials and crossover trials that compared NAVA and other modes were identified in this study. The primary outcome was weaning success which was defined as the absence of ventilatory support for more than 48 h. Summary estimates of effect using odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with accompanying 95% confidence interval (CI) were expressed. Results Seven studies (n = 693 patients) were included. Regarding the primary outcome, patients weaned with NAVA had a higher success rate compared with other partial support modes (OR = 1.93; 95% CI 1.12 to 3.32; P = 0.02). For the secondary outcomes, NAVA may reduce duration of mechanical ventilation (MD = − 2.63; 95% CI − 4.22 to − 1.03; P = 0.001) and hospital mortality (OR = 0.58; 95% CI 0.40 to 0.84; P = 0.004) and prolongs ventilator-free days (MD = 3.48; 95% CI 0.97 to 6.00; P = 0.007) when compared with other modes. Conclusions Our study suggests that the NAVA mode may improve the rate of weaning success compared with other partial support modes for difficult to wean patients.

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