Retrospective study of the effect of vaccination against SARS-CoV-2 in seriously ill patients admitted to an intensive care unit. / Estudio retrospectivo del efecto de la vacunación frente al SARS-CoV-2 en enfermos graves que ingresan en una unidad de cuidados intensivos.

BACKGROUND AND OBJECTIVE: Our study aims to compare the clinical and epidemiological characteristics, length of stay in the ICU, and mortality rates of COVID-19 patients admitted to the ICU who are fully vaccinated, partially vaccinated, or unvaccinated. PATIENTS AND METHODS: Retrospective cohort study (March 2020-March 2022). Patients were classified into unvaccinated, fully vaccinated, and partially vaccinated groups. We initially performed a descriptive analysis of the sample, a multivariable survival analysis adjusting for a Cox regression model, and a 90-day survival analysis using the Kaplan-Meier method for the death time variable. RESULTS: A total of 894 patients were analyzed: 179 with full vaccination, 32 with incomplete vaccination, and 683 were unvaccinated. Vaccinated patients had a lower incidence (10% vs. 21% and 18%) of severe ARDS. The survival curve did not show any differences in the probability of surviving for 90 days among the studied groups (p = 0.898). In the Cox regression analysis, only the need for mechanical ventilation during admission and the value of LDH (per unit of measurement) in the first 24 hours of admission were significantly associated with mortality at 90 days (HR: 5.78; 95% CI: 1.36-24.48); p = 0.01 and HR: 1.01; 95% CI: 1.00-1.02; p = 0.03, respectively. CONCLUSIONS: Patients with severe SARS-CoV-2 disease who are vaccinated against COVID-19 have a lower incidence of severe ARDS and mechanical ventilation than unvaccinated patients.

COVID-19-associated lung weakness (CALW): Systematic review and meta-analysis.

OBJECTIVES: To assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). DESIGN: Systematic review with meta-analysis. SETTING: Intensive Care Unit (ICU). PARTICIPANTS: Original research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19, who developed atraumatic PNX or PNMD on admission or during hospital stay. INTERVENTIONS: Data of interest were obtained from each article and analyzed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed with data derived from studies including patients who developed atraumatic PNX or PNMD. MAIN VARIABLES OF INTEREST: Mortality, mean ICU stay and mean PaO2/FiO2 at diagnosis. RESULTS: Information was collected from 12 longitudinal studies. Data from a total of 4901 patients were included in the meta-analysis. A total of 1629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite the finding of significantly strong associations, the great heterogeneity between studies implies that the interpretation of results should be made with caution. CONCLUSIONS: Mortality among COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose grouping these cases under the term COVID-19-associated lung weakness (CALW).

Papel de la ecografía en la insuficiencia respiratoria aguda y en el weaning de la ventilación mecánica

Resumen La evaluación integral mediante ecografía se ha convertido en una herramienta indispensable para facilitar el diagnóstico y el manejo terapéutico en los pacientes críticos con insuficiencia respiratoria aguda (IRA). Existe evidencia que apoya el uso de la ecografía para el diagnóstico de neumotórax, síndrome de distrés respiratorio agudo, edema pulmonar cardiogénico, neumonía, tromboembolismo pulmonar agudo y el paciente con COVID-19. Además, en los últimos años se ha desarrollado el uso de la ecografía para evaluar la respuesta a los tratamientos en los pacientes críticos con IRA, brindando una herramienta no invasiva para la titulación de la presión positiva al final de la espiración, monitorizar las maniobras de reclutamiento y la respuesta al prono, así como para facilitar la retirada de la ventilación mecánica. El objetivo de esta revisión es resumir los conceptos básicos sobre la utilidad de la ecografía en el diagnóstico y la monitorización de los pacientes críticos con IRA. Comprehensive ultrasound assessment has become an essential tool to facilitate diagnosis and therapeutic management in critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia, acute pulmonary thromboembolism, and the patient with COVID-19. In addition, in recent years, the use of ultrasound to evaluate response to treatments in critically ill patients with ARF has been developed, providing a non-invasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone, as well as to facilitate weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.

Effect of the duration of prone position in ARDS patients during the SARS-CoV-2 pandemic.

OBJECTIVE: To describe the characteristics of patients with acute respiratory distress syndrome (ARDS) due to bilateral COVID-19 pneumonia on invasive mechanical ventilation (IMV), and to analyze the effect of prone position >24 h (prolonged) (PPP) compared to prone decubitus <24 h (PP). DESIGN: A retrospective observational descriptive study was carried out, with uni- and bivariate analyses. SETTING: Department of Intensive Care Medicine. Hospital General Universitario de Elche (Elche, Alicante, Spain). PARTICIPANTS: Patients with SARS-CoV-2 pneumonia (2020-2021) on IMV due to moderate-severe ARDS, ventilated in prone position (PP). INTERVENTIONS: IMV. PP maneuvers. MAIN VARIABLES OF INTEREST: Sociodemographic characteristics, analgo-sedation, neuromuscular blockade (NMB), PD duration, ICU stay and mortality, days of IMV, non-infectious complications, healthcare associated infections. RESULTS: Fifty-one patients required PP, and of these, 31 (69.78%) required PPP. No differences were observed in terms of patient characteristics (gender, age, comorbidities, initial severity, antiviral and antiinflammatory treatment received). Patients on PPP had poorer tolerance to supine ventilation (61.29% vs 89.47%, p = 0.031), longer hospital stay (41 vs 30 days, p = 0.023), more days of IMV (32 vs 20 days, p = 0.032), longer duration of NMB (10.5 vs 3 days, p = 0.0002), as well as a higher percentage of episodes of orotracheal tube obstruction (48.39% vs 15%, p = 0.014). CONCLUSIONS: PPP was associated with greater resource use and complications in patients with moderate-severe ARDS due to COVID-19.

Multidisciplinary approach of the sequelae one month after hospital discharge in patients with severe bilateral COVID-19 pneumonia, are there differences depending on the respiratory therapy used during admission to intensive care?

OBJECTIVE: To describe the sequelae one month after hospital discharge in patients who required admission to Intensive Care for severe COVID 19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation. DESIGN: Cohort, prospective and observational study. SETTING: Post-intensive care multidisciplinary program. PATIENTS OR PARTICIPANTS: Patients who survived admission to the intensive care unit (ICU) for severe COVID 19 pneumonia from April 2020 to October 2021. INTERVENTIONS: Inclusion in the post-ICU multidisciplinary program. MAIN VARIABLES OF INTEREST: Motor, sensory, psychological/psychiatric, respiratory and nutritional sequelae after hospital admission. RESULTS: 104 patients were included. 48 patients received high-flow nasal oxygen therapy (ONAF) and 56 invasive mechanical ventilation (IMV). The main sequelae found were distal neuropathy (33.9% IMV vs 10.4% ONAF); brachial plexopathy (10.7% IMV vs 0% ONAF); decrease in grip strength: right hand 20.67kg (±8.27) in VMI vs 31.8kg (±11.59) in ONAF and left hand 19.39kg (±8.45) in VMI vs 30.26kg (±12.74) in ONAF; and limited muscle balance in the lower limbs (28.6% VMI vs 8.6% ONAF). The differences observed between both groups did not reach statistical significance in the multivariable study. CONCLUSIONS: The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used, whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation, although more studies are needed to be able to draw conclusions.

The Bayes factor in the analysis of mechanical power in patients with severe respiratory failure due to SARS-CoV-2.

OBJECTIVE: To specify the degree of probative force of the statistical hypotheses in relation to mortality at 28 days and the threshold value of 17 J/min mechanical power (MP) in patients with respiratory failure secondary to SARS-CoV-2. DESIGN: Cohort study, longitudinal, analytical. SETTING: Intensive care unit of a third level hospital in Spain. PATIENTS: Patients admitted for SARS-CoV-2 infection with admission to the ICU between March 2020 and March 2022. INTERVENTIONS: Bayesian analysis with the beta binomial model. MAIN VARIABLES OF INTEREST: Bayes factor, mechanical power. RESULTS: A total of 253 patients were analyzed. Baseline respiratory rate (BF10: 3.83 × 106), peak pressure value (BF10: 3.72 × 1013) and neumothorax (BF10: 17,663) were the values most likely to be different between the two groups of patients compared. In the group of patients with MP < 17 J/min, a BF10 of 12.71 and a BF01 of 0.07 were established with an 95%CI of 0.27-0.58. For the group of patients with MP ≥ 17 J/min the BF10 was 36,100 and the BF01 of 2.77e-05 with an 95%CI of 0.42-0.72. CONCLUSIONS: A MP ≥ 17 J/min value is associated with extreme evidence with 28-day mortality in patients requiring MV due to respiratory failure secondary to SARS-CoV-2 disease.

Adjuvant treatments to invasive mechanical ventilation in the management of acute respiratory distress syndrome secondary to COVID-19.

INTRODUCTION: This bibliographic review is carried out in order to obtain answers about aspects related to techniques and treatments, as well as care associated with the critically ill patient diagnosed with Covid-19. OBJECTIVE: To analyze the available scientific evidence on the effectiveness of the use of invasive mechanical ventilation together with other adjuvant techniques, in reducing the mortality rate in patients with Acute Respiratory Distress Syndrome and clinical trial of Covid-19 treated in intensive care units. METHODOLOGY: A systematized bibliographic review was carried out in the Pubmed, Cuiden, Lilacs, Medline, Cinahl and Google Scholar databases, using MeSH terms (Adult Respiratory Distress Syndrome, Mechanical Ventilation, Prone Position, Nitric Oxide, Extracorporeal Membrane Oxygenation, Nursing Care) and the corresponding Boolean operators. The selected studies underwent a critical reading carried out between December 6, 2020 and March 27, 2021 using the Critical Appraisal Skills Program tool in Spanish and a cross-sectional epidemiological studies evaluation instrument. RESULTS: A total of 85 articles were selected. After performing the critical reading, a total of 7 articles were included in the review, 6 being descriptive studies and 1 cohort study. After analyzing these studies, it appears that the technique that has obtained the best results is ECMO, with the care provided by qualified and trained nursing staff being very important. CONCLUSION: Mortality from Covid-19 increases in patients treated with invasive mechanical ventilation compared to patients treated with extracorporeal membrane oxygenation. Nursing care and specialization can have an impact on improving patient outcomes.

Dysphagia in intensive care, a real problem: analysis of risk factors.

AIMS: To identify risk factors present in patients with dysphagia in a population of critically ill patients. METHODS: Case series of a cohort of patients recruited in the intensive care unit (ICU) until hospital discharge. Patients who gave consent and met the inclusion criteria were recruited. The Volume-Viscosity clinical examination method was used for the screening of dysphagia. An uni- and bivariate statistical analysis was performed using odds ratio (OR) to detect risk factors for dysphagia. OUTCOMES: 103 patients were recruited from 401 possible. The mean age was 59,33 ± 13,23, men represented 76,7%. The severity of the sample was: APACHE II (12,74 ± 6,17) and Charlson (2,98 ± 3,31). 45,6% of patients showed dysphagia, obtaining significant OR values (p < 0,050) for the development of dysphagia: older age, neurological antecedents, COVID19, long stay in ICU and hospitalization, and the presence of tracheotomy. COVID19 patients represented 46,6% of the sample, so an analysis of this subgroup was performed, showing similar results, with a Charlson risk (OR:4,65; 95% CI:1,31-16,47; p = 0,014) and a hospital stay (OR: 8,50; 95%CI: 2,20-32,83; p < 0,001) On discharge from the ICU, 37,9% of the population still had dysphagia; 12,6% maintained this problem at hospital discharge. CONCLUSIONS: Almost half of our patients developed dysphagia. Clinical severity and the presence of tracheotomy were risk factors. We observed in patients with dysphagia a longer stay in both ICU and hospitalization.

Impacts of a fraction of inspired oxygen adjustment protocol in COVID-19 patients under mechanical ventilation: A prospective cohort study.

OBJECTIVE: We examined weather a protocol for fraction of inspired oxygen (FiO2) adjustment can reduce hyperoxemia and excess oxygen use in COVID-19 patients mechanically ventilated. DESIGN: Prospective cohort study. SETTING: Two intensive care units (ICUs) dedicated to COVID-19 patients in Brazil. PATIENTS: Consecutive patients with COVID-19 mechanically ventilated. INTERVENTIONS: One ICU followed a FiO2 adjustment protocol based on SpO2 (conservative-oxygen ICU) and the other, which did not follow the protocol, constituted the control ICU. MAIN VARIABLES OF INTEREST: Prevalence of hyperoxemia (PaO2>100mmHg) on day 1, sustained hyperoxemia (present on days 1 and 2), and excess oxygen use (FiO2>0.6 in patients with hyperoxemia) were compared between the two ICUs. RESULTS: Eighty two patients from the conservative-oxygen ICU and 145 from the control ICU were included. The conservative-oxygen ICU presented lower prevalence of hyperoxemia on day 1 (40.2% vs. 75.9%, p<0.001) and of sustained hyperoxemia (12.2% vs. 49.6%, p<0.001). Excess oxygen use was less frequent in the conservative-oxygen ICU on day 1 (18.3% vs. 52.4%, p<0.001). Being admitted in the control ICU was independently associated with hyperoxemia and excess oxygen use. Multivariable analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FiO2 use and adverse clinical outcomes. CONCLUSIONS: Following FiO2 protocol was associated with lower hyperoxemia and less excess oxygen use. Although those results were not associated with better clinical outcomes, adopting FiO2 protocol may be useful in a scenario of depleted oxygen resources, as was seen during the COVID-19 pandemic.

Adherence to protective mechanical ventilation in COVID-19 versus non-COVID-19-associated acute respiratory distress syndrome: Comparison between two prospective cohorts.

OBJECTIVE: To compare adherence to protective mechanical ventilation (MV) parameters in patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 with patients with ARDS from other etiologies. DESIGN: Multiple prospective cohort study. SETTING: Two Brazilian cohorts of ARDS patients were evaluated. One with COVID-19 patients admitted to two Brazilian intensive care units (ICUs) in 2020 and 2021 (C-ARDS, n=282), the other with ARDS-patients from other etiologies admitted to 37 Brazilian ICUs in 2016 (NC-ARDS, n=120). PATIENTS: ARDS patients under MV. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Adherence to protective MV (tidal volume ≤8mL/kg PBW; plateau pressure ≤30cmH2O; and driving pressure ≤15cmH2O), adherence to each individual component of the protective MV, and the association between protective MV and mortality. RESULTS: Adherence to protective MV was higher in C-ARDS than in NC-ARDS patients (65.8% vs. 50.0%, p=0.005), mainly due to a higher adherence to driving pressure ≤15cmH2O (75.0% vs. 62.4%, p=0.02). Multivariable logistic regression showed that the C-ARDS cohort was independently associated with adherence to protective MV. Among the components of the protective MV, only limiting driving pressure was independently associated with lower ICU mortality. CONCLUSIONS: Higher adherence to protective MV in patients with C-ARDS was secondary to higher adherence to limiting driving pressure. Additionally, lower driving pressure was independently associated with lower ICU mortality, which suggests that limiting exposure to driving pressure may improve survival in these patients.

La disfagia en cuidados intensivos, un problema real: análisis de factores de riesgo

Resumen Objetivos Determinar los factores de riesgo presentes en los pacientes con disfagia en relación con una población de pacientes críticos. Método Serie de casos de una cohorte de pacientes reclutados en la unidad de cuidados intensivos (UCI) hasta el alta hospitalaria. Se reclutaron a aquellos pacientes que dieron su consentimiento y cumplían los criterios de inclusión. El método de exploración clínica Volumen-Viscosidad fue utilizado para la detección de la disfagia. Se realizó un análisis estadístico uni- y bivariante, a través del odds ratio (OR) para detectar los factores de riesgo en la disfagia. Resultados 103 pacientes fueron reclutados de 401 posibles. La media de edad fue de 59,33±13,23;los hombres representaban el 76,7%. La gravedad media fue: APACHE II (12,74±6,17) y Charlson (2,98±3,31). Un 45,6% de los pacientes desarrollaron disfagia, obteniendo valores significativos de OR (p<0,050) para el desarrollo de disfagia: la mayor edad, los antecedentes neurológicos, COVID19, la alta estancia en UCI y hospitalización y la presencia de traqueotomía. Los pacientes COVID19 representaban el 46,6%, por lo que se realizó un análisis de este subgrupo observando resultados similares, con un riesgo de Charlson (OR:4,65;IC95%: 1,31-16,47;p=0,014) y una estancia hospitalaria (OR: 8,50;IC95%: 2,20-32,83;p<0,001). Al alta de UCI, el 37,9% de la población presentaba todavía disfagia, y mantenía este problema al alta hospitalaria el 12,6%. Conclusiones Casi la mitad de nuestros pacientes presentaron disfagia. Fueron factores de riesgo la gravedad clínica y la presencia de traqueotomía. Se observó en estos pacientes una mayor estancia tanto en UCI como en hospitalización. Aims To identify risk factors present in patients with dysphagia in a population of critically ill patients. Methods Case series of a cohort of patients recruited in the intensive care unit (ICU) until hospital discharge. Patients who gave consent and met the inclusion criteria were recruited. The Volume-Viscosity clinical examination method was used for the screening of dysphagia. An uni- and bivariate statistical analysis was performed using odds ratio (OR) to detect risk factors for dysphagia. Outcomes 103 patients were recruited from 401 possible. The mean age was 59,33±13,23, men represented 76,7%. The severity of the sample was: APACHE II (12,74±6,17) and Charlson (2,98±3,31). 45,6% of patients showed dysphagia, obtaining significant OR values (p<0,050) for the development of dysphagia: older age, neurological antecedents, COVID19, long stay in ICU and hospitalization, and the presence of tracheotomy. COVID19 patients represented 46,6% of the sample, so an analysis of this subgroup was performed, showing similar results, with a Charlson risk (OR:4,65;95% CI:1,31-16,47;p=0,014) and a hospital stay (OR: 8,50;95%CI: 2,20-32,83;p<0,001). On discharge from the ICU, 37,9% of the population still had dysphagia;12,6% maintained this problem at hospital discharge. Conclusions Almost half of our patients developed dysphagia. Clinical severity and the presence of tracheotomy were risk factors. We observed in patients with dysphagia a longer stay in both ICU and hospitalization.

Characteristics and Outcomes of Patients with COVID-19 in Intensive Care in the First Year of the Pandemic: A Colombian Observational Study

Background: The COVID-19 pandemic has had a devastating impact on the world, mainly during the first year of the pandemic, where strategies such as vaccination were not available. Information on the outcomes of patients admitted to the intensive care unit (ICU) in Colombia is scarce. Our main objective was to characterize critically ill patients with COVID-19 in our region. Methods: We conducted a single-centre retrospective observational study in which we included patients with COVID-19 confirmed by RT-PCR who were admitted to the adult ICU between March 18, 2020 and March 18, 2021, in Quindío, Colombia. We identify the clinical and laboratory characteristics at admission, the support used, and their relationship with mortality during ICU hospitalization. Results: Three hundred and fifty-nine patients with a confirmed diagnosis of COVID-19 were admitted, 64% men, mean age was 62.7 years (SD±12.3), body mass index 27.9Kg/m2 (±5.8), SOFA score was 7.6 (±3.12), Pa/FiO2 96.2 (±62.3), and lung compliance 30.5 ml/cmH2O (±18.4). Mortality was 60%. The variables with the highest mortality association were obesity OR: 2.38 (95% CI:1.39 – 4.09, p: <.001), Glasgow coma scale at admission <12 : 17.5, (5.21 – 58.8, p: <.001), PaFiO2 <100: 5.63, (3.38 – 9.39, p: <.001), static lung compliance less than 50 ml / cmH2O: 3.54, (3.38 – 9.39, p: <.001), SOFA score >5: 3.75 (2.19– 6.42, p: <0.001), ferritin > 1000: 2.58, (1.66 – 4.02, p: <.001), C-reactive protein > 5: 2.52 (1.42 – 4.26, p: <.001), and LDH > 280: 2.71 (1.55 – 4.74, p: <.001). Patients who required PEEP > 10cmH2O: 2.34 (1.48 – 3.70, p: <.001), FiO2 > 60%: 4.01, (2.46 – 6.53, p: <.001), and ventilation in the prone position. Conclusion: Mortality in the first year of the pandemic in our region was high, mainly associated with obesity, inflammation, altered mental status upon admission, and increased lung elastance. Resumen Contexto: La pandemia de COVID-19 ha tenido un impacto devastador en el mundo, principalmente durante el primer año de la pandemia, donde no se disponía de estrategias como la vacunación. La información sobre los resultados de los pacientes ingresados ​​en la unidad de cuidados intensivos (UCI) en Colombia es escasa. Nuestro principal objetivo fue caracterizar a los pacientes críticos con COVID-19 en nuestra región. Métodos: Realizamos un estudio observacional retrospectivo unicéntrico donde incluimos pacientes confirmados con RT-PCR para COVID-19 que ingresaron a la UCI de adultos entre el 18 de marzo de 2020 y el 18 de marzo de 2021, en Quindío, Colombia. Identificamos las características clínicas y de laboratorio al ingreso, los soportes utilizados y su relación con la mortalidad durante la hospitalización en UCI. Resultados: Ingresaron 359 pacientes con diagnóstico confirmado de COVID-19, 64% hombres, edad 62,7 años (DE±12,3), índice de masa corporal 27,9Kg/m2 (±5,8), SOFA score 7,6 (±3,12), Pa /FiO2 96,2 (±62,3) y distensibilidad pulmonar 30,5 ml/cmH2O (±18,4). La mortalidad fue del 60%. Las variables con mayor asociación a mortalidad fueron la obesidad OR: 2,38 (IC 95%: 1,39 – 4,09, P: <0,001), escala de coma de Glasgow al ingreso <12: 17,5, (5,21 – 58,8, P: <0,001), PaFiO2 <100 : 5,63, (3,38 – 9,39, P: <0,001), distensibilidad pulmonar estática inferior a 50 ml/cmH2O: 3,54, (3,38 – 9,39, P: <0,001), puntuación SOFA >5: 3,75 (2,19– 6,42, P: <0,001), ferritina > 1000: 2,58, (1,66 – 4,02, P: <0,001), proteína C reactiva > 5: 2,52 (1,42 – 4,26, P: <0,001) y LDH > 280: 2,71 (1,55 – 4,74), P: <0,001). Pacientes que requirieron PEEP > 10cmH2O: 2,34 (1,48 – 3,70, P: <0,001), FiO2 > 60%: 4,01, (2,46 – 6,53, P: <0,001) y ventilación en decúbito prono. Conclusión: La mortalidad en el primer año de la pandemia en nuestra región fue alta, asociada principalmente a obesidad, inflamación, alteración del estado mental al ingreso y aumento de la elastancia pulmonar.

Pre-clinical validation of a turbine-based ventilator for invasive ventilation-The ACUTE-19 ventilator.

BACKGROUND: The Severe Acute Respiratory Syndrome (SARS)-Coronavirus 2 (CoV-2) pandemic pressure on healthcare systems can exhaust ventilator resources, especially where resources are restricted. Our objective was a rapid preclinical evaluation of a newly developed turbine-based ventilator, named the ACUTE-19, for invasive ventilation. METHODS: Validation consisted of (a) testing tidal volume (V_T) delivery in 11 simulated models, with various resistances and compliances; (b) comparison with a commercial ventilator (VIVO-50) adapting the United Kingdom Medicines and Healthcare products Regulatory Agency-recommendations for rapidly manufactured ventilators; and (c) in vivo testing in a sheep before and after inducing acute respiratory distress syndrome (ARDS) by saline lavage. RESULTS: Differences in V_T in the simulated models were marginally different (largest difference 33ml [95%-confidence interval (CI) 31-36]; P<.001ml). Plateau pressure (P_plat) was not different (-0.3cmH₂O [95%-CI -0.9 to 0.3]; P=.409), and positive end-expiratory pressure (PEEP) was marginally different (0.3 cmH₂O [95%-CI 0.2 to 0.3]; P<.001) between the ACUTE-19 and the commercial ventilator. Bland-Altman analyses showed good agreement (mean bias, -0.29, [limits of agreement, 0.82 to -1.42], and mean bias 0.56 [limits of agreement, 1.94 to -0.81], at a P_plat of 15 and 30cmH₂O, respectively). The ACUTE-19 achieved optimal oxygenation and ventilation before and after ARDS induction. CONCLUSIONS: The ACUTE-19 performed accurately in simulated and animal models yielding a comparable performance with a VIVO-50 commercial device. The acute 19 can provide the basis for the development of a future affordable commercial ventilator.

D dimer concentration variation as predictor of mortality in patients with COVID-19.

OBJECTIVE: To evaluate the D dimer levels after the admission of patients with COVID-19 and to stablish cut-off points that are associated with more complications. MATERIALS AND METHODS: Prospective study with inpatients with severity criteria that compared the D dimer levels at admission and 48 hours later;mean D dimer concentrations were evaluated and cut-off points were stablished. RESULTS: Considering D dimer 48 hours after admission, patients that did not survive had mean levels of 5380 ng/mL versus 1811.3 ng/mL among those that survived (p < 0.005);a cut-off point of 1725 ng/mL was stablished that predicted mortality with sensitivity of 85.7%, specificity of 63%, and negative predictive value of 89.4%. In the group of patients that required invasive mechanical ventilation, mean D dimer was 4672.2 ng/mL versus 1652.6 ng/mL in those who did not need it (p < 0.001) and a cut-off point of 1770 ng/mL was calculated which predicted invasive mechanical ventilation with sensitivity of 84.6%, specificity of 63%, and negative predictive value of 89.4%. CONCLUSIONS: D dimer concentrations after 48 hours of admission can discard the development of complications, so its determination may be useful for determining the adverse evolution risk. (English) [ FROM AUTHOR] OBJETIVO: Evaluar las concentraciones de dímero D posteriores al ingreso de pacientes con COVID-19 y estipular puntos de corte que se asocien con complicaciones. MATERIALES Y MÉTODOS: Estudio prospectivo efectuado en pacientes hospitalizados con criterios de severidad que comparó las concentraciones de dímero D al ingreso y a las 48 horas;se compararon las medias de dímero D y se estipularon puntos de corte. RESULTADOS: Respecto al dímero D a las 48 horas, los pacientes que fallecieron tuvieron una media de 5380 ng/mL, a diferencia de los que no con 1811.3 ng/mL (p < 0.005);se estableció un punto de corte de 1725 ng/mL para predecir mortalidad con sensibilidad del 85.7%, especificidad del 63% y valor predictivo negativo del 89.4%. La media de dímero D de los que requirieron ventilación mecánica invasiva fue de 4672.2 ng/mL contra 1652.6 ng/mL (p < 0.001) y el punto de corte de 1770 ng/mL predice ventilación mecánica invasiva con sensibilidad del 84.6%, especificidad del 63% y valor predictivo negativo del 89.4%. CONCLUSIONES: Las concentraciones de dímero D a las 48 horas de ingreso en pacientes con COVID-19 pueden descartar la aparición de complicaciones, por lo que este marcador es útil para determinar el riesgo de evoluciones adversas. (Spanish) [ FROM AUTHOR] Copyright of Medicina Interna de Mexico is the property of Colegio de Medicina Interna de Mexico and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Clinical characteristics of pediatric patients with acute respiratory distress syndrome due to COVID-19.

BACKGROUND: There are only a few reports of acute respiratory distress syndrome (ARDS) in patients with SARS-CoV-2 in pediatrics. This study aimed to describe the characteristics of critically ill pediatric patients with COVID-19, the frequency of ARDS, ventilatory mechanics and results of prone position. METHODS: We conducted a retrospective, observational study of patients admitted to the pediatric intensive care unit (PICU) between April 1 to September 30, 2020. RESULTS: Thirty-four patients were admitted to pediatric intensive care unit, 31.7% were SARS-CoV-2 positive. 13 presented ARDS, 11 required invasive mechanical ventilation, and seven were pronated as an oxygenation strategy. All patients classified as severe ARDS were pronated. Obesity was the most important comorbidity. The complications associated with ARDS were multisystemic inflammatory syndrome (8 vs. 4; p < 0.05) and acute kidney injury (8 vs. 3; p < 0.05). Procalcitonin was higher in patients with ARDS, as were the days of stay in PICU (p < 0.05). The success of the pronation maneuver was achieved 8 hours later , with the following results: arterial oxygen partial pressure to fractional inspired oxygen ratio 128 vs. 204, oxygenation index 8.9 vs. 5.9, static lung compliance 0.54 vs. 0.70 ml/cmH2O/kg, plateau pressure 24 vs. 19 cmH2O (p < 0.05). The use of narcotics was higher in the group with ARDS plus pronation 124 vs. 27 hours in the non-pronated (p < 0.01). Mortality associated with SARS-CoV-2 was 5.8%. CONCLUSIONS: ARDS was presented in 38.2% of the children admitted to PICU and was more frequent in obese patients. Pronation, performed in severe cases, improved oxygenation and lung mechanics indexes. No patient died of ARDS.

INTRODUCCIÓN: Existen pocos reportes de síndrome de dificultad respiratoria aguda (SDRA) con COVID-19 en pacientes pediátricos. El objetivo de este estudio fue describir las características de los pacientes pediátricos críticamente enfermos con COVID-19, la frecuencia del SDRA, la mecánica ventilatoria y los resultados de la posición prona. MÉTODOS: Se llevó a cabo un estudio retrospectivo y observacional de los pacientes ingresados del 1 de abril al 30 de septiembre de 2020. RESULTADOS: Ingresaron 34 pacientes a la unidad de terapia intensiva pediátrica (UTIP) con prueba positiva para SARS-CoV-2. De ellos, 13 presentaron SDRA, 11 requirieron ventilación mecánica invasiva y siete fueron pronados como estrategia de oxigenación. Todos los pacientes clasificados como SDRA graves fueron pronados. La obesidad fue la comorbilidad más importante. Las complicaciones asociadas con SDRA fueron el síndrome inflamatorio multisistémico (p < 0.05) y la lesión renal aguda (p < 0.05). La procalcitonina fue mayor en los pacientes con SDRA, al igual que los días de estancia en la UTIP (p < 0.05). El éxito de la maniobra de pronación se alcanzó 8 horas después.Los resultados observados fueron los siguientes relación presión arterial de oxígeno/fracción inspirada de oxígeno 128 vs. 204, índice de oxigenación 8.9 vs. 5.9, distensibilidad pulmonar estática 0.54 vs. 0.70 ml/cmH2O/kg, y presión meseta 24 vs. 19 cmH2O (p < 0.05). El uso de narcóticos fue mayor en el grupo de SDRA más pronación que en los no pronados (124 vs. 27 h; p < 0.01). La mortalidad asociada con SARS-CoV-2 fue del 5.8%. CONCLUSIONES: El SDRA se presentó en el 38.2% de los niños admitidos a UTIP, y con mayor frecuencia en los pacientes con obesidad. La maniobra de pronación aplicada en los casos severos, mejoró la oxigenación de la mécanica pulmonar. Ninguno de los pacientes falleció por SDRA.

Mortality and renal long-term outcome of critically ill COVID-19 patients with acute kidney failure, continuous renal replacement therapy and invasive mechanical ventilation. / Mortalidad y función renal a largo plazo en pacientes ingresados en la UCI por COVID-19 con fracaso renal agudo, terapia continua de reemplazo renal y ventilación mecánica invasiva.

BACKGROUND: There are limited data describing the long-term renal outcomes of critically ill COVID-19 patients with acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) and invasive mechanical ventilation. METHODS: In this retrospective observational study we analyzed the long-term clinical course and outcomes of 30 critically ill patients hospitalized with COVID-19 during the peak of highest incidence in the first wave, with acute respiratory distress syndrome (ARDS) and AKI that required CRRT. Baseline features, clinical course, laboratory data, therapies and filters used in CRRT were compared between survivors and non-survivors to identify risk factors associated with in-hospital death. Renal parameters: glomerular filtration rate, proteinuria and microhematuria were collected at 6months after discharge. RESULTS: 19 patients (63%) died and 11 were discharged. Mean time to death was 48days (7-206) after admission. Patients with worse baseline renal function had higher mortality (P=.009). Patients were treated with CRRT for an average of 18.4days. Filters with adsorptive capacity (43%) did not offer survival benefits. Regarding long-term renal outcomes, survivor patients did not receive any additional dialysis, but 9 out of 11 patients had an important loss of renal function (median of eGF of 44 (13-76)ml/min/1.73m2) after 6months. CONCLUSION: Mortality among critically ill hospitalized patients diagnosed with COVID-19 on CRRT is extremely high (63%). Baseline renal function is a predictor factor of mortality. Filters with adsorption capacity did not modify survival. None survivor patients required long-term dialysis, but an important loss of renal function occurred after AKI episode related to COVID-19 infection.

Superinfección por Stenotrophomonas maltophilia en pacientes con COVID-19 críticamente enfermos. Análisis de una serie de casos

Resumen En pacientes con neumonía por SARS-CoV-2 el aumento de infección secundaria por microorganismos nosocomiales ha alertado al sistema de salud. Esto debido, al incrementar la estancia hospitalaria y el desenlace final fatal en los pacientes críticamente enfermos. La siguiente serie de casos se realizó teniendo como objetivo evaluar en muestras de secreción bronquial el aislamiento de la Stenotrophomonas maltophilia en pacientes hospitalizados con COVID-19. Se encontraron 7 pacientes asociados a una excesiva prescripción de antibióticos con baja susceptibilidad para Stenotrophomonas maltophilia y la presencia de infección secundaria bacteriana por este microorganismo asociado al uso de ventilación mecánica invasiva. Esto genera un dilema en las estrategias y recomendaciones médicas utilizadas en muchas instituciones para los pacientes con neumonía por SARS-CoV-2 con necesidad de unidad de cuidados intensivos. In patients with SARS-CoV-2 pneumonia, the increase in secondary infection by nosocomial microorganisms has alerted the health system. This is due to the increase in hospital stay and the final fatal outcome in critically ill patients. The following series of cases was carried out to evaluate the isolation of Stenotrophomonas maltophilia in hospitalized patients with COVID-19 in bronchial secretion samples. Seven patients were found associated with an excessive prescription of antibiotics with low susceptibility to Stenotrophomonas maltophilia and the presence of secondary bacterial infection by this microorganism associated with the use of invasive mechanical ventilation. This creates a dilemma in the medical strategies and recommendations used in many institutions for patients with SARS-CoV-2 pneumonia in need of an intensive care unit.

Viral etiology and outcome of severe lower respiratory tract infections among critically ill children admitted to the PICU.

OBJECTIVE: To determine the viral etiology of severe lower respiratory tract infections (LRTIs), their clinical significance and prognosis among critically ill children. DESIGN: A prospective descriptive study was carried out. SETTING: Pediatric Intensive Care Unit (PICU) of Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey. PATIENTS: A total of 115 patients hospitalized in the PICU were evaluated for inclusion in the study. Children with underlying comorbidities and those who did not require mechanical ventilation were excluded. MAIN VARIABLES OF INTEREST: Demographic, clinical, laboratory test and radiographic data were recorded. RESULTS: A total of 63 patients were eligible for the study. The most common diagnosis was bronchiolitis (57.1%). Respiratory syncytial virus (RSV) was the most frequent causal virus (36.5%). The most common complication was acute respiratory distress syndrome (ARDS) (28.6%). Multiple viral infection was identified in 20.6% of the patients, the most common in this subgroup being rhinovirus. Patients with bocavirus infection had a higher likelihood of needing invasive mechanical ventilation (IMV) at presentation. Children who died were likely to be <12 months old, have ARDS, hepatitis, pneumomediastinum, multiple viral infection, and required IMV support with an increased duration of MV. Additionally, they were found to have a high Pediatric Risk of Mortality III score, Predicted Death Rate and increased need for inotropic support at admission. CONCLUSIONS: Our study showed critically ill children with LRTI without known risk factors to have high mortality when aged <12 months, in the presence of multiple agents and when certain complications (ARDS, hepatitis) and X-ray findings were identified.

Characteristics and mortality of Mexican patients with COVID-19 and mechanical ventilation.

INTRODUCTION: COVID-19-associated mortality in patients who require mechanical ventilation is unknown in the Mexican population. OBJECTIVE: To describe the characteristics of Mexican patients with COVID-19 who required mechanical ventilation. METHODS: Observational cohort study carried out in an intensive care unit from March 25 to July 17, 2020. Data were obtained from a prospective database and electronic medical records, and were analyzed with the chi-square test, Fisher's exact test or Mann-Whitney's U-test. RESULTS: One hundred patients required mechanical ventilation; median age was 56 years, 31 % were females and 97 % were Latin American. Most common comorbidities were obesity (36 %), diabetes (26 %), hypertension (20 %), and chronic or end-stage kidney disease (10 %). At the end of the analysis, 11 patients remained in the ICU, 31 had been discharged alive and 58 (65.2 %) died; survivors were younger, had lower scores on severity and organ dysfunction scales, lower levels of C-reactive protein at ICU admission, were less likely to receive hemodialysis and vasopressors, and had longer hospital and ICU stays. CONCLUSIONS: This study adds information on the presentation and results of SARS-CoV-2-infected patients who require mechanical ventilation.

INTRODUCCIÓN: La mortalidad por COVID-19 en quienes requieren ventilación mecánica se desconoce en la población mexicana. OBJETIVO: Describir las características de pacientes mexicanos con COVID-19 que requirieron ventilación mecánica. MÉTODOS: Estudio de cohorte observacional en una unidad de terapia intensiva, del 25 de marzo al 17 de julio de 2020. Los datos se obtuvieron de una base de datos prospectiva y de registros clínicos electrónicos; fueron analizados con c2, prueba exacta de Fisher o prueba U de Mann-Whitney. RESULTADOS: Cien pacientes recibieron ventilación mecánica, la edad media fue de 56 años, 31 % era del sexo femenino y 97 %, latinoamericano. Las comorbilidades más comunes fueron obesidad (36 %), diabetes (26 %), hipertensión (20 %) y enfermedad renal crónica o renal terminal (10 %). Al término del análisis, 11 pacientes permanecían en la UCI, 31 egresaron vivos y 58 (65.2 %) fallecieron; los sobrevivientes fueron más jóvenes, con menores puntuación en las escalas de gravedad y disfunción orgánica, menores niveles de proteína C reactiva al ingreso a la UCI, menor propensión a hemodiálisis, necesidad de, necesidad de vasopresores y con mayor estancia hospitalaria y en la UCI. CONCLUSIONES: Este estudio agrega información sobre la presentación y resultados de pacientes con ventilación mecánica infectados con SARS-CoV-2.

COVID-19 and pregnancy: clinical case of critical presentation, placental inflammation and demonstrated fetal vertical transmission / COVID-19 y embarazo: caso clínico de presentación crítica, inflamación placentaria y transmisión vertical fetal demostrada

ANTECEDENTES: La pandemia global de COVID-19 llega al continente americano en marzo del año 2020 y en menos de dos meses reúne a más de la mitad de los casos a nivel global. OBJETIVO: Caso clínico de una mujer embarazada con una presentación crítica de COVID-19 y embarazo a las 25 semanas de gestación, en el contexto del peak de la pandemia en Chile en el otoño del año 2020. CASO CLÍNICO: El 20 de junio de 2020, una mujer de 34 años, con 25 semanas de embarazo, es trasladada desde Hospital de San Bernardo a Clínica Las Condes en Santiago, Chile, con un cuadro de 10 días de evolución de COVID-19, que evoluciona a una situación crítica con insuficiencia respiratoria severa. Ingresa a unidad de cuidados intensivos para ventilación mecánica. Las imágenes de radiología simple y de tomografía axial computarizada de tórax demuestran una neumopatía bilateral con imágenes características opacidades en vidrio esmerilado, asociado a engrosamiento intersticial, imágenes descritas previamente como características para COVID-19. La paciente permanece en unidad de cuidados intensivos en ventilación mecánica por siete días, con evolución favorable posterior, mejoría del cuadro séptico y alta después de 22 días de hospitalización. El parto ocurre en forma espontánea a las 38 semanas, la madre y el recién nacido evolucionan en buen estado general. El examen histopatológico placentario demuestra compromiso inflamatorio vellositario y los exámenes de anticuerpos en sangre del recién nacido demuestran la presencia de anticuerpos del tipo IgG e IgM. Se trata de uno de los pocos casos demostrados reportados de transmisión transplacentaria vía sanguínea de SARS-CoV-2 de la madre al recién nacido.

BACKGROUND: The global COVID-19 pandemic reaches the American continent in March 2020 and in less than two months it brings together more than half of the cases globally.OBJECTIVE: The clinical case of a 25-week pregnant woman with a critical presentation of COVID-19 and pregnancy at 25 weeks of gestation, is presented in the context of the peak of the pandemic in Chile in the fall of 2020. CLINICAL CASE: On June 20, 2020, a 34-year-old woman, 25 weeks pregnant, is transferred from Hospital de San Bernardo to Clinica Las Condes in Santiago, Chile, with a ten-day evolution of a COVID-19 that evolves to critical with severe respiratory failure. She is admitted to the intensive care unit for mechanical ventilation. Chest computerized axial tomography images demonstrate bilateral pneumopathy with characteristic images of ground-glass opacities, associated with interstitial thickening, images previously described as characteristics for COVID-19. The patient remains in the intensive care unit on mechanical ventilation for seven days, with subsequent favorable evolution, improvement of the septic condition, and discharge after 22 days of hospitalization. Delivery occurs at 38 weeks, the mother and the newborn evolve in good general condition. The placental histopathological examination demonstrates villous inflammatory involvement, and the newborn's blood tests show the presence of IgG and IgM antibodies. It is one of the few reported cases of transplacental transmission of SARS-CoV-2 from the mother to the newborn.