The impact of pre-existing chronic heart failure on the intensive care treatment and outcome of old intensive care patients suffering from COVID-19

Background: Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19. Method(s): Patients with severe COVID-19 and who were >=70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality. Result(s): The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77+/-5 versus 76+/-5, p<0.001) and more frail (Clinical Frailty Scale 4+/-2 versus 3+/-2, p<0.0001). The other comorbidities were also significantly more common in CHF patients. Before hospital admission, CHF patients suffered fewer days from symptoms (5 days (3-8) versus 7 days (4-10), p<0.001), but there was no difference in the days in the hospital before ICU admission (2 days (1-5) versus 2 (1-5) days, p=0.21). At ICU admission, disease severity assessed by SOFA scores was significantly higher in CHF patients (7+/-3 versus 5+/-3). During ICU-stay, intubation, mechanical ventilation, and tracheostomy occurred significantly more often in patients without CHF (63% versus 69%, p=0.017;and 13% versus 18%, p=0.002, respectively). In contrast, there was no difference regarding non-invasive ventilation (28% versus 27%, p=0.20), and the need for vasoactive drugs (66% versus 64, p=0.30). Regarding the limitation of life-sustaining therapy, therapy was significantly more often withheld (32% versus 25%, p=0.001) but not withdrawn (18% versus 17%, p=0.21) in CHF patients. Length of ICU stay was significantly shorter in CHF patients (166 (72-336) hours versus 260 hours (120-528), p<0.001). CHF patients had significantly higher ICU-(52% versus 46%, p=0.007), 30-day mortality (60% vs. 48%, p<0.001;OR 1.87, 95% CI 1.5- 2.3) and 3-month mortality (69% vs. 56%, p<0.001). In the univariate regression analysis, having pre-existing CHF was significantly associated with 30-day mortality (OR 1.89, 95% CI 1.5-2.3;p<0.001), but after adjusting for confounders (SOFA, age, gender, frailty), heart failure was not independently associated any more (aOR 1.2, 95% CI 0.5-1.5;p=0.137). Conclusion(s): In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short-and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders.

Corimmuno19-BEVA : essai ouvert controle randomise evaluant l'efficacite et l'innocuite du bevacizumab (BEV) (Zirabev) en addition du traitement standard (STD) chez les patients atteints de pneumonie COVID-19 hypoxemique severe (ClinicalTrials.gov, NCT04822818)

Declaration de liens d'interets: Les auteurs declarent ne pas avoir de liens d'interets. Copyright © 2022

Interleukine 6 is associated with severity and poor outcome in ICU-patients with SARS-CoV-2 infection

Background-aim: SARS coronavirus 2 (SARS-CoV-2) is responsible for high morbidity and mortality worldwide, mostly due to the exacerbated inflammatory response observed in critically ill patients. However, little is known about the kinetics of the systemic immune response and its association with survival in Covid-19 patients admitted in ICU Methods: We performed a retrospective multicenter study including all patients with SARS-Cov-2 infection admitted in 3 ICUs between March 1st and April 15th 2020, with at least 2 measurements of Interleukin 6 (IL6) in 4 days (baseline and day 3-4). Patients who received immunomodulatory treatment were excluded. IL6 was measured on serum by ELISA (Quantikine R&D Systems) and results were expressed at median [25th – 75th percentile]. The relationship between IL6 and CRP, organ failure severity (SOFA score) or in-ICU mortality was analyzed. Results: From the 140 patients admitted in the 3 ICU for SARS-Cov2 infection (PCR diagnosis), 101 patients were included, the mean age was 59 ± 11 years with a high proportion of men (82%). Patients had severe respiratory disease with media SOFA score of 4 [3-7] and 83 required endotracheal intubation/mechanical ventilation at baseline. An increase of SOFA score between baseline and day3-4 was observed in 32 patients (worsening group). Baseline measurements were done 14 days [11-20] after onset of symptoms. At the end of the study, on April 15th 2020, 47 patients had been discharged from ICU, 35 were still in ICU, and 19 had died in ICU. Baseline IL6 concentrations were positively associated with SOFA score. Moreover, baseline IL-6 and CRP concentrations were significantly higher in the worsening group vs the non-worsening: 278 [70-622] vs 71 [29-153] pg/mL (P<0.01) for IL6 and 178 [100-295] vs 100 [37-213] mg/L (P<0.05) for CRP. However, IL6 concentrations were not correlated with CRP. Il6 and CRP concentrations were higher in non-survivors at baseline and at day 3-4. CRP significantly decreased in survivors (190 [80-248] to 108 [45-185], P<0.05) whereas IL6 decreased in both groups. Conclusions: In this multicenter cohort of ICU patients with SARS-CoV-2 infection, we found that Il6 was associated with organ failure severity, worsening and poor outcome.

Prédiction de la survie à 90 jours des patients atteints de COVID-19 hospitalisés en réanimation : Survival Of Severely Ill COVID (SOSIC) scores

Introduction Prédire le devenir des patients gravement malades hospitalisés en unité de soins intensifs (USI)  et atteints de la maladie du coronavirus 19 (COVID-19) est un défi majeur pour éviter les séjours futiles et prolongés en USI. L'objectif de cette recherche était de développer des modèles de prédictifs de la survie à 90 jours applicable à ce type de patients à différents moments de leur séjour en USI. Methodes Sur la base de la cohorte nationale multicentrique COVID-ICU, qui a recueilli de manière prospective les caractéristiques, la prise en charge et le devenir des patients atteints de COVID-19 et hospitalisés en USI pendant la première vague de la pandémie, nous avons utilisé un algorithme d'apprentissage automatique (eXtreme Gradient Boosting) pour développer des modèles destinés à prédire la mortalité à 90 jours à l'aide d'informations recueillies à J1, J7 ou J14 du séjour du patient, en tenant compte des données manquantes (que ce soit pendant l'estimation, ou lors de l'utilisation de ces modèles sur de nouveaux individus). Ces modèles ont été évalués par une double validation interne (bootstrap et échantillon de validation) et l'estimation de l'aire sous la courbe ROC, la courbe de calibration, et le score de Brier. Resultats Les scores Survival Of Severely Ill COVID (SOSIC)-1, SOSIC-7 et SOSIC-14 ont été construits et validés avec 4244, 2877 et 1349 patients respectivement. Dans l’échantillon de validation, l'aire sous la courbe ROC de SOSIC-7 était légèrement supérieure (0,80 [0,74-0,86]) à celles de SOSIC-1 (0,76 [0,71-0,81]) et de SOSIC-14 (0,76 [0,68-0,83]). SOSIC-1 et SOSIC-7 présentaient d'excellentes courbes de calibration, avec des scores de Brier similaires pour les trois modèles. Conclusion Les scores SOSIC-1, -7 et -14 ont globalement montré une bonne capacité discriminante et une bonne calibration. D'autres études sont maintenant nécessaires pour évaluer la validité externe de ces scores dans des cohortes plus récentes de patients hospitalisés en USI. L'application web disponible publiquement (sosic.shinyapps.io/shiny) devrait faciliter cet objectif. Légende de la figure : Calibration et discrimination des scores SOSIC-1, SOSIC-7, and SOSIC-14 dans l’échantillon de validation Mots clés  Syndrome de détresse respiratoire aiguë ;COVID-19 ;Score prédictif Déclaration de liens d'intérêts  Les auteurs n'ont pas précisé leurs éventuels liens d'intérêts

[Priorisation of old critically-ill patients for an ICU admission]

PRIORISATION OF OLD CRITICALLY-ILL PATIENTS FOR AN ICU ADMISSION There are currently no national or international recommendations for admission decisions to an intensive care unit (icu) for patients over 80 years of age. The decision, whether, or not to admit an elderly patient to intensive care is probably one of the most difficult decisions for an intensivist with the double risk of loss of chance in the event of refusal or non-beneficial care in the event of acceptance. Doubt should always benefit the patient with icu admission in case of prognosis uncertainty. In that case the patient should be reassessed after a few days for tailoring of the level of care. The best criterion for judging the accuracy of decisions is the vital but also the functional prognosis and the long-term expected quality of life for the patient and his relatives. Current and future demographic changes as well as financial constraints justify producing general guidelines in order to ease the decision-making process and reduce practice heterogeneity. The principle of distributive justice must apply in situations of strain on icu bed availability, as in times of a Covid wave.

[Intensive care and Covid]. / Réanimation et Covid.

The health crisis linked to COVID-19 has put the whole hospital under stress. Intensive care units (ICU) have been on the front line to manage the most serious cases. The number of new admissions together with cumulative number of occupied intensive care beds have been and still are a key element in measuring the intensity of the crisis. Intensive care is a specialty largely unknown to the general public which is problematic when dealing with such difficult questions as should we give priority to health or to the economy; is there a loss of chance for non-COVID patients due to deprogramming? The increase in the demand for critical care has necessitated an extension of hospitalization capacities by transforming intermediate care beds into ICU beds, by creating neo-ICU, or in some regions by carrying out critical care, usually performed in ICU, in regular wards. Among the several limiting factors, human resources with qualified personnel was a key element together with the relative shortage of drugs. The mismatch between demand and supply has led to the establishment of rules for prioritizing access to ICU. This review deals with all these issues and can contribute to a reflection on the adaptation of the critical care department to cope with major sanitary crisis.

Réanimation et Covid☆ Intensive care and Covid

La crise sanitaire liée à la COVID-19 a mis l’ensemble de l’hôpital en tension. Les services de réanimation ont été en première ligne pour prendre en charge les cas les plus graves. Le bilan des entrées et de l’occupation des lits de réanimation a été et est toujours un élément clé de mesure de l’intensité de la crise. La réanimation est une spécialité largement méconnue du grand public alors que des questions majeures se posent : capacité d’augmentation de l’offre de soins sans altérer la qualité de la prise en charge ;perte de chance pour les malades non-COVID du fait de la déprogrammation. Les facteurs limitants de l’augmentation du capacitaire sont multiples mais la principale difficulté concerne la mobilisation de personnel formé à la réanimation et la relative pénurie de médicaments. L’inadéquation entre la demande et l’offre a conduit à édicter des règles de priorisation d’accès à la réanimation. Cette revue peut contribuer à une réflexion sur l’adaptation des secteurs de soins critiques en situation de crise sanitaire majeure.