Bronchoscopy-guided percutaneous tracheostomy during the COVID-19 pandemic.

BACKGROUND: Assessment of the efficacy and complications associated with performing bronchoscopy-guided percutaneous tracheostomy in COVID-19 and non-COVID-19 patients. METHODS: Prospective observational study conducted between March of 2020 and February of 2022. All adult patients who underwent elective bronchoscopy-guided percutaneous tracheostomy were included. The efficacy of the procedure was evaluated based either on the success rate in the execution or on the need for conversion to open technique. Percutaneous tracheostomy-related complications were registered during the procedure. We performed 6-month follow-up for identifying late complications. RESULTS: During the study period, 312 bronchoscopy-guided percutaneous tracheostomies were analyzed. One hundred and eighty-three were performed in COVID-19 patients and 129 among non-COVID-19 patients. Overall, 64.1% (200) of patients were male, with a median age of 66 (interquartile range 54-74), and 65% (205) presented at least 1 comorbidity. Overall, oxygen desaturation was the main complication observed (20.8% [65]), being more frequent in the COVID-19 group occurring in 27.3% (50) with a statistically significant difference versus the non-COVID-19 patients' group (11.6% [15]); P < .01). Major complications such as hypotension, arrhythmias, and pneumothorax were more frequently observed among COVID-19 patients as well but with no significant differences. Percutaneous tracheostomy could be executed quickly and satisfactorily in all the patients with no need for conversion to the open technique. Likewise, no suspension of the procedure was required in any case. During 6-month follow-up, we found an incidence of 0.96% (n = 3) late complications, 2 tracheal granulomas, and 1 ostomal infection. CONCLUSION: Bronchoscopy-guided percutaneous tracheostomy can be considered an effective and safe procedure in COVID-19 patients. Nevertheless, it is highly remarkable that in the series under study, a great number of COVID-19 patients presented oxygen desaturation during the procedure.

[Multicenter validation of Early Warning Scores for detection of clinical deterioration in COVID-19 hospitalized patients]. / Validación multicéntrica de Sistemas de Alerta Temprana para la detección precoz de deterioro clínico en pacientes hospitalizados por COVID-19.

OBJECTIVE: investigate the predictive value of NEWS2, NEWS-C, and COVID-19 Severity Index for predicting intensive care unit (ICU) transfer in the next 24 hours. DESIGN: retrospective multicenter studySetting: two third-level hospitals in ArgentinaPatients: all adult patients with confirmed COVID-19, admitted on general wards, excluding patients with non-intubated orders. INTERVENTIONS: Patients were divided between those who were admitted to ICU and non-admitted. We calculated the three scores for each day of hospitalization. VARIABLES: we evaluate the calibration and discrimination of the three scores for the outcome ICU admission within 24, 48 h, and at hospital admission. RESULTS: we evaluate 13,768 days of hospitalizations on general medical wards of 1318 patients. Among these, 126 (9.5%) were transferred to ICU. The AUROC of NEWS2 was 0.73 (95%CI 0.68-0.78) 24 hours before ICU admission, and 0.52 (95%CI 0.47-0.57) at hospital admission. The AUROC of NEWS-C was 0.73 (95%CI 0.68-0.78) and 0.52 (95%CI 0.47-0.57) respectively, and the AUROC of COVID-19 Severity Index was 0.80 (95%CI 0.77-0.84) and 0.61 (95%CI 0.58-0.66) respectively. COVID-19 Severity Index presented better calibration than NEWS2 and NEWS-C. CONCLUSION: COVID-19 Severity index has better calibration and discrimination than NEWS2 and NEWS-C to predict ICU transfer during hospitalization.

Evaluation of the discrimination and calibration of predictive scores of mortality in ECMO for patients with COVID-19.

BACKGROUND: The criteria for the selection of COVID-19 patients that could benefit most from ECMO organ support are yet to be defined. In this study, we evaluated the predictive performance of ECMO mortality predictive models in patients with COVID-19. We also performed a cost-benefit analysis depending on the mortality predicted probability. We conducted a retrospective cohort study in COVID-19 patients who received ECMO at two tertiary care hospitals between March 2020 to July 2021. MATERIALS AND METHODS: We evaluated the discrimination (C-statistic), calibration (Cox calibration), and accuracy of the prediction of death due to severe ARDS in V-V ECMO score (PRESERVE), the Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score, and the PREdiction of Survival on ECMO Therapy-Score (PRESET) score. In addition, we compared the RESP score with Plateau pressure instead of Peak pressure. RESULTS: We included a total of 36 patients, 29 (80%) of them male and with a median (IQR) APACHE of 10 (8-15). The PRESET score had the highest discrimination (AUROCs 0.81 [95%CI 0.67-0.94]) and calibration (calibration-in-the-large 0.5 [95%CI -1.4 to 0.3]; calibration slope 2.2 [95%CI 0.7/3.7]). The RESP score with Plateau pressure had higher discrimination than the conventional RESP score. The cost per QALY in the USA, adjusted to life expectancy, was higher than USD 100 000 in patients older than 45 years with a PRESET > 10. CONCLUSION: The PRESET score had the highest predictive performance and could help in the selection of patients that benefit most from this resource-demanding and highly invasive organ support.

Validación multicéntrica de Sistemas de Alerta Temprana para la detección precoz de deterioro clínico en pacientes hospitalizados por COVID-19 Multicenter validation of Early Warning Scores for detection of clinical deterioration in COVID-19 hospitalized patients

Objetivo: investigar el valor predictivo de los scores NEWS2, NEWS-C y COVID-19 Severity Index para predecir la transferencia de urgencia a la unidad de cuidados intensivos (UCI) en las próximas 24 horas. Diseño: estudio multicéntrico retrospectivo Ámbito: dos hospitales de tercer nivel en Argentina Pacientes: pacientes adultos con COVID-19, ingresados ​​en salas generales, excluyendo pacientes con órdenes de no intubar. Intervenciones: Se dividió a los pacientes entre los que ingresaron en la UCI y los que no ingresaron. Calculamos las tres puntuaciones para cada día de hospitalización. Variables: evaluamos la calibración y discriminación de las tres puntuaciones predecir el traslado de urgencia a UCI en las 24, 48 hs previas al pase a UCI y al ingreso hospitalario. Resultados: evaluamos 13,768 días de hospitalización en internación general de 1318 pacientes, de los cuales 126 (9,5%) fueron trasladados a UCI. El AUROC del NEWS2 fue de 0,73 (IC 95% 0,68-0,78) 24 antes del ingreso en UCI y de 0,52 (IC 95% 0,47-0,57) al ingreso hospitalario. El AUROC de NEWS-C fue de 0,73 (95% CI 0,68-0,78) y 0,52 (95% CI 0,47-0,57) respectivamente, y el AUROC del COVID-19 Severity Index fue 0,80 ( 95% CI 0,77-0,84) y 0,61 (95% CI 0,58-0,66) respectivamente. El COVID-19 Severity Index presentó una mejor calibración que NEWS2 y NEWS-C. Conclusión: El COVID-19 Severity Index presento una mejor calibración y discriminación que NEWS2 y NEWS-C para predecir la transferencia de la UCI durante la hospitalización.

Changes in the management and clinical outcomes of critically ill patients without COVID-19 during the pandemic. / Modificações no manejo e desfechos clínicos de pacientes críticos sem COVID-19 durante a pandemia.

OBJECTIVE: To analyze whether changes in medical care due to the application of COVID-19 protocols affected clinical outcomes in patients without COVID-19 during the pandemic. METHODS: This was a retrospective, observational cohort study carried out in a thirty-eight-bed surgical and medical intensive care unit of a high complexity private hospital. Patients with respiratory failure admitted to the intensive care unit during March and April 2020 and the same months in 2019 were selected. We compared interventions and outcomes of patients without COVID-19 during the pandemic with patients admitted in 2019. The main variables analyzed were intensive care unit respiratory management, number of chest tomography scans and bronchoalveolar lavages, intensive care unit complications, and status at hospital discharge. RESULTS: In 2020, a significant reduction in the use of a high-flow nasal cannula was observed: 14 (42%) in 2019 compared to 1 (3%) in 2020. Additionally, in 2020, a significant increase was observed in the number of patients under mechanical ventilation admitted to the intensive care unit from the emergency department, 23 (69%) compared to 11 (31%) in 2019. Nevertheless, the number of patients with mechanical ventilation after 5 days of admission was similar in both years: 24 (69%) in 2019 and 26 (79%) in 2020. CONCLUSION: Intensive care unit protocols based on international recommendations for the COVID-19 pandemic have produced a change in non-COVID-19 patient management. We observed a reduction in the use of a high-flow nasal cannula and an increased number of tracheal intubations in the emergency department. However, no changes in the percentage of intubated patients in the intensive care unit, the number of mechanical ventilation days or the length of stay in intensive care unit.

OBJETIVO: Analisar se as modificações na atenção médica em razão da aplicação dos protocolos para COVID-19 afetaram os desfechos clínicos de pacientes sem a doença durante a pandemia. MÉTODOS: Este foi um estudo observacional de coorte retrospectiva conduzido em uma unidade de terapia intensiva clínica e cirúrgica com 38 leitos, localizada em hospital privado de alta complexidade na cidade de Buenos Aires, Argentina, e envolveu os pacientes com insuficiência respiratória admitidos à unidade de terapia intensiva no período compreendido entre março e abril de 2020 em comparação com o mesmo período no ano de 2019. Compararam-se as intervenções e os desfechos dos pacientes sem COVID-19 tratados durante a pandemia em 2020 e os pacientes admitidos em 2019. As principais variáveis avaliadas foram os cuidados respiratórios na unidade de terapia intensiva, o número de exames de tomografia computadorizada do tórax e lavados broncoalveolares, complicações na unidade de terapia intensiva e condições quando da alta hospitalar. RESULTADOS: Observou-se, em 2020, uma redução significante do uso de cânula nasal de alto fluxo: 14 (42%), em 2019, em comparação com 1 (3%), em 2020. Além disso, em 2020, observou-se aumento significante no número de pacientes sob ventilação mecânica admitidos à unidade de terapia intensiva a partir do pronto-socorro, de 23 (69%) em comparação com 11 (31%) em 2019. Contudo, o número de pacientes com ventilação mecânica 5 dias após a admissão foi semelhante em ambos os anos: 24 (69%), em 2019, e 26 (79%) em 2020. CONCLUSÃO: Os protocolos para unidades de terapia intensiva com base em recomendações internacionais para a pandemia de COVID-19 modificaram o manejo de pacientes sem COVID-19. Observamos redução do uso da cânula nasal de alto fluxo e aumento no número de intubações traqueais no pronto-socorro. Entretanto, não se identificaram alterações na percentagem de pacientes intubados na unidade de terapia intensiva, número de dias sob ventilação mecânica ou número de dias na unidade de terapia intensiva.