ABSTRACT
Introduction: Community-acquired pneumonia due to COVID-19 has been a recent and frequent cause of admission to intensive care units worldwide. Its rapid expansion and high number of cases mean that there are many open questions regarding its management, treatment and prognosis. One of these is the performing of a tracheostomy in patients affected by this pneumonia admitted to intensive care. Material and methods: A retrospective, observational study was carried out on all the patients admitted to the Intensive Medicine Department at a University Hospital with the clinical or analytical diagnosis of COVID-19 pneumonia. An analysis was performed on all patients that required mechanical ventilation connection and tracheostomy during their management. Results: A total of 37 patients were analysed, of whom 70.3% (26/37) were male. The mean age was 59.4±9.4, and the APACHE II score was 14.8±4.67. The mean number of days of mechanical ventilation prior to the performing of the tracheostomy was 11±2.66. On 3 occasions it was done during the first week, and on 31 occasions during the second. Percutaneous tracheostomy was performed in 86.5% (32/37) of the cases, and 17 (46%) patients were decannulated. The mean number of days from tracheostomy to decannulation was 17.7±10.6 days, with 16 of these 17 patients having been discharged from the hospital. In the study sample, the type of technique was not associated with a higher mortality or complication rate. Conclusions: The results are presented on 37 patients who required a tracheostomy as part of the management of COVID-19 pneumonia in a University Hospital, as well as a description of the technique performed and prognosis. © 2020 Asociación Colombiana de Medicina Crítica y Cuidado lntensivo
ABSTRACT
BACKGROUND AND AIMS: The clinical follow-up of CKD patients by nephrologists before RRT initiation (RRTi) is recommended by the practice guidelines starting with stage 3b CKD [1]. Despite this, the real-life implementation in clinical practice suggests otherwise, based on the paucity of papers reporting on the matter [2, 3]. In Romania, where the representation of the nephrology outpatient care is scarce, partly because of the low number of specialists, the establishment of outpatient clinics attached to dialysis units could be a solution. The purpose of this analysis is to evaluate, for the first time, if nephrological monitoring through the Diaverum outpatient clinics has benefits for CKD patients. METHOD: A total of 344 patients from 9 Diaverum clinics have been evaluated (335 haemodialysis, 9 peritoneal dialysis), our present analysis retaining only those starting haemodialysis, of which 118 started RRT in the 3 years between 1 January 2015 and 31 December 2017 and were monitored through the nephrology outpatient and 217 were patients there were not referred to a nephrology unit until RRTi, in the 2 years between 1 July 2016 and 1 July 2018. Clinical and laboratory data were gathered at RRTi and the follow up was investigated over a period of 3 years for both groups, starting from the end of the inclusion period, using anonymized records from the electronic database of Diaverum. Collected data were compared using the Pearson test for nominal variables and the Student's t-test and Wilcoxon Mann-Whitney U-tests for continuous variables. Survival analysis was employed using the Kaplan-Meier estimate and Cox regression models. RESULTS: The patient groups had similar general characteristics: most were men, >40% being elder (>65 yo), ∼30% had DM and both groups were comprised of subjects with multiple comorbidities (a mean Charlson score of 6). For patients that were not nephrologically referred, RRT was started in 100% of the cases using a CVC, while AVFs were employed in a majority of those followed through the outpatient clinics. In both groups, the mean eGFR was similarly <10 mL/min/1/73 m2, but >7 mL/min/1.73 m2, reflecting an alignment to clinical practice guidelines [1]. The median level of haemoglobin and the percentage of those with an optimal level of haemoglobin were higher in the group of monitored patients (9.9 versus 8.4 g/dL, respectively, 42% versus 15%).The nutrition status faired better in monitored patients: BMI (26 versus 23.3 kg/m2) and serum albumin (3.8 versus 3.5 g/dL). Serum calcium levels were higher (8.8 versus 8.3 mg/dL) and serum iPTH levels were lower (264 versus 331 pg/mL) in monitored patients, suggesting a better control of CKD-MBD, but serum phosphate was higher (5.7 versus 4.64 mg/dL), possibly reflecting a better nutrition status. The number of hospital admissions, COVID-19 cases and deaths are hard to compare, given the different observation periods that covered different periods and waves of the COVID-19 pandemic. However, hospital admissions and COVID-19 cases seemed more frequent in those that were not monitored. The 4 year survival rate was significantly higher (59% versus 51%) in the Kaplan- Meier analysis for those monitored through the outpatient. In the multivariate analysis, statistically significant associations with mortality were observed for diabetic and unmonitored patients. A major bias in our analysis is the difference between the periods of follow-up, which featured different periods of the COVID-19 pandemic. CONCLUSION: This is the first observational analysis on a nephrological patient population from Romania, which was followed through outpatient units until the initiation of RRT. Patient monitoring before RRTi potentially allows: for a better control of the main complications of CKD (anaemia, CKD-MBD), a better preparation for RRTi (a more frequent use of an AVF) and possibly for an improvement in morbidity and mortality, as suggested by previous studies on the benefits of nephrological monitoring before RRTi [4, 5].
ABSTRACT
Resumen Introducción: La neumonía adquirida en la comunidad por COVID 19 ha sido una causa reciente y frecuente de ingreso en las unidades de cuidados intensivos en todo el mundo. Su rápida expansión y elevado número de casos hace que existan muchas preguntas abiertas en cuanto a su manejo, tratamiento y seguimiento. Uno de estos es la realización de traqueostomía en los pacientes afectados por esta neumonía ingresados en cuidados intensivos. Material y métodos: Se realiza un estudio retrospectivo, observacional, con todos los enfermos que ingresan en el Servicio de Medicina Intensiva en un Hospital Universitario con el diagnóstico clínico o analítico de neumonía por COVID-19. Se analizan todos los pacientes que durante su ingreso requieren conexión a ventilación mecánica y realización de traqueostomía durante su manejo. Resultados: Se analizan un total de 37 pacientes. El 70,3% de la muestra son hombres (26/37). Edad media 59,4 ± 9,4. APACHE II 14,8 ± 4,67. Los días medios de ventilación mecánica previa a la realización de traqueostomía fue de 11 ± 2,66. Se realizó traqueostomía percutánea en el 86,5% (32/37) de los casos. En 3 ocasiones se realizó en la primera semana. En 3 tras los primeros 14 días y en 31/37 en el trascurso de la segunda semana. 17 pacientes han sido decanulados (46%). Los días medios desde realización de traqueostomía hasta decanulación ha sido de 17,7 ± 10,6 días. 16 de estos 17 pacientes ha sido dado de alta del hospital. En nuestra muestra, el tipo de técnica no se asocia a mayor mortalidad o tasa de complicaciones. Conclusiones: Presentamos los resultados de 37 pacientes que requieren traqueostomía como parte del manejo de neumonía por COVID 19 en un Hospital Universitario. Descripción de la técnica realizada y pronóstico. Introduction: Community-acquired pneumonia due to COVID 19 has been a recent and frequent cause of admission to intensive care units worldwide. Its rapid expansion and high number of cases mean that there are many open questions regarding its management, treatment and prognosis. One of these is the performing of a tracheostomy in patients affected by this pneumonia admitted to intensive care. Material and methods: A retrospective, observational study was carried out on all the patients admitted to the Intensive Medicine Department at a University Hospital with the clinical or analytical diagnosis of COVID-19 pneumonia. An analysis was performed on all patients that required mechanical ventilation connection and tracheostomy during their management. Results: A total of 37 patients were analysed, of whom 70.3% (26/37) were male. The mean age was 59.4 ± 9.4, and the APACHE II score was 14.8 ± 4.67. The mean number of days of mechanical ventilation prior to the performing of the tracheostomy was 11 ± 2.66. On 3 occasions it was done during the first week, and on 31 occasions during the second. Percutaneous tracheostomy was performed in 86.5% (32/37) of the cases, and 17 (46%) patients were decannulated. The mean number of days from tracheostomy to decannulation was 17.7 ± 10.6 days, with 16 of these 17 patients having been discharged from the hospital. In the study sample, the type of technique was not associated with a higher mortality or complication rate. Conclusions: The results are presented on 37 patients who required a tracheostomy as part of the management of COVID 19 pneumonia in a University Hospital, as well as a description of the technique performed and prognosis.