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1.
J Intensive Care Med ; 37(2): 240-247, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1463146

ABSTRACT

INTRODUCTION: Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. STUDY DESIGN AND METHODS: A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. RESULTS: 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). INTERPRETATION: This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.


Subject(s)
Analgesia , COVID-19 , Humans , Registries , Retrospective Studies , SARS-CoV-2 , Tracheostomy
2.
Ann Intern Med ; 174(5): 613-621, 2021 05.
Article in English | MEDLINE | ID: covidwho-1239133

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE: To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN: Single-health system, multihospital retrospective cohort study. SETTING: 5 hospitals within the University of Pennsylvania Health System. PATIENTS: Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS: The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS: Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS: Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION: Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.


Subject(s)
COVID-19/mortality , COVID-19/therapy , Critical Illness/mortality , Critical Illness/therapy , Pneumonia, Viral/mortality , Pneumonia, Viral/therapy , Shock/mortality , Shock/therapy , APACHE , Academic Medical Centers , Aged , Female , Hospital Mortality , Humans , Intensive Care Units , Length of Stay/statistics & numerical data , Male , Middle Aged , Pandemics , Patient Readmission/statistics & numerical data , Pennsylvania/epidemiology , Pneumonia, Viral/virology , Respiration, Artificial/statistics & numerical data , Retrospective Studies , SARS-CoV-2 , Shock/virology , Survival Rate
3.
Ann Surg ; 272(3): e181-e186, 2020 09 01.
Article in English | MEDLINE | ID: covidwho-1066507

ABSTRACT

OBJECTIVE: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ±â€Š6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ±â€Š6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.


Subject(s)
COVID-19/therapy , Critical Care , Intubation, Intratracheal , Respiration, Artificial , Tracheostomy , Adult , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/mortality , Extracorporeal Membrane Oxygenation , Female , Humans , Male , Middle Aged , Prospective Studies , Treatment Outcome , Young Adult
4.
Anesthesiology ; 133(5): 961-963, 2020 11 01.
Article in English | MEDLINE | ID: covidwho-889596
6.
World J Otorhinolaryngol Head Neck Surg ; 6: S36-S39, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-548040

ABSTRACT

IMPORTANCE: The COVID-19 pandemic is characterized by high transmissibility from patients with prolonged minimally- or asymptomatic periods, with a particularly increased risk of spread during aerosol-generating procedures, including endotracheal intubation. OBSERVATIONS: All patients presenting with upper airway obstruction due to angioedema during this time should be carefully managed in a way that is safest for both patient and provider. CONCLUSIONS: For patients requiring emergent airway management during the COVID-19 pandemic, minimization of aerosols while taking the necessary precautions to protect healthcare workers should are critical principles for their management.

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