Trauma: a stress during pandemic?

Introduction: Coronavirus disease 2019 pandemic significantly impacted on trauma systems, since emergency departments (ED) suddenly were overwhelmed by patients requiring intensive care unit (ICU) admission. Once, trauma volume was supposed to decrease due to lockdown policies, we aimed to describe ICU trauma admissions during this period. Method(s): Retrospective observational study of all trauma patients admitted to the ICU of a Portuguese Trauma Center between January 2020 and December 2021. Data were collected from clinical hospital records. Result(s): 437 trauma patients (15% of all admissions), mostly male (71%), with a median age of 59 years-old (42-74) were included. At least one comorbidity was present in 71% of the patients. Median severity scores were: SAPS II 26 (19-38), SOFA 3 (1-6), ISS 13 (9-22), RTS 8 (6-8) and TRISS 96,75 (81.1-98.6). The most frequent mechanisms of injury were falls (59%) and road traffic accidents (25%). The majority consisted of blunt trauma (88%), 65% of brain trauma and 35% of musculoeskeletal trauma. Trauma Team assessment was started in < 3 min in all cases and median length of stay (LOS) in the ED was 261 min (154-418). Surgical intervention was performed in < 4 h in 56% of surgical brain trauma injuries, in < 6 h in 67% of extremity open fractures and in < 1 h in 6% of a penetrating trauma. Shock, mainly hemorrhagic, was present in 8% of the patients on hospital admission. 38% were submitted to invasive mechanical ventilation and 34% to vasopressors. The most common complication was nosocomial infection (18%). The median LOS in the UCI was 12 days (5-24). Only 8% of the patients died in the ICU and 11% in the hospital. Conclusion(s): During pandemic, trauma persisted a major health problem with a significant consumption of time and critical care resources. The high influx of patients may have influenced the LOS in the ED before ICU admission and the time until the surgical intervention. Despite it, mortality remained low.

Long-Term Sequelae of severe COVID-19: Outpatient assessment of radiological and pulmonary function tests

Objective: Identify lung sequelae of COVID-19 through radiological and pulmonary function assessment. Design(s): Prospective, longitudinal, cohort study from March 2020 to March 2021. Setting(s): Intensive Care Units (ICU) in a tertiary hospital in Portugal. Patient(s): 254 patients with COVID-19 admitted to ICU due to respiratory illness. Intervention(s): A chest computed tomography (CT) scan and pulmonary function tests (PFT) were performed at 3 to 6 months. Main variables of interest: CT-scan;PFT;decreased diffusion capacity of carbon monoxide (DLCO). Result(s): All CT scans revealed improvement in the follow-up, with 72% of patients still showing abnormalities, 58% with ground glass opacities and 62% with evidence of fibrosis. PFT had abnormalities in 94 patients (46%): thirteen patients (7%) had an obstructive pattern, 35 (18%) had a restrictive pattern, and 58 (30%) had decreased DLCO. There was a statistically significant association between abnormalities in the follow-up CT scan and older age, more extended hospital and ICU stay, higher SAPS II and APACHE scores and invasive ventilation. Mechanical ventilation, especially with no lung protective parameters, was associated with abnormalities in PFT. Multivariate regression showed more abnormalities in lung function with more extended ICU hospitalization, chronic obstructive pulmonary disease (COPD), chronic kidney disease, invasive mechanical ventilation, and ventilation with higher plateau pressure, and more abnormalities in CT-scan with older age, more extended ICU stay, organ solid transplants and ventilation with higher positive end-expiratory pressure (PEEP). Conclusion(s): Most patients with severe COVID-19 still exhibit abnormalities in CT scans or lung function tests three to six months after discharge.Copyright © 2023

Sepsis: Past, Present, and Future—Lessons Learned from COVID-19

It is paradoxical that being the immune response the key of the evolution from infection to sepsis, rapid tests for monitoring the immune response at bedside have not been developed and successfully implemented. The epidemic of COVID has provided a good sepsis paradigm originated from a viral trigger. It emphasizes the importance on individualization on different clinical phenotypes and the importance of time in therapeutic management. Whereas measures effective in reducing the viral burden can be effective if started very early, they are useless if delayed. Moreover, the effectiveness of some monoclonal antibodies used very early opens an opportunity to expand therapy in other viral or bacterial infections, particularly in immunocompromised subjects. Lastly, the success in reducing mortality by the use of steroids in patients requiring additional oxygen is a new paradigm to be expanded through the use of different immunomodulatory agents in a precision therapy approach. With the experience learned from COVID-19 disease, next steps for sepsis management improvement with potential impact on outcomes should focus on: (a) identification of subclinical phenotypes at the bedside, using clinical and biological markers;(b) implementation of a precision medicine strategy, balancing the use of therapy targeted to reduce the organism burden at the onset and of immunomodulatory agents in a second time window;(c) development of immune response assessment at the bedside, early after the diagnosis of serious infections, to anticipate individual infected patients at high risk of developing sepsis and to customize specific preemptive therapies based on the risk. © 2023 Elsevier Inc. All rights reserved.

Influence of Deep Sedation in Intensive Care Medicine Memories of Critical COVID-19 Survivors.

Introduction: Critical care survivors sustain a variety of sequelae after intensive care medicine (ICM) admission, and the Coronavirus Disease 2019 (COVID-19) pandemic has added further challenges. Specifically, ICM memories play a significant role, and delusional memories are associated with poor outcomes post-discharge including a delayed return to work and sleep problems. Deep sedation has been associated with a greater risk of perceiving delusional memories, bringing a move toward lighter sedation. However, there are limited reports on post-ICM memories in COVID-19, and influence of deep sedation has not been fully defined. Therefore, we aimed to evaluate ICM-memory recall in COVID-19 survivors and their relation with deep sedation. Materials/Methods: Adult COVID-19 ICM survivors admitted to a Portuguese University Hospital between October 2020 and April 2021 (second/third "waves") were evaluated 1 to 2 months post-discharge using "ICU Memory Tool," to assess real, emotional, and delusional memories. Results: The study included 132 patients (67% male; median age = 62 years, Acute Physiology and Chronic Health Evaluation [APACHE]-II = 15, Simplified Acute Physiology Score [SAPS]-II = 35, ICM stay = 9 days). Approximately 42% received deep sedation (median duration = 19 days). Most participants reported real (87%) and emotional (77%) recalls, with lesser delusional memories (36.4%). Deeply sedated patients reported significantly fewer real memories (78.6% vs 93.4%, P = .012) and increased delusional memories (60.7% vs 18.4%, P < .001), with no difference in emotional memories (75% vs 80.4%, P = .468). In multivariate analysis, deep sedation had a significant, independent association with delusional memories, increasing their likelihood by a factor of approximately 6 (OR = 6.274; 95% confidence interval = 1.165-33.773, P = .032), without influencing real (P = .545) or emotional (P = .133) memories. Conclusions: This study contributes to a better understanding of the potential adverse effects of deep sedation on ICM memories in critical COVID-19 survivors, indicating a significant, independent association with the incidence of delusional recalls. Although further studies are needed to support these findings, they suggest that strategies targeted to minimize sedation should be favored, aiming to improve long-term recovery.

Critical COVID-19 and neurological dysfunction - a direct comparative analysis between SARS-CoV-2 and other infectious pathogens

Objective: To evaluate whether critical SARS-CoV-2 infection is more frequently associated with signs of corticospinal tract dysfunction and other neurological signs, symptoms, and syndromes, than other infectious pathogens. Methods: This was a prospective cohort study with consecutive inclusion of patients admitted to intensive care units due to primary infectious acute respiratory distress syndrome requiring invasive mechanical ventilation > 48 hours. Eligible patients were randomly assigned to three investigators for clinical evaluation, which encompassed the examination of signs of corticospinal tract dysfunction. Clinical data, including other neurological complications and possible predictors, were independently obtained from clinical records. Results: We consecutively included 54 patients with acute respiratory distress syndrome, 27 due to SARS-CoV-2 and 27 due to other infectious pathogens. The groups were comparable in most characteristics. COVID-19 patients presented a significantly higher risk of neurological complications (RR = 1.98;95%CI 1.23 - 3.26). Signs of corticospinal tract dysfunction tended to be more prevalent in COVID-19 patients (RR = 1.62;95%CI 0.72 - 3.44). Conclusion: Our study is the first comparative analysis between SARS-CoV-2 and other infectious pathogens, in an intensive care unit setting, assessing neurological dysfunction. We report a significantly higher risk of neurological dysfunction among COVID-19 patients. As such, we suggest systematic screening for neurological complications in severe COVID-19 patients.

Anxiety symptoms in critically ill COVID-19 survivors and its association with post-discharge health concerns

Introduction: Evidence suggest that critically ill COVID-19 patients are at higher risk of developing anxiety symptoms, which may be related to or exacerbated by patients concerns regarding their health status and recovery. Objective(s): To assess anxiety symptoms in critically ill COVID-19 survivors, 1-2 months after hospital discharge and to analyze its association with concerns reported by patients regarding their own health status and recovery. Method(s): In the framework of MAPA prospective research, this preliminary study included COVID-19 patients admitted in the Intensive Care Medicine Department (ICMD) of a University Hospital. Patients were excluded if they had an ICMD length of stay (LoS) <=24h, terminal illness, major auditory impairment or inability to communicate at the evaluation time. Participants were assessed at a scheduled telephone follow-up appointment, with Generalized Anxiety Disorder Scale (GAD-7). Additional questions were asked to assess the survivors' post-discharge concerns regarding discrimination against for COVID-19, infection of a family member, re-infection or sequelae related to COVID-19. Result(s): Eighty-three patients were included (median age=63 years;63% male) and 24% had anxiety symptoms. Anxiety scores were higher in survivors who reported being afraid of being discriminated against for COVID-19 (30% vs 10%;p=0.034), being re-infected (100% vs 79%;p=0.032) and having sequelae (94% vs 44%;p<0.001). Conclusion(s): These findings revealed that anxiety is common in COVID-19 survivors and is associated with post-discharge patients concerns that may limit patient daily living. This study emphasizes the importance of psychological assessment and follow-up of the COVID-19 survivors, in order to support these patients recovery.

Depression and health-related quality of life in critical COVID-19 survivors

Introduction: Long-term neuropsychiatric consequences of critical illness are well known. Therefore, it is expected that critical COVID-19 patients might also present several psychiatric symptoms such as depression, with inevitable negative effect on healthrelated quality of life (HRQoL), commonly used as an indicator of illness and treatment impact. Objective(s): To identify depressive symptoms in critical COVID-19 survivors and to examine its association with HRQoL domains. Method(s): This preliminary study involved critical COVID-19 patients admitted into the Intensive Care Medicine Department (ICMD) of a University Hospital, between October and December of 2020. Patients with an ICMD length of stay (LoS)<=24h, terminal illness, major auditory loss, or inability to communicate at the follow-up time were excluded. From 1-2 months after discharge, all participants were evaluated by telephone at follow-up appointment, with Patient Health Questionnaire (PHQ-9) (depression) and EuroQol 5-dimension 5-level EQ-5D-5L (HRQoL). This study is part of the longitudinal MAPA project. Result(s): Eighty-three patients were included with a median age of 63 years (range: 31-86) and the majority were male (63%). The most reported problems on EQ-5D-5L domains were usual activities (82%) and mobility (76%). About 27% presented depressive symptoms, and with more problems of self-care (68%vs41%;p=0.029), pain/discomfort (86%vs49%;p=0.002), and anxiety/depression (96%vs54%;p<0.001). Conclusion(s): These preliminary results are in line in previous studies in critical COVID-19 survivors, with depression being associated with worse HRQoL. Bearing this in mind, follow-up approaches with an early screening and treatment of these psychiatric symptoms will be fundamental to optimize the recovery of these patients.

Delirium and health-related quality of life in severe COVID-19 survivors

Introduction: Severe COVID-19 survivors experience long-term neuropsychiatric morbidity, particularly those who developed delirium, with a negative impact on health-related quality of life (HRQoL). Objective(s): To identify the cases of delirium in severe COVID-19 patients and to describe its association with post-hospital discharge HRQoL. Method(s): In the context of the longitudinal MAPA project, we included adult patients (>= 18 years old) admitted with COVID-19 to the Intensive Care Medicine Department (ICMD) of a Portuguese University Hospital (October 2020-April 2021). Exclusion criteria were: ICMD length of stay <=24h, terminal illness, major auditory loss, or inability to communicate at the time of assessment. Delirium during ICMD stay was ascertained based on patients' clinical records. HRQoL was evaluated using the 5-Level EQ-5D questionnaire (EQ-5D-5L), at a scheduled telephone follow-up appointment on average 1-2 months after hospital discharge. Result(s): Overall, 124 patients were included with a median age of 62 (range: 24-86) years, being mostly male (65%). About 19% had delirium, 42% were deeply sedated and 43% required invasive mechanical ventilation. Most survivors reported problems on the EQ-5D-5L domains: usual activities (85%), mobility (73%) and anxiety/depression (65%). Patients with delirium reported more pain/discomfort (75%vs46%;p=0.011) and considerably anxiety/ depression (83%vs60%;p=0.032). Conclusion(s): These findings pointed that COVID-19 patients who experienced delirium reported worse HRQoL, regarding pain/discomfort and anxiety/depression. This study highlights the importance of not only prevention but also early screening of delirium during hospital stay, as well as the crucial role of the timely interventions at discharge, in order to minimize delirium longterm impacts.

Depressive symptoms and health-related quality of life in critical COVID-19 survivors: Preliminary results of 1-year follow-up

Introduction: A higher risk of mental health consequences in critical COVID-19 patients is expected due to several reasons, including prolonged mechanical ventilation with exposure to high sedation. In this context, post-discharge depression has been reported in previous COVID-19 studies, with a profound impact on patients' health-related quality of life (HRQoL). Objective(s): To identify depressive symptoms in COVID-19 survivors 1-year after hospital discharge and to analyse its association with HRQoL. Method(s): As part of the longitudinal MAPA project, this study enrolled critical COVID-19 patients admitted in the Intensive Care Medicine Department of a University Hospital (March-May 2020). Participants were assessed through telephone by an intensive care nurse and a psychologist, with the Patient Health Questionnaire (PHQ-9) (depressive symptoms), EuroQol five-dimension fivelevel questionnaire (EQ-5D-5L) and EQ-Visual Analogue Scale (EQ-VAS) (global health status patient record). Result(s): A sample of 55 survivors (median age=66 years;69% males) were included, with 20% showing depressive symptoms. Pain/discomfort (67%) and anxiety/depression (67%) were the most EQ-5D-5L domains reported. Survivors scoring for depression had more problems in all HRQoL areas (mobility:91%vs.48%, p=0.015;self-care:64%vs.27%, p=0.035;usual activities:91%vs.50%, p=0.017;pain/discomfort:100%vs.59%, p=0.010;anxiety/depression:100% vs.59%, p=0.010). Moreover, they had a lower EQ-VAS median, corresponding a worse self-perception of health status (50vs.80, p=0.010). Conclusion(s): Even after 1-year, a significant proportion of survivors presented depressive symptoms with repercussions in all HRQoL dimensions and association with worse self-perception of global quality of life. Taking this in mind, early screening and treatment of depression in COVID-19 survivors will be crucial, minimizing its impact on quality of life.

High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020

Residents in long-term care facilities (LTCF) are a vulnerable population group. Coronavirus disease (COVID-19)-related deaths in LTCF residents represent 30-60% of all COVID-19 deaths in many European countries. This situation demands that countries implement local and national testing, infection prevention and control, and monitoring programmes for COVID-19 in LTCF in order to identify clusters early, decrease the spread within and between facilities and reduce the size and severity of outbreaks.

P.0811 Factors and outcomes associated with delirium in critically ill COVID-19 patients

Introduction: Evidence demonstrates that 25-33% of hospitalized patients with COVID-19 develop delirium [1,2], with rates up to 65% in critically ill patients [3]. Several potential reasons, including the use of deep sedation and invasive mechanical ventilation (IMV), as well as the restrictions to limit infection transmission, such as prohibition of family visits and minimal contact with health staff were identified [4]. Although factors and outcomes associated with delirium are well documented, limited data are available regarding severe COVID-19 patients. Aims: This study aims to estimate the rates of delirium in critically ill COVID-19 patients and to analyze factors that may be associated with its development, as well as to examine long-term outcomes. Methods: From March to May 2020 (in COVID-19 first wave), all adult patients (≥18y.o.) admitted due to COVID-19, in the Intensive Care Medicine Department (ICMD) of a University Hospital (CHUSJ), in Porto, Portugal, were assessed, unless they had a ICMD length of stay (LoS) ≤24h, terminal illness or major sensory loss or inability to communicate at the time of follow-up. Participants were evaluated during a scheduled telephone follow-up appointment with a comprehensive protocol, including: Six-item Cognitive Impairment Test (6CIT) (cognitive impairment);Patient Health Questionnaire (PHQ-9) (symptoms of depression);General Anxiety Disorder (GAD-7) (symptoms of anxiety);and EuroQol five-dimension five-level questionnaire (EQ-5D-5L) (health-related quality of life-HRQoL), which includes EQ-Visual Analogue Scale (EQ-VAS) (global health status patient perception). Data on acute illness severity, sedative/analgesic drugs use, respiratory support and major complications (including delirium, nosocomial infections and difficulty weaning from mechanical ventilation) during ICMD stay, were obtained from hospital electronic records review. Patients with and without delirium were compared, using Mann-Whitney test for continuous variables, and Chi-square or Fisher tests for paired categorical variables (significance level of 0.05). This study is part of an ongoing larger multidisciplinary research project (MAPA-Mental Health in Critically ill patients with COVID-19). Results: The sample included 59 patients (median age=65 years;66.1% male). Delirium was registered in almost half of the sample (49.2%). Patients with delirium were significantly older (median=72 vs. 62;p=0.010) and presented more nosocomial infections (82.8% vs 53.3%;p=0.032) particularly ventilator-associated pneumonia (75.9% vs. 33.3%;p=0.003). Also, they were significantly more likely to be deeply sedated (89.7% vs 60%;p=0.021), more often required IMV (89.7% vs 60%;p=0.021). Moreover, those with delirium stayed longer in the hospital (median=67 vs 37 days;p=0.014). Concerning HRQoL, assessed at follow-up appointment, patients who have developed delirium reported more problems in self-care (48.3% vs 10%;p=0.003) and in everyday activities (79.3% vs 53.3%;p=0.035) after hospital discharge. Nevertheless, no statistically significant differences were found for cognitive impairment, symptoms of anxiety and depression. Conclusions: Delirium was common in this critically ill COVID-19 sample, namely in older patients, who have been deeply sedated, invasively ventilated or had major ICU complications. It was associated with longer hospital stay and worse HRQoL. Recognizing potential associated factors will allow the identification of high-risk patients that should be targeted for early screening with preventive interventions to minimize the adverse outcomes associated to delirium in critical COVID-19 patients. No conflict of interest