Clinical characteristics and outcomes of patients with COVID-19 admitted to the intensive care unit during the first and second waves of the pandemic in Brazil: a single-center retrospective cohort study

ABSTRACT Objective To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic. Methods In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic. Results In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves. Conclusion In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.

COVID-19-associated coagulopathy and acute kidney injury in critically ill patients

ABSTRACT Objective The incidence of thrombotic events and acute kidney injury is high in critically ill patients with COVID-19. We aimed to evaluate and compare the coagulation profiles of patients with COVID-19 developing acute kidney injury versus those who did not, during their intensive care unit stay. Methods Conventional coagulation and platelet function tests, fibrinolysis, endogenous inhibitors of coagulation tests, and rotational thromboelastometry were conducted on days 0, 1, 3, 7, and 14 following intensive care unit admission. Results Out of 30 patients included, 13 (43.4%) met the criteria for acute kidney injury. Comparing both groups, patients with acute kidney injury were older: 73 (60-84) versus 54 (47-64) years, p=0.027, and had a lower baseline glomerular filtration rate: 70 (51-81) versus 93 (83-106) mL/min/1.73m2, p=0.004. On day 1, D-dimer and fibrinogen levels were elevated but similar between groups: 1780 (1319-5517) versus 1794 (726-2324) ng/mL, p=0.145 and 608 (550-700) versus 642 (469-722) g/dL, p=0.95, respectively. Rotational thromboelastometry data were also similar between groups. However, antithrombin activity and protein C levels were lower in patients who developed acute kidney injury: 82 (75-92) versus 98 (90-116), p=0.028 and 70 (52-82) versus 88 (78-101) µ/mL, p=0.038, respectively. Mean protein C levels were lower in the group with acute kidney injury across multiple time points during their stay in the intensive care unit. Conclusion Critically ill patients experiencing acute kidney injury exhibited lower endogenous anticoagulant levels. Further studies are needed to understand the role of natural anticoagulants in the pathophysiology of acute kidney injury within this population.

Uso de cetamina em pacientes críticos: uma revisão narrativa / Ketamine use in critically ill patients: a narrative review

RESUMO A cetamina é única entre os anestésicos e analgésicos. A droga é um anestésico geral de ação rápida que produz um estado anestésico caracterizado por analgesia profunda, reflexos faríngeolaríngeos preservados, tônus músculo esquelético normal ou ligeiramente aumentado, estimulação cardiovascular e respiratória e, ocasionalmente, insuficiência respiratória transitória e mínima. Estudos demonstraram a eficácia de seu uso em anestesia, na dor, em cuidados paliativos e em cuidados intensivos. Recentemente, tem sido empregada para dores pós-operatórias e crônicas, como coadjuvante em psicoterapia, como tratamento para depressão e transtorno de estresse pós-traumático, como sedativo para procedimentos cirúrgicos e como tratamento para condições clínicas respiratórias e/ou neurológicas. Apesar de ser um medicamento seguro e amplamente utilizado, muitos médicos, como intensivistas e emergencistas, não estão cientes das aplicações clínicas atuais da cetamina. O objetivo desta revisão bibliográfica narrativa é apresentar aspectos teóricos e práticos das aplicações clínicas da cetamina em ambientes de unidade de terapia intensiva e serviços de emergência.

ABSTRACT Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study / Características clínicas e desfechos de pacientes com COVID-19 admitidos em unidade de terapia intensiva durante o primeiro ano de pandemia no Brasil: um estudo de coorte retrospectivo em centro único

ABSTRACT Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. Conclusion: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

RESUMO Objetivo: Descrever características clínicas, uso de recursos e desfechos e identificar preditores de mortalidade intra-hospitalar de pacientes com COVID-19 admitidos na unidade de terapia intensiva. Métodos: Estudo de coorte retrospectivo, em centro único, realizado em um hospital privado localizado em São Paulo (SP). Pacientes adultos (≥18 anos) admitidos consecutivamente na unidade de terapia intensiva, entre 4 de março de 2020 a 28 de fevereiro de 2021, foram incluídos neste estudo. Os pacientes foram classificados como sobreviventes e não sobreviventes, de acordo com a alta hospitalar. Resultados: Durante o período do estudo, 1.296 pacientes [mediana (intervalo interquartil) de idade: 66 (53-77) anos] com COVID-19 foram admitidos na unidade de terapia intensiva. Destes, 170 (13,6%) pacientes morreram no hospital (não sobreviventes), e 1.078 (86,4%) receberam alta hospitalar (sobreviventes). Comparados aos sobreviventes, os não sobreviventes eram mais idosos [80 (70-88) versus 63 (50-74) anos; p<0,001], apresentavam pontuação mais alta no sistema prognóstico Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53); pontos p<0,001] e tinham mais comorbidades. Durante a internação na unidade de terapia intensiva, 56,6% dos pacientes usaram ventilação não invasiva, 32,9% usaram ventilação mecânica invasiva, 31,3% usaram cateter nasal de alto fluxo, 11,7% foram submetidos à terapia renal substitutiva, e 1,5% usou oxigenação por membrana extracorpórea. Os preditores independentes de mortalidade intra-hospitalar foram idade, Sequential Organ Failure Assessment, Índice de Comorbidade de Charlson, necessidade de ventilação mecânica, uso de cateter nasal de alto fluxo, uso de terapia renal substitutiva e suporte por oxigenação por membrana extracorpórea. Conclusão: Pacientes com quadros graves da COVID-19 admitidos na unidade de terapia intensiva apresentaram considerável mortalidade e morbidade, com alta demanda de terapia de suporte e internação prolongada em unidade de terapia intensiva e hospitalar.

Impact of intensive care unit admission during handover on mortality: propensity matched cohort study / Impacto na mortalidade da admissão de pacientes em unidade de terapia intensiva durante a passagem de plantão: estudo de coorte utilizando escore de propensão

ABSTRACT Objective: To investigate the impact of intensive care unit admission during medical handover on mortality. Methods: Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. Results: A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. Conclusion: Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study.

RESUMO Objetivo: Avaliar o impacto na mortalidade da admissão em unidade de terapia intensiva durante passagem de plantão médico. Métodos: Análise post-hoc de estudo original publicado previamente, com o objetivo de avaliar os impactos da readmissão em unidade de terapia intensiva nos desfechos clínicos. Este estudo de coorte retrospectivo, em centro único, com pareamento por escore de propensão, foi conduzido em uma unidade de terapia intensiva geral, aberta, com 41 leitos. Com base no tempo de internação na unidade de terapia intensiva, os pacientes foram categorizados em duas coortes: Grupo Passagem de Plantão (admissão entre 6h30 e 7h30 ou 18h30 e 19h30) ou Grupo Controle (internação entre 7h31 e 18h29 ou 19h31 e 6h29). Pacientes no Grupo Passagem de Plantão foram pareados com Grupo Controle na proporção de 1:2. Resultados: Entre 1° de junho de 2013 e 31 de maio de 2015, 6.650 pacientes adultos foram admitidos na unidade de terapia intensiva. Após a exclusão de participantes inelegíveis, 5.779 pacientes (389; 6,7% no Grupo de Admissão na Passagem de Plantão e 5.390; 93,3% no Grupo de Controle) foram elegíveis para pareamento por escore de propensão, dos quais 1.166 foram pareados com sucesso (389; 33,4% no Grupo Passagem de Plantão e 777; 66,6% no Grupo Controle). Após pareamento, admissão na unidade de terapia intensiva durante a passagem plantão não foi associada ao aumento da chance de óbito na unidade de terapia intensiva (RC: 1,40; IC95%: 0,92-2,11; p=0,113) ou no hospital (RC: 1,23; IC95%: 0,85-1,75; p=0,265). Conclusão: Internação em unidade de terapia intensiva durante passagem de plantão médico não impactou na mortalidade hospitalar.

Satisfação dos familiares de pacientes críticos admitidos em unidade de terapia intensiva de hospital público e fatores correlacionados / Satisfaction of family members of critically ill patients admitted to a public hospital intensive care unit and correlated factors

RESUMO Objetivo: Analisar a satisfação, a compreensão e os sintomas de ansiedade e depressão em familiares de pacientes admitidos na unidade de terapia intensiva. Métodos: O familiar do paciente com tempo de internação ≥ 72 horas foi convidado a participar do estudo, realizado em um hospital público. Foram respondidos questionários para avaliar a compreensão do diagnóstico, do tratamento e do prognóstico, e o suporte recebido na unidade de terapia intensiva. Também foram avaliadas as necessidades da família por meio da versão modificada do Critical Care Family Needs Inventory (CCFNI) e foi aplicada a Hospital Anxiety and Depression Scale (HADS), para avaliar os sintomas de ansiedade e depressão. Resultados: Foram entrevistados 35 familiares em sua primeira semana de permanência na unidade de terapia intensiva. A maioria dos pacientes (57,1%) era do sexo masculino, com 54 ± 19 anos de idade. A sepse foi o principal motivo da internação na unidade de terapia intensiva (40%); a mediana do Simplified Acute Physiology Score (SAPS) 3 foi de 68 (48 - 77) e 51,4% faleceram na unidade de terapia intensiva. A maioria dos familiares era do sexo feminino (74,3%), filhos ou filhas dos pacientes (54,3%), com idade de 43,2 ± 14 anos. Foi observado que 77,1% dos familiares encontravam-se satisfeitos com a unidade de terapia intensiva. A incompreensão do prognóstico foi observada em 37,1% dos familiares. As informações claras e completas recebidas na unidade de terapia intensiva e o médico ser acessível tiveram correlação significativa com a satisfação geral da família. Foi grande a prevalência dos sintomas de ansiedade (60%) e depressão em (54,3%) nos familiares. Conclusão: O sofrimento emocional dos familiares é grande durante a internação do paciente na unidade de terapia intensiva, embora a satisfação seja alta. As informações claras e completas dadas pelo intensivista e o suporte recebido na unidade de terapia intensiva têm correlação significativa com a satisfação dos familiares em um hospital público.

ABSTRACT Objective: To analyze the satisfaction, medical situation understanding and symptoms of anxiety and depression in family members of patients admitted to the intensive care unit. Methods: The family members of patients who were hospitalized for ≥ 72 hours were invited to participate in the study, which was performed in a public hospital. Questionnaires were answered to assess the understanding of the diagnosis, treatment and prognosis, and the support received in the intensive care unit. The family needs were also evaluated using a modified version of the Critical Care Family Needs Inventory (CCFNI). The Hospital Anxiety and Depression Scale (HADS) was used to assess the symptoms of anxiety and depression. Results: A total of 35 family members were interviewed within the patients' first week of stay in the intensive care unit. Most patients (57.1%) were male, aged 54 ± 19 years. Sepsis was the main reason for admission to the intensive care unit (40%); the median of the Simplified Acute Physiology Score (SAPS) 3 was 68 (48 - 77), and 51.4% of the patients died in the intensive care unit. The majority of the family members were female (74.3%) and were sons or daughters of patients (54.3%), with a mean age of 43.2 ± 14 years. Overall, 77.1% of the family members were satisfied with the intensive care unit. A total of 37.1% of the family members did not understand the prognosis. Receiving clear and complete information in the intensive care unit and the doctor being accessible were factors that were significantly correlated with the overall family satisfaction. The prevalence of symptoms of anxiety (60%) and depression (54.3%) in the family members was high. Conclusion: The emotional distress of family members is high during a patient's hospitalization in the intensive care unit, although satisfaction is also high. Clear and complete information provided by the intensivist and the support received in the intensive care unit are significantly correlated with the satisfaction of family members in a public hospital.