Iliopsoas haematoma during extracorporeal membrane oxygenation: A registry report from the COVID-19 critical care consortium across 30 countries.

INTRODUCTION: Iliopsoas haematoma (IPH) during extracorporeal membrane oxygenation (ECMO) is a rare bleeding complication that can be fatal due to its progression to abdominal compartment syndrome, but its incidence and risk factors are not well known. We have previously reported an IPH incidence rate of 16% in Japan. Among possible reasons for this high incidence, ethnicity has been hypothesised to play a role. Therefore, we used an international multi-centre cohort registry to test this hypothesis by determining the incidence rate of IPH. METHODS: This study was performed using the COVID-19 Critical Care Consortium database, conducted in 30 countries across five continents between 3 January 2020, and 20 June 2022. RESULTS: Overall, 1102 patients received ECMO for COVID-19-related acute respiratory distress syndrome. Of them, only seven were reported to have IPH, indicating an incidence rate of 0.64%, with comparable rates between the countries. The IPH group tended to have a higher mortality rate (71.4%) than the non-IPH group (51%). CONCLUSIONS: Overall incidence of IPH in the studied COVID-19 ECMO cohort was 0.64%. Most cases were reported from Japan, Belgium, and Italy. In our study, this rare complication did not appear to be confined to Asian patients. Due to the high fatality rate, awareness about the occurrence of IPH should be recognised.

Trends in survival during the pandemic in patients with critical COVID-19 receiving mechanical ventilation with or without ECMO: analysis of the Japanese national registry data.

BACKGROUND: The survival rate of patients with critical coronavirus disease-19 (COVID-19) over time is inconsistent in different settings. In Japan, a national database was organized to monitor and share the patient generation across the country in an immediate response to the COVID-19 pandemic. This study aimed to evaluate changes in survival over time and the prognostic factors in critical COVID-19 patients receiving mechanical ventilation with/without extracorporeal membrane oxygenation (ECMO) using the largest database in Japan. METHODS: This is a prospective observational cohort study of patients admitted to intensive care units in Japan with fatal COVID-19 pneumonia receiving mechanical ventilation and/or ECMO. We developed a prospective nationwide registry covering > 80% of intensive care units in Japan, and analyzed the association between patients' backgrounds, institutional ECMO experience, and timing of treatment initiation and prognosis between February 2020 and November 2021. Prognostic factors were evaluated by Kaplan-Meier analysis and Cox proportional hazards analysis. RESULTS: A total of 9418 patients were ventilated, of whom 1214 (13%) received ECMO. The overall survival rate for ventilated patients was 79%, 65% for those receiving ECMO. There have been five outbreaks in Japan to date. The survival rate of ventilated patients increased from 76% in the first outbreak to 84% in the fifth outbreak (p < 0.001). The survival rate of ECMO patients remained unchanged at 60-68% from the first to fifth outbreaks (p = 0.084). Age of ≥ 59 (hazard ratio [HR] 2.17; 95% confidence interval [CI] 1.76-2.68), ventilator days of ≥ 3 before starting ECMO (HR 1.91; 95% CI 1.57-2.32), and institutional ECMO experiences of ≥ 11 (HR 0.70; 95% CI 0.58-0.85) were independent prognostic factors for ECMO. CONCLUSIONS: During five COVID-19 outbreaks in Japan, the survival rate of ventilated patients tended to have gradually improved, and that of ECMO patients did not deteriorate. Older age, longer ventilator days before starting ECMO, and fewer institutional ECMO experiences may be independent prognostic factors for critical COVID-19 patients receiving ECMO.

Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study.

INTRODUCTION: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. METHODS: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. RESULTS: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1-4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05-1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. CONCLUSION: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

Mobilization and Rehabilitation Practice in ICUs During the COVID-19 Pandemic.

BACKGROUND: Mobilization and acute rehabilitation are essential in the intensive care unit (ICU), with substantial evidence supporting their benefits. This study aimed to characterize ICU mobilization practices during the COVID-19 pandemic for patients with and without COVID-19. METHODS: This was a secondary analysis of an international point prevalence study. All ICUs across the world were eligible to participate and were required to enroll all patients in each ICU on the survey date, 27 January 2021. The primary outcome was the achievement of mobilization at the level of sitting over the edge of the bed. Independent factors associated with mobilization, including COVID-19 infection, were analyzed by multivariable analysis. RESULTS: A total of 135 ICUs in 33 countries participated, for inclusion of 1229 patients. Among patients who were not receiving mechanical ventilation (MV), those with COVID-19 infection were mobilized more than those without COVID-19 (60% vs. 34%, p < 0.001). Among patients who were receiving MV, mobilization was low in both groups (7% vs. 9%, p = .56). These findings were consistent irrespective of ICU length of stay. Multivariable analysis showed that COVID-19 infection was associated with achievement of mobilization in patients without (adjusted odds ratio [aOR] = 4.48, 95% confidence interval [CI] = 2.71-7.42) and with MV (aOR = 2.13, 95% CI = 1.00-4.51). Factors that prevented mobilization were prone positioning in patients without MV and continuous use of neuromuscular blockade and sedation agents in patients with MV, whereas facilitating factors were the presence of targets/goals in both groups. CONCLUSION: Mobilization rates for ICU patients across the globe are severely low, with the greatest immobility observed in mechanically ventilated patients. Although COVID-19 is not an independent barrier to the mobilization of patients with or without MV, this study has highlighted the current lack of mobility practice for all ICU patients during the COVID-19 pandemic.(299 words).

Relation between nutrition therapy in the acute phase and outcomes of ventilated patients with COVID-19 infection: a multicenter prospective observational study.

BACKGROUND: Optimal nutrition therapy has not yet been established for the acute phase of severe coronavirus disease 2019 (COVID-19) infection. OBJECTIVES: We aimed to examine the effects of nutrition delivery in the acute phase on mortality and the long-term outcomes of post-intensive care syndrome (PICS). METHODS: A multicenter prospective study was conducted on adult patients with COVID-19 infection requiring mechanical ventilation during an intensive care unit (ICU) stay. Daily total energy (kcal/kg) and protein (g/kg) deliveries in the first week of the ICU stay were calculated. The questionnaire for PICS evaluation was mailed within a median of 6 mo after hospital discharge. The primary outcome was in-hospital mortality, and secondary outcomes were the PICS components of physical impairment, cognitive dysfunction, and mental illness. RESULTS: Among 414 eligible patients, 297 who received mechanical ventilation for 7 d or longer were examined. PICS was evaluated in 175 patients among them. High protein delivery on days 4-7 correlated with a low in-hospital mortality rate. In contrast, high protein delivery on days 1-3 correlated with physical impairment. A multivariate logistic regression analysis adjusted for age, sex, BMI, and severity revealed that average energy and protein deliveries on days 4-7 correlated with decreased in-hospital mortality (OR: 0.94; 95% CI: 0.89, 0.99; P = 0.013 and OR: 0.40; 95% CI: 0.17, 0.93; P = 0.031, respectively). Nutrition delivery did not correlate with PICS outcomes after adjustments. In the multivariate regression using a restricted cubic spline model, in-hospital mortality monotonically decreased with increases in average nutrition delivery on days 4-7. CONCLUSIONS: In patents with COVID-19 on mechanical ventilation for ≥7 d, nutrition delivery in the late period of the acute phase was monotonically associated with a decrease in in-hospital mortality. Adequate protein delivery is needed on days 4-7.This trial was registered at https://www.umin.ac.jp as UMIN000041276.

Effects of the Intensity and Activity Time of Early Rehabilitation on Activities of Daily Living Dependence in Mechanically Ventilated Patients.

OBJECTIVES: The aim of this study was to investigate the association between the Rehabilitation Activity Time score (RATs)-a score based on the level and duration of rehabilitation activities-of ventilated patients in the intensive care unit (ICU) and activities of daily living (ADL) dependence at discharge. METHODS: This retrospective, single-center study evaluated patients aged >18 years who underwent mechanical ventilation in the ICU for at least 48 h. The patients were categorized into the low- and high-dose rehabilitation groups based on the median RATs. The primary outcome was the rate of ADL dependence at discharge, defined as a Barthel index of <70. The association between low or high doses of rehabilitation and the primary outcome was assessed using multiple logistic regression analysis adjusted by baseline factors. RESULTS: The rate of ADL dependence at discharge was significantly lower in the high-dose rehabilitation group (low dose 81% vs. high dose 22%, P<0.001). Multivariate analysis showed a significantly lower ADL dependence at discharge among those who received high-dose rehabilitation (P<0.001). Increased RATs during the entire ICU admission period and during ICU admission after meeting the criteria for physiological stability was significantly associated with lower ADL dependence at discharge (P<0.001). Moreover, a higher RATs from low-level activity before meeting the criteria for physiological stability also showed a significant association with lower ADL dependence at discharge (P=0.047). CONCLUSIONS: ADL dependence was significantly lower among those who underwent high-dose rehabilitation. The RATs was consistently associated with ADL dependence at discharge.

Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study.

Background: Data regarding delivery of evidence-based care to critically ill patients in Intensive Care Units (ICU) during the COVID-19 pandemic is crucial but lacking. This study aimed to evaluate the implementation rate of the ABCDEF bundle, which is a collection of six evidence-based ICU care initiatives which are strongly recommended to be incorporated into clinical practice, and ICU diaries for patients with and without COVID-19 infections in ICUs, and to analyze the impact of COVID-19 on implementation of each element of the bundle and independent associated factors. Methods: A world-wide 1-day point prevalence study investigated the delivery of the ABCDEF bundle and ICU diary to patients without or with COVID-19 infections on 27 January 2021 via an online questionnaire. Multivariable logistic regression analysis with adjustment for patient demographics evaluated the impact of COVID-19 and identified factors in ICU administrative structures and policies independently associated with delivery. Results: From 54 countries and 135 ICUs, 1,229 patients were eligible, and 607 (49%) had COVID-19 infections. Implementation rates were: entire bundle (without COVID-19: 0% and with COVID-19: 1%), Element A (regular pain assessment: 64 and 55%), Element B (both spontaneous awakening and breathing trials: 17 and 10%), Element C (regular sedation assessment: 45 and 61%), Element D (regular delirium assessment: 39 and 35%), Element E (exercise: 22 and 25%), Element F (family engagement/empowerment: 16 and 30%), and ICU diary (17 and 21%). The presence of COVID-19 was not associated with failure to implement individual elements. Independently associated factors for each element in common between the two groups included presence of a specific written protocol, application of a target/goal, and tele-ICU management. A lower income status country and a 3:1 nurse-patient ratio were significantly associated with non-implementation of elements A, C, and D, while a lower income status country was also associated with implementation of element F. Conclusions: Regardless of COVID-19 infection status, implementation rates for the ABCDEF bundle, for each element individually and an ICU diary were extremely low for patients without and with COVID-19 infections during the pandemic. Strategies to facilitate implementation of and adherence to the complete ABCDEF bundle should be optimized and addressed based on unit-specific barriers and facilitators.

Nutrition therapy in the intensive care unit during the COVID-19 pandemic: Findings from the ISIIC point prevalence study.

BACKGROUND & AIMS: Nutrition therapy for Intensive Care Unit (ICU) patients involves complex decision-making, especially during the COVID-19 pandemic. We investigated the use of nutrition therapy in ICU patients with and without COVID-19 infections. METHODS: Nutrition therapy was evaluated during a world-wide one-day prevalence study focused on implementation of the ABCDEF bundle (A: regular pain assessment, B: both spontaneous awakening and breathing trials, C: regular sedation assessment, D: regular delirium assessment, E: early mobility and exercise, and F: family engagement and empowerment) during the COVID-19 pandemic. Basic ICU and patient demographics including nutrition therapy delivery were collected on the survey day. Physical activity for patients with and without COVID infections was categorized using the ICU mobility scale (IMS). Multivariable regression analysis of nutrition was conducted using ICU parameters. RESULTS: The survey included 627 non-COVID and 602 COVID patients. A higher proportion of COVID-19 patients received energy ≥20 kcal/kg/day (55% vs. 45%; p = 0.0007) and protein ≥1.2 g/kg/day (45% vs. 35%; p = 0.0011) compared to non-COVID patients. Enteral nutrition was provided to most COVID patients even with prone positioning (91%). Despite nutrition therapy, IMS was extremely low in both groups; median IMS was 1 in non-COVID patients and 0 in COVID patients. The rate of energy delivery ≥20 kcal/kg/day was significantly higher in patients with COVID-19 infections in the subgroup of ICU days ≤5 days and IMS ≤2. Having a dedicated ICU nutritionist/dietitian was significantly associated with appropriate energy delivery in patients both with and without COVID-19 infections, but not with protein delivery. CONCLUSION: During the COVID-19 pandemic, patients with COVID-19 infections received higher energy and protein delivery. Generally low mobility levels highlight the need to optimize early mobilization with nutrition therapy in all ICU patients.

Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives.

Intensive care unit survivors experience prolonged physical impairments, cognitive impairments, and mental health problems, commonly referred to as post-intensive care syndrome (PICS). Previous studies reported the prevalence, assessment, and prevention of PICS, including the ABCDEF bundle approach. Although the management of PICS has been advanced, the outbreak of coronavirus disease 2019 (COVID-19) posed an additional challenge to PICS. The prevalence of PICS after COVID-19 extensively varied with 28-87% of cases pertaining to physical impairments, 20-57% pertaining to cognitive impairments, and 6-60% pertaining to mental health problems after 1-6 months after discharge. Each component of the ABCDEF bundle is not sufficiently provided from 16% to 52% owing to the highly transmissible nature of the virus. However, new data are emerging about analgesia, sedation, delirium care, nursing care, early mobilization, nutrition, and family support. In this review, we summarize the recent data on PICS and its new challenge in PICS after COVID-19 infection.

Establishment of a Disaster Management-like System for COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation in Japan.

The coronavirus disease 2019 (COVID-19) pandemic has increased the number of patients who require extracorporeal membrane oxygenation (ECMO). To manage the demand for ECMO, Japan ECMOnet for COVID-19 was developed as a "disaster management-like system", utilizing the Cross ICU Searchable Information System (CRISIS) database. This study investigated the effect of the establishment of this disaster management-like system in Japan. This was a nationwide retrospective observational study conducted from 1 February to 31 July in 2020. A total of 187 patients with COVID-19 who received ECMO were included. The median age was 60 years (interquartile range, 53-68), the median length of ventilatory support before ECMO was 3 days (1-5), and the median PaO2 to FiO2 ratio at ECMO initiation was 86 (71.3-101.5). During the study period, 165 telephone consultations were conducted, including general questions about ECMO. Among them, 44 concerned patients who were already on ECMO or who ultimately received ECMO. Further coordination, including transport and ECMO physician dispatch, was provided for 23 cases. Overall, 125/187 (66.8%) patients were successfully weaned from ECMO. This study demonstrated that Japan has achieved favorable survival outcomes for patients with COVID-19 who received ECMO with a disaster management-like system. Further research on the causes of these outcomes is needed.

ABCDEF Bundle and Supportive ICU Practices for Patients With Coronavirus Disease 2019 Infection: An International Point Prevalence Study.

OBJECTIVES: To investigate implementation of evidence-based and supportive cares in ICUs, such as the ABCDEF, nutrition therapy, and ICU diary, for patients with coronavirus disease 2019 infection in ICUs and their association with ICU clinical practice and setting. DESIGN: A worldwide, 2-day point prevalence study. SETTING: The study was carried out on June 3, 2020, and July 1, 2020. A total of 212 ICUs in 38 countries participated. Clinicians in each participating ICU completed web-based online surveys. PATIENTS: The ICU patients with coronavirus disease 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The implementation rate for the elements of the ABCDEF bundle, other supportive ICU care measures, and implementation-associated structures were investigated. Data were collected for 262 patients, of whom 47.3% underwent mechanical ventilation and 4.6% were treated with extracorporeal membrane oxygenation. Each element was implemented for the following percentages of patients: elements A (regular pain assessment), 45%; B (both spontaneous awakening and breathing trials), 28%; C (regular sedation assessment), 52%; D (regular delirium assessment), 35%; E (early mobility and exercise), 47%; and F (family engagement and empowerment), 16%. The implementation of element E was 4% for patients on mechanical ventilation and 8% for patients on extracorporeal membrane oxygenation. Supportive care, such as protein provision throughout the ICU stay (under 1.2 g/kg for more than 50% of the patients) and introduction of ICU diary (25%), was infrequent. Implementation rates of elements A and D were higher in ICUs with specific protocols and fewer ICU beds exclusively for patients with coronavirus disease 2019 infection. Element E was implemented at a higher rate in ICUs that had more ICU beds assigned for them. CONCLUSIONS: This point prevalence study showed low implementation of the ABCDEF bundle. Specific protocols and the number of ICU beds reserved for patients with coronavirus disease 2019 infection might be key factors for delivering appropriate supportive care.