ABSTRACT
Background: Previous studies usually identified patients who benefit the most from prone positioning by oxygenation improvement. However, inconsistent results have been reported. Physiologically, pulmonary dead space fraction may be more appropriate in evaluating the prone response. As an easily calculated bedside index, ventilatory ratio (VR) correlates well with pulmonary dead space fraction. Hence, we investigated whether the change in VR after prone positioning is associated with weaning outcomes at day 28 and to identify patients who will benefit the most from prone positioning. Materials and methods: This retrospective cohort study was performed in a group of mechanically ventilated, non-COVID ARDS patients who received prone positioning in the ICU at Zhongda hospital, Southeast University. The primary outcome was the rate of successful weaning patients at day 28. Arterial blood gas results and corresponding ventilatory parameters on five different time points around the first prone positioning were collected, retrospectively. VR responders were identified by Youden's index. Competing-risk regression models were used to identify the association between the VR change and liberation from mechanical ventilation at day 28. Results: One hundred and three ARDS patients receiving prone positioning were included, of whom 53 (51%) successfully weaned from the ventilator at day 28. VR responders were defined as patients showing a decrease in VR of greater than or equal to 0.037 from the baseline to within 4 h after prone. VR responders have significant longer ventilator-free days, higher successful weaning rates and lower mortality compared with non-responders at day 28. And a significant between-group difference exists in the respiratory mechanics improvement after prone (P < 0.05). A linear relationship was also found between VR change and compliance of the respiratory system (Crs) change after prone (r = 0.32, P = 0.025). In the multivariable competing-risk analysis, VR change (sHR 0.57; 95% CI, 0.35-0.92) was independently associated with liberation from mechanical ventilation at day 28. Conclusion: Ventilatory ratio decreased more significantly within 4 h after prone positioning in patients with successful weaning at day 28. VR change was independently associated with liberation from mechanical ventilation at day 28.
ABSTRACT
Background: The associations of frailty with the risk of mortality and resource utilization in the elderly patients admitted to intensive care unit (ICU) remain unclear. To address these issues, we performed a meta-analysis to determine whether frailty is associated with adverse outcomes and increased resource utilization in elderly patients admitted to the ICU. Methods: We searched PubMed, EMBASE, ScienceDirect, and Cochrane Central Register of Controlled Trials through August 2021 to identify the relevant studies that investigated frailty in elderly (≥ 65 years old) patients admitted to an ICU and compared outcomes and resource utilization between frail and non-frail patients. The primary outcome was mortality. We also investigated the prevalence of frailty and the impact of frailty on the health resource utilization, such as hospital length of stay (LOS) and resource utilization of ICU. Results: A total of 13 observational studies enrolling 64,279 participants (28,951 frail and 35,328 non-frail) were finally included. Frailty was associated with an increased risk of short-term mortality (10 studies, relative risk [RR]: 1.70; 95% CI: 1.45-1.98), in-hospital mortality (five studies, RR: 1.73; 95% CI: 1.55-1.93), and long-term mortality (six studies, RR: 1.86; 95% CI: 1.44-2.42). Subgroup analysis showed that retrospective studies identified a stronger correlation between frailty and hospital LOS (three studies, MD 1.14 d; 95% CI: 0.92-1.36). Conclusions: Frailty is common in the elderly patients admitted to ICU, and is associated with increased mortality and prolonged hospital LOS. Trial registration: This study was registered in the PROSPERO database (CRD42020207242).
ABSTRACT
BACKGROUND: The characteristics of the coronavirus disease 2019 (COVID-19) patients with hypotension are still limited. We aim to describe the clinical features and outcomes of the patients. METHODS: This was a multicenter retrospective study of critically ill patients with COVID-19 from ICUs in 19 hospitals in China. All patients were followed up to day 28 or death, which came first. Clinical and outcome data were collected and analyzed. Patients were classified as early-onset or late-onset hypotension, and clinical characteristics and outcomes were compared. RESULTS: A total of 649 patients were included in the final analysis, and 240 (37.0%) were hypotension patients. The median age of hypotension patients was 67 years (IQR, 60-73 years), and 159 (66.2%) were male. 172 (71.7%) of the hypotension patients had at least one comorbidity. The 28-day mortality of the patients with hypotension was 85.4%, which was significantly higher than that of patients without hypotension. Compared with late-onset hypotension patients, the 28-day mortality of patients with early-onset hypotension was significantly higher (90.1% vs. 78.6%, P=0.02). CONCLUSIONS: Approximately one third critically ill COVID-19 patients progressed to hypotension. The mortality was significantly higher in hypotension patients than that in patients without hypotension. Compared with patients with late-onset hypotension, the mortality of patients with early-onset hypotension was significantly higher.